Trauma encompasses physical and psychological injuries from various incidents. Research indicates that traumatic experiences are prevalent and occur early. Trauma can lead to severe long-term health issues if left unrecognized and untreated. Implementing Trauma-Informed Care (TIC) and Family-Centered Care (FCC) is essential to providing quality health care. TIC focuses on creating a safe, supportive environment to avoid retraumatization and improve outcomes, while FCC involves families in the care process to enhance patient health and satisfaction. Integrating TIC with FCC offers a holistic approach that addresses the needs of patients and their families, aiming to improve the overall quality of care.
Key points
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Trauma-Informed Care creates an environment that avoids retraumatization and improves outcomes.
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Family-Centered Care supports families in the care process and enhances patient health outcomes and overall satisfaction.
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Incorporating Family-Centered Trauma-Informed Care improves patient experiences and quality of care.
Introduction
Trauma refers to physical or psychological injuries sustained due to various incidents or events. It encompasses a wide range of conditions such as accidental injuries, medical trauma, abuse and neglect, emotional abuse, exposure to violence, and traumatic loss. Research consistently shows that traumatic and adverse childhood experiences (ACEs) are prevalent, with 50% of adults reporting at least 1 ACE and 6% experiencing up to 4 ACEs. Approximately 1 in 4 children will face a traumatic event before reaching 16 years of age.
The risk of physical and mental health issues increases with the number of traumatic exposures and can have long-term health problems without treatment. Implementing routine screening for trauma and incorporating trauma-informed practices is increasingly recognized as an essential component to providing quality care in the health care setting. Trauma-Informed Care (TIC) acknowledges the widespread impact of trauma and strives to respond in ways that prevent retraumatization. TIC helps create an environment that improves health outcomes, medical adherence, therapeutic relationships, and provider and staff wellness.
Family-Centered Care (FCC) is a concept that empowers family members in the care and treatment process of a patient. It involves integrating the family members in the clinical decision-making process and care planning due to the recognition of the importance of the patient’s support system to their health and well-being. FCC can help improve patient health outcomes and satisfaction for the patient, family, and care team by offering a holistic and inclusive approach.
Family-Centered Trauma-Informed Care (FC-TIC) offers a holistic and supportive approach to health care by addressing the needs of the patient and their family while being sensitive to past trauma. Integrating TIC with FCC creates a more compassionate, responsive, and effective health care environment that supports both individual patients and their families by addressing a wide range of needs and experiences. The objectives of this article are to illustrate the theoretic frameworks of Trauma-Informed Care and Family-Centered Care and the integration of these models of care to better serve clients and their families. The benefits of this integrated care model will be reviewed and how to apply this framework in a health care setting.
Theoretic framework
Principles of Trauma-Informed Care
According to the Substance Abuse and Mental Health Services Administration, there are 6 key principles that guide TIC. These include as follows:
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Safety;
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Trustworthiness and transparency;
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Peer support;
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Collaboration and mutuality;
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Empowerment, voice, and choice;
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Cultural, historical, and gender issues.
Safety refers to patients and families feeling physically, psychologically, and emotionally safe. Survivors of abuse have experienced a breach of trust and ensuring that patients feel safe aids in the development of a trusting relationship between the provider, the patient, and their family. Providers can maintain trust and transparency with trauma survivors by practicing integrity and accountability. Providers can ensure that the clinic structure and policies are clearly defined for patients and families. Peer support and self-help encourages patients to share their stories with peers, other survivors, or family members to promote healing. As patients have experienced relational trauma, sharing their experiences with others can help them build trust and feel safe. Collaboration and mutuality refer to the partnership with patients and their families. This involves leveling of power differentials and recognizing that everyone has an important role. Patients should have a choice in their goals and care plans and should be treated as the expert in their own lived experiences. Empowerment, voice, and choice complement the principles of collaboration and mutuality. It is imperative that recovery involves choices for patients and their families so that they can regain some of the power that has been lost through trauma. Finally, attending to cultural, historical, and gender issues ensures that providers are considering the multifaceted needs of the individual and family. Providers should acknowledge and move past stereotypes and biases to provide culturally competent and inclusive care.
