Assessment tools, relationships key to addressing child trauma

Two new studies led by researchers at the Johns Hopkins Bloomberg School of Public Health suggest that the bevy of tools available to assess and address childhood adversity and trauma, as well as the interconnected webs of relationships among families and the providers who care for children, are key to healing the effects of these potentially life-altering circumstances.

The findings, published online in a special issue of Academic Pediatrics, offer useful insights in helping children and their families recover from adverse childhood experiences, which can have myriad and serious health consequences.

Researchers have known for decades that adverse childhood experiences—which can include physical, sexual, or emotional abuse and neglect, parental incarceration, and household substance abuse, among other circumstances—are associated with a variety of other long-term health problems or high-risk behaviors, including depression, heart disease, substance abuse and sleep disorders. Only more recently have researchers understood the prevalence of these experiences among children and youth. A 2014 study found that nearly half of all US children had experienced at least one and that effects on health, school success and well-being show up early.

Despite this knowledge, public health efforts have thus far not fully addressed these issues, setting many children up for what could be lifelong health problems.

 "This really is a public health opportunity, because we know children can thrive with proper support systems," says Christina D. Bethell, PhD, professor in the Bloomberg School's Department of Population, Family and Reproductive Health and director of the Child and Adolescent Health Measurement Initiative. "With a clear agenda, we can help create a paradigm shift. And that will help more children do well despite adverse experiences."

To establish a research and policy agenda, Bethell and her colleagues at the Bloomberg School and elsewhere worked with more than 500 individuals across a dozen stakeholder groups to address what priorities should be for preventing and treating traumatic childhood experiences in children's health services.

The resulting agenda, published in the same issue of Academic Pediatrics, lays out four primary goals: educating policymakers and healthcare providers; cultivating cross-sector collaboration; restoring and rewarding healthy relationships; and launching research, innovation and implementation efforts.

Critical to this agenda is understanding which assessment tools are most useful. In another paper in the special issue, Bethell and her co-authors assessed the state of tools used to evaluate adverse childhood experiences. The researchers identified and compared 14 assessment tools, each of which used parent responses to evaluate adverse childhood experiences.

The study found that each of these tools share four adverse experiences: parental incarceration, domestic violence, household mental illness/suicide, and household alcohol or substance abuse. Other experiences common to many of the 14 tools are exposure to domestic/household violence, neighborhood violence, bullying, discrimination, or a parent's death.

Each assessment tool used cumulative scoring methodology that assessed health risks based on the number of adverse experiences that an individual had been exposed to, rather than giving more weight to different ones.

The researchers focused on a new measure included in the the National Survey of Children's Health which looked at children's past or current exposure to adversity. Several methods were employed to validate the tool and its scoring.

"Assessing childhood adversity is strongly linked to the health and school success of children and youth.  Counting exposures rather than specific events holds up," Bethell says.

A separate paper also recommends encouraging relationships that promote healing. In a review article in the same issue of Academic Pediatrics, Lawrence Wissow, MD, MPH, who holds joint appointments at the Johns Hopkins University School of Medicine and the Bloomberg School, and his colleagues combine conclusions from three previous systematic reviews examining relationships between pediatric patients and healthcare providers, among healthcare staff at the same practice, and among primary care providers and specialists.

This research suggests that it's vital for patients to form healthy relationships with staff from the moment they contact a care facility, not only including those that directly provide healthcare, but also those that answer phones or check them into appointments.

"For trauma patients, knowing that you'll be respected, that people will explain things to you, that you'll have choices and won't be trapped, all of this is important to achieving good outcomes," Wissow says.

Similarly, he adds, research shows that having staff at the same healthcare practice who collaborate well despite constant exposure to patients' crises, as well primary care providers who have personal relationships with specialists and community organizations that also assist trauma patients, is key to getting patients the resources they need to heal.

"Trauma care really depends not only on what you do for patients but how you do it," says Wissow, who is board certified in pediatrics, psychiatry, and child/adolescent psychiatry. "Forging these strong and healthy relationships among staff creates an environment where you can deliver care that makes a positive impact."