https://orcid.org/0009-0008-9662-9669
ABSTRACT
The prevalence of children exposed to a potentially traumatic event (PTE), or Adverse Childhood Experience (ACE) is high, with exposure to long-lasting and severe PTEs and ACEs associated with negative health outcomes. Health care professionals who predominantly work with the paediatric population have limited training on how to screen, assess, and treat children after exposure. This study aimed to assess differences in learner outcomes between three healthcare provider types (PCPs, behavioural health providers, and other care team members [e.g. nurses, community health workers]) after participating in a continuing education programme designed to improve health outcomes of paediatric patients experiencing trauma. Learner outcomes were assessed as pre- and post-series changes in self-reported knowledge, self-efficacy, skills, and attitudes related to the programme’s learning objectives. Self-reported learner outcomes of 31 participants revealed significant increases in knowledge among all provider types, and significant increases in self-efficacy and skills for behavioural health providers and care team members. Additionally, results revealed that behavioural health providers significantly outperformed medical providers in self-efficacy and skills outcomes. These findings suggest that interprofessional continuing education programmes to enhance trauma care can be successful at training PCPs, behavioural health providers, and care team members, but learner outcomes may vary by discipline.
Introduction
Childhood Trauma Background
According to a study using data from the 2011/12 National Survey of Children’s Health (NSCH) conducted in the United States, 46% of children have been exposed to a potentially traumatic event (PTE), or adverse childhood experience (ACE), with 11% having experienced three or more [Citation1]. In another sample of over 1400 children, 68% of children experienced a PTE [Citation2]. Prevalence is not equally distributed across racial and ethnic groups. For instance, over 60% of Black non-Hispanic children and over 50% of Hispanic children have experienced one or more PTEs, higher than children identifying as White (40%) and Asian (23%) [Citation3].
PTEs can be experienced both inside the home through parental neglect, abuse, or substance use and within communities and schools through bullying, mass violence, or sex trafficking [Citation4]. Common exposures include economic hardship, divorce, alcohol, violence, and mental illness [Citation3].
Exposure can lead to poor short-term and long-term health implications for children [Citation5]. A greater incidence of PTEs and length of exposure are positively associated with an increased risk for negative health outcomes [Citation6,Citation7]. Posttraumatic stress disorder (PTSD) can also result, with one study reporting that 11% of children developed PTSD following an event [Citation2]. Exposure affects brain development, including emotional and cognitive functioning, which may result in decreased school performance and increased absenteeism and behavioural issues [Citation8, Citation9]). Exposure to long-lasting and severe ACEs can lead to toxic stress, which is associated with negative health outcomes, and a myriad of diseases later in life [Citation5, Citation10, Citation11]. These diseases include behavioural health conditions like substance use, depression, and insomnia, as well as chronic diseases like obesity, cardiovascular disease, and cancer [Citation12–14]).
While the prevalence of exposure to these events is high and the outcomes dire, health care professionals who work with paediatric populations have limited training on how to screen, assess, and treat children after exposure [Citation15]. Similar to past studies, more recent studies have found that 81% of physicians were unfamiliar with the ACE screening tool, with only 3% using it in practice, and have showed that only 2% of children under 21 received ACE screening [Citation16–18]. While the screening workflow of ACEs in paediatric primary care is not yet standardised, and workflows should also screen symptoms of trauma in addition to ACE screening tools, these studies show the limited familiarity and use of screening tools to address PTEs in practice [Citation15,Citation19].
Furthermore, primary care providers (PCPs) lack knowledge and training to address ACEs once identified [Citation15, Citation20]. Primary care teams play an important role in responding appropriately and applying trauma-informed practices to assess and treat identified health problems. It is critical to incorporate an integrated approach, especially including behavioural health, in the care of children exposed to PTEs. Interventions by behavioural health professionals have shown to improve behavioural challenges, depression symptoms, posttraumatic symptoms, and other health outcomes [Citation21; Citation22]. Furthermore, it is crucial that after experiencing PTEs, children receive trauma-informed health services, which may reduce anxiety, depression, and suicide attempts, and increase academic performance and attendance [Citation23]. While time is often listed as a limitation to incorporating trauma-informed practices, incorporating trauma-informed care into primary care through training that increases self-efficacy has been found to be feasible, effective, and time-efficient in primary care settings [Citation24, Citation25].
To our knowledge, no long-term training exists for an interprofessional audience of primary healthcare professionals from across the United States to improve their knowledge, skills, and self-efficacy to screen, assess, and treat children experiencing PTEs using team-based, trauma-informed practices. This continuing education project, Weitzman ECHO Childhood Trauma, was implemented to fill this educational gap.
