Content uploaded by Lenora Marcellus
Author content
All content in this area was uploaded by Lenora Marcellus on Aug 20, 2015
Content may be subject to copyright.
A preview of the PDF is not available
Supporting Women with Substance Use Issues: Trauma-Informed Care as a Foundation for Practice in the NICU
Abstract and Figures
Infants with neonatal abstinence syndrome and their mothers require extended support through health and social service systems. Practitioners are interested in exploring innovative approaches to caring for infants and mothers. There is now compelling evidence linking women's substance
use to experiences of trauma and violence. A significant shift in the fields of addiction and mental health has been awareness of the impact of trauma and violence on infants and children, women, their families, and communities. In this article, the current state of knowledge of trauma-informed
care is reviewed, in particular for application to practice within the NICU. Trauma survivors are at risk of being retraumatized because of health care providers' limited understanding of how to work effectively with them. Recognizing the impact of trauma and implementing evidence-based trauma-informed
practices in the NICU holds promise for improving outcomes for women and their infants.
Figures - uploaded by Lenora Marcellus
Author content
All figure content in this area was uploaded by Lenora Marcellus
Content may be subject to copyright.
... To that end, the START model screens all individuals for trauma exposure and refers them to trauma-informed services. This is in line with best practices indicating trauma informed approaches in addiction treatment for improved treatment effectiveness (Savage et al., 2007) and with respect to youth, a way to interrupt the intergenerational nature of trauma exposure and substance misuse (Marcellus, 2014). Moreover, because older siblings influence substance misuse in younger siblings (Kim et al., 2007;Low et al., 2012), older youth may be able to influence substance misuse initiation in younger siblings. ...
... Medical literature on trauma-informed care in the NICU initially focused on its provision to NICU mothers and their infants in the setting of maternal substance use disorder and subsequent neonatal abstinence syndrome [60], given the link between maternal substance use disorder and trauma [61]. More recently, trauma-informed care was adapted to the needs of NICU families in general [44]. ...
Existing NICU family centered care models lack the key elements of equity, inclusion and cultural humility. These models were conceived to support families during the stressful life event of an infant's NICU admission. Their development, however, occurred prior to recognition of the medical field's systematic shortcomings in providing equitable care and their impact on outcome disparities for marginalized communities; thus, they do not include cultural or equitable healthcare considerations. Given the significant neonatal care inequities for marginalized groups, incorporating the experience of these patients in a targeted manner into family centered care frameworks is of critical importance to ensure culturally humble and thus more just and equitable treatment. Here, we review past approaches to NICU family centered care and propose a novel, updated framework which integrates culturally humble care into the NICU family centered care framework.
... Our relationship to substances is impacted by the environment in which we live, love, and work (Gage & Sumnall, 2019), as well as experiences of trauma (Marcellus, 2014). Cycles of trauma can be interrupted by access to the social determinants of health. ...
Harm reduction is a framework built upon respect for people who use drugs. Pregnancy is a priceless window of opportunity for positive change, when parents are driven to improve their health and well-being for their future child, and harm reduction can provide direction for this motivation. Perinatal harm reduction can include goals of abstinence, decreased use, safer use, or a goal unrelated to substance use, such as obtaining housing or employment. We engage in harm reduction, not only by promoting beneficial practices, but by eliminating harmful ones. Despite the science, effective program models, and overwhelming agreement that substance use disorder is a health condition and not deviant behavior, harm reduction programs for pregnant and parenting people are rare, and punitive treatment is the norm. To achieve equitable treatment for people with perinatal substance use disorder and protect the parent-infant dyad, we must stop harmful practices, respect the autonomy of people who use drugs, and address substance use disorders while increasing access to the social determinants of health.
... Trauma and Adverse Childhood Experiences (ACEs) are consistently linked to the opioid epidemic and the negative impact of opiate misuse (Marcellus, 2014;Toler, 2019). Trauma-informed care (TIC) is an accepted, established, and federally recognized response to the effects of opioids on individuals directly and indirectly impacted by misuse (Bowen & Irish, 2020;Lowery & Hess, 2022;Rishel et al., 2019). ...
