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

Population studies indicate that virtually everyone experiences one or more traumatic events in their lifetime (Atwoli, Stein, Koenen, & McLaughlin, 2015; Fink & Galea, 2015; Kilpatrick et al., 2013), and almost half experience a trauma in childhood (Bethell, Newacheck, Hawes, & Halfon, 2014; SAMHSA, 2014b). By trauma, we refer to an event or series of events experienced as harmful or life threatening that has persistent adverse effects on individual “functioning, and mental, physical, social, emotional, or spiritual well-being” (SAMHSA, 2014a, p. 7). Traumatic stress refers to the persistent reactions that occur following exposure to extreme adversity that overwhelm one’s ability to cope effectively (Donish, Bray, & Gerwitz, 2016; Magruder, Kassam-Adams, Thoresen, & Olff, 2016; NCTSN, 2019). In the U.S., persons of color, sexual minorities, persons of lower socioeconomic status (SES), and individuals with intellectual and developmental disabilities have higher rates of traumatic stress exposure (Hatch & Dohrenwend, 2007; Lloyd & Turner, 2008; Merrick, Ford, Ports, & Guinn, 2018; SAMHSA, 2014b).

The ubiquity of trauma is a pervasive public health problem (Bloom, 2016; Magruder et al., 2016). In recent decades, scholars and practitioners have implemented trauma-informed practices to address the effects of trauma (Becker-Blease, 2017); these include responses by individuals, professionals, and service systems to mitigate effects for those experiencing a potentially traumatic event (Branson, Baetz, Horwitz, & Hoagwood, 2017). Trauma-informed practices are characterized by: a) a realization that trauma has widespread impact and that there are various paths to recovery, b) a recognition that one’s experience of trauma may be accompanied by specific signs and symptoms of trauma, c) a response from individuals, programs, organizations, and systems to the person experiencing trauma that is comprehensive and integrative, and d) an attempt to prevent re-traumatization (SAMHSA, 2014a).

Some scholars have distinguished between various types of responses to trauma – trauma-informed, trauma-responsive, trauma-sensitive, trauma-focused, and trauma-specific (Bloom, 2016; Branson et al., 2017; Hanson et al. 2018; SAMHSA, 2014a). Here we use the term “trauma-informed” to refer to the broad class of responses to trauma that incorporates the SAMHSA (2014a) definition, and thus encompass each of the types of responses above. In addition, we use the term trauma-informed practice as a verb to encompass actions taken to address the consequences of trauma, including the creation of trauma-informed systems and communities (Matlin et al., 2019). This is analogous to using the term evidence-based practice as a verb (i.e., a decision-making process about intervention) rather than as a noun (i.e., a specific intervention) (Proctor, 2007).¹ This broader conceptualization of trauma-informed practice thus opens up a wide range of actions – trauma-informed practices – that can be taken by professionals and the public to impact the health and well-being of individuals, families, organizations, and communities.

As currently conceptualized, trauma-informed practices do not address the population health consequences of trauma and its aftermath (Bowen & Murshid, 2016). Population health refers to the aggregated health status of individuals who share some characteristic and the determinants that shape the distribution of health outcomes of those individuals (Galea & Vaughan, 2018). Thus, in relation to trauma, population health is concerned with the health status and related determinants of individuals with trauma exposure in the population at large.²

Understanding population health determinants requires attention to biological, behavioral, social, economic, political, geographic, and cultural considerations at multiple socio-ecological levels to reduce risk and promote health (Kindig & Stoddart, 2003; Lushniak, Alley, Ulin, & Graffunder, 2015; Marmot & Wilkinson, 2005). Research on population health determinants, also referred to as macrosocial determinants³, is inherently interdisciplinary, translational, and concerned with issues of health equity, since reducing health inequities enhances the overall health of a population (Bowen & Murshid, 2016; Diez Roux, 2016). Community psychology, with its abiding commitment to equity and social justice, its emphasis on systems change, its focus on multi-level understanding of social-ecological determinants of health and well-being, and its use of empirically-based models for action (Tebes, Thai, & Matlin, 2014; Kloos, Hill, Thomas, Wandersman, & Ellis, 2012), aligns well with the broader discipline of public health and the field of population health science within it.

In this paper, we propose a new direction for trauma-informed practice that is informed by population health science. Population health science is a relatively new field, but it offers a complementary perspective on trauma-informed practice that shifts the focus from clinical practice to the development of trauma-informed programs, systems, and policies that will benefit the health of specific populations to enhance overall public health. In the sections that follow, we: 1) discuss essential concepts about trauma over the life course; 2) describe foundational principles of population health science relevant to research and intervention for trauma-informed practice; and 3) discuss the implications of these principles for developing priorities for trauma-informed practice to enhance population health.