Study Purpose
This study aimed to assess differences in learner outcomes between three healthcare provider types (PCPs, behavioural health providers, and other care team members [e.g. nurses, community health workers]) after they participated in a long-term continuing education programme designed to improve health outcomes of their paediatric patients experiencing trauma. Learner outcomes were assessed as changes in self-reported knowledge, self-efficacy, skills, and attitudes related to the programme’s learning objectives measured pre- and post-series.
Methods
Weitzman ECHO Programme
In 2012, the Weitzman Institute (WI), through its founding organisation, Community Health Center, Inc., was the first federally qualified health centre to implement the Project ECHO (Extension for Community Healthcare Outcomes) model [Citation26]. WI has leveraged Project ECHO to educate over 8,000 providers and care team members from all 50 states, Washington, D.C., Guam, and Puerto Rico. WI has implemented Project ECHO programmes on 22 distinct topic areas and continues to grow.
Weitzman ECHO Childhood Trauma: COVID-19 and Beyond (Childhood Trauma ECHO) consisted of 22 virtual, one-hour sessions via Zoom Conferencing Platform occurring two to three times monthly from October 2021 to June 2022, and was led by six expert faculty members [Citation27]. The interdisciplinary faculty were selected for their expertise on paediatric and adolescent trauma, and included two psychologists, one licenced counsellor, one paediatric nurse practitioner, one educational consultant, and one clinical professor of social work with expertise as a racial scholar.
The focus of Childhood Trauma ECHO was to improve care for paediatric and adolescent patients experiencing the effects of trauma by training medical and behavioural health providers and care team members, especially those working in primary care settings. Each one-hour ECHO session consisted of a 20–25 minute didactic presentation from rotating faculty members on a related topic in the field. Didactic topics are displayed in . Didactic presentations were followed by a participant case presentation and discussion of a paediatric or adolescent patient experiencing the effects of trauma, where faculty and participants provided case recommendations. Sessions ended with a self-care tip taught by faculty members. Childhood Trauma ECHO captured a national audience in the United States, including participants from 30 states, Washington, D.C., and Puerto Rico.
Table 1. Childhood trauma ECHO series didactic topics by session.
Recruitment and Study Design
This study utilised a quasi-experimental, pre-post study design without control group. The study was approved by the Community Health Center, Inc. Institutional Review Board (IRB) and given exemption status. Participants of the study were recruited through convenience sampling of all Childhood Trauma ECHO attendees. Childhood Trauma ECHO attendees were recruited into the continuing education programme through email blasts, posts to social media, and word of mouth.
Instruments
The pre-series and post-series surveys were informed by the Consolidated Framework for Implementation Research (CFIR) and Moore’s Model of Outcomes Assessment Framework [Citation28, Citation29]. Following the aforementioned frameworks, the pre- and post-series surveys assessed changes in participants’ self-reported knowledge, self-efficacy, skills, and attitudes through statements centred on the programme’s learning objectives. Refer to for the programme’s learning objectives. The pre-series survey also gathered participant characteristics, team-based care practices, and asked for any barriers to care provisions. The post-series survey also gauged engagement with components of the ECHO series and qualitatively assessed practice changes on an individual, team-based, and organisational level. See Appendix 1 for the pre-series survey instrument and Appendix 2 for the post-series survey instrument.
Table 2. Childhood trauma ECHO series learning objectives.
While both the pre-series and post-series surveys were informed by CFIR and Moore’s Model of Outcomes Assessment Framework, they were both internally derived [Citation28, Citation29]. The research and evaluation and ECHO programmatic teams developed the surveys through an iterative process following the Analyse, Design, Develop, Implement, and Evaluate (ADDIE) model, which is an instructional design model [Citation30]. The process surrounding the survey design also consisted of selecting the appropriate domain to assess each of the programme’s learning objective, which were then reviewed and received approval from the ECHO programme’s stakeholders and faculty before distributing to the ECHO attendees. The knowledge domain assessed all five of the programme’s learning objectives utilising a 5-point Likert scale. The self-efficacy, skills, and attitudes domains each assessed two of the programme’s learning objectives on 5-point Likert scales that the internal research and evaluation and ECHO programmatic teams selected and discussed as appropriate for each domain. Each learning objective was assessed at least twice through two different domains. See for the programme’s learning objectives assessed by domain and the corresponding Likert scales.
Table 3. Childhood Trauma ECHO survey statements by domain.