In this qualitative study, we examined how school leaders in rural Appalachia improvise to foster and maintain external relationships with partners and community supports to address the effects of opioids. Data was collected through semi-structured interviews of 27 public school leaders (superintendents, principals, and assistant principals) in schools throughout the region of Appalachian Ohio, focusing on schools in counties that were identified as high rates of opioid-related incidents. Participants expressed a need for access to external partners and increased professional development to address issues relating to the opioid crisis. They experienced frustrations of unpreparedness and a sense of being overwhelmed and under-resourced. Nonetheless, findings indicate that both building and district leaders engage in bricolage when making decisions and mobilizing resources. Often this implies leveraging external support for the wellbeing of all stakeholders to create stable educational environments for their students that have been negatively impacted by opioid.
... Recognizing that psychological trauma and adverse childhood experiences are highly correlated with the initiation of opioid use and drug injection and relapse (Merrick et al., 2020;Taplin et al., 2014), researchers have assessed the utility of trauma-informed practice (TIP) in addressing the health of PWUD (Fatkin et al., 2021;Kurtz et al., 2019;López-Castro et al., 2015;Marcellus, 2014;Morgan et al., 2020;Sperlich et al., 2021). TIP is most centrally a calibration of foundational biomedical ideas associated with the theory of dysgenics (i.e., that "undesirable" traits, such as drug use, are biologically transmitted across generations) and that a supposed natural predilection is most associated with drug use initiation. ...
Strengths-based theory, a pillar of clinical social work practice, emphasizes the importance of recognizing the inherent
and learned skills and abilities that people possess and can leverage toward self-actualization and wellness. However,
strengths-based approaches are under-investigated in the field of drug use management and treatment, foreclosing a richer
view into how to better understand, engage, and support people who nonmedically use drugs (PWUD) through practice
and research. Focusing on interventions conducted with PWUD, we conducted a systematic literature review to identify,
classify, and characterize existing strengths-based paradigms and approaches to drug use management and treatment.
Using these findings, we formulate and describe a holistic conceptual model for advancing training, practice, and research
in this space. The following domains emerged and were contextualized for their strengths-based dimensions: (1) Harm
Reduction Services; (2) Strengths-Based Case Management; (3) Trauma-Informed Practice; and (4) Collectivist Racial,
Ethnic, Gender, Sexual, and Intersectional Identity-Focused Interventions. These bodies of literature showed limited connectivity
as a comprehensive clinical modality, which we proposed to address through the Integrated Strengths-Based
Engagement Framework (ISBEF). To this end, a complex array of strengths-based paradigms have been developed and
implemented to support the well-being of PWUD. However, there is a need for more rigorous and uniform approaches
for the implementation and measurement of strengths-based approaches, particularly in work with racial, ethnic, gender,
and sexual minority populations, which the ISBEF provides a structure for.
Background: Chronic physical conditions (CPC) and alcohol and substance use disorders (SUD) frequently co-occur, but this has not been examined perinatally. We explored the combined effects of CPC and prepregnancy SUD on perinatal SUD-related adverse events and outpatient care. Materials and methods: This population-based study comprised 77,474 people with and 664,751 without CPC with a birth in Ontario, Canada, 2013-2020. We measured the prevalence of prepregnancy SUD in both groups. We then calculated adjusted relative risks (aRR) of: (1) SUD-related adverse events (toxicity resulting in acute care use/death, or other SUD-related acute care use) and (2) outpatient care for SUD between conception and 365 days postpartum, comparing individuals with prepregnancy CPC and SUD (CPC + SUD), and those with CPC or SUD alone, to those with neither condition. Finally, adjusted relative excess risk due to interaction (aRERI) was calculated to quantify excess risk of the outcomes associated with CPC + SUD, wherein RERI > 0 indicated positive interaction. Results: aRRs of perinatal SUD-related adverse events were 26.79 (95% confidence interval [CI]: 23.12, 31.04) for people with CPC + SUD, 22.09 (95% CI: 19.59, 24.91) for SUD alone, and 2.01 (95% CI: 1.78, 2.27) for CPC alone-each relative to neither condition. There was evidence of positive interaction for CPC + SUD (aRERI: 3.69, 95% CI: 1.13, 6.46). Similar elevated aRRs were observed for perinatal outpatient care for SUD, but without a positive interaction for people with CPC + SUD. Conclusion: As people with both CPC and SUD have the highest risk of perinatal SUD-related adversity, they may need greater preconception and perinatal support.
