Course:SOWK551/2021/Trauma-Informed Care Literature Review
Short Summary
Literature review on utilizing trauma-informed care within adolescent mental health settings.
Introduction
With the prevalence of mental health awareness, it is vital to understand the underlying causes and techniques used to support struggling individuals. This literature review’s specific focus will be on utilizing trauma-informed care within adolescent mental health settings. Supporting adolescents in their formative years is crucial, as untreated concerns can affect all aspects of health. The following search terms: trauma-informed ‘care OR practice OR application OR approach,’ adolescent, mental health, social work, and adverse childhood experiences were applied to the UBC library database for appropriate literature. The search was constricted only to include research that was published since the year 2000. Global research and all healthcare professions were included to procure a more comprehensive array of knowledge. This literature review discusses adverse childhood experiences (ACEs), trauma-informed care (TIC), how TIC can be applied when working with adolescents within a mental health setting, and theories that complement TIC.
Adverse Childhood Experiences
Before TIC can be discussed thoroughly, understanding the causes of trauma within adolescents is crucial. ACEs are commonly related to trauma leading to mental health concerns. A consensus agreement from the literature reviewed defines ACEs as traumatic circumstances that occur over time or as single events within the adolescent or child’s environment (Brennan et al., 2018, as cited by Chizimba, 2021). Researchers have established connections between ACEs and negative health outcomes, demonstrating a plethora of detrimental physical, emotional, and behavioral impacts that ACEs have on an individual life (Murphy, 2016, as cited by Hatcher, 2022). This is also supported by findings displaying “a strong proportionate relationship between respondents’ ACE scores and subsequent lifelong medical and mental health pathology and early mortality rates” (Felitti & Anda, 2010, as cited by Bryson & Bosma, 2018, p.597, and Oral et al., 2021). It was also revealed that exposure to trauma during childhood is disproportionately high within mental health populations (Alvarez et al., 2011; Glad et al., 2017; Helpman et al., 2015; Rossiter et al., 2015, as cited by Knight, 2018). Research also connects the relationship between ACEs and children with behavioral and learning challenges (Oral et al., 2021).
With essential data on the effects of ACEs, early intervention is vital to improving child development. Goddard outlines that a “proactive, preventive approach[es] to childhood trauma includes a call to action to pediatric clinicians to recognize the tangible effects on brain development across the lifetime” (2021, p.146). With the awareness of how ACEs affect the developing mind, TIC can be used as a foundation to support individuals (Goddard, 2021). Thus, the foundation of TIC can be used as a scaffolding for supporting individuals with ACEs (Goddard, 2021). In summary, “scholars have suggested that TIC as a standard of practice in clinical settings can mitigate the health effects of ACEs during the lifetime of individuals, families, and communities” (Hatcher, 2022, p.3).
Trauma-Informed Care
This literature review emphasizes the implementation of trauma-informed care within mental health settings. However, the use of TIC also encompasses trauma-informed services and applications. As noted within the introduction, trauma-informed practice (TIP) was also a keyword and search string that was applied; as such, a distinction between the two must be made. Other authors acknowledge that TIP and TIC are habitually used interchangeably; however, TIP is applied to clinical interventions, and TIC refers to the specific organizational context where services are provided to clients (Bassuk et al., 2017; Conover et al., 2015, as cited by Knight, 2018). Therefore, implementing TIP requires the foundation to be built by the organization, while TIC involves an entire paradigm shift. Brewerton (2019) echoes this by affirming that TIC requires individual, organizational, and systemic endorsement. Fundamentally, TIP directs attention to an individual by embedding an understanding of traumatic stress response “in all aspects of service delivery and plac[ing] priority on the individual’s safety, choice, and control” (Harris & Fallot, 2001, as cited by Bryson & Bosma, 2018, p.599).
The literature reveals many themes that lead to the success of TIC. One particular theme in the literature reveals the reduction in restraints and seclusion rooms when TIC is implemented. Notably, “a recent Canadian HSW realist systematic review of TIC implementation reveals a wide range of positive outcomes, including reductions in patient symptomatology, patient and staff injuries, episodes of seclusion and restraint, and staff morale” (Bryson et al., 2017, p.598). Azeem et al.’s research also demonstrates the reduction in the use of seclusion and restraints when specific TIC strategies are implemented (2011). The core strategies discussed by Azeem et al. were developed by the National Association of State Mental Health Program Directors and are: “leadership towards organizational change, use of data to inform practice, workforce development, use of restraint and seclusion reduction tools, improve consumer’s role in an inpatient setting, and vigorous debriefing techniques” (2011, p.12). In the United Kingdom, Chizimba (2021) also noted a reduction in restrictive interventions after the implementation of TIC.