Data Collection
All ECHO attendees were invited to complete the pre-series survey via email before the ECHO programme began and through the first session. Following the conclusion of the series, all active attendees (i.e. those that were still active in the programme and had not dropped) were invited to complete the post-series survey via email. The pre-series survey remained open for two weeks and was administered from 29 September 2021 to 15 October 2021 and the post-series survey remained open for two weeks and was administered from 27 June 2022 to 14 July 2022. All data was collected via Qualtrics Survey Software. The pre-series survey was sent to 125 attendees (n=125) who enrolled in the programme and received 96 (n=96) responses, for a 77% response rate. The post-series survey was sent to 100 attendees (n=100) who were active at the conclusion of the programme and received 47 responses (n=47), for a 47% response rate. Attendees that completed both the pre- and post- series surveys were included as participants in this study (n=31). Furthermore, differences in sample size per assessed domain (i.e. knowledge, skills, self-efficacy, and attitudes) occurred due to the completion of each survey item within each domain. Scores for any participant that did not complete all survey items within a domain were omitted from that specific domain’s analysis.
Analysis Strategy
The quantitative analyses and demographics were analysed utilising IBM SPSS Statistics Version 26.0 [Citation31]. Participant self-reported learner outcomes were evaluated to assess change in scores from pre- to post-series within provider type groups using a paired samples t-test. Differences in learner outcomes between provider type groups were assessed using a one-way between-subjects analysis of variance (ANOVA) with three different provider types serving as the independent variable: behavioural health providers, medical providers, and care team members. The data set was tested for normality and homogeneity of variance and both assumptions were met. When statistically significant results were observed, Tukey’s HSD post-hoc test was performed, also known as Tukey-Kramer, due to the unequal independent group sizes [Citation32]. Statistical significance was set at 0.05.
Results
Participant Characteristics
Of the participants included in this study, 61% (n=19) were behavioural health providers, 23% (n=7) were other care team members, and 16% (n=5) were medical providers. Regarding years of experience treating paediatric patients, 89% (n=17) of behavioural health providers reported one to five years of experience and 11% (n = 2) reported six to ten years. Sixty percent (n = 3) of medical providers reported one to five years of experience, and 40% (n = 2) reported six to ten years. Fifty-seven percent (n = 4) of care team members reported one to five years of experience, and 43% (n = 3) reported six to ten years. Full participant characteristics are reported in , including organisation types represented by each provider type group and team-based care practices.
Table 4. Childhood trauma ECHO participant characteristics.
Analysis Outcomes
Knowledge
A paired samples t-test was performed to examine differences from pre- to post-series knowledge scores within provider type groups. Statistically significant increases from pre- to post-series scores were observed among behavioural health providers (P < .001), medical providers (P=.002), and care team members (P=.002). The results are reported in . Additionally, a one-way between-subjects ANOVA was performed examining the differences between provider types for self-reported learner outcomes. No statistically significant differences were observed between provider types for outcome knowledge scores. Full results are reported in and . Mean scores were reported on a scale of 5 to 25.
Table 5. Results of the paired samples t-test analysis of participant self-reported learner outcomes.
Table 6. Results of the one-way between-subjects ANOVA analysis of learner outcomes by provider type.
Table 7. Summary table of Tukey’s HSD post-hoc test results among provider types’ self-reported learner outcome scores.
Self-Efficacy
Participants indicated levels of self-efficacy related to their ability to use trauma-informed treatment practices and communicating effectively with patients/clients/students and their families. The paired samples t-test indicated statistically significant increases from pre- to post-series scores for behavioural health providers (P=.01) and care team members (P=.007). The results are reported in . The one-way ANOVA of self-efficacy scores indicated a statistically significant difference between provider types (F (2, 26) = 4.678, P=.02). Tukey’s HSD post-hoc test indicated that the post-survey mean scores of provider types were significantly different between behavioural health providers and medical providers (P=.02, 95% C.I. = [−3.67, −0.33]). There were no statistically significant differences observed between care team members and the other provider groups. Full results are reported in and . Mean scores were reported on a scale of 2 to 10.
Skills
Participants’ skill levels were assessed for using evidence-based screening strategies for the side effects of trauma and the ability to use self-care strategies in practice. The paired samples t-test indicated statistically significant increases from pre- to post-series scores for behavioural health providers (P=.002) and care team members (P=.01). The results are reported in . Additionally, the one-way between-subjects ANOVA of overall skill levels indicated a statistically significant difference between provider types (F (2, 24) = 5.005, P=.02). Tukey’s HSD indicated that post-survey mean scores of provider types were significantly different between behavioural health providers and medical providers (P=.01, 95% C.I. = [−3.81, −0.44]). There were no statistically significant differences observed between care team members and the other provider groups. Full results are reported in and . Mean scores were reported on a scale of 2 to 10.
Attitudes
After examining differences in attitudes associated with the programme’s learning objectives, no statistically significant changes or differences were observed for the paired samples t-test or one-way ANOVA. The t-test results are reported in and the ANOVA results are reported in and . Mean scores were reported on a scale of 2 to 10.
