Search

This paper 1) discusses two important contributions that are shaping work with vulnerable and under-resourced populations: Kaiser Permanente's (1998) Adverse Childhood Experiences Study (ACE) which includes the impact of adverse experiences in childhood on adult health and health behaviors and the more recent advent of what has come to be known as Trauma-Informed Care (TIC), programs which incorporate knowledge of the impact of early trauma into policies and programs. 2) Despite many positive benefits that have come from both contributions there are unintended consequences, described in the paper, that have an impact on research and program evaluation as well as social policies and programs. 3) Three key neuroscience concepts are recommended for inclusion in Trauma-Informed Care programs and practices in ways that can enrich program design and guide the development of practical, resilience-oriented interventions that can be evaluated for outcomes. 4) Finally, a resilience-oriented approach to TIC is recommended that moves from trauma information to neuroscience-based action with practical skills to build greater capacity for self-regulation and self-care in both service providers and clients. Examples from criminal justice are used.

Adverse childhood experiences have a strong negative impact on health and are a significant public health concern. Adverse childhood experiences, including various forms of child maltreatment, together with their mental health sequelae (eg, posttraumatic stress disorder, depression, dissociation) also contribute to adverse pregnancy outcomes (eg, preterm birth, low birth weight), poor postpartum mental health, and impaired or delayed bonding. Intergenerational patterns of maltreatment and mental health disorders have been reported that could be addressed in the childbearing year. Trauma-informed care is increasingly used in health care organizations and has the potential to assist in improving maternal and infant health. This article presents an overview of traumatic stress sequelae of childhood maltreatment and adversity, the impact of traumatic stress on childbearing, and technical assistance that is available from the National Center for Trauma-Informed Care (NCTIC) before articulating some steps to conceptualizing and implementing trauma-informed care into midwifery and other maternity care practices.

Despite growing support and increased rate of which trauma-informed approaches are being promoted and implemented in schools, evidence to support this approach is lacking. Exposure to different types of trauma have been associated with varying types and complexity of adverse outcomes, including adverse effects on cognitive functioning, attention, memory, academic performance, and school-related behaviors. Given the growing research on trauma and increased knowledge about the prevalence, consequences and costs associated with trauma, there have been increased efforts at the local, state and federal levels to make systems “trauma-informed” (Lang, Campbell, & Vanerploeg, 2015). While the intent of creating trauma-informed approaches in schools is a noble one, relatively little is known about the benefits, costs, and how trauma-informed approaches are being defined and evaluated (Berliner & Kolko, 2016). Adopting a trauma-informed approach in a complex system such as a school building or district is a time consuming and potentially costly endeavor and thus it is important to assess the effects of this approach to inform policy and practice. This aim of this review was to assess trauma-informed approaches in schools on trauma symptoms/mental health, academic performance, behavior, and socioemotional functioning. Trauma-informed approaches include programs, organizations, or systems that realize the impact of trauma, recognize the symptoms of trauma, respond by integrating knowledge about trauma policies and practices, and seeks to reduce retraumatization. At least two of the three key elements of a trauma-informed approach must have been present: Workforce development, trauma-focused services, and organizational environment and practices, which differ from trauma-specific interventions designed to treat or otherwise address the impact/symptoms of trauma and facilitate healing. What is the aim of this review? This Campbell systematic review sought to examine the effects trauma-informed schools on trauma symptoms/mental health, academic performance, behavior, and socioemotional functioning. Although we conducted a comprehensive search to find studies testing trauma-informed approaches in schools, no studies met the inclusion criteria. No studies met criteria for this review, indicating that there is a lack of evidence of trauma-informed approaches in schools. Despite widespread support and growing adoption of trauma-informed approaches in schools across the globe, we found no studies to provide good evidence to suggest that this approach is effective in achieving the stated goals. Given the degree to which trauma-informed approaches are being adopted in schools across the US and other countries, it is important that the effects of these programs be assessed. The review authors searched for studies June through September, 2017. Exposure to different types of trauma have been associated with varying types and complexity of adverse outcomes, including adverse effects on cognitive functioning, attention, memory, academic performance, and school-related behaviors. Given the growing research on trauma and increased knowledge about the prevalence, consequences and costs associated with trauma, there have been increased efforts at the local, state and federal levels to make systems “trauma-informed” (Lang et al., 2015). Indeed, federal legislation has been proposed to advance trauma-informed practice, with approximately 49 bills introduced between 1973 and 2015 that explicitly mentioned trauma-informed practice, with more than half introduced in 2015 alone (Purtle & Lewis, 2017). The promotion and provision of trauma-informed approaches in school settings in particular is growing at a rapid rate across the United States. At least 17 states have implemented trauma-informed approaches at the school, district, and even state-wide levels (Overstreet & Chafouleas, 2016). This rapid increase in the growth of trauma-informed approaches in schools has been fueled by a number of local, state, and federal initiatives and increasing support by education related organizations. While the intent