Objective: Trauma-informed care (TIC) is an innovative concept that recognizes the lasting impact of psychological trauma. Critical care nurses’ attitude toward TIC plays an essential role in assessing, monitoring, and addressing trauma experienced by patients. This study aimed to describe critical care nurses’ attitudes toward TIC in critical care units at Jordanian military hospitals. Methods: This descriptive-analytical cross-sectional study was performed on 315 critical care nurses at seven military hospitals (two from the north, three from the center, and two from the south) in 2022. The data collection tool was the Attitudes Related to Trauma-Informed Care-35 (ARTIC-35) scale. Multi-stage sampling approach was used to recruit critical care nurses. Statistical Package for Social Science (IBM-SPSS) V. 23 was used to analyze data. Results: In the sample of 315 nurses, gender was significantly associated with the reactions subscale (P=0.001). Also, there were statistical differences between nurses working in the emergency department and those working in intensive care units regarding the responses and behaviors subscales, with emergency department nurses scoring higher on the scale (P=0.003). Regarding in-service training in trauma-related care, the causes subscale was significantly different based on the number of training sessions with higher scores among nurses with higher training (P=0.02). Conclusion: Critical care nurses had an unfavorable attitude toward TIC. Health organizations, nurse managers, universities, and other stakeholders should collaborate to achieve a national strategy to raise awareness about TIC. Much research is needed to explore nurses’ attitudes toward TIC in diverse health sectors.
Historically, public and political discourse around people who nonmedically use opioids has largely been rendered via a deficits-oriented lens, presenting this population as weak, disinterested, and deviant, and thus undesirable and ill-positioned for wellness and communal integration. These narratives, and subsequent policies used to engage people who use opioids, are intermittently formed and disrupted by geopolitical changes, as public and institutional attitudes, often driven by racial and class-related considerations, shift. As part of what we term the crimedical cycle, a population’s behaviors fluctuate between periods of medicalization and criminalization. Strengths-based theory, an offshoot of positive psychology’ that helps contextualize the crimedical cycle, emphasizes the value of recognizing and affirming the inherent and learned skills that individuals possess and can leverage toward self-actualization. A strengths-based orientation and approach to clinical praxis is particularly critical in improving the health and well-being of populations, namely those who nonmedically use opioids, that are highly criminalized and disenfranchized through social and public policy. However, strengths-based theory is underdeveloped in addiction medicine, despite it having deep roots in the treatment field. This ongoing omission engenders narratives around opioid use that congeal to propel the stigmatization,over-policing, economic marginalization, and poor health of those who use opioids. This article discusses the historical trajectory of views and attitudes on opioid use and presents a model that advances strengths-based approaches to engaging this population.
Systematic uptake of family-centered care (FCC) interventions remains challenging and frequently suboptimal in many neonatal intensive care units (NICUs). Across NICUs in the United States, integrating family members as partners in infant caregiving and decision-making has not been well supported and routine screening and provision of psychological support for parents remains inadequate. Trauma-informed care (TIC) may offer a more comprehensive approach to NICU care which can encompass FCC principles and promote family recovery and resilience by recognizing and responding to the traumas experienced by NICU infants and families. The current paper aimed to understand needs identified by mothers of NICU-hospitalized children and reports a focused analysis of one-on-one interview data (n = 13 mothers) collected during a larger mixed methods study. Reflexive thematic analysis was used to understand needs identified by mothers and to explore how these needs aligned with TIC principles. Six themes were identified and subsequently examined in the context of the principles of TIC: I Just Had No Control, That Really Caught Us Off Guard, So Much Was Already Taken Away, We're People and There Needs To Be More Support and Practices Which Helped. Mothers' care needs were found to align with TIC principles. Findings suggest that implementation of TIC principles in NICU settings can support parental presence, participation in infant care, and mental health and support the potential of TIC as a more comprehensive approach to meeting the needs of NICU parents.