Discussion
Effective assessment and treatment of childhood trauma necessitates an interdisciplinary, team-based approach. Both physical and behavioural manifestations are common, and a child may enter the primary care system and require referrals to appropriate health professionals, so it is vital that health professionals across these points of entry understand how to recognise and assess trauma and how to collaborate with professionals in different disciplines (e.g. medical with behavioural health) when warranted [Citation33]. Correspondingly, there are examples of CE programmes addressing this topic that have trained interprofessional groups of health care providers together [Citation34–36]. Childhood Trauma ECHO elected a similar approach by recruiting an interprofessional audience from both integrated and smaller practice settings to facilitate interprofessional case-sharing, discussion, and didactic learning.
While other CE programmes have educated interprofessional groups together as noted, to our knowledge, no studies have directly compared learner outcomes in CE programmes across an interprofessional audience. To address this gap in the literature and to ensure that Childhood Trauma ECHO improved learner outcomes for the multiple health professions recruited, not just a subset of learners, this study comprised a novel analysis to assess differences in learner outcomes between three participating healthcare provider types (PCPs, behavioural health providers, and other care team members [e.g. nurses, community health workers]). Learner outcomes were assessed as changes in self-reported knowledge, self-efficacy, skills, and attitudes related to the programme’s learning objectives measured pre- and post- series.
Significant improvements pre-to-post participation were observed across the knowledge domain for all three provider types, across the skills domain for behavioural health and care team members, and across the self-efficacy domain for behavioural health and care team members. There were no significant changes observed in the attitudes domain. Additionally, the comparison of outcomes between provider types demonstrated significant differences between the post-series scores of medical and behavioural health providers within the self-efficacy and skills domains. This may indicate that Childhood Trauma ECHO was more successful at improving behavioural health providers’ self-efficacy and skills than those of other learners. This interpretation is further strengthened by our findings from the paired samples t-test results, which demonstrated significant improvements for behavioural health providers but not medical providers in these two domains. There were no significant post-series score differences observed between care team members and the other groups within any of the domains, which may have been a result of a lack of variance in scores between care team members and the other groups.
As many of the topics covered within Childhood Trauma ECHO align more closely with behavioural health providers’ scope of practice, results suggesting that it may have been more successful at improving behavioural health outcomes are as expected. However, it is vital to ensure that interprofessional education in mental health-related topic areas such as trauma also improve medical providers’ outcomes so that patients presenting first in this setting can receive early and effective intervention. Despite post-series score differences in self-efficacy and skills, medical providers’ achieved significant improvements within the knowledge domain, suggesting that Childhood Trauma ECHO was still beneficial for this group.
Relevance to Field
The overall finding that Childhood Trauma ECHO was beneficial for medical providers, behavioural health providers, and care team members aligns with past evidence that Project ECHO is an effective model for training this audience. For example, positive learner outcomes have been found in topics such as chronic pain and mental health, among others [Citation37–39]. Regarding childhood trauma specifically, Buysse and colleagues recently demonstrated that Project ECHO improved the knowledge and self-efficacy of participants, who included PCPs, behavioural health providers, and care team members located within three California counties [Citation34]. The present findings reinforce Buysse and colleagues’ results that Project ECHO may be an effective training modality for educating interprofessional health care professionals about childhood trauma by demonstrating similar improvements in learner outcomes. This study also builds upon their results by expanding to a broader geographic audience and contributing new findings that medical and behavioural health providers may experience different learner outcomes from such a programme.
Like Childhood Trauma ECHO, Project ECHO is frequently utilised for interprofessional education. Although the present study appears to be the first of its kind in comparing learner outcomes between health professions, past qualitative studies have explored the benefits of this interprofessional structure. For example, Agley and colleagues discovered, through interviews and focus groups, that participants appreciated the interprofessional nature of Project ECHO in “leveling practitioner hierarchy” and providing a space to value all health care professions’ perspectives [Citation40]. Hassan and colleagues’ qualitative research explored the benefits of an interdisciplinary, chronic pain-focused ECHO, in which physicians reported appreciating learning about other professionals’ skills and services, while non-physicians appreciated that ECHO offered a space to have their perspectives heard [Citation41]. Our findings add quantitative support for educating an interprofessional audience using Project ECHO, but also caution other implementers to consider how learner outcomes may differ between the health professions.
Results from other modalities of trauma-focused CE programmes engaging interprofessional audiences align with the finding of improved learner outcomes, but typically do not report between-group differences, limiting their applicability to the present findings [Citation35, Citation36, Citation42, Citation43]. For instance, Cerny and colleagues, assessing a trauma-focused CE programme for interprofessional paediatric providers, reported that learners demonstrated perceived improvements in knowledge, beliefs, and self-efficacy, and prompted learners to become more aware of other health professional roles [Citation35, Citation42]. Dublin and colleagues’ retrospective pre-post assessment across adaptable trauma-informed trainings for multidisciplinary audiences (n=1,908), found improved skills. Researchers also reported small differences in aggregate satisfaction scores between behavioural health provider types (e.g. social work, psychologists) [Citation36]. Although this finding was limited to role types within a discipline (i.e. behavioural health) and found only slight variation in satisfaction, this supports our present findings that provider types may experience different outcomes following interprofessional CE.