of creating trauma-informed approaches in schools is a noble one, relatively little is known about the benefits, costs, and how trauma-informed approaches are being defined and evaluated (Berliner & Kolko, 2016). Adopting a trauma-informed approach in a complex system such as a school building or district is a time consuming and potentially costly endeavor, and there is potential for harm; therefore, it is important to assess the effects of this approach to inform policy and practice. The purpose of this review was to identify, describe and synthesize the evidence of effects of trauma-informed approaches in schools to provide guidance for policymakers and educators and to identify important gaps in the evidence base. We conducted a search for published and unpublished studies using a comprehensive search that included nine electronic databases and searches of various research registers, gray literature sources, reference lists of prior reviews and relevant studies, and contacts with authors and researchers in the field of trauma and school-based intervention research. Must have used a randomized or quasi-experimental study design in which participants who received intervention with a no or must have been conducted in a school must have effects of a trauma-informed defined as a or system that the impact of trauma, the symptoms of trauma, by integrating knowledge about trauma policies and practices, and seeks to reduce retraumatization. At two of the three key elements of a trauma-informed approach must have been present: Workforce development, trauma-focused services, and organizational environment and & 2016). This approach is from trauma-specific which are interventions designed to treat or otherwise address the impact/symptoms of trauma and facilitate healing. must have a related to trauma symptoms/mental health, academic performance, behavior, or socioemotional functioning. We studies on or We searched for studies that been published in the as this is a relatively searched and potentially relevant to a systematic review for by two of the for using a related to and between the two and was to no studies met criteria for inclusion in the of from searches to for of and studies The studies for by two studies 49 randomized quasi-experimental design examine effects of a trauma-informed of a trauma-informed approach organizational was a school-based studies have been for the for was for of the search and of studies be found in to No studies met criteria for inclusion in this Trauma-informed approaches are being promoted and used across and the number of states and school trauma-informed approaches in schools is growing (Overstreet & Chafouleas, 2016). While the of a trauma-informed schools approach is a noble one, it is as to the of this is the types of and and are in the the of a trauma-informed approach in schools The purpose of this systematic review was to and synthesize effects of trauma-informed approaches in schools to inform policy and practice. While there are a number of that describe trauma-informed for the for trauma-informed and the potential of such approach in schools, we found no through search this review, it the for school and school to be to with in of a trauma-informed approach as and these We have the evidence to this approach and we trauma-informed approaches in schools have consequences for and school We have evidence of other potential costs in this approach in schools, be or other costs, and the costs of and this approach in schools. for in a trauma-informed approach in schools schools from to programs that trauma symptoms in or that for the research to provide We and by the schools who are a trauma-informed approach and of schools are and guidance it is schools are are using a trauma-informed we more research on the and research on is being implemented be a to the literature in this We that schools be are a trauma-informed is being from school to school or district to district in the and of this research is in the effects of using a trauma-informed approach in schools and we designed studies in this complex interventions such as this is and from research on approaches in schools inform research approaches to assess the effects of trauma-informed approaches in schools. trauma has been increased and it is being as a (Lang et al., 2015). or or that is or that have to a one, or to of of trauma in or by of and how and the is between and & et al., & and by as are by and have levels of trauma & 2017). Exposure to and have and adverse effects on and including in functioning, and behavior, academic and school and and et al., et al., & & et al., et al., a systematic review school-related of and studies that cognitive functioning, that academic functioning, and that functioning. suggest that who have trauma are at for across various cognitive including memory, and academic and school-related such as and and of and Exposure to different types of trauma have been associated with varying types and complexity of adverse and study of and found that different types of trauma impact different of cognitive functioning, including memory, and study effects of different types of trauma, to was found to be associated with and to was associated with et al., there is evidence that the effects of trauma are thus who a number of are more at for adverse and more complex symptoms through & et al., et al., and from to the and between adverse and for and The effects of trauma as the and of trauma has been to be important has been found to have a with than other of and et al., et al., While to or potentially are associated with a of and outcomes, there are through which trauma impact various across the the in the and symptoms a et al., Given the growing research on trauma and increased knowledge about the prevalence, consequences and costs associated with trauma, there have been increased efforts at the local, state, and federal levels to make systems “trauma-informed” (Lang et al., 2015). to examine the to which federal legislation has been proposed to advance trauma-informed practice, and conducted a policy study of federal from 1973 to 2015 that explicitly mentioned trauma-informed practice. The authors 49 bills in with the and and a increase time with bills being introduced in 2015 the 49 bills that included trauma-informed with the of in and schools the United the in through a that is by the and The is a growing of and with a to and to for and The and at intervention development, systems and the of