Pediatric Approach to Trauma Treatment and Resilience (PATTeR) – A novel relationship-based curriculum and approach to train pediatric professionals to provide trauma-informed care

Background

Promoting resilience and recognizing and responding to the effects of trauma on children have been identified as critical roles for pediatricians.^1–3 However, practical guidance and clinical tools are limited.^4–6 Pediatric encounters offer opportunities to promote resilience, identify trauma symptoms and intervene early. Yet, this necessitates that resilience-promotion and trauma-response literatures be translated into practical, brief, and effective trauma-informed interventions that fit the workflow and structure of pediatric visits and enable the pediatric professional to appropriately triage patients and provide psychoeducation and skill-building guidance that can be scaffolded and delivered in pediatric settings.

Educational Approach and Innovation

The biomedical scientific literature amply describes: the physiology of adversity at the molecular, cellular, organ and system levels; the consequences of adversity on long-term health; and, the benefits of caregiver support on child physiology and outcomes.¹ However, there is limited literature about practical pediatric interventions to prevent and ameliorate the impacts of trauma.

The mental health (MH), social science, and parenting literatures contain evidence-base practices for promoting safe, stable, nurturing caregiving to build child and caregiver resilience and to help children recover from trauma. We engaged stakeholders with trauma expertise and completed an extensive environmental scan and literature review to translate this evidence-base into the language of pediatrics for two Pediatric Approach to Trauma Treatment and Resilience (PATTeR) courses (see Figure).

Figure.

Logic model of development and implementation of the Pediatric Approach to Trauma Treatment and Resilience (PATTeR) curriculum

In the Level 1 Trauma Aware course, we describe how the physiology of trauma and resilience explains the clinical presentation of traumatized children and adapted standard MH strategies for relationship-centered care (engagement, psychoeducation, motivational interviewing, and attachment-based attunement by caregivers) to the flow of pediatric clinical care. Mnemonics were employed as a learning strategy. The social science concepts of resilience and child resilience attributes were summarized as THREADS: Thinking brain, Hope, Regulation, Efficacy, Attachment, Developmental skills, Social connectedness. The common symptoms of childhood trauma drawn from the MH literature were summarized as FRAYED: Fear, Regulation difficulties, Attachment difficulties, Yelling and Yawning, Education delays, Dissociation/depression.

The Level 2 Trauma Responsive course provides in-depth topics to enhance pediatricians’ understanding of and ability to respond to child trauma (e.g., the intersection of trauma and culture, epigenetics and intergenerational trauma, and secondary traumatic stress). Techniques from the MH literature (e.g., reflective thinking to promote attachment, cognitive coping and emotional regulation strategies to promote recovery) were adapted to fit pediatric visits, including brief anticipatory guidance for children across the trauma spectrum (with risk factors but asymptomatic; mild to moderate symptoms; complex multi-domain symptoms). Level 2 was designed to enable pediatricians to more specifically identify which strategies to apply based on the child’s presentation, including when referral to community resources and evidence-based MH treatment are indicated.

Both UCLA and AAP institutional review boards reviewed and determined the project exempt. Curriculum implementation and data collection were piloted in Level 1, Cohort 1. Practicing U.S. pediatricians were recruited by email using a randomized ordering of 13 American Academy of Pediatrics (AAP) sections and councils. Within each cohort, participants were enrolled on a first-come first-serve basis.

Pediatricians participated in a 6-session (1-hour/week) Level 1 course followed by a 12-session (1-hour/week) Level 2 course. We leveraged Project ECHO⁷ (Extension for Community Healthcare Outcomes), a tele-mentoring program designed to create knowledge networks of medical providers and subject matter experts to promote learning through didactics, case presentations and discussion. We provided case presentation and guidance forms to reinforce course content; live case discussion reinforced the clinical application of practical concepts, techniques, and tools.

Participants self-reported personal and professional data, including practice size, location, and patient demographics. Pre- and post-course online surveys assessed starting and ending proficiency about specific course content using an established Likert-scale for acquisition of knowledge and skills ranging from 1 (no knowledge) to 6 (expert).⁸ Pre-post differences were determined using analysis of variance. Free-response questions assessed participant change in practice and satisfaction with course content. Three team members independently identified themes from free responses and coded responses. The team subsequently consolidated the themes into mutually agreed upon categories, with responses coded accordingly [Figure].

Results:

A total of 327 pediatric providers from 47 states, representative of AAP member ethnicity and gender participated in Levels 1 and/or 2.

The post-course evaluation showed statistically significant pre-post improvement (p<0.05) in knowledge for each PATTeR concept for Level 1 and Level 2 participants. The median pre-post difference in PATTeR concept proficiency was 1.6 and 1.8 for Levels 1 and 2, respectively, on the 1–6 scale. In Level 1, participants reported the most improvement for the following concepts: physiology of trauma, trauma and executive function, parenting, and attunement. In Level 2, participants reported the most improvement for: clinical presentation of trauma by age, child behavioral responses to trauma, and therapeutic supports derived from MH literature. The average post-course proficiency level of “4” on the Likert scale represented knowing how, when, and where to apply the concept. On free-response questions, participants self-reported: high satisfaction, improved knowledge and skills in trauma recognition and tools for response in the office setting, and the ability to share course information with patients, families, colleagues, and community partners (Figure).

Discussion and Next Steps:

The PATTeR curriculum is a novel approach to building a trauma-informed workforce in pediatrics. Building on the physiologic and neuroscience literature, we adapted practical strategies from evidence-based MH treatment and parenting and resilience literatures to pediatric care and workflow. Pre-post differences in knowledge and skills indicated that pediatricians made progress in incorporating these complex concepts into pragmatic clinical approaches. Practical tools and the opportunity to review and apply concepts in case discussion with content experts contributed to participant-reported change in practice and confidence.

Limitations include: participants restricted to AAP members; potential for recall bias; lack of a control group; and a short follow-up period.

Future directions include expanding access to training for pediatric trainees and practicing physicians by adapting PATTeR to other formats beyond ECHO and studying change in practice and patient experience and outcomes. The PATTeR curriculum contributes to the literature of existing knowledge-based trauma trainings. It embeds trauma-informed care, including response and management, into clinical workflow in a variety of pediatric settings. PATTeR encourages pediatricians to integrate trauma-informed care into all ambulatory visits, whether primary care or subspecialty, from well-child visits to those for specific behavioral, developmental and medical concerns, and into hospital settings.