Trauma Over the Life Course

There is now widespread evidence that childhood trauma – also known as adverse childhood experiences (ACEs) – increases adult risk for depression, heart disease, cancer, obesity, and other health conditions, as well as health risk behaviors, such as substance abuse (Anda et al., 2006; Campbell, Walker, & Egede, 2016; Fellitti et al., 1998; McEwen, 2012; Merksy, Topitzes, & Reynolds, 2013). Early studies defined ACEs as childhood experiences of maltreatment; exposure to parental substance abuse, mental illness, or incarceration; and witnessing family violence (Cronholm et al., 2015; Fellitti et al., 1998). Later research expanded the definition of ACEs to include witnessing any form of violence; living in an unsafe neighborhood, in foster care, or in poverty or financial hardship; and experiencing bullying or discrimination due to race or ethnicity (Cronholm et al., 2015; Mersky, Janczewski, & Topitzes, 2017). There is also accumulating evidence that the genetic, cellular, brain, and behavioral changes that result from ACEs exposure function as mechanisms that accelerate health risks (Lupien, McEwen, Gunnar, & Heim, 2009; Miller, Chen, & Parker, 2011). This research also shows that although early adversity may confer short-term advantages in adaptation because of the accelerated maturation of specific brain processes and related adaptive behaviors, these changes may incur longer-term health costs (Callaghan & Tottenham, 2016; McEwen, 2012).

Adult experiences of trauma also increase risk for persistent health conditions (Fink & Galea, 2015; Kilpatrick et al., 2013). A traumatic event not only can result in significant immediate disruptions in well-being, but can initiate a chain of cascading risk that results in secondary traumas that emerge in the aftermath of the original event (Fink & Galea, 2015; McEwen, 2012). Such risk cascades can occur following any number of traumas, such as a natural disaster (Kessler, MacLaughlin, Koenen, Petukhova, & Hill, 2012), a motor vehicle accident (Kazantzis et al., 2012), or exposure to interpersonal violence (Sylaska & Edwards, 2014). In some instances, cascading risks can be experienced across generations by population groups with a shared identity or circumstance, such as holocaust survivors or Native Americans, resulting in intergenerational or historical trauma (Brave Heart & DeBruyn, 1998; Mohatt, Thompson, Thai, & Tebes, 2014). Actions to address trauma over the life course must thus be specific enough to be effective in the immediate aftermath of trauma, but also flexible enough to enable the individual to adapt to new traumatic stressors over time and, potentially, across generations.

Although trauma is ubiquitous and has significant potential for damaging individual and inter-generational health impacts throughout life, studies have also shown that there are tremendous individual differences in response to trauma, including offering opportunities for resilience and psychological growth that can promote health (Denham, 2008; McAdams, Reynolds, Lewis, Patten, & Bowman; 2001; Tebes, Perkins, Irish, & Puglisi, 2004). Rutter (1987) characterizes resilience as an interactive process fostered through controlled exposure to manageable stressors. He also notes several protective mechanisms that can help foster resilience, such as: 1) reduction of the risk impacts of trauma exposure, 2) reduction of negative chain reactions in the aftermath of trauma, 3) establishment and maintenance of self-esteem and self-efficacy through successful task accomplishment after the trauma, and 4) the opening up of opportunities after the trauma that alter one’s life circumstances and trajectory (Rutter, 1987). Thus, a resilience perspective indicates that trauma exposure can have not only costs but benefits to individual and population health.

Existing frameworks for addressing trauma mostly draw on research in psychology, psychiatry, social work, and nursing that informs clinical practice and clinical medicine (Champine, Matlin, Strambler, & Tebes, 2018; Galea & Vaughan, 2018; Hanson et al., 2018; Orkin et al., 2017). These frameworks prioritize treatment of acute trauma, partly in response to the urgency of caring for individuals experiencing severe disruptions in cognition, behavior, and emotion due to one or a series of traumatic events (SAMHSA, 2014a, 2014b). Advances in evidence-based clinical practice have been effective in reducing symptoms and the disruptions caused by trauma (Hanson et al., 2018). These are important developments that have improved the lives of individuals and families receiving treatment after trauma. However, such approaches do not emphasize risk prevention, health promotion, and policy development in response to trauma exposure, and thus have had only a limited impact on the distribution of aggregated health outcomes within and across populations that are impacted by trauma or that one day will be impacted. A population health perspective addresses this need.

Population Health and Trauma-Informed Practice

Although population health science is a relatively new field in public health (Bachrach & Daley, 2017; Galea & Vaughan, 2018), it has a set of foundational principles that are especially relevant to trauma-informed practice. Keyes and Galea (2016) describe nine such principles; four of which we discuss here in relation to trauma-informed practice.

A Population Health Continuum

One principle is that “population health manifests as a continuum” (Keyes & Galea, 2016, p. 8). Although trauma is ubiquitous to the human experience, there is individual variation in who experiences a traumatic event at any given time and who subsequently reports symptoms and disruptions in their life in the aftermath of trauma. Individual differences in the impact of trauma exposure make it difficult to predict any specific person’s response to a potentially traumatic event, the types and course of symptoms or functional disruptions the person may experience, or the trajectory of the person’s recovery. Thus, the health of the population following trauma exposure may not align with the health of specific individual “cases” in the population, given individual variation in response to trauma exposure. A clinical perspective directs our attention to resolving those individual cases, such as PTSD or other disruptions to well-being, following trauma exposure.⁴ This is understandable since individuals who are suffering can clearly benefit from an evidence-based clinical intervention to reduce symptoms and disruptions caused by the trauma. Even though clinical practice may reduce individual suffering, it does not have a marked impact on the overall health of the population at large or other individuals experiencing a similar adverse experience currently or in the future.

