Search

This study evaluated the effectiveness of a system-wide reform effort to implement trauma-informed care (Trauma Systems Therapy [TST]) across a large, private child welfare system. The longitudinal associations among implementation of TST and four measures of children's well-being (functioning, emotional regulation, and behavioral regulation) and placement stability were examined. A description of the implementation of TST can be found in a separate article in this issue. Latent growth curve models were estimated using child-level administrative data on children's well-being, placement stability, and exposure to TST dosage for 1499 children in out-of-home placements. Results indicate that, as children's care teams implement TST, children demonstrate greater improvements in functioning, emotional regulation, and behavioral regulation and they experience increased placement stability. Moreover, results demonstrate that positive effects of implementation of TST are produced by both those who work closely with the child (caregivers, case managers, and therapists) and those who work more distally with the child (case manager supervisors and family service coordinators), suggesting that no one staff member or caregiver is central to providing trauma-informed care; rather it may be the confluence of the TST skills of the child's entire care team that produces better outcomes.

PURPOSE: Given the ubiquity of traumatic exposures and the profound impact of trauma on health, a trauma-informed care (TIC) approach in health care is critical. TIC seeks to promote safety within health care and prevent retraumatization. The lack of systems-level data has been a major barrier to TIC implementation. This study aimed to understand the mechanisms and outcomes effective in implementing TIC across health systems using a systematic review of reviews and realist synthesis. METHODS: A systematic search of MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Applied Social Science Index & Abstracts identified reviews addressing TIC in health care published in the last 10 years in peer-reviewed journals. Realist synthesis methodology was used to develop context-mechanism-outcome configurations. Thematic analysis was performed to generate a framework for the mechanisms of implementation that produce successful TIC outcomes. RESULTS: Sixteen articles featuring varied review types were included. The results, highlighting the strategies that lead to improved outcomes for patients and systems, were mapped to SAMHSA's 10 TIC implementation domains, including engagement and involvement; training and workforce development; cross-sector collaboration; screening, assessment, and treatment services; governance and leadership; policy; evaluation; progress monitoring and quality assurance; financing; and physical environment. CONCLUSION: The findings support the use of SAMHSA's 10 implementation domains in varied health care contexts to facilitate effective TIC processes. Future work should continue to evaluate the effectiveness of TIC approaches and may consider how health equity and strengths-based approaches fit within SAMHSA's framework.

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.

This Commission covers a range of topics that need to be addressed to confront the global burden of TBI and reduce its effects on individuals and society: epidemiology (section 1); health economics (section 2); prevention (section 3); systems of care (section 4); clinical management (section 5); characterisation of TBI (section 6); outcome assessment (section 7); prognosis (section 8); and new directions for acquiring and implementing evidence (section 9).Table 1 summarises key messages from the Commission and provides recommendations to advance clinical care and research in TBI.We must increase awareness of the scale of the challenge posed by TBI.If we are to tackle the individual and societal burden of TBI, these efforts need to go beyond a clinical and research audience and address the public, politicians, and other stakeholders.We need to develop and implement policies for better prevention and systems of care in order to improve outcomes for individuals with TBI.We also need a commitment to substantial long-term investment in TBI research across a range of disciplines to determine best practice and facilitate individualised management strategies.A combination of innovative research methods and global collaboration, and ways to effectively translate progress in basic and clinical research into clinical practice and public health policy, will be vital for progress in the field. Key messages Assess responses in three domainsEye (score range 1-4) Motor (score range 1-6) Verbal (score range 1-5) Add scores from the three components to give a sum score (3-15) GCS 13-15: mild TBI GCS 9-12: moderate TBI GCS 3-8: severe TBI Panel 2: Definitions of traumatic brain injuryWorld Health Organization definition 39 "...an acute brain injury resulting from mechanical energy to the head from external physical forces", excluding manifestations relating to "drugs, alcohol, medications, caused by other injuries or treatment for other injuries (eg, systemic injuries, facial injuries or intubation), caused by other problems (eg, psychological trauma, language barrier or coexisting medical conditions) or caused by penetrating craniocerebral injury."This broad definition of traumatic brain injury (TBI) is widely used, but some ambiguity exists as to what constitutes "an acute brain injury".Furthermore, the definition focuses on mild TBI, and therefore excludes patients with penetrating craniocerebral injury.American Congress of Rehabilitation Medicine definition 40 "A patient with mild traumatic brain injury is a person who has had a traumatically induced physiological disruption of brain function, as manifested by at least one of the following:(1) any period of loss of consciousness; (2) any loss of memory for events immediately before or after the accident; (3) any alteration in mental state at the time of the accident (eg, feeling dazed, disoriented, or confused); and (4) focal neurological deficit(s) that may or may not be transient; but where the severity of the injury does not exceed the following: loss of consciousness of approximately 30 minutes or less; after 30 minutes, an initial Glasgow Coma Scale score of 13-15; and posttraumatic amnesia (PTA) not greater than 24 hours."This definition is specific to mild TBI and excludes patients with more severe TBI, which conflicts with the concept that the severity of TBI lies along a continuum.Note that the term "concussion" is often used synonymously with "mild TBI".41 See figure 2 for classification of clinical severity with the Glasgow Coma Scale. National Institute of Neurological Disorders and Stroke definition1 "TBI is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force."This statement acknowledges potential confounders to TBI diagnosis, and suggests that symptomatology, imaging findings, details of the incident, and wider context should all be taken into account to inform diagnosis.1

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.