Overall, interprofessional CE opportunities (IPCE) are on the rise. The Joint Accreditation for Interprofessional Continuing Education allows CE providers to become “jointly accredited” to offer continuing education credits to learners across 10 health professions. Since its founding in 2010, the number of jointly accredited providers has increased each year [Citation44]. With this streamlined process likely acting as a catalyst for more organisations to offer IPCE, it is even more important to develop activities that are successful at educating all professions represented in the target audience. This will require testing relevant evaluation methods, such as the analysis presented here, to ensure positive outcomes are achieved across targeted provider type groups.
Strengths and Limitations
Considering strengths of this study, the diversity of the ECHO participants allowed for the representation of various roles in the sample. Assessing how learner outcomes vary among provider types is novel in relation to continuing education programmes and contributes to the overall knowledge base.
Regarding limitations, the larger proportion of behavioural health providers represented in our sample could impact generalisability since these providers may have more opportunities to utilise knowledge and skills gained from the ECHO in their roles as compared to other provider types. Additionally, since the participant sample comes from the ECHO attendees, self-selection bias is another limitation to consider. Utilising self-reported data when assessing knowledge and skill levels could present participant biases. Furthermore, the varying years of care experience among the providers presents as a limitation as care experience may impact the application of knowledge and tools received through the ECHO programme. Finally, both the pre- and post-series survey instruments employed in this study were internally derived as compared to utilising validated instruments, which presents as a limitation.
Future research should focus on understanding participants’ experiences utilising what they gained from the ECHO in their respective roles and any related organisational facilitators or barriers. Furthermore, performing this analysis with a larger, more even sample would better account for generalisability. Continuing to evaluate the effectiveness of IPCE programmes with representation of all professions in the audience is crucial to advance research.
Conclusions and Significance
This study demonstrates that, overall, Childhood Trauma ECHO improved learner outcomes of three different healthcare provider types (PCPs, behavioural health providers, and care team members) from settings across the U.S. after their participation in a long-term, interdisciplinary CE programme focused on team-based, trauma-informed practices. This study, which set out to determine whether different provider types received different educational benefits, suggests that provider types may have different learner outcomes, although, every provider type did show significant improvements in at least one domain. Findings likely demonstrate that behavioural health providers experienced more learner benefits compared to PCPs in this educational programme focused on improving the care of paediatric patients experiencing trauma. These findings suggest that IPCE programmes can train and educate interprofessional health professionals, but learner outcomes may vary by discipline. Furthermore, these results add to the limited research that Project ECHO is an effective tool to educate and train interdisciplinary health professionals on trauma-informed care for paediatric populations. Future research should analyse learner outcomes of target audience provider types in IPCE programmes to determine if similar patterns exist for other topic areas.
Author Contributions
MK wrote the manuscript, reviewed the manuscript, designed the evaluation plan, and conducted the statistical analyses. AP wrote the manuscript, reviewed the manuscript, performed the literature review, and assisted with the evaluation design. RM wrote the manuscript, reviewed the manuscript, performed the literature review, and assisted with the evaluation design. RO wrote the manuscript, reviewed the manuscript, and performed the literature review. MM wrote the manuscript, reviewed the manuscript, assisted with the evaluation design, and assisted with the statistical analyses. SAB wrote the manuscript and reviewed the manuscript. KA critically reviewed the manuscript. MO critically reviewed the manuscript.
Ethical Approval
The study was approved as exempt by the Community Health Center Inc. Institutional Review Board (IRB) and a waiver of informed consent was approved by the IRB [Approval date: 2/10/2023].
Statement
This manuscript has not been published elsewhere.
Acknowledgments
The authors would like to acknowledge the National Council for Mental Wellbeing for their support and partnership. Finally, we would like to thank the faculty that led the ECHO sessions: Pamela Black, MA, MEd, Terence Fitzgerald, PhD, MEd, MSW, Georgette Harrison, EdM, LPC, R. Timothy Kearney, PhD, Naomi Schapiro, RN, PhD, CPNP-PC, Jessica Welt, PsyD, and additional guest faculty members. To learn more about Weitzman ECHO Childhood Trauma, visit https://www.weitzmaninstitute.org/education/weitzman-echo/childhood-trauma/.
Disclosure Statement
No potential conflict of interest was reported by the authors.
Data Availability Statement
The participants of this study did not give written consent for their data to be shared publicly. The IRB approved our application on an exemption basis. So, due to the sensitive nature of the research supporting data is not available.