trauma-informed and in The for and for and the of and the of have the impact of trauma on and and are initiatives and policies designed to the and of trauma-informed systems and programs across and (Lang et al., and The promotion and provision of trauma-informed approaches in school settings is growing at a rapid rate across the United States. At least 17 states have been in which trauma-informed approaches have been implemented at the school, district, and even state-wide levels (Overstreet & Chafouleas, 2016). This rapid increase in the growth of trauma-informed approaches in schools has been fueled by a number of local, state, and federal initiatives and increasing support by education related organizations. there are for trauma-informed in the the legislation that No including of school in and how to by trauma, and programs that provide to support that are on trauma-informed that are The promotion of trauma-informed schools is by the and have been efforts to and and across school there is of the impact of trauma on and the consequences for the school systems in services, health, have the for using a trauma-informed in practice. The system was in that the and met for in and with complex trauma and to a trauma-informed as a intervention to these by in the schools in with with the of and the of in conducted a study to the and for and the for comprehensive and support for school the United to the between and the education the for and have conducted and in to provide approaches to and for have trauma, and as key schools guidance of & for 2017). to the of the of and such as the for the to the to school approaches and in trauma-focused to address the that to of the there is and and schools as of and to such as the have education as for and and to that have to and to schools are the support the 2015). The United in the which to that and and have the for support for who have trauma & and the knowledge of environment support be the lack of schools from trauma-informed Trauma-informed approaches are being promoted and used across systems and a relatively approach to trauma for and being the health, and education While trauma-specific such as are known and used to treat symptoms and in and trauma-informed approaches to are from trauma-specific is to a has been and the approach and of the approach have been to in varying for & 2016). there is no on the of these which efforts to and study trauma-informed approaches to While there is and of the various in this of and we are from and the to trauma-informed approaches for the purpose of this and trauma-informed approaches the with as trauma the organizational of the or system trauma-informed approach is thus more to a such as & and is on key and key to that are across levels of than a of or interventions and trauma-informed approach (Lang et al., 2015). and the widespread impact of trauma and potential for the and symptoms of trauma in and with the by integrating knowledge about trauma and to of and The key of a trauma-informed approach include and and and and and and recognize and respond to the impact of on who have with the including and and such a system and trauma and organizational practices, and in with who are with the using the to facilitate and support the and of the and a trauma-informed approach is a intervention that be in a to trauma-informed approach include trauma-specific trauma-specific interventions alone are as for achieving or to systems and and identify three to trauma-informed that from and across and including and organizational and of trauma-informed approaches implemented in schools trauma-informed approaches are complex interventions and a number of at various thus of such programs be in this of a trauma-informed approach is the and to in that was implemented in schools in the is a by the of to school for who have been by trauma & 2016). This approach used the to intervention of and interventions and included at the and levels at in school policies and and for school and and and of and trauma-informed in & is of a trauma-informed school approach being in This on the impact of trauma on across the school, a school that policies and in the school, school in and and school in the for a school Trauma-informed approaches are used at the implemented a trauma-informed approach in programs in the of the US & 2016). This the of in the to provide three of The was to to or to and trauma-informed through and of The of to and to address of in the which the trauma The included the provision of the and to and who trauma, the the to and other at various the While schools be trauma-informed it is to or how there is in schools are or how are on various organizational and schools trauma-informed approaches on the of or other of school has been to a which impact school performance, and and the of who have trauma services, and who are to a potentially intervention et al., to the relatively of to and the of on academic and outcomes, schools a system in which to and reduce the adverse effects of trauma and more in the et al., 2016). Trauma-informed schools the trauma-informed approach to that are to the of through the of effective and (Overstreet & Chafouleas, trauma-informed approach in schools is designed to a systematic for schools to the impact of trauma on & and more address and socioemotional by and to from a trauma-informed This is through a approach to the school environment through trauma-informed policies and increase the of school to recognize and more respond to through and and reduce symptoms through practices, to and socioemotional a trauma-informed approach implemented at various levels in the school and organizational and using & 2016). The and is to increase knowledge about the and effects of trauma and associated and socioemotional effects of is to increase to recognize and symptoms of trauma and in to trauma symptoms that more address and make for more school that on consequences for with trauma and to more being to a trauma-informed school and that the and the environment for the and impact behavior, socioemotional and academic (Lang et al., 2015). initiatives the of and to with and which in of the policies and to realize organizational that and reduce of and retraumatization. practices, which the of of to trauma, in and for the school, and to the environment to with and to and et al., The to trauma-informed schools and intervention programs that knowledge about trauma and are provide and intervention in the school or with other to programs and in the