A population health perspective focuses our attention elsewhere – on the underlying causes of the incidence of cases in a population (Keyes & Galea, 2016). Thus, for example, if we define the population as all U.S. children living in persistent urban poverty, we instead focus on macrosocial determinants of health associated with extreme adversity in that context, such as food insecurity, substandard housing, parental under/unemployment, inadequate adult supervision of youth, and community violence. To the extent that one of those determinants, such as inadequate adult supervision of youth, is a causal factor in a case of child sexual abuse by an adolescent neighbor, our response to this adversity will focus on population causes – rather than on causes of trauma exposure in the individual case – in an effort to reduce the incidence of trauma for the population. For example, we might focus on addressing underlying mechanisms that led to the abuse, such as ensuring that under-resourced parents have access to subsidized child care or that youth have available meaningful after school activities or access to mentoring by non-parental adults. These sorts of interventions could reasonably be expected to reduce the incidence of acute trauma among our targeted child population – U.S. children living in urban poverty – and thus enhance the population health of this group. If such interventions were supported by policies that were intentional about reducing trauma exposure, those policies would be trauma-informed.⁵

Ubiquitous vs. Rare Causes of Ill-Health

A related foundational principle of population health relevant to trauma-informed practice pertains to the ubiquity of trauma in the human experience: “Small changes in ubiquitous causes may result in more substantial change in the health of populations than larger changes in rarer causes” (Keyes & Galea, 2016, p. 72). As indicated in our previous example, a clinical perspective does not address the health of a population following trauma exposure but focuses on the individual case. From a population health perspective, clinical practices are delivered by professionals or para-professionals to a relatively small number of individuals with trauma exposure. Epidemiological data on the lifetime prevalence of PTSD in the U.S. following trauma exposure is 9.4 percent, with a 12-month prevalence of 5.3 percent; lifetime trauma exposure of any kind is substantially higher, at 93.7 percent (Kilpatrick et al., 2013). Thus, if we allocate resources to alleviate the suffering of 5 percent of the population health distribution in any given year, as is the case with a clinical approach, we are targeting relatively rarer causes of population ill-health. However, if we allocate resources to address the health needs of more than 90 percent of the population with lifetime trauma exposure, more individuals will benefit, thus improving the overall health of the population.

Even if one assumes that annually all individuals with PTSD receive treatment (highly unlikely) and that the treatment is evidence-based (somewhat unlikely) and successful in reducing symptomatology (likely if an evidence-based treatment is used), at the population level, only a small percentage of individuals annually will show improved health.⁶ In contrast, a population health approach focuses on macrosocial determinants of health for the 90 percent of the population that has some trauma exposure over their lifetime, but who may or may not develop PTSD. Since trauma exposure is often accompanied by cascading risk impacts that result in exposure to other adversities that can affect health, even small changes in reducing cascading risks for the 90 percent of the population with lifetime trauma exposure is likely to yield a population health benefit, particularly for specific populations with higher rates of trauma exposure. Targeting ubiquitous causes of ill-health in the population, such as macrosocial determinants for the 90 percent with some lifetime trauma exposure, has obvious benefits to population health.⁷

The health of a population increases when interventions are undertaken to benefit everyone even if they do not necessarily benefit specific persons in their lifetime (Keyes & Galea, 2016), a phenomenon known as the prevention paradox (Rose, 1981). Policies such as immunization, food fortification, fluoridation, smoke-free workplaces, and the use of seatbelts are examples of successful interventions that have enhanced population health. This is different from what happens when implementing an intervention tailored to address rarer causes of ill-health in a population, such as trauma-informed treatment for PTSD. The latter addresses rarer causes of population ill-health while the former address ubiquitous causes.

A corollary to the above principle is the observation that there are inequities in the distribution of ubiquitous causes of ill-health by race, ethnicity, social class, and sexual orientation; in general, U.S. racial, ethnic, economically-disadvantaged, and sexual minority populations are more likely to experience adverse experiences in their life time (Hatch & Dohrenwend, 2007; Lloyd & Turner, 2008; Merrick et al., 2018; Roberts, Austin, Corliss, Vandermorris, & Koenen, 2010; SAMHSA, 2014b; Schulz & Mullings, 2006). A population health perspective directs attention to these inequities because reducing them will enhance overall population health.

Prevention’s Return on Investment

Population health offers another foundational principle relevant to trauma-informed practice, one that is closely related to the previous principle: “Prevention of disease often yields a greater return on investment than curing disease after it has started” (Keyes & Gales, 2016, p. 121). Although community psychologists, social workers, and other behavioral health professionals may not be entirely comfortable with the language of “disease” and “cure” when it comes to the impact of psychological trauma, as noted earlier, the evidence is incontrovertible that early trauma exposure can set in motion genetic, cellular, brain, and behavioral processes that lead to later serious and disabling health conditions (Anda et al., 2006; Fellitti et al., 1998; Lupien et al., 2009; McEwen, 2012; Miller et al., 2011). Even if one does not consider specific disease processes, early trauma exposure has been found to result in various problem behaviors, relationship challenges, and impairments in daily activities that affect well-being and quality of life (Herrenkohl, Leeb, & Higgins, 2016; Monson, Caron, McCloskey, & Brunet, 2017; Nurius, Green, Logan-Greene, & Borja, 2015). In addition, as noted earlier, trauma exposure in childhood is highly prevalent (Bethell et al., 2014; SAMHSA, 2018) especially for underrepresented racial/ethnic groups (Sanders-Phillips, Settles-Reaves, Walker, & Brownlow, 2009), and is ubiquitous in adulthood (Kilpatrick et al., 2013).

