"What Does it Mean to be Trauma-Informed?": A Mixed-Methods Study of a Trauma-Informed Community Initiative.

Trauma during childhood has the potential to adversely affect one's physical, cognitive, emotional, and social development across the life span. However, the adverse effects of trauma can be prevented and mitigated through holistic services and supports that are trauma-informed. The Pottstown Trauma-Informed Community Connection (PTICC) is a community-based initiative that aims to build a trauma-informed community through training diverse stakeholders (e.g., school staff, providers, community leaders, parents) on the potential signs and symptoms of child trauma and how to create safe physical and emotional environments for children and families. This paper presents findings from a mixed-methods study of education and community partners' (N = 82) experiences in PTICC and their understandings of what it means to become trauma-informed. Paired sample t-tests found significant changes in participants' beliefs about trauma-informed practice, but there were no changes in participants' perceptions of the impacts of PTICC on their use of trauma-informed practices and supports. Focus groups with education (n = 6) and community (n = 5) partners found that participants regarded being "trauma-informed" as reframing one's perspective, being more self-reflective, acquiring skills to respond more effectively to others who have experienced trauma, and having a sense of hope for the future. Findings also revealed perceived benefits of trauma training and challenges associated with getting others to buy-in to trauma-informed work. Potential methodological considerations for future community-engaged research in building trauma-informed communities are discussed. These considerations include the need to address ceiling effects, disaggregate data, and mitigate challenges associated with participant engagement.

Predictors of Service Dosage, Recommendation, and Usage in an Early Childhood System of Care.

OBJECTIVES: Children and families enrolled in early childhood systems of care (SOC) present with various psychological and behavioral risk factors that may inhibit healthy development. Within a SOC, wraparound services are designed to increase families' access to numerous child-serving sectors in order to target those risk factors. This study examined whether child and family risk factors at enrollment in an early childhood SOC predicted dosage, service recommendation, and usage of recommended services. METHODS: Participants were 144 children ranging in age from 1.38 to 5.89 years and their caregivers. Families completed measures of child and caregiver functioning prior to participation in the SOC. Service recommendation and usage were measured at intake and three months, respectively. We used multiple regression analysis to examine the relationship between risk factors and dosage of services received. Logistic regression analyses identified the relationships between risk factors and service recommendation and usage according to specific service types within the SOC. RESULTS: Children with greater behavior problems received more services overall (R2 = .103, ß = .243, p = .033). Child risk factors predicted recommendation for child welfare (trauma exposure: O R ^ = 1.352 , p = .052) and mental health services (behavior problems: O R ^ = 1.061 , p = .034; trauma exposure: O R ^ = 1.316 , p = .046), whereas families with substance use issues were less likely to be recommended for mental health services ( O R ^ = .229 , p = .017). CONCLUSIONS: Findings highlight opportunities for improved service provision and service-level decision making in early childhood SOCs.

A Community's Response to Adverse Childhood Experiences: Building a Resilient, Trauma-Informed Community.

Adverse childhood experiences, or ACEs, may be mitigated by trauma-informed social environments-programs, services, systems, communities-that offer responses to trauma that promote healing, recovery, and resilience. However, there is currently little empirical evidence to support the use of specific approaches to do so. Guided by a population health perspective, this paper describes a participatory community change process in response to ACEs that seeks to build a resilient, trauma-informed community in Pottstown, PA. We examine the initial implementation phase of this change process, centered originally on the education sector and the social and behavioral health services sector, and then eventually expanding to 14 community sectors across two years. A variety of data sources and methods are used to track individual and organizational processes, as well as service system network processes. A central feature of this research is the use of data to generate hypotheses rather than test them. Data were also used to guide understanding and decision-making during implementation. The results show that moving forward the community is well-positioned to establish stronger inter-agency and system supports for trauma-informed practice in the service system and in the broader community. We discuss results for their implications for building resilient, trauma-informed communities.

Systems Measures of a Trauma-Informed Approach: A Systematic Review.

Interest in trauma-informed approaches has grown substantially. These approaches are characterized by integrating understanding of trauma throughout a program, organization, or system to enhance the quality, effectiveness, and delivery of services provided to individuals and groups. However, variation in definitions of trauma-informed approaches, coupled with underdeveloped research on measurement, poses challenges for evaluating the effectiveness of models designed to support a trauma-informed approach. This systematic review of peer-reviewed and gray literature identified 49 systems-based measures that were created to assess the extent to which relational, organizational, and community/system practices were trauma-informed. Measures were included if they assessed at least one component of a trauma-informed approach, were not screening or diagnostic instruments, were standardized, were relevant to practices addressing the psychological impacts of trauma, were printed in English, and were published between 1988 and 2018. Most (77.6%) measures assessed organizational-level staff and climate characteristics. There remain several challenges to this emerging field, including inconsistently reported psychometric data, redundancy across measures, insufficient evidence of a link to stakeholder outcomes, and limited information about measurement development processes. We discuss these opportunities and challenges and their implications for future research and practice.