school or for and in the trauma-informed schools provide and interventions at levels or schools have the to provide levels of and Although about the or of schools a trauma-informed trauma-informed approaches are being promoted and used across and the number of states and school trauma-informed approaches in schools is growing (Overstreet & Chafouleas, 2016). While the intent of creating trauma-informed approaches in schools is a noble one, there is relatively little known about the benefits, costs, and how trauma-informed approaches are being defined and evaluated (Berliner & Kolko, 2016). Indeed, it is schools a trauma-informed approach being a are effective in trauma symptoms or or academic outcomes, as the of the Adopting a trauma-informed approach in a complex system such as a school building or district is a time consuming and potentially costly endeavor and thus it is important to assess the effects of this approach to inform policy and practice. from review of the the of the trauma-informed approaches being implemented in schools in of the types of used in of the three and the on the three and thus it is important to a systematic and of the trauma-informed approaches implemented in schools to more how this approach is being in schools, and in the impact we have systematic reviews effects of trauma-informed approaches in schools. We have reviews that have trauma-specific interventions for & & and that examine school-based interventions for such as & these reviews are effects of trauma-specific interventions than trauma-informed of these research and inclusion the of these reviews designed to examine effects of a trauma-informed approach in schools. This purpose of this review was to identify, describe and synthesize the evidence of effects of trauma-informed approaches in schools to provide guidance for policymakers and educators and to identify important gaps in the evidence base. What evidence is to examine the of trauma-informed in What are the and of studies that have evaluated the effects of trauma-informed What are the of trauma-informed approaches being used in What are the effects of trauma-informed schools on trauma socioemotional outcomes, behavior, and academic there of trauma-informed approaches that are more effective than What adverse are by for this review was published in the Campbell & 2017). be included in this review, studies must have used of the research or with a and using a no and therefore, studies be We studies in which the received intervention that criteria as a trauma-informed approach included studies in which received that that criteria a a trauma intervention be The of used in study was Given the of research in this we quasi-experimental and Although provide we in the research that and the of that research to inform research in this we that studies provide or make we to study design and elements and these in and there a number of We included studies that effects of the intervention in a school in through levels in other and a trauma-informed approach as a or system that the impact of trauma, the symptoms of trauma, by integrating knowledge about trauma policies and practices, and seeks to reduce retraumatization. key elements of a trauma-informed approach include development, trauma-focused services, and organizational environment and & 2016). between a trauma-informed approach from trauma-specific the which are interventions designed to treat or otherwise address the impact/symptoms of trauma and facilitate healing. We to examine the effects of trauma-informed approaches implemented in school to as trauma-informed schools. We that there be in the of the trauma-informed approach used in schools and in the and adopted by schools. We that and this be a to the literature as is as on this or that to a be and of the are designed to increase knowledge and of school on the and symptoms of trauma, including have to be to school in a school, there must be as of the include policies and or to a trauma-informed environment integrating the key of the trauma-informed and of trauma the must in across the school, including trauma-specific intervention We to of the and describe studies included three and which symptoms/mental of and other time on of have been conducted using or using or or be included in the study authors must have to to was we to make to study authors and the We study authors at different levels and to and related to We in of adverse that of the as we to the and for there a number of studies the outcomes, we to and a We to include at and time and synthesize across studies that time to there more than two studies that We included studies of interventions conducted in a through school We studies on or We searched for studies that been published in the as this is a relatively We conducted a search for published and unpublished studies using a comprehensive search that included electronic research registers, gray literature sources, and reference lists of prior reviews and relevant studies, and contacts with authors and researchers in the field of trauma and school-based intervention research. of on and We used of related to the study and to search the electronic for including the of and and to more search are of the types of we in and for the search for Trauma-informed trauma school intervention of of of for on for and and be to identify potentially relevant searches The for on for on for on for and of The US of of programs and The of What of intervention and for for The reference lists from prior reviews and studies for for potential We to searches for included no studies met inclusion criteria. We to authors of for conducted the search in and and in electronic databases conducted June 2017. in gray literature sources, and and other by 2017. of of was on and authors of 2017. and of that review, prior to that the the and the of the for using a review et al., 2017). which the two through and No studies met inclusion thus was from No studies met inclusion thus of was assessed. No studies met inclusion thus no of from searches to for and of by and the of the 49 examine effects of a trauma-informed of a trauma-informed approach organizational was a school-based studies have been for the for was for of the search and of at the be found in to in the and No studies met criteria for inclusion in this No studies met inclusion thus no studies for of No studies met inclusion criteria for this review, thus no was Trauma-informed approaches are being promoted and used across and