Additional information
Funding
References
- Sacks V, Murphey D, Moore K. Adverse childhood experiences: national and state-level prevalence. Research brief. Child Trends. 2014 July cited 2023 Feb 15. https://cms.childtrends.org/wp-content/uploads/2014/07/Brief-adverse-childhood-experiences_FINAL.pdf
- Copeland WE, Keeler G, Angold A, et al. Traumatic events and posttraumatic stress in childhood. Arch Gen Psychiatry. 2007;64(5):577–15. doi: 10.1001/archpsyc.64.5.577.
- Sacks V, Murphey D The prevalence of adverse childhood experiences, nationally, by state, and by race or ethnicity. Child Trends. 2018, Feb 12. [cited February 15, 2023]. https://www.childtrends.org/publications/prevalence-adverse-childhood-experiences-nationally-state-race-ethnicity
- The National Child Traumatic Stress Network. Trauma types. 2018, May 25 [cited February 15, 2023]. https://www.nctsn.org/what-is-child-trauma/trauma-types
- Bartlett JD, Sacks V Adverse childhood experiences are different than child trauma, and it’s critical to understand why. Child Trends. 2019 April 10 [cited February 15, 2023]. https://www.childtrends.org/adverse-childhood-experiences-different-than-child-trauma-critical-to-understand-why
- Chartier MJ, Walker JR, Naimark B. Separate and cumulative effects of adverse childhood experiences in predicting adult health and health care utilization. Child Abuse Negl. 2010;34 (6):454–464. doi: 10.1016/j.chiabu.2009.09.020
- Dube SR, Edwards VJ, Anda RF. Adverse childhood experiences and the risk of depressive disorders in adulthood. J Affective Disorders. 2004;82(2):217–225. doi: 10.1016/j.jad.2003.12.013
- Bick J, Nelson CA. Early adverse experiences and the developing brain. Neuropsychopharmacology. 2016;41(1):177–196. doi: 10.1038/npp.2015.252
- U.S. Department of Health and Human Services, Children’s Bureau. Supporting brain development in traumatized children and youth. Child Welfare Information Gateway. 2017 Sep cited 2023 February 15. https://www.childwelfare.gov/pubpdfs/braindevtrauma.pdf
- National Scientific Council on the Developing Child (2005/2014). Excessive stress disrupts the architecture of the developing brain: working paper 3. Updated Edition. [cited February 15, 2023]. https://developingchild.harvard.edu/wp-content/uploads/2005/05/Stress_Disrupts_Architecture_Developing_Brain-1.pdf
- Shonkoff JP, Garner AS. Committee on psychosocial aspects of child and family health, committee on early Childhood, adoption, and dependent care, section on developmental and behavioral pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232–e246. doi: 10.1542/peds.2011-2663
- Zarse EM, Neff MR, Yoder R, et al. The adverse childhood experiences questionnaire: two decades of research on childhood trauma as a primary cause of adult mental illness, addiction, and medical diseases. Cogent Med. 2019; 6(1):1. doi: 10.1080/2331205X.2019.1581447
- American Academy of Pediatrics. Adverse childhood experiences and the lifelong consequences of trauma. 2014 [cited February 16, 2023]. https://cdn.ymaws.com/www.ncpeds.org/resource/collection/69DEAA33-A258-493B-A63F-E0BFAB6BD2CB/ttb_aces_consequences.pdf
- Gilbert LK, Breiding MJ, Merrick MT, et al. Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010. Am J Preventive Med. 2015;48(3):345–349. doi: 10.1016/j.amepre.2014.09.006.
- Forkey H, Szilagyi M, Kelly ET, et al. The council on foster care, adoption, and kinship care, council on community pediatrics, council on Child Abuse and neglect, Committee on Psychosocial Aspects of Child and Family Health. (2021). Trauma-informed care. Pediatrics. 2021;148(2):e2021052580. doi: https://doi.org/10.1542/peds.2021-052580
- Kerker BD, Storfer-Isser A, Szilagyi M, et al. Do pediatricians ask about adverse childhood experiences in pediatric primary care? Acad Pediatr. 2016;16(2):154–160. doi: 10.1016/j.acap.2015.08.002
- Stork BR, Akselberg NJ, Qin Y, et al. Adverse childhood experiences (ACEs) and community physicians: what we’ve learned. Perm J. 2020;24(2):19.099. doi: 10.7812/TPP/19.099
- Aces Aware. Aces aware initiative ace screening medi-cal claims data: March 2021 update. 2021, March 2. cited February 16, 2023. https://www.acesaware.org/wp-content/uploads/2021/03/March-ACEs-Claims-Data-Report-FINAL-2-25-21_a11y.pdf
- Reading J, Nunez D, Torices T, et al. A qualitative study of pediatricians’ adverse childhood experiences screening workflows. Acad Pediatr. 2022;22 (8):1346–1352. doi: 10.1016/j.acap.2022.03.021
- Carlson M, Kamimura A, Al-Obaydi S, et al. Background and clinical knowledge of intimate partner violence: a study of primary care residents and medical students at a United States medical school. Health Equity. 2017;1(1):77–82. doi: 10.1089/heq.2017.0008.