Principles of Family-Centered Care
Family-Centered Care (FCC) defines the mutually beneficial partnership between a patient, their family, and the health care provider. The core principles of FCC include respect and dignity, information sharing, participation, and collaboration. Respect and dignity refer to respecting a patient and family’s choices, perspectives, and knowledge. This includes honoring racial, ethnic, and socioeconomic backgrounds and religious or spiritual beliefs. Providers should maintain a mutual respect for the family’s preferences and incorporate these into the plan and delivery of health care. Information sharing describes open and objective communication that is both complete and unbiased. It includes the free flow and accessibility of information that considers health literacy and cultural and linguistic diversity. Participation encourages patients and families to be engaged in decision-making and care as much as they desire. This should be an individual approach for each child that can change as they grow. Collaboration refers to patients and families being included on an institution-wide basis for program development and education. Families should be engaged at all levels of care beyond the patient encounter, including institution and policy settings. This can include serving on advisory councils, committees, or task forces.
Integration of Trauma-Informed Care and Family-Centered Care
Integrating TIC with FCC enhances the quality of care for patients and their families. The principles of TIC and FCC are complementary and have overlapping principles, including highlighting the importance of transparency with information sharing, encouraging patient and family participation in care, providing families with autonomy and choice, and practicing cultural competence ( Fig. 1 ). TIC can support and strengthen FCC principles and brings a distinct focus on the awareness of traumatic stress. It provides a central role for involving families and promoting family strengths.
Application of family-centered trauma-informed care
Assessment and Screening
Trauma-informed screening can be integrated into practice to identify patients and families needing more support and resources. Screening tools should be brief, focused, and aimed to identify children who have experienced traumatic events and have symptoms related to their trauma. There are different types of trauma screening tools including child-completed, caregiver-completed, and provider-completed. To honor the TIC principle of trustworthiness and transparency, providers and practices should be clear about both the purpose of the screening and about results and next steps.
There are several validated screening tools to evaluate traumatic stress symptoms in children or to identify psychosocial problems in families. The Acute Stress Checklist for Children can be child or provider-completed. It includes a brief version with 3 to 6 questions (1–2 minutes) or a full version with 29 items (5–10 minutes). It is available in both English and Spanish. The Child Trauma Screening Questionnaire is a 10-item screening tool that aims to predict children at risk of developing Post Traumatic Stress Disorder symptoms after an accidental injury. It can be child or provider-completed and takes 2 to 3 minutes to complete. The Acute Stress Disorder Scale is a 19-item child-reported checklist designed for older teens or adults. It assesses acute stress disorder and predicts PTSD. The Child Stress Disorders Checklist includes a 35-item checklist or a 4-item short form that can be parent or provider-completed. It assesses acute stress or PTSD symptoms. The Safe Environment for Every Kid parent questionnaire screens for targeted psychosocial problems including parental depression, parental substance use, major parental stress, intimate partner violence, food insecurity, and harsh punishment. It is available in several languages. The Psychosocial Assessment Tool is a parent-reported screen for psychosocial risk. There are many other validated screening tools, including tools that target specific populations such as trafficking victims. Healthcaretoolbox.org and the National Child Traumatic Stress Network list many available screening tools, some of which are described in article—Screening Children for Adverse and Positive Childhood Experiences in Primary Care.
Creating a Safe and Supportive Environment
Safety is an important principle of TIC, and simple changes to a health care organization’s environment can help people with histories of trauma feel safe. This includes changes to both the physical and social-emotional environments. Physical changes include optimizing the waiting area by choosing warm colors and including artwork that represents the diverse population served by the clinic. The waiting area should be kept as quiet as possible, and should include soft, soothing music. All patient areas should be clearly labeled and well-lit. Dedicated security guards or cameras can provide an additional layer of safety. Clinics can include private waiting areas for individuals who might not feel safe sitting with others. Finally, all patient areas should include information both about patient rights and trauma resources.
Creating a safe social and emotional environment ensures that patients feel safe in all interpersonal interactions. There are many ways that we can make patients feel safe in their medical encounters, including training all providers and staff on how to effectively communicate with and greet patients. Giving patients choices when appropriate can help them feel empowered, which promotes safety. Patients should be made aware of all clinic policies, including expectations regarding communication with clinic staff or providers after-hours. Medical or screening forms can be sent to patients before the visit or patients can be provided with a private area when filling out sensitive forms to help promote safety.