the number of states and school trauma-informed approaches in schools in the US and other is growing (Overstreet & Chafouleas, 2016). While the of a trauma-informed schools approach is a noble one, it is as to the of this is the types of and and are in the the of a trauma-informed approach in schools The purpose of this systematic review was to and synthesize effects of trauma-informed approaches in schools to inform policy and practice. Despite search for studies, we found no studies that met criteria for inclusion in this While there are a number of that describe trauma-informed for the for trauma-informed and the potential of such approach in schools, there have been no of trauma-informed approaches in schools that we While the of research in this is it is The adoption of a trauma-informed approach is relatively and it is that there has been time for the research to to the for this approach in schools. research on and approaches be complex and to the which the of research. We found no studies that met thus the evidence in this is lacking. While this review the lack of evidence to inform policy and trauma-informed approaches in schools, the study is Despite at a comprehensive search there is the that we have potentially we the is the search we are of studies, there are no published to provide more about these studies in this This review was to studies that included at least two of the three of a trauma-informed approach or thus we have studies that authors or a trauma-informed This review at in of the trauma-informed in education with a of and that is by of the interventions or being implemented The trauma-informed approach to be no the increasing adoption of trauma-informed approaches in schools, we found no of trauma-informed approaches in schools that or how this approach to address the various of trauma on and This review provide evidence to of the are of this such as academic and and about the that the trauma-informed or evidence to support as other school interventions have in the & While we have in review that there are programs with evidence to support as school-based interventions for with trauma, there to be that programs alone as evidence that using a trauma-informed approach in We have this in and in of the studies that to be using a and or intervention programs be effective in trauma a trauma-informed approach as defined by is important that a of a trauma-informed approach in schools be and that schools, and be in between are a trauma-informed or intervention to or treat This review to the of and of in education and on how this is with the trauma-informed approach is for education to be and adopted on a relatively prior to evidence Indeed, this is with The that in the was federal in the and and time a evidence to support in and for in schools & & & 2015). it is that the of have been implemented in schools, of the interventions in schools & The trauma-informed approach this we to of trauma-informed approaches in schools than the of the trauma-informed we from & for of the of & for which of the by the and the that to be with the trauma-informed approach is the of the trauma-informed it to be a of the trauma-informed approach has to education at a rapid This rapid has the potential to of education that evidence to et al., 2015). This review that the other of & of the are from literature on trauma-informed approaches in schools. this review, it the for school and school to be with in of a trauma-informed approach as and of this We have the evidence to this and we using a trauma-informed approach have consequences for and school We have evidence of other potential costs in this approach in schools, be or other costs, and the costs of and this approach in schools. for in in schools schools from to programs that trauma symptoms in or that for the research to provide The of the trauma-informed approach being by and other policymakers is that these the for a school school to to and this approach in schools. potential for a trauma-informed approach be the various in schools to as systems of to and to these Indeed, has for the trauma-informed approach to be to of the in and with the of to identify who are by trauma & & 2017). The of for trauma is as and school the of in schools for that are the of and systems to & The for research are Trauma-informed interventions to be we are of studies that are to various of the trauma-informed approach in the studies have been Given the complexity of this approach and knowledge about research of other and in schools, such as and and to researchers from in the of research with these approaches to inform studies of trauma-informed We studies that examine the of trauma-informed approaches in schools. schools are how are trauma-informed and in being included is important to and how trauma-informed school approaches and is to this approach in schools. of and the review The review at least on the review who has at least who has and at least who has is to have with authors for the related to trauma-informed schools. review has and in systematic review and have in and systematic has been in and has conducted authors are in and with the at in the and of the search and the search and for this We the from at the and review and the of the in and support in the of the and be for a for the review in approximately The review received from the through a to support the of this The authors that there are no of

Define's and clarifies what trauma-informed service delivery means in the context of delivering child/family welfare services in Australia. Summary This paper aims to define and clarify what trauma-informed service delivery means in the context of delivering child/family welfare services in Australia. Exposure to traumatic life events such as child abuse, neglect and domestic violence is a driver of service need. Policies and service providers must respond appropriately to people who are dealing with trauma and its effects in order to ensure best outcomes for individuals and families using these services. In addition to evidence-based programs or clinical interventions that are specific to addressing trauma symptoms, such as trauma-focused cognitive behaviour therapy, there is a need for broader organisational- or service-level systems of care that respond to the needs of clients with a lived experience of trauma that go beyond a clinical response. Some of the challenges identified in implementing and embedding trauma-informed care across services and systems are discussed.