This principle prioritizes prevention over treatment when seeking to promote population health, and when combined with the previous principle on prioritizing ubiquitous over rare causes of population ill-health, the value of a population health perspective for trauma-informed practice is evident. Let us illustrate this by returning to Rose’s (1981) prevention paradox, a now widely-established concept in epidemiology, preventive medicine, and population health. Rose sought to prevent cardiovascular disease by selecting individuals with the disease so he could identify key risk factors for it (Khaw & Marmot, 2008). Intervening with those at highest risk, those at the extreme end of the population distribution of cardiovascular risk, allows for prevention of the disease among these individuals. Such a “high risk” strategy is consistent with a clinical perspective, which prioritizes having an impact on individuals at high risk but does not concern itself with reducing the overall burden of disease for the entire population. However, since there are many more people in the middle of the risk distribution for cardiovascular disease, small changes in risk for that large middle group is very likely to have a larger impact on the overall burden of disease for the entire population, since some proportion of individuals from the middle will also develop cardiovascular disease. This reveals one of the implications of Rose’s prevention paradox for understanding the effects of trauma exposure: that by reducing risk among the large number of people in the middle of the risk distribution through universal, trauma-informed interventions, one is likely to improve the health of the population, even if most of those in the middle never experience a behavioral health condition following trauma exposure.

Because trauma exposure is ubiquitous among adults and highly prevalent among children, it represents a significant risk to the health of the population. A clinical perspective uses a high-risk strategy to improve health, whereas a population health perspective emphasizes a risk reduction and health promotion strategy that targets macrosocial determinants and factors that interact with those determinants to affect health. Trauma-informed practices that emphasize risk prevention, health promotion, and policy development alongside clinical treatment are thus essential to enhancing population health.

Within psychology, medicine, and public health, there have been numerous instances that show the value of prioritizing risk prevention over clinical treatment to enhance the health of the public. It has now been 25 years since the Institute of Medicine (IOM) published its landmark report demonstrating the return on investment of prevention and health promotion interventions in behavioral health (IOM, 1994). That report appeared to echo George Albee’s seminal work in prevention, commissioned by the President’s Commission on Mental Health in 1961, that showed how investments in mental health treatment alone were insufficient to meet the mental health needs of the general population (Albee, 1959). There have been many examples since then that have extended the argument for prevention and health promotion to advance the overall health of the population. For example, Heckman and colleagues (Cunha, Heckman, Lochner, & Masterov, 2006; García, Heckman, Leaf, & Prados, 2017; Heckman, 2008) have shown that investments in early intervention, at the family and school level, and particularly among lower-income families, have demonstrable benefits in adulthood, including increased educational attainment, increased employment, reduced teenage pregnancy, and reduced crime. These effects undoubtedly have positive cascading impacts on health to reduce eventual trauma exposure from any number of macrosocial determinants of health. Also, meta-analyses of prevention and health promotion programs for children and adolescents, including social and emotional learning (SEL) programs, have shown that such programs not only reduce problem behaviors but also increase competencies (Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011; Durlak & Wells, 1997), which also are very likely to have downstream effects on population health. Finally, evidence from large-scale implementation of community-wide prevention trials, such as Communities that Care (CTC) (Hawkins, Oesterle, Brown, Abbott, & Catalano, 2014) and PROSPER (Spoth, Greenberg, Bierman, & Redmond, 2004), also have shown the benefits of a population health approach because of their respective impact on the population prevalence of various risk behaviors.

A Life Course Perspective

A final foundational population health principle that informs our understanding and response to trauma is that the health of a population has multi-level causes that “accumulate throughout the life course and are embedded in dynamic interpersonal relationships” (Keyes & Galea, 2016, p. 62). Returning to our example of the population of U.S. children living in urban poverty, it is apparent that the macrosocial determinants noted earlier that increase risk for trauma due to poverty (e.g., food insecurity, substandard housing, familial disruption, parental under/unemployment, community violence) operate at multiple levels – the individual, the family, the neighborhood, the community, and policy. These determinants intersect as causes of adverse childhood experiences over the life course (Champine et al., 2018; Rutter, 1987), such that early exposures to adversity (familial disruption, parental unemployment) can set the stage for later risk exposures (food insecurity, substandard housing). Addressing the causes and consequences of trauma over the life course will require attention to complex multi-level system dynamics as opposed to focusing on risk and protective factors in isolation (Herrenkohl, Higgins, Merrick, & Leeb, 2015; Keyes & Galea, 2016).

A population health perspective to trauma and its sequelae also redirects the focus away from clinical practices alone to prioritizing a multi-modal strategy of research and intervention that emphasizes risk prevention, health promotion, and policy development (Bachrach & Daley, 2017; Herrenkohl et al., 2015; Matlin et al., 2019). This perspective aligns with the initial call for a National Program for Prevention Research (Coie et al., 1993), the aforementioned IOM report on the prevention of mental disorders (IOM, 1994), and numerous more recent large-scale, prevention initiatives, such as PROSPER (Spoth et al., 2004), CTC (Hawkins et al., 2014), Public Health 3.0 (DeSalvo & Wang, 2018), and the CDC’s Essentials for Childhood (CDC, 2019a). These initiatives usually make it a priority to establish cross-sector community partnerships to address social determinants of health (Bommerbach et al., 2018; CDC, 2019a; Spoth et al., 2004). Such partnerships are also increasingly part of a global movement toward engaging public stakeholders as collaborators in translational research and social action to address public health, environmental, and social challenges, an approach endemic to community psychology research and practice (Tebes & Thai, 2018).