Engaging Families in the Care Process
Children receive care and support primarily from their families, so engaging families in decision-making and treatment planning is imperative. In addition, families often provide perspectives regarding the experienced trauma, and their engagement increases the likelihood of positive outcomes for the child. Families should be included both on the individual or patient level and on a large-scale institution or systemic level. The TIC principles of collaboration and mutuality and empowerment, voice, and choice are the key to including families into a child’s care.
Providers should ask about the strengths a family already has to help build on their already present attributes. Starting with something positive can help empower children and families in their treatment. Health care systems can additionally screen family members for their own traumatic events and provide resources for them to obtain their own dedicated care. Trauma-informed practices can integrate medical, behavioral, and social services to optimize care for families. A thorough psychosocial evaluation can be completed to identify barriers to family engagement, and resources provided to mitigate these barriers. Care plans should be discussed in detail, and providers should offer choices to the family as appropriate to ensure the family’s engagement. Health care facilities should train all staff members, both nonclinicians and clinicians, in trauma-informed care. This ensures that families are receiving a minimum standard of treatment and that they can expect consistency at each touchpoint of the health care system.
Addressing Cultural and Historical Contexts
A key component to engaging families and promoting safety is addressing cultural and historical contexts. In order to provide effective TIC, providers must pay attention to all of the different factors that influence a child and family’s beliefs and perceptions related to their health care. These factors include race and ethnicity, religion and faith, socioeconomic status, education and literacy level, sexual orientation and gender identity, and region of residence. Providers should ask about preferences for communication and decision-making and respect those preferences to build trust with families. As possible, incorporating a family’s ideas and values regarding healing and treatment can increase the buy-in and success of a plan. Listening, being open, and respecting a family’s unique experiences and beliefs are integral to the success of TIC.
Benefits to family-centered trauma-informed care
Improved Outcomes for Families
There are many benefits to family-centered trauma-informed care (FC-TIC), such as improved child welfare outcomes, psychological support, generational healing, and cultural responsiveness. Research has shown that FC-TIC establishes reliable, collaborative connections between children and the trusted adults involved in their lives. By doing so, FC-TIC enhances communication among families and alleviates the effects of adversity, making children more resilient. Regarding children in out-of-home care, FC-TIC initiatives encourage reducing the use of restraints and seclusion, thereby decreasing patient injury rates and reducing symptoms of posttraumatic stress, depression, and anxiety.
Enhanced Provider-Patient Relationships
Agencies that incorporate TIC observe decreased use of crisis services or residential treatment centers, decreased necessity for psychotropic medications, decreased foster care placements, and in general improved functioning and well-being of the child. A health care professional who practices TIC is less likely to walk into an unintentionally triggering situation as they are familiarized with the history of trauma, either by the patient or the family. Recognizing and healing one generation’s trauma ultimately leads to improved health and mental health outcomes for future generations. TIC focuses on how an individual may respond to trauma based on their previous life experiences, accounting for their physical, social, and cultural environments. By practicing respect for the patient’s cultural differences, one can adequately address the mental health necessities of a larger population in a culturally diverse society.
Systemic Benefits
Trauma-informed care has been shown to reduce burnout and increase job satisfaction by fostering resilience and creating a supportive work environment. TIC emphasizes safety, trust, and collaboration, which prevents retraumatization and promotes provider well-being. Implementing TIC can lead to decreased compassion fatigue, as seen in studies where staff reported improved empathy and camaraderie after TIC training. Organizations that adopt trauma-informed practices often experience reduced stress, increased productivity, and less burnout, contributing to a more engaged and fulfilled workforce. Specifically, family-centered TIC improves service delivery by fostering a respectful and inclusive environment that acknowledges the unique experiences and needs of families affected by trauma. This approach enhances trust and engagement between service providers and families, ultimately leading to better outcomes. It ensures that services are tailored to support the healing and resilience of the individual. By integrating trauma awareness into organizational practices, service delivery becomes more effective, reducing the risk of retraumatization and improving the overall well-being of both families and service providers.
Challenges and barriers
Organizational and Systemic Challenges
There are challenges and limitations to providing family-centered trauma-informed care that are worth mentioning. Resource constraints such as time, administrative, and financial limitations often hinder the ability to implement trauma-informed practices. There is a lack of dedicated funding and billing codes for these types of services. Additionally, providers may face challenges accessing training and resources necessary for effective implementation.