Population Health and Trauma-Informed Practice: Implications for Programs, Systems, and Policies.

Population studies indicate that trauma exposure is ubiquitous and has a significant impact on health. Trauma-informed practice seeks to address the health consequences of trauma through integrative responses that incorporate an understanding of the effects of trauma, the multiple pathways to recovery, and the potential for re-traumatization. Current trauma-informed practice considers trauma exposure an individual clinical problem rather than a societal problem with population health consequences. Population health refers to the aggregated health status of individuals who share some characteristic, such as trauma exposure, and includes the study of determinants that shape the distribution of health outcomes in specific populations. In this paper, we describe a population health perspective for trauma-informed practice that complements the current clinical perspective, and then discuss implications of that perspective for programs, systems, and policies. We summarize essential concepts about trauma over the life course and describe principles of population health science relevant to trauma-informed practice. We then discuss implications of these principles by identifying four priorities for trauma-informed practice from a population health perspective: (a) adopting trauma-informed policies to prevent trauma exposure and to foster resilience in the aftermath of trauma; (b) infusing trauma-informed practice into everyday activities so it is a routine part of interpersonal transactions; (c) incorporating trauma-informed practices into existing service systems; and (d) adapting existing treatments to incorporate trauma-informed principles for population health impact.

Service-Related Barriers and Facilitators in an Early Childhood System of Care: Comparing the Perspectives of Parents and Providers.

Systems of care (SOCs) have the potential to enhance underserved families' access to integrated health and support services. Most scholarship on SOCs has involved school-aged children and adolescents. Thus, research is needed to better understand barriers to, and facilitators of, families' access to services during early childhood. The present study included a community-based participatory approach in understanding services for families of children under age six years with severe emotional and behavioral problems. We analyzed data from two focus groups with caregivers (n = 7) and three focus groups with service providers (n = 22). Our thematic analysis of participants' responses revealed five primary barriers to family service access, including challenges associated with transition planning. In comparison, participants described four primary facilitators of family service access, including providers' adoption of "whole-family" service delivery approaches. Findings indicated areas of convergence and divergence in caregivers' and providers' responses. We discuss limitations and potential implications.

Examining the service-related experiences and outcomes of caregivers involved in a system of care who experienced everyday discrimination.

Individuals who report everyday experiences of discrimination are at heightened risk for adverse health outcomes and tend to report underutilization of health services. Systems of care (SOCs) have the potential to engage members of minority groups and to reduce health disparities. We examined the service-related experiences of predominantly Latinx caregivers enrolled in a SOC for their children with severe psychological health needs. We used independent samples t-tests and regression analyses to compare relations among service access, perceived service characteristics, and caregiver stress according to whether caregivers reported frequent or infrequent discrimination. The frequent discrimination group scored significantly higher on dimensions of stress and had greater dosage than the infrequent group. There were no differences in relations between service characteristics and outcomes by group. Findings indicated important differences in the service-related experiences and outcomes of caregivers who reported frequent and infrequent discrimination. We discuss limitations and implications.

Is the Scoutreach Initiative of Boy Scouts of America Linked to Character Development among Socioeconomically, Racially, and Ethnically Diverse Youth?: Initial Explorations.

Youth development programs represent key tools in the work of youth-serving practitioners and researchers who strive to promote character development and other attributes of youth thriving, particularly among youth who may confront structural and social challenges related to their racial, ethnic, and/or economic backgrounds. This article conducts secondary analyses of two previously reported studies of a relatively recent innovation in Boy Scouts of America (BSA) developed for youth from low-income communities, Scoutreach. Our goal is to provide descriptive and admittedly preliminary exploratory information about whether these data sets-one involving a sample of 266 youth of color from socioeconomically impoverished communities in Philadelphia (M age = 10.54 years, SD = 1.58 years) and the other involving a pilot investigation of 32 youth of color from similar socioeconomic backgrounds in Boston (M age = 9.97 years, SD = 2.46 years)-provide evidence for a link between program participation and a key indicator of positive development; that is, character development. Across the two data sets, quantitative and qualitative evidence suggested the presence of character development among Scoutreach participants. Limitations of both studies are discussed and implications for future longitudinal research are presented. We suggest that future longitudinal research should test the hypothesis that emotional engagement is key to creating the conditions wherein Scoutreach participation is linked to character development.

Profiles of problematic behaviors across adolescence: covariations with indicators of positive youth development.