A second theme was acknowledging prior ACEs and trauma history to prevent future physical and emotional re-traumatization (Mkandawire-Walhmu, 2018; Muskett, 2014; Wand et al., 2020). TIC considers that the system and service providers do not have a fulsome idea of the “trauma experiences of their clientele, which may lead to re-traumatization and failure to provide appropriate referrals” (Oral et al., 2016, p.231). Which Mkandawire-Valhmu (2018) believes can be alleviated by the conscious and intentional use of TIC. Fialkowski et al. (2022) also stress that service providers should avoid inquiring about overwhelming events too soon during the initial assessment, which can disrupt relationships and re-traumatize patients. The use of TIC acknowledges history and ACEs by individuals who need mental health services (Wand et al., 2020). Fialkowski et al. (2022) stressed the importance of building relationships and rapport to create a therapeutic relationship before discussing past trauma.
A third theme is the adjustment of environments and systems to utilize TIC best. Infrastructure that responds appropriately to traumatized individuals (2016). Muskett believes that clear leadership and responsibility in systemic changes lead to higher degrees of service users adopting TIC (2014). Oral et al. reinforce this belief by stating that the transformation of organizations towards TIC requires the creation of culturally sensitive infrastructure (2016). Brewerton also prompts the influence of western cultural beliefs regarding mental health which is crucial to historical trauma (2019). The physical environments also play a role in supporting TIC. Muskett shares that the trauma symptoms can arise from environments perceived as unsupportive and can create obstacles for best practice (2014). Oral et al. suggest that architecture and physical spaces must be inviting (2016). Furthermore, Muskett maintains that studies identified physical environments as a reasonable and positive step toward TIC strategies (2014). Boles amplifies this and states that TIC should extend to any points of contact with healthcare as minor actions can lead to potential trauma. (2017)
There are also limitations to requiring the change in settings and environments that utilize TIC. Practicing TIC requires organizational and systemic shifts, especially at an educational level. Ranjbar and Erb state that “the implementation of TIC requires additional training for most rehabilitation professionals because it has not been traditionally incorporated into their core studies” (2019, p.4). Goddard supports this claim by stating the value of an educational shift towards including ACEs and TIC as core concepts (Goddard, 2021). Fialkowski et al. (2022) continue this claim by stating that research needs to be completed on how to instruct both faculty and trainees on TIC methods with a way to assess their skills. Knight (2019) further builds upon this statement by asserting that “future efforts must not only be directed at helping field instructors adopt a trauma-informed orientation but also at advocating that their employing organizations do this same” (2019, p. 87).
Trauma-informed Care Within Adolescent Mental Health
As mentioned previously, ACEs result in trauma which can lead to adolescents requiring support within a healthcare setting. Literature prompts the advantages of TIC within a mental health setting. “Traumatic stress is now understood to be at the root of many behavioral issues for which children are psychiatrically hospitalized or placed in residential facilities” (Hummer, Dollard, Robst, & Armstrong, 2010; Ko et al., 2008, as cited by Bryson & Bosma, 2018, p.597). This claim is supported by Fialkowski et al., (2022) who states that adolescents who face trauma are associated with lower mental and physical health outcomes as well as challenging behaviors in school, home, and work.Research by Keeshin et al. (2014) and Goddard (2021) stresses the value of TIC to adequately diagnose adolescents, as behavior can be misunderstood within a clinical setting. Azeem (2011) believes that TIC supports children within psychiatry units by setting the goal for hospitalization and medication rates to be standardized to match those of psychiatrically ill children to those who have not experienced trauma in other areas of healthcare. Keeshin et al. further state that taking ACEs into perspective when using TIC reduces psychiatric suffering and prevents future admissions to the hospital (2014).
Trauma-informed Care and Other Theories
The application of TIC is flexible and versatile and can be applied within many different healthcare fields. Brewerton (2019) asserts that TIC can be implemented in any setting requiring individual assessments or treatments. However, as beneficial as TIC can be independent, it can be further strengthened by amalgamating it with other theories. One critical practice that is closely connected with TIC is the application of cultural safety (CS). Applying CS conveys that the service provider understands the history of trauma suffered by the individual and their strengths and resilience (Tujague & Ryan, 2021). CS aligns with TIC by considering how past trauma affects current health. Furthermore, Tujague and Ryan (2021) and Hatcher (2022) reinforce the importance of ongoing training and self-reflection on the service provider’s privilege, culture, and organization to seek further improvements. The knowledge of past trauma and critical reflection allows for the growth of entire systems. (Tujague & Ryan, 2021). The benefits of uniting TIC and CS are immeasurable when evaluating the number of racialized and Indigenous health service users there are in Canada.
A second fundamental theory that harmonizes well with TIC is strength-based theory. Boles contrasts TIC against conventional concepts of trauma-based care and highlights the influences of a strength-based theory (2017). Two authors stress the significance of assessments being a large proponent of utilizing strength-based theory (Ranjgar & Erb, 2021 and Want et al., 2020). These authors scrutinize the continuous need to assess and reassess service users that it is important to focus on forward-thinking language (Ranjgar & Erb, 2021 and Want et al., 2020). TIC considers the impacts of trauma and empowers individuals through grounding responses through personal strengths, skills, and attributes (Ranjbar & Erb, 2021 and Want et al., 2020). Boles continues by expressing that these actions can also support building coping strategies (2017).
