Implementing a trauma-informed approach in a tiered model of pediatric population mental health care: a pilot study in primary and secondary care.

backgroundChildhood adversity and trauma are prevalent risk factors for the development of mental health conditions. This two-part paper describes the conceptual basis and pilot implementation of a tiered model of pediatric population mental health, highlighting the local socioecological context in which it was developed and the trauma-informed approach used.

methodsUsing retrospective record review of three datasets from the primary and secondary care pediatric clinics of a large academic medical center, which were harmonized to cover the study period from July 1, 2023 to June 30, 2024, we conducted descriptive analyses of patients across three levels: pediatric primary care (n = 9535), an integrated primary care program, which embeds mental health clinicians in primary care (n = 267), and family-centered trauma-informed psychotherapies in secondary care (n = 63), designed to address emotion dysregulation in pre-adolescent children. Demographics and lifetime history of trauma and adversity (assessed with a comprehensive 19-item list coded based on standardized screeners) were assessed through electronic medical records.

resultsRelative to the pediatric primary care population, more patients in the integrated primary care program and trauma-informed psychotherapies identified as White. Using our 19-item assessment, the lifetime prevalence of adversity or trauma was nearly universal among patients in the integrated primary care (94.4%) and trauma-informed psychotherapy (98.4%) programs. However, the lifetime prevalence of childhood adversities differed significantly across the two programs (integrated primary care: 76.8%; trauma-informed psychotherapy: 98.4%) when we assessed prevalence based only on the 10-item Adverse Childhood Experiences Questionnaire (Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS, Am J Prev Med 14:245-58, 1998). There was a higher prevalence of family and parent-related adversities in the trauma-informed psychotherapy program.

conclusionsFindings support the need for trauma-informed, population mental health approaches in pediatric care. Developmentally tailored, family-centered, transdiagnostic screening and interventions are essential. Study findings, including gaps in programmatic fiscal sustainability, suggest avenues for policy reform to support and scale trauma-informed programs like ours. Programs seeking to implement trauma-informed approaches should leverage implementation and participatory research to ensure effectiveness and equitable accessibility for patients of diverse identities.