Previous analyses of data from the 4-H Study of Positive Youth Development (PYD) have examined concurrent trajectories of positive development and risk/problem behaviors among adolescents, finding complex and not necessarily inverse relationships among them. In this article, we expand on prior research by employing a person-centered approach to modeling risk behaviors, assessing development from approximately 6th grade through 12th grade among 4,391 adolescents (59.9% female). Latent profiles involving the problematic behaviors of delinquency, depressive symptoms, substance use, sexual activity, disordered eating behaviors, and bullying were then assessed for concurrent relationships with the Five Cs of PYD: Competence, Confidence, Character, Caring, and Connection. We found six latent profiles, based primarily on mental health, aggression, and alcohol use, with significant differences in Confidence levels among many of the profiles, as well as some differences in the four other Cs. We discuss directions for future research and implications for application to youth policies and programs.

Activity involvement as an ecological asset: profiles of participation and youth outcomes.

Prior research has demonstrated that participation in out-of-school time activities is associated with positive and healthy development among adolescents. However, fewer studies have examined how trajectories of participation across multiple activities can impact developmental outcomes. Using data from Wave 3 (approximately Grade 7) through Wave 8 (approximately Grade 12) of the 4-H Study of Positive Youth Development, this study examined patterns of breadth in out-of-school time participation in activities and associated outcomes in positive youth development (PYD), Contribution to self and community, risk behaviors, and depressive symptoms. We assessed 927 students (on average across waves, 65.4% female) from a relatively racially and ethnically homogeneous sample (about 74% European American, across waves) with a mean age in Wave 3 of 12.98 years (SD = 0.52). The results indicated that high likelihood of participation in activities was consistently associated with fewer negative outcomes and higher scores on PYD and Contribution, as compared to low likelihood of participation in activities. Changes in the breadth of participation (in particular, moving from a high to a low likelihood of participation) were associated with increased substance use, depressive symptoms, and risk behaviors. Limitations of the current study, implications for future research, and applications to youth programs are discussed.

Pathological gamblers respond equally well to cognitive-behavioral therapy regardless of other mental health treatment status.

Data consistently demonstrate comorbidity between pathological gambling and psychiatric disorders. This study compares severity of gambling and psychosocial problems and gambling treatment outcomes in treatment-seeking pathological gamblers (n = 231) based on their self-reported mental health treatment utilization. As expected, participants currently receiving mental health treatment demonstrated the most psychiatric problems, and those with no mental health treatment the least. Although preferred gambling activity differed according to mental health treatment status, severity of gambling problems, and gambling treatment outcomes did not. Individual cognitive-behavioral therapy was efficacious in reducing gambling problems irrespective of mental health treatment utilization.

Toward a blue revolution.

PIP: Coordinated policies and responses to problems at international, national and local levels are required in achieving a blue revolution in water management. Countries have agreed to numerous recommendations at international conferences on water. Thus, a water resource strategy by the international development community and national governments has been put into action. Crafting and implementing a national water strategy is essential to sustainable development in countries with water shortages, wherein, national governments give water resource management their highest priority. Poor communities had notable distribution of water either through special arrangements with water authority or with private vendors. Thus, a vital part of a long-term solution is the worldwide recognition of the links between rapidly growing populations and shrinking water supplies.^ieng

Speeding the reproductive revolution.

PIP: In 1994, at the International Conference on Population and Development (ICPD) held in Cairo, the international community set the goal of ensuring universal access to reproductive health care by 2015 and agreed to finance its costs. Few governments and donor countries, however, have made good on commitments made at the ICPD. Reproductive health is not improving and may actually be getting worse. Specific goals to be reached by 2015 include meeting all unmet need for family planning, reducing maternal mortality by 75% compared with 1990 levels, and reducing infant mortality to lower than 35 deaths/1000 births. Reaching these and the related reproductive health goals of the ICPD was calculated to cost about US$17 billion/year until 2000, then to increase to $22 billion/year by 2015 (in constant 1993 US dollars). Developing countries agreed to pay 66% of the cost, while donor countries paid the remainder. Immediately after the ICPD, reproductive health funding increased substantially, then declined again, with most donor countries failing to meet their funding commitments. Failure to deliver on the promised financial support for the ICPD goals will result in higher levels of unintended pregnancies, induced abortions, cases of maternal mortality, and infant deaths. Governments need to be convinced that paying for reproductive health programs is an urgent priority and that developing countries, donor countries, and multilateral institutions all have much to gain from reaching the ICPD goals.^ieng

Why family planning matters.

PIP: This Population Reports issue focuses on family planning and the importance of advocacy in family planning programs. Key evidences supporting family planning programs are summarized. This article presents the importance of advocacy for the improvement of the family planning programs in developing countries. Advocacy for family planning is becoming crucial as demand for reproductive health care grows. As many as 600 million people have used contraception, and millions more would do so with better access to good-quality services. Although fertility levels are falling in much of the world, rapid population growth remains a critical issue in most developing countries. This is where advocacy is very much needed. Through advocacy, many individuals and countries will benefit especially in the area of family planning. The benefits include saving the lives of women and children; offering women more choices; and encouraging adoption of safer sexual behavior. Through effective family planning programs, population growth will also be affected. Slower population growth helps protect the environment and it aids development.^ieng

Male participation in reproductive health.