Implications of a Population Health Perspective for Research and Action in Trauma-Informed Practice

A population health perspective acknowledges the benefits of a clinical approach to the health of individual cases following trauma exposure, particularly using an evidence-based practice. However, since population health focuses on macrosocial determinants that shape the distribution of health outcomes in specific populations, focusing on individual cases is insufficient. What types of priorities should guide trauma-informed practice from a population health perspective?

Elsewhere, we have described a tripartite population health model of trauma-informed practice to guide priorities for intervention and related research (Champine et al., 2018; Matlin et al., 2019; Tebes et al., 2017). The model specifies a range of responses to adversity in three domains (Matlin et al., 2019): 1) intervention approach (risk prevention and health promotion or treatment and healing), 2) socio-ecological level of intervention (individual, relational, organizational, community/systems), and intervention target (universal or trauma-specific).

Risk prevention and health promotion intervention approaches seek to enhance well-being despite trauma exposure whereas treatment or healing approaches, especially those employing evidence-based practices, seek to reduce signs and symptoms of disruption in the aftermath of trauma (Matlin et al., 2019). As noted earlier, only risk prevention and health promotion approaches, especially those implemented as policies, hold potential for significant population health impact. The second domain of the model specifies interventions at various socio-ecological levels, consistent with Magruder et al. (2016): individual, relational, organizational, and community/systems. Individual attitudes, beliefs, and behaviors comprise the individual level; family, couple, peer, and interpersonal relationships comprise the relational level; schools, workplaces, businesses, faith communities, and neighborhoods comprise the organizational level; and communities and service systems comprise the community/systems level (Matlin et al., 2019). This domain allows for a wide range of trauma-informed practices to address macrosocial determinants of health that can complement individually-based clinical practice. The third domain of the model specifies intervention targets: universal or trauma-specific. Trauma-specific targets focus on individuals, organizations, or communities with current trauma exposure whereas universal targets focus on everyone receiving an intervention regardless of their current exposure (Matlin et al., 2019). Universal interventions, particularly those emphasizing risk prevention and health promotion and implemented at the community/system level as trauma-informed informed policies, have the greatest potential for population health impact (Bachrach & Daley, 2017; Bloom, 2016; Matlin et al., 2019).

The tripartite model aligns well with a “blended prevention” approach to promoting population health (Higgins, Sanders, Lonne, & Richardson, 2019; Prinz, 2015, 2019; Sanders, Higgins, & Prinz, 2018). Blended prevention combines universal and targeted approaches as part of an integrated risk prevention and health promotion strategy to achieve population health outcomes, such as reducing the prevalence of child maltreatment (Prinz, 2015). Such hybrid approaches combine a universal intervention with a selective or indicated intervention⁸ to expand the population health impact and related benefits of an intervention. For example, in the case of child maltreatment, blended parenting interventions may involve implementing a parenting program such as Triple P (Prinz, 2015, 2019) at varying levels of intensity, ranging from implementation with a general population to implementation with populations at varying levels of risk. Although large-scale implementations of blended prevention approaches are only recent developments, the evidence in support of their population health impact in various contexts is impressive and promising (Higgins et al., 2019; Prinz, 2019; Sanders et al., 2018). In the tripartite model for trauma-informed practice, blended prevention approaches can be conceptualized along a continuum of intervention from universal, selective and indicated prevention and health promotion approaches to clinical treatment or healing approaches at multiple socio-ecological levels.

Drawing on population health principles and the tripartite model, below we describe four priorities for research and action, listed in descending order of emphasis: 1) adopting trauma-informed policies; 2) infusing trauma-informed practices into everyday activities; 3) incorporating trauma-informed practices into existing service systems; and 4) adapting existing treatments to be trauma-informed.

Adopting Trauma-Informed Policies

The ubiquity of trauma makes it essential that public policy make it a priority to reduce trauma exposure throughout the lifecycle. The Essentials for Childhood framework (EfC), developed by the CDC in 2013 as a population health approach to prevent child maltreatment, is one such initiative (CDC, 2019a). The EfC framework has four primary goals: “1) Raise awareness and commitment to provide safe, stable, nurturing relationships and environments for all children. 2) Use data to inform actions. 3) Create the context for healthy children and families through norms change and programs. 4) Create the context for healthy children and families through policies” (CDC, 2019a). Each goal has related priority tasks, such as raising awareness about the health impact of maltreatment and interpersonal violence (goal 1) or promoting community norms about acceptable parenting behaviors (goal 3). The framework uses a collective impact approach (Kania & Kramer, 2011) that brings together diverse community stakeholders to build commitment for a shared vision and agenda with consistent and strategic messaging about goals and priorities (CDC, 2019a; Herrenkohl et al., 2015). An emphasis of the initiative is to promote the use of evidence-based interventions, such as Triple P (www.triplep.net/glo-en/home), the Nurse-Family Partnership (www.nursefamilypartnership.org), and the Incredible Years (www.incredibleyears.com), to strengthen positive relationships between caregivers and children and to create a local environment with policies that support safe, stable, and nurturing environments for children (CDC, 2019a; Fortson, Klevens, Gilbert, & Alexander, 2016; Klevens & Alexander, 2019). Initial implementation results of the EfC framework by several state health departments is promising (Wasilewski, Shaw, & Hawley, 2019) but reveals several challenges (Abbot & Wirtz, 2019; Mora, Runyan, Brandspigel, & Kuehl, 2019; Shanahan, Ries, Joyner, & Zolotor, 2019).