- Oral R, Coohey C, Zarei K, et al. Nationwide efforts for trauma-informed care implementation and workforce development in healthcare and related fields: a systematic review. Turk J Pediatr. 2020;62(6):906–920. PMID: 33372429. doi: 10.24953/turkjped.2020.06.002
- Marie-Mitchell A, Kostolansky R. A systematic review of trials to improve child outcomes associated with adverse childhood experiences. Am J Preventive Med. 2019;56 (5):756–764. doi: 10.1016/j.amepre.2018.11.030
- U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration (SAMHSA). Helping children and youth who have traumatic experiences. 2018, May 10 [cited February 16, 2023]. https://www.samhsa.gov/sites/default/files/brief_report_natl_childrens_mh_awareness_day.pdf
- Mishra K, Atkins DE, Gutierrez B, et al. Screening for adverse childhood experiences in preventive medicine settings: a scoping review. J Public Health. 2021;31(4):613–622. doi: 10.1007/s10389-021-01548-4
- Garg A, Butz AM, Dworkin PH, et al. Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE project. Pediatrics. 2007;120 (3):547–558. doi: 10.1542/peds.2007-0398
- Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364(23):2199–2207. doi: 10.1056/nejmoa1009370.
- Zoom Video Communications, Inc. 2023. Zoom one. Version 5.12.11 [desktop app]. San Jose, CA: Zoom Video Communications, Inc.
- Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. doi: 10.1186/1748-5908-4-50
- Moore DE Jr., Green JS, Gallis HA. Achieving desired results and improved outcomes: integrating planning and assessment throughout learning activities. J Contin Educ Health Prof. 2009;29 (1):1–15. doi: 10.1002/chp.20001
- Patel SR, Margolies PJ, Covell NH, et al. Using instructional design, analyze, design, develop, implement, and evaluate, to develop e-learning modules to disseminate supported employment for community behavioral health treatment programs in New York State. Front Public Health. 2018;6:113. https://doi.org/10.3389/fpubh.2018.00113
- IBM Corp.IBM SPSS statistics for windows, version 26.0. Armonk, NY: IBM Corp; 2019
- Stoline MR. The status of multiple comparisons: simultaneous estimation of all pairwise comparisons in one-way ANOVA designs. Am Stat. 1981;35 (3):134–141. doi: 10.1080/00031305.1981.10479331
- U.S. Department of Health & Human Services. Substance Abuse and Mental Health Services Administration (SAMHSA). Understanding child trauma. 2023 March 17. cited March 1, 2023. https://www.samhsa.gov/child-trauma/understanding-child-trauma
- Buysse CA, Bentley B, Baer LG, et al. Community ECHO (extension for community healthcare outcomes) project promotes cross-sector collaboration and evidence-based trauma-informed care. Maternal Child Health J. 2022;26(3):461–468. doi: 10.1007/s10995-021-03328-8.
- Berg-Poppe P, Anis Abdellatif M, Cerny S, et al. Changes in knowledge, beliefs, self-efficacy, and affective commitment to change following trauma-informed care education for pediatric service providers. Psychol Trauma Theory Res Prac Policy. 2022;14(4):535–544. doi: 10.1037/tra0001083
- Dublin S, Abramovitz R, Layne CM, et al. Building a trauma-informed national mental health workforce: learning outcomes from use of the core curriculum on childhood trauma in multidisciplinary practice settings. Psychol Trauma Theory Res Prac Policy. 2022;14(8):1383–1386. doi: 10.1037/tra0000540
- Anderson D, Zlateva I, Davis B, et al. Improving pain care with project ECHO in community health centers. Pain Med. 2017;18(10):1882–1889. doi: 10.1093/pm/pnx187.
- Panjwani S, Porto A, Motz R, et al. Participation in project ECHO to advance rural primary care providers’ ability to address patient mental health needs. Med Educ Online. 2023;28 (1):2164470. doi: 10.1080/10872981.2022.2164470
- Zhou C, Crawford A, Serhal E, et al. The impact of project ECHO on participant and patient outcomes: a systematic review. Acad Med. 2016;91(10):1439–1461. doi: 10.1097/acm.0000000000001328.