PIP: Family planning programs (FPPs) have traditionally viewed women as their main clients because it is women who become pregnant, most contraceptive methods are designed for women, and reproductive health services can be conveniently offered as part of maternal and child health services. Some FPPs have avoided serving men because they believe that women need privacy and autonomy in reproductive health matters. However, this assumption that men are not interested in taking responsibility for family planning has become a self-fulfilling prophecy. FPPs have made little effort to consider men's reproductive health needs or to reach out to men. As such, men have few contacts with the reproductive health care system. Recent survey and study findings instead suggest that many men are highly interested in family planning and other reproductive health issues, and would participate in family planning if given the chance. While some family planning programs have been interested in involving men for more than a decade, men's participation has only recently become the focus of considerable attention. One reason for this newly directed focus is growing concern over the rapid spread of HIV and the targeting of HIV prevention programs upon both men and women to an almost equal extent.^ieng

Meeting unmet need: new strategies.

PIP: This issue of "Population Reports" explores the concept of "unmet need" for family planning (FP) and presents new strategies FP programs can use to meet this need. To focus on unmet need, FP programs solicit the statements of women through surveys, identify the groups most likely to be interested in accepting contraception, and attempt to reach these groups with services. Unmet need affects over 100 million women in developing countries (a third of them in India) and an average of 20% of all married women of reproductive age in the developing world. Strategies to address unmet need should 1) maximize access to good quality services, 2) emphasize communication, 3) focus on men as well as women, and 4) collaborate with other services for new mothers and young children. This report opens with an introductory summary and then focuses on the relationship of unmet need and FP programs through a consideration of the concept and measurement of unmet need, the extent of unmet need, trends in unmet need, abortion as an indicator of unmet need, and unmet need versus demand for contraception. The second major section addresses the reasons for unmet need (which include health concerns and side effects, lack of information, family and community opposition, a perception that there is little risk of pregnancy, and apparent ambivalence). The third section considers who has unmet need and discusses unmet need levels by women's characteristics as well as differences among women with unmet need. The next section details the program implications and strategies mentioned above. Finally, a process to address unmet need is presented that depends upon analysis, strategic design, implementation, and monitoring/evaluation. Among the highlighted information is a checklist of possible programmatic steps to address the most common reasons for unmet need.^ieng

Induction of the glucokinase gene by insulin in cultured neonatal rat hepatocytes. Relationship with DNase-I hypersensitive sites and functional analysis of a putative insulin-response element.

Previous, in vivo experiments have shown that an appropriate hormonal environment (high plasma insulin, low plasma glucagon) was unable to induce the accumulation of glucokinase mRNA in term fetal rat liver, whereas it was very efficient in the newly born rat. We have confirmed in the present study that insulin induced the accumulation of glucokinase mRNA in cultured hepatocytes from 1-day-old newborn rats, but not in cultured hepatocytes from 21-day-old fetuses. To identify regulatory regions of the glucokinase gene involved in the insulin response, we have scanned the glucokinase locus for DNase I hypersensitive sites in its in vivo conformation. We confirmed the presence of four liver-specific DNase I hypersensitive sites located in the 5' flanking region of the gene. Moreover, two additional hypersensitive sites, located at 2.5 kb and 3.5 kb upstream of the cap site were found but none of these new sites displayed inducibility by insulin. Finally, an increase of the sensitivity of hypersensitive site-1 and hypersensitive site-2 to DNase I correlates with the ability of insulin to induce glucokinase gene expression in cultured hepatocytes from 1-day-old rats, as observed in previous in vivo studies. This suggests that neither a prior exposure to insulin nor a simple aging of the fetal cells in the presence of the hormone in culture are instrumental for the full DNase-I hypersensitivity of the two proximal sites necessary for the neonatal response of the glucokinase gene to insulin. The proximal hypersensitive site-1, which is close to the transcription start site in the liver, does coincide with a sequence (designated IRSL) that is 80% identical to the phosphoenolpyruvate carboxykinase IRS and with a DNase-I footprint that has been identified overlapping this sequence. Nevertheless, functional analysis of this sequence suggested that it is unlikely that the insulin-response sequence like alone is sufficient to mediate the transcriptional effect of insulin on the hepatic glucokinase gene.

Helping the news media cover family planning.

To make informed choices about family planning, women and men need accurate information in the media as well as in the clinic. The media are looking for news important to the millions of people they reach each day. Thus helping the news media cover family planning fully and accurately merits the efforts of every family planning program.