The EfC framework seeks to prevent trauma exposure by making investments in young children and families and related macrosocial determinants that influence their well-being. Policies that support quality early care and education and schooling, as well as ensuring that youth and adults have opportunities for meaningful employment, quality housing, health care, and safe neighborhood environments, would also clearly reduce the likelihood of trauma exposure. For example, as noted earlier, investments in early childhood care and education – a macrosocial determinant of population health – yield sizeable returns in adult quality of life indicators (García et al., 2017; Heckman, 2008). Such investments require policies that support children and families early in life, particularly those who are lower-income and who may experience social inequities, which are likely to reduce the incidence of cases of trauma exposure later in life. Essential to a just society is creating opportunities for individuals to achieve their capabilities (Nussbaum, 2000), which includes minimizing structural inequities by gender, race, class, and other social identities, as well as trauma exposure which can stifle one’s capabilities.

A more recent emphasis in preventing trauma and promoting resilience is the development of policies and interventions to build resilient, trauma-informed communities (Hargreaves, Pecora, & Williamson, 2017; MARC, 2016; Matlin et al., 2019; Pinderhughes, Davis, & Williams, 2015; SAMHSA, 2014a; Verbitsky-Savitz et al., 2016). Such initiatives bring together community members, parents, policymakers, practitioners, funders, and researchers to develop a coordinated community response to trauma exposure, such as family or community violence, poverty, crime, or traumatic stress. Community efforts may include policies to prevent trauma exposure through neighborhood coalition development that address food insecurity and neighborhood safety; providing education and training in trauma awareness for law enforcement, parents, educators, and community members; establishing networks for service providers, teachers, and clergy to refer to services in a trauma-informed service network; and adopting workplace-, school-, and community-based programs aligned with the principles of trauma-informed practice (Matlin et al., 2019; Pinderhughes et al., 2015; SAMHSA, 2014a). Addressing ubiquitous causes of ill-health by building trauma-informed communities can have a dramatic impact on trauma exposure if implemented widely in specific population groups, such as individuals who are food insecure, those who come in contact with police, or school children. Increasingly, community stakeholders, researchers, and policymakers are advocating for implementation of trauma-informed policies at the federal and state level (Bloom, 2016; Bowen & Murshid, 2016). Central to this effort is the recognition that many health and social problems as well as structural social inequities are rooted in trauma exposure (Bowen & Murshid, 2016), thus making it essential that public policy be aligned with a trauma-informed approach.

Infusing Trauma-Informed Practice into Everyday Activities

Adopting trauma-informed policies offers a structural response to promoting population health, but infusing trauma-informed practice into everyday activities can also have substantial and positive population health impact. Two major types of everyday activities include parenting or caregiving and schooling. A parent is a primary socialization agent in a child’s life, but socialization is also influenced by other kith and kin, including caring adults in early care and education settings. Thus, from a population health perspective, one promising strategy to promote the health of specific populations is to incorporate trauma-informed practices into everyday caregiving. As noted earlier, improved caregiving at a population level is one element of the CDC Essentials for Childhood initiative and also underlying blended prevention approaches for families at varying levels of risk for poor child developmental and health outcomes (Sanders & Kirby, 2014; Sanders et al., 2018). Specifically, however, to what extent can everyday caregiving promote SAMHSA’s six core concepts of trauma-informed practice (SAMHSA, 2014a): safety, trustworthiness and transparency, collaboration, empowerment, choice, and intersectionality?

We do not intend for trauma-informed caregiving to replace existing interventions for children in need of services, but simply to infuse trauma-informed thinking and practice into everyday interactions that shape a developing child’s life. Well-established parenting programs that emphasize effective parent-child communication in response to emotional and interpersonal challenges (CDC, 2019a; Gordon, 2000) or that focus on parent management in response to parent-child conflict (Forgatch & Patterson, 2010) align well with trauma-informed principles. Also, trauma-informed training programs for parents or caregivers of children in the child welfare system or who have experienced an acute trauma are promising developments (Champine et al., 2018; Sullivan, Murray, & Ake, 2016), as is the CDC’s Essentials for Parenting Toddlers and Preschoolers (CDC, 2019b), which is an online resource for caregivers. Many of these materials, as well as other examples of evidence-based parenting programs noted earlier, emphasize building positive relationships between caregiver and child, which may be particularly important for young children with prior trauma exposure (Yamaoka & Bard, 2019). What we are proposing goes beyond focusing on specific populations that are experiencing acute traumatic stress or adversity. Rather, by infusing everyday caregiving with the principles of trauma-informed practice in order to develop resilient children, we leverage a primary socialization process as part of a broader strategy to enhance population health.