BACKGROUND: Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Opinion leaders disseminating and implementing 'best evidence' is one method that holds promise as a strategy to bridge evidence-practice gaps. OBJECTIVES: To assess the effectiveness of the use of local opinion leaders in improving professional practice and patient outcomes. SEARCH STRATEGY: We searched Cochrane EPOC Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, HMIC, Science Citation Index, Social Science Citation Index, ISI Conference Proceedings and World Cat Dissertations up to 5 May 2009. In addition, we searched reference lists of included articles. SELECTION CRITERIA: Studies eligible for inclusion were randomised controlled trials investigating the effectiveness of using opinion leaders to disseminate evidence-based practice and reporting objective measures of professional performance and/or health outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from each study and assessed its risk of bias. For each trial, we calculated the median risk difference (RD) for compliance with desired practice, adjusting for baseline where data were available. We reported the median adjusted RD for each of the main comparisons. MAIN RESULTS: We included 18 studies involving more than 296 hospitals and 318 PCPs. Fifteen studies (18 comparisons) contributed to the calculations of the median adjusted RD for the main comparisons. The effects of interventions varied across the 63 outcomes from 15% decrease in compliance to 72% increase in compliance with desired practice. The median adjusted RD for the main comparisons were: i) Opinion leaders compared to no intervention, +0.09; ii) Opinion leaders alone compared to a single intervention, +0.14; iii) Opinion leaders with one or more additional intervention(s) compared to the one or more additional intervention(s), +0.10; iv) Opinion leaders as part of multiple interventions compared to no intervention, +0.10. Overall, across all 18 studies the median adjusted RD was +0.12 representing a 12% absolute increase in compliance in the intervention group. AUTHORS' CONCLUSIONS: Opinion leaders alone or in combination with other interventions may successfully promote evidence-based practice, but effectiveness varies both within and between studies. These results are based on heterogeneous studies differing in terms of type of intervention, setting, and outcomes measured. In most of the studies the role of the opinion leader was not clearly described, and it is therefore not possible to say what the best way is to optimise the effectiveness of opinion leaders.

A concerted effort to tackle the global health problem posed by traumatic brain injury (TBI) is long overdue. TBI is a public health challenge of vast, but insufficiently recognised, proportions. Worldwide, more than 50 million people have a TBI each year, and it is estimated that about half the world's population will have one or more TBIs over their lifetime. TBI is the leading cause of mortality in young adults and a major cause of death and disability across all ages in all countries, with a disproportionate burden of disability and death occurring in low-income and middle-income countries (LMICs). It has been estimated that TBI costs the global economy approximately $US400 billion annually. Deficiencies in prevention, care, and research urgently need to be addressed to reduce the huge burden and societal costs of TBI. This Commission highlights priorities and provides expert recommendations for all stakeholders—policy makers, funders, health-care professionals, researchers, and patient representatives—on clinical and research strategies to reduce this growing public health problem and improve the lives of people with TBI.

This report builds and expands upon the analyses of Report Card 6 which considered relative income poverty affecting children and policies to mitigate it. Report Card 7 provides a pioneering, comprehensive picture of child well being through the consideration of six dimensions: material well-being, health and safety, education, family and peer relationships, subjective well-being, behaviours and lifestyles informed by the Convention on the Rights of the Child and relevant academic literature.