Ask an answerable question (PICO)：
Child abuse is a global issue that not only causes physical harm but also significantly impacts children's mental well-being. Many children experience long-term effects, including a higher propensity for criminal behavior and difficulties in adapting to life. Trauma-informed care (TIC), proposed by clinical psychologists Maxine Harris and Roger Fallot, emphasizes a positive and integrative approach in understanding the role of trauma and its impact on life. TIC comprises four elements: recognizing trauma symptoms, understanding potential trauma experiences, responding using trauma knowledge, and preventing re-victimization. While TIC has been advocated in healthcare, its clinical effectiveness remains inconclusive. This study aims to determine whether trauma-informed care for abused children reduces behavioral problems.
The Method and Analysis of Literature Review：
(Based on the evidence-based approach and the formulation of a PICO question, searches were conducted across databases such as Cochrane Library, PubMed, Embase, CINAHL, PsycINFO, and the airiti Library. The search included MeSH terms and free-text keywords, utilizing Boolean logic for both union and intersection of terms, with language filters for both Chinese and English. Keywords used were: P (Child abuse, Children, Childhood abuse, Domestic violence, Maltreatment, Neglect), I (Trauma-informed care, Trauma informed), C (Standard care), O (Behavioral problem) encompassing anxiety, depression, withdrawal, social problems, cognitive issues, attention problems, etc. A total of 320 articles were initially found, subsequently refined by removing duplicates, titles, abstracts, studies not aligned with the research design, and those not exploring behavioral issues or of low evidence quality, resulting in 2 remaining articles.
Critical Appraisal：
TIC (Trauma-Informed Care) involves four steps: "Awareness/ Understanding of Trauma," "Recognition of Trauma," "Utilizing Trauma Knowledge in Response," and "Preventing Re-traumatization." A systematic review, assessed using the 2018 CASP (Critical Appraisal Skills Programme) Systematic Review Checklist, revealed that implementing TIC effectively reduces post-traumatic stress disorder (SMD = 0.37), behavioral issues (SMD = 0.52), and enhances psychological well-being (SMD = 0.45). A randomized controlled trial, evaluated using the 2020 CASP Randomised Controlled Trial Checklist, demonstrated that TIC effectively reduces behavioral problems (p < .05) and symptoms of post-traumatic stress disorder (p < .05). The combined findings from both articles indicate that the application of TIC can alleviate symptoms of post-traumatic stress disorder, reduce behavioral issues, and improve overall mental health.
Clinical Application of Evidence：
Based on the results, a pilot randomized controlled trial (RCT) is planned to be conducted from December 27, 2021, to June 27, 2022, spanning a duration of six months. The study will take place in the intensive care unit of a medical center in the southern region. Participants will consist of children who have experienced abuse, selected via convenient random sampling, and allocated to either the experimental or control group by random drawing. The intervention for the experimental group will involve trauma-informed care, applying the TIC model's four-step process throughout the entire care procedure, along with a daily 5-minute conversation with the child. Regarding trauma responses, the children will be asked about their current condition, such as "Do you feel anxious right now?" to ascertain their post-traumatic state, provide emotional support, ensure a sense of safety, engage in deep breathing exercises, offer water, relaxation techniques, play games for distraction, and eliminate stressors. The children will be guided in self-identification and redirection, with reassurance that negative emotions will pass, allowing them autonomy to decide whether to leave a situation triggering anxiety. The control group will receive standard care, primarily focusing on symptom management through medication. Both groups will undergo the Child Behavior Checklist (CBCL) assessment on the day of admission and after two weeks to evaluate the improvement in behavioral issues resulting from abuse, using pre- and post-test scores.
Evaluation of Effectiveness：
The pilot randomized controlled trial enrolled a total of 11 participants (7 in the experimental group and 4 in the control group). The study results indicated significant improvements in "anxiety/withdrawal" behavior for the experimental group between pre-test and post-test, with an average decrease of 5.43 points. When comparing the experimental group with the control group, there was a significant reduction in "anxiety/depression" and "anxiety/withdrawal" behaviors in the experimental group, with average decreases of 5.42 ± 0.06 points and 5.43 ± 2.71 points, respectively. These statistical values showed a significant difference (p < .05).
Conclusions and Recommendations：
This study's findings demonstrate that implementing Trauma-Informed Care (TIC) can reduce behavioral issues in children who have experienced abuse. However, due to the limited sample size in this study, it is hoped that future research will increase the sample size to further confirm its effectiveness. The aim is to utilize trauma-informed care interventions in acute clinical settings to improve behavioral issues and symptoms of post-traumatic stress disorder in abused children.