Schooling is another everyday activity with a significant population health impact if aligned with trauma-informed principles. Recent research has described the benefits of infusing trauma-informed principles into school policies and teacher training (Overstreet and Chafouleas, 2016) and how teacher training in trauma-awareness can promote positive teacher-student relationships (Whitaker et al., 2019). However, a more extensive impact on schools and children could be achieved through school-wide implementation of SEL, which as noted earlier, is consistent with principles of trauma-informed practice. Teaching children SEL skills in early childhood and school settings can enhance population health because these programs emphasize five core competencies essential to coping with stress: self-awareness, self-management, social awareness, relationship skills, and responsible decision-making (CASEL, 2017). SEL competencies encourage children and adults to tune into their own and others’ emotions in response to stress, to manage those emotions for oneself and with others by responding with respect and empathy, and to make thoughtful, value-based decisions that take one’s specific context into account. In a meta-analysis of school-based SEL programs, Durlak et al. (2011) showed that SEL participation had significant positive effects on children’s social and emotional skills, attitudes, behavior, and academic performance, all of which are likely to yield population health benefits if implemented widely, which is increasingly likely as many states now require SEL in public education (CASEL, 2013). Local implementation of SEL could also reinforce initiatives to build resilient, trauma-informed communities (Matlin et al., 2019).

Incorporating Trauma-Informed Practices into Existing Service Systems

Service system interventions have the potential to reach the entire population since everyone participates in one or several service systems at any given time, such as health, education, child care, behavioral health, child welfare, criminal justice, or recreation. When trauma-informed practices are embedded into how such systems operate, they have the potential to change small ubiquitous causes of population ill-health and to address inequities in those ubiquitous causes. We return to SAMHSA’s (2014a) core principles of trauma-informed practice – safety, trustworthiness and transparency, collaboration, empowerment, choice, and intersectionality – and ask: Can service systems be aligned with trauma-informed principles?

Recent developments suggest that they can, as various service sectors likely to encounter individuals with trauma exposure increasingly seek to become trauma-informed (Becker-Blease, 2017; Branson et al., 2017; SAMHSA, 2014b). Examples include systems focused on behavioral health, child welfare, juvenile justice, primary care, and education (American Academy of Pediatrics, 2019; Becker-Blease, 2017; Branson et al., 2017; Burke Harris, Marques, Oh, Bucci, & Cloutier, 2017; Hanson et al., 2018; Lang, Campbell, Shanley, Crusto, & Connell, 2016; Overstreet & Chafouleas, 2016; SAMHSA, 2014a, 2014b). Trauma-informed systems seek to provide safe and supportive environments for clients and staff by incorporating best practices about trauma and its effects (Bloom, 2013; Hanson et al., 2018). Although one purpose of these systems is to address traumatic reactions among individuals receiving trauma-specific services, they all seek to prevent re-traumatization for individuals with trauma exposure and to reduce secondary traumatic reactions among staff and family members (Hanson et al., 2018; SAMHSA, 2014a, 2014b).

From a population health perspective, schools and health care systems, especially primary care, are key targets for implementing trauma-informed practices because everyone comes in contact with them and they are essential to human health and development. Even small changes in ubiquitous causes of ill-health and inequities in these systems can have significant population health benefits because of their wide reach. Overstreet and Chafouleas (2016) describe a variety of trauma-informed school-based initiatives, prevention- and treatment-focused, that are infusing trauma-informed principles into schools. As noted earlier, schools are also important opportunities to prevent trauma exposure by implementing school-based risk prevention and health promotion programs. Primary care has also begun to emphasize trauma-informed health services. Burke Harris and colleagues (Burke Harris, et al., 2017) describe how trauma-informed thinking, centered on ACEs, shapes services delivered in an urban, pediatric primary care clinic. In addition, the American Academy of Pediatrics has developed a Trauma Toolbox for Primary Care (American Academy of Pediatrics, 2019) to facilitate the use of trauma-informed practice in primary care. The Toolbox helps to educate pediatricians, nurses, and other health care professionals about how to ask families about ACEs and trauma exposure and how to provide care that takes this information into account.

Finally, Bloom (2013) describes an organization-wide program, the Sanctuary Model, that infuses trauma-informed thinking into all sectors of an organization. Its purpose is to create an organizational culture that supports nonviolent, democratic, and empowering relationships among individuals with trauma exposure, their family, and staff. The model is intended to promote healing and prevent retraumatization among individuals receiving services and enable staff and family members to better support them. Originally developed for use in an acute inpatient psychiatric setting for adults, the Sanctuary Model has now been successfully implemented in hundreds of residential settings for children, youth, and adults. Although implementing such an approach alone may have only a limited impact on population health, when integrated with related multi-level community efforts, its impact may increase.

Adapting Existing Treatments to be Trauma-Informed

Evidence-based behavioral health treatments have been shown to benefit individuals with acute or chronic trauma exposure with PTSD (Hanson et al., 2018; Keane et al., 2006; SAMHSA, 2014b). As previously discussed, these treatments are likely to have only a small overall impact on population health because they emphasize symptom reduction for individuals in the tail of the population health distribution. However, it is useful to consider ways in which these treatments can be leveraged for greater population health impact.

One strategy would be to increase the capacity of behavioral health settings to deliver evidence-based treatments for PTSD to achieve targeted population health benefits for specific groups. For example, in the U.S., members of the military and racial/ethnic minorities are less likely to utilize treatment for PTSD and traumatic stress (Roberts, Gilman, Breslau, Breslau, & Koenen, 2011; Seal et al., 2010). Targeting these populations and tailoring treatments to their needs, a strategy consistent with SAMHSA’s Treatment Improvement Protocol initiative (SAMHSA, 2014b), might increase treatment utilization rates and enhance population health. However, several barriers to utilization would need to be addressed, including the stigma of mental health treatment (Clement et al., 2015) and state-by-state inequities in the application of mental health parity laws (Kennedy & Miller, 2018).