- Agley J, Delong J, Janota A, et al. Reflections on project ECHO: qualitative findings from five different ECHO programs. Med Educ Online. 2021;26 (1):1936435. doi: 10.1080/10872981.2021.1936435
- Hassan S, Carlin L, Zhao J, et al. Promoting an interprofessional approach to chronic pain management in primary care using project ECHO. J Interprof Care. 2021;35 (3):464–467. doi: 10.1080/13561820.2020.1733502
- Cerny S, Berg-Poppe P, Anis M, et al. Outcomes from an interprofessional curriculum on trauma-informed care among pediatric service providers. J Interprof Care. 2023;37 (2):288–299. doi: 10.1080/13561820.2022.2070142
- Jobst S, Windeisen M, Wuensch A, et al. Supporting migrants and refugees with posttraumatic stress disorder: development, pilot implementation, and pilot evaluation of a continuing interprofessional education for healthcare providers. BMC Med Educ. 2020;20(1):311. https://doi.org/10.1186/s12909-020-02220-3
- Regnier K, Travlos DV, Pace D, et al. Leading change together: supporting collaborative practice through joint accreditation for interprofessional continuing education. J Eur CME. 2022;11 (1):2146372. doi: 10.1080/21614083.2022.2146372
Appendix 1.
Weitzman ECHO: Childhood Trauma pre-series survey instrument
Q1 Full Name: ________________________________________________________________
Q2 Please indicate the number of years you have been working with paediatric patients/clients/students who have been exposed to a potentially traumatic event?
o Less than 1 year (please specify): ________________________________________________
o 1-5 years
o 6-10 years
o 11-20 years
o 21-30 years
o 31-40 years
o 40+ years (please specify): ________________________________________________
o I do not work directly with patients/clients/students
Q3 Please rate your knowledge of the following:
Q4 How would you rate your skills with the following:
Q5 How would you rate your confidence regarding the following, related to your patients/clients/students who have been exposed to a potentially traumatic event and its side effects:
Q6 To what extent do you agree with the following statements:
Q7 Please indicate how often you do the following:
Q8 Please indicate to what extent your organisation has done the following:
Q9 How often do you work with other members of the care team in the following capacities, related to your patients/clients/students who have been exposed to a potentially traumatic event and its side effects:
Q10 What do you perceive as being the primary barriers to screening and treating patients/clients/students experiencing side effects from potentially traumatic events for your organisation?
____________________________________________________________________
Q11 What is motivating you to participate in this ECHO? (check all that apply)
o I am interested in the topic
o I have paediatric patients/clients/students who been exposed to a potentially traumatic event
o I want to improve my ability to treat patients/clients/students who been exposed to a potentially traumatic event
o I want to receive Continuing Education Credits
o I want to be part of a multi-disciplinary learning community
o Others from my agency are participating in this programme
o My supervisor advised I participate in this programme
o Leadership at my agency advised that I participate in this programme
o I want to use this knowledge to support my team based care practice
o I want to use this knowledge to support organisational development efforts at my agency
o Other (Please specify) ________________________________________________
Appendix 2.
Weitzman ECHO: Childhood Trauma post-series survey instrument
Q1 Please insert your participant ID (from the email sent to you requesting you to complete this survey)
Q2 Which two words or phrases would you use to describe Weitzman ECHO: Childhood Trauma? ________________________________________________________________
Q3 How would you rate the length of the series?
o Too short (I wish we had more sessions)
o Just right (The number of sessions held was perfect)
o Too long (I would have preferred fewer sessions)
Q4 Please indicate your agreement with the following statements
Q5 How would you rate your overall satisfaction of the following:
Q6 Please rate your knowledge of the following:
Q7 Please indicate your perception of your skill in the following:
Q8 Please indicate how confident you are in the following:
Q9 Please rate your level of agreement with the following statements:
Q10 How often do you work with members of the care team in the following capacities:
Q11 Please rate your level of agreement with the following statements:
Q12 Please rate your level of agreement with the following statements:
Q13 Please rate your level of agreement with the following statements:
Q14 Please list any changes you made because of what you learned in Weitzman ECHO: Childhood Trauma. If you did not make any changes to these areas, please write “no changes”.
o Changes in your individual practice: _________________________________________________
o Changes in your Team-Based Care practice: __________________________________________________
o Changes in operations at your organisation: __________________________________________________
Q15 Please list any barriers you faced while trying to make changes because of what you learned in Weitzman ECHO: Childhood Trauma. If you did not encounter barriers in these areas, please write “no barriers”.
o Changes in your individual practice: __________________________________________________
o Changes in your Team-Based Care practice: __________________________________________________
o Changes in operations at your organisation: __________________________________________________
Q16 What ideas or solutions can you identify to help you overcome any of the barriers you listed above? Write “n/a” if you did not list barriers or “don’t know” if you can’t think of ideas or solutions.
__________________________________________________________________________
Q17 Please use this space to provide any additional feedback about your experience in this ECHO. (Optional)
__________________________________________________________________________