Organizations often struggle with integrating TIC into existing systems due to a lack of evidence-based guidelines and assessment metrics to practice implementation which can limit the availability and quality of services provided to families. There is also the challenge of ongoing training to ensure providers are equipped with the necessary skills and knowledge to deliver trauma-informed care effectively. Training programs, like those for family medicine residents, have shown that focused skills training can improve trauma-informed interactions and knowledge. Still, these programs require significant time and resources to implement.
Transforming complex systems into a family-centered, trauma-informed model necessitates both cultural and programmatic shifts grounded in building strong family partnerships and can be challenging due to several barriers that have been illustrated in Virginia’s juvenile justice system. Some noteworthy challenges include as follows:
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Resistance to change due to existing culture norms, given the punitive nature of the juvenile justice system.
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Systemic issues due to imbalance of power and resources causing difficulty navigating the complex justice system for families.
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Cultural competency deficiencies with inadequate sensitivity and understanding of diverse backgrounds that hinder engagement with families—that is, narrow definitions of family (parent, guardian, and caregiver) can limit and hinder the support system of an individual.
Family-Level Challenges
Family readiness and engagement are crucial for effective family-centered trauma-informed care. When families are actively engaged, they provide valuable insights and participate in decision-making, which enhances the care process. Engaged families help create a supportive environment that acknowledges trauma and its effects, fostering resilience and healing. The challenge of lack of family engagement in providing family-centered trauma-informed care can significantly hinder the effectiveness of such care. Without active family involvement, it becomes difficult to build trust, share critical information, and create a supportive environment that acknowledges and addresses trauma. Engaging families helps in understanding their unique cultural and historical contexts, which is crucial for effective trauma-informed practices. Programs must respect and integrate each family’s cultures, languages, and structures, ensuring inclusivity and sensitivity to cultural, historical, and gender issues. Recognizing and responding to the intersections of trauma with culture, race, and language is crucial for equitable support.
Solutions and strategies
To overcome barriers to family-centered trauma-informed care, several strategies can be recommended implementing systemic approaches that integrate trauma awareness into organizational culture, practices, and policies. This includes leadership engagement, adequate resources, and flexible protocols. Providing accessible training for staff enhances their understanding of trauma and its impacts, allowing them to develop skills to engage with families effectively. Development of practice guidelines and performance measures can further help organizations in integrating TIC and FCC as seen in a recent study done in pediatric resuscitation that proposed a framework with 6 domains and a 71-item check list of observable behaviors that integrate both approaches. Fostering cross-sector partnerships and engaging families in decision-making processes to align best practices and policies, and additionally utilizing virtual platforms for delivering trauma-informed care, especially for families facing barriers to in-person services.
One example of the successful integration of family-focused trauma-informed care is the FOCUS-EC (Families OverComing Under Stress – Early Childhood) program. This program, designed for military-connected families with young children, uses a trauma-informed, family-centered approach to enhance family resilience, parenting, and psychological well-being. Delivered via virtual home visits, FOCUS-EC provides personalized psychoeducation, parenting guidance, and resilience skills development. It has shown positive outcomes in reducing parental psychological symptoms and improving parent-child relationships, demonstrating the effectiveness of adapting trauma-informed care for remote delivery.
The pediatric heart transplant program at the University of California Los Angeles used an adapted version of the evidence-based FOCUS model to electronically screen their patients and families in real-time during their outpatient clinic appointments. A FOCUS web-based consultation was provided to families that included psychoeducation and resiliency skills training, such as emotion regulation, communication, problem-solving, goal setting, and managing trauma/stress if deemed necessary by the screen. Additional follow-up and referrals were provided at subsequent clinic visits. This program demonstrated how to incorporate a personalized, family-centered behavioral health plan in a busy outpatient pediatric clinic setting.
The National Child Traumatic Stress Network illustrated how the overlapping principles of trauma-informed care and family engagement were used in the juvenile justice system in the state of Virginia to address challenges identified in Table 1 . They recommend recruiting culturally competent team members and offering training that fosters a culture of respect and collaboration with families. Additionally, implementing a peer support model can empower family members to take on leadership roles, aiding others in navigating complex systems. Engaging families at all levels of the organization, including in policy development and decision-making, can help address power imbalances and reduce disparities.