Given the ubiquity of trauma across the life course and its impact on health, another strategy to increase the population health impact of clinical practices is to adapt existing behavioral health treatments, such as for addiction or ADHD, to become trauma-informed. As noted earlier, individual differences in response to a potentially traumatic event show that exposure can lead not only to PTSD but a variety of behavioral health conditions (e.g., depression, anxiety, substance abuse, suicidal ideation, relationship impairment) that may also prompt a person to enter treatment. Incorporating trauma-informed practices into existing evidence-based treatments for these other conditions would expand the impact of treatments that address trauma well beyond the 5 percent of the population annually who have PTSD to as many as 18.9 percent of the adult population with some diagnosable mental disorder (SAMHSA, 2018). Several promising efforts to adapt existing treatments to become trauma-informed have already taken place (Champine et al., 2018).

Challenges to a Population Health Approach to Trauma-Informed Practice

Adopting a population health perspective to trauma-informed practice faces several challenges that we discuss below.

Shifting perspective

A significant challenge to adopting a population health perspective is that doing so will require a shift in how best to address trauma and its effects. The symptoms and disruption that can follow trauma exposure are real, and a clinical response to individual suffering is a moral and professional imperative. However, adopting a population health perspective is also essential for benefitting larger segments of the population who will experience lifetime trauma exposure. This requires making a conceptual shift toward addressing macrosocial determinants of health, many of which are embedded in structural conditions and inequities. The EfC framework illustrates how a population health perspective can complement existing service system efforts to address trauma exposure. EfC seeks to reduce family and societal violence and prevent child maltreatment, but does so, in part, by focusing on community policies and norms about violence and parenting (CDC, 2019a). In addition, EfC emphasizes collective action to achieve positive community goals – “creating safe, stable, nurturing relationships and environments for all children and families” (CDC, 2019a) – rather than focusing on preventing risks, such as violence and maltreatment. Such positive and affirmative language is essential to public acceptance for the initiative and for community buy-in (Klevens & Alexander, 2019), and similar affirming language has been used by community coalitions to create a shared vision for building resilient, trauma-informed communities (Hargreaves et al., 2017; Matlin et al., 2019; Pinderhughes et al., 2015). The need to make a shift in perspective from clinical to population priorities is common in prevention and public health, in which the education of professionals, policymakers, and the public is essential to garnering acceptance and support for new priorities for research and action (Coie et al., 1993; DeSalvo & Wang, 2018; IOM, 1994; Herrenkohl, Lonne, Scott, & Higgins, 2019; Price, Cowen, Lorion, & Ramos-McKay, 1988).

Thinking big

Along with a shift in perspective toward addressing macrosocial determinants is the need to “think big” when it comes to intervention approaches, targets, and levels, as indicated in the tripartite population health model described earlier. Interventions should be considered for their population health impact (Spoth et al., 2013) with priority given to universal (vs. trauma-specific) targets using prevention and health promotion (vs. treatment or healing) approaches, with implementation taking place at the largest socio-ecological level that is appropriate (community/systems, organizational, relational, individual). Thinking big will require extensive cross-sector collaboration, perhaps through public-academic-industry partnerships, that bring together diverse stakeholders through collective impact (Kania & Kramer, 2011) or participatory science (Tebes & Thai, 2018) initiatives. By involving local, diverse stakeholders who may be affected by trauma or efforts to address it, such large-scale, participatory initiatives not only generate knowledge but also align with principles of social justice (Tebes, 2018). As initial results from the early implementation of the EfC framework have shown, large-scale interventions encounter numerous challenges, such as developing a shared vision for the work and a common measurement approach, ensuring ongoing stakeholder participation, and developing a sustainable backbone infrastructure (Abbot & Wirtz, 2019; Mora et al., 2019; Shanahan et al., 2019). Critical to these efforts will be addressing key challenges in translation science to strengthen capacity for scaling up evidence-based interventions (Spoth et al., 2013). Examples of successful large-scale, cross-sector, community-based prevention initiatives, such as PROSPER (Spoth et al., 2004) and CTC (Hawkins et al., 2014), offer exemplars of the benefits of thinking big.

Allocating resources

A third challenge facing adoption of a population health perspective is resources. Adopting trauma-informed policies, infusing trauma-informed practices into everyday activities, such as caregiving and schooling, incorporating trauma-informed practices into existing service systems, and adapting existing treatments to be trauma-informed, costs money. Despite clear and compelling economic evidence that prevention and population health approaches more than pay for themselves over time (e.g., García et al., 2017; Heckman, 2008; IOM, 1994; Keyes & Galea, 2016; Kindig & Stoddart, 2003; Price et al., 1988), new funds will need to be obtained and existing funds reallocated to implement a population health approach that complements the current clinical approach. Costs will need to include support for research on macrosocial determinants of health related to trauma exposure and expansion of graduate and professional training to include a population health perspective on trauma-informed practice. In addition, resources will be needed to develop valid systems-based measures of trauma-informed practice (Champine, Lang, Nelson, Hanson, & Tebes, 2019) and create data systems and local data infrastructures to support large-scale population health initiatives.⁹

Conclusions

The ubiquity of trauma and its effects is an individual and societal problem with population health consequences. A population health perspective rebalances the priorities for research and action about trauma exposure to complement the current clinical perspective. If we hope to move the population health curve shaped by trauma exposure over the life course, we must embrace a population health perspective to trauma-informed practice.