Conclusion
In conclusion, mental health continues to be a universal issue among individuals, especially adolescents. Determining and exercising the appropriate approaches can significantly improve the conditions within healthcare settings and individual vitality. Firstly, ACEs were examined for their correlation to mental health. The impacts of trauma within the early stages of life can have detrimental effects. Secondly, TIC was contrasted against synonymous language, and the differences were illustrated. Thirdly, TIC was defined, and the application of TIC within adolescent mental health was explored and how it can be applied. Lastly, the usage of TIC was integrated with other modalities to understand best how to support service users. Ultimately, “given social work’s complex understanding of trauma, intersectional identities, and mental health, social work is primed to continue to make contributions to the growing study and implementation of [trauma-informed services] in adult and child health settings” (Bryson & Bosma, 2018, p.598).
References
Azeem, M. W., Aujla, A., Rammerth, M., Binsfeld, G., & Jones, R. B. (2011). Effectiveness of six core strategies based on trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. Journal of Child and Adolescent Psychiatric Nursing, 24(1), 11-15. https://doi.org/10.1111/j.1744-6171.2010.00262.x
Boles, J. (2017). Trauma-informed care: An intentional approach.(the children's corner: Perspectives on supportive care). Pediatric Nursing, 43(5), 250-255A.
Brewerton, T. D. (2019). An overview of trauma-informed care and practice for eating disorders. Journal of Aggression, Maltreatment & Trauma, 28(4), 445-462. https://doi.org/10.1080/10926771.2018.1532940
Bryson, S. A., & Bosma, H. (2018). Health social work in canada: Five trends worth noting. Social Work in Health Care, 57(8), 1-26. https://doi.org/10.1080/00981389.2018.1474161
Chizimba, B. (2021). Assessing the knowledge and skills gap for adverse childhood experiences (ACEs) and trauma-informed practice in children and young people’s services across the education, health, care and voluntary sector. Adoption & Fostering, 45(1), 105-111. https://doi.org/10.1177/0308575921995439
Fialkowski, A., Shaffer, K., Ball-Burack, M., Brooks, T. L., Trinh, N. T., Potter, J. E., & Peeler, K. R. (2022). Trauma-informed care for hospitalized adolescents. Current Pediatrics Reports (Philadelphia, PA), 10(2), 45-54. https://doi.org/10.1007/s40124-022-00262-3
Goddard, A. (2021). Adverse childhood experiences and trauma-informed care. Journal of Pediatric Health Care, 35(2), 145-155. https://doi.org/10.1016/j.pedhc.2020.09.001
Hatcher, B. (2022). Accelerating trauma-informed care practices in behavioral health settings to address patients’ adverse childhood experiences
Keeshin, B. R., Strawn, J. R., Luebbe, A. M., Saldaña, S. N., Wehry, A. M., DelBello, M. P., & Putnam, F. W. (2013;2014;). Hospitalized youth and child abuse: A systematic examination of psychiatric morbidity and clinical severity. Child Abuse & Neglect, 38(1), 76-83. https://doi.org/10.1016/j.chiabu.2013.08.013
Knight, C. (2019). Trauma informed practice and care: Implications for field instruction. Clinical Social Work Journal, 47(1), 79-89. https://doi.org/10.1007/s10615-018-0661-x
Mkandawire-Valhmu, L., & Taylor & Francis eBooks A-Z. (2018). Cultural safety, healthcare and vulnerable populations: A critical theoretical perspective (1st ed.). Routledge, Taylor and Francis Group. https://doi.org/10.4324/9781315708706
Muskett, C. (2014). Trauma-informed care in inpatient mental health settings: A review of the literature. International Journal of Mental Health Nursing, 23(1), 51-59. https://doi.org/10.1111/inm.12012
Oral, R., Ramirez, M., Coohey, C., Nakada, S., Walz, A., Kuntz, A., Benoit, J., & Peek-Asa, C. (2016;2015;). Adverse childhood experiences and trauma informed care: The future of healthcare. Pediatric Research, 79(1-2), 227-233. https://doi.org/10.1038/pr.2015.197
Ranjbar, N., & Erb, M. (2019). Adverse childhood experiences and trauma-informed care in rehabilitation clinical practice. Archives of Rehabilitation Research and Clinical Translation, 1(1-2), 100003-100003. https://doi.org/10.1016/j.arrct.2019.100003
Tujague, N. A., & Ryan, K. L. (2021). Ticking the box of ‘cultural safety’ is not enough: Why trauma-informed practice is critical to indigenous healing. Rural and Remote Health, 21(3), 6411-6411. https://doi.org/10.22605/RRH6411
Wand, T., Buchanan‐Hagen, S., Derrick, K., & Harris, M. (2020). Are current mental health assessment formats consistent with contemporary thinking and practice? International Journal of Mental Health Nursing, 29(2), 171-176. https://doi.org/10.1111/inm.12656
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