Since the 1990s, many communities in Canada have worked to develop specialized programs to meet the needs of pregnant and early parenting women who use alcohol and other substances. These programs provide a range of services under one roof (a “single-access” or “one-stop shop” model), address women’s needs from a holistic perspective, provide practical and emotional support, and strive to reduce barriers to accessing care and support. Over the years, these programs have trialed new approaches to working with indigenous and non-indigenous women, their families, and their communities. In this paper, we describe the development of single-access programs in four different communities in Canada, discuss some of the elements of what makes these programs successful, and share our "lessons learned" over the years. We use examples from four different programs, including the Maxxine Wright Place Project in Surrey, BC; the Healthy, Empowered, Resilient (H.E.R) Pregnancy Program in Edmonton, AB; HerWay Home in Victoria, BC; and Manito Ikwe Kagiikwe in Winnipeg, MB. All four programs are based upon the "best practices" elements of: (1) engagement and outreach, (2) harm reduction, (3) cultural safety (4) supporting mother and child, and (5) partnerships. In addition to serving First Nations, Métis, Inuit and other indigenous women and their families, these programs have drawn upon indigenous knowledge in their program design, values, and philosophy and have collaborated with indigenous women in evaluation and research to track the successes of these programs and to improve service delivery.
Trauma: Contemporary Directions in Theory, Practice, and Research is a comprehensive text on trauma, including such phenomena as sexual abuse, childhood trauma, PTSD, terrorism, natural disasters, cultural trauma, school shootings, and combat trauma. Addressing multiple theoretical systems and how each system conceptualizes trauma, the book offers valuable information about therapeutic process dimensions and the use of specialized methods and clinical techniques in trauma work, with an emphasis on how trauma treatment may affect the clinician. Intended for courses in clinical practice and psychopathology, the book may also be useful as a graduate-level text in the allied mental health professions.
Postpartum depression has become a more recognized mental illness over the past decade as a result of education and increased awareness. Traumatic childbirth, however, is still often overlooked, resulting in a scarcity of information for health professionals. This is in spite of up to 34% of new mothers reporting experiencing a traumatic childbirth and prevalence rates rising for high risk mothers, such as those who experience stillbirth or who had very low birth weight infants.
Description
This innovative text for Neonatal Nurses and NICU clinicians introduces new, evidence-based care protocols proven to mitigate or reduce the profound morbidities and subsequent developmental challenges that afflict newborns in the NICU. The book reframes the concept of developmentally supportive care to trauma-informed, age-appropriate care of the hospitalized premature infant. Aimed at transforming NICU practice, the book links developmental care to quality standards and Joint Commission requirements. The text is also unique in its provision of engaging online learning activities that facilitate the translation of content into clinical practice, whereby the user can also earn CEUs.
The text highlights the ways in which Nightingale's tenets of nursing and Watson's theory of human caring science resonate with the its subject matter and are applied in the NICU. It includes examples of favorable outcomes associated with the protocols described in this book from practitioners in the U.S. and overseas. Additionally, the text aligns with NANN guidelines for Age Appropriate Care of the Premature and Hospitalized Infant. This book will provide the neonatal nurse/APN with best available, evidence-based caring strategies to consistently and reliably manage the trauma associated with the NICU experience and mitigate both short-term and long-term complications associated with this developmental trauma.
Key Features:
Introduces cutting-edge, evidence-based care protocols proven to reduce the profound morbidities and developmental challenges of premature infants
Reframes the concept of developmentally supportive care to trauma-informed, age-appropriate care
Meets Joint Commission requirements for age-appropriate staff education
Includes examples from researchers and practitioners worldwide
Presents innovative online learning activities to facilitate translation of content to clinical practice
The battered-child syndrome, a clinical condition in young children who have received serious physical abuse, is a frequent cause of permanent injury or death. The syndrome should be considered in any child exhibiting evidence of fracture of any bone, subdural hematoma, failure to thrive, soft tissue swellings or skin bruising, in any child who dies suddenly, or where the degree and type of injury is at variance with the history given regarding the occurrence of the trauma. Psychiatric factors are probably of prime importance in the pathogenesis of the disorder, but knowledge of these factors is limited. Physicians have a duty and responsibility to the child to require a full evaluation of the problem and to guarantee that no expected repetition of trauma will be permitted to occur.
There is evidence to suggest that having one's baby in the neonatal intensive care unit (NICU) may cause post traumatic stress disorder (PTSD). PTSD is defined in the Diagnostic Statistical Manual IV (DSM IV) as state in which having been exposed to a traumatic event, the victim persistently re-experiences the traumatic event (intrusive recollections, dreams, intense psychological/ physiological distress to cues that symbolize event). As a result the victim avoids the stimuli associated with trauma and has increased arousal (ex hyper vigilance, exaggerated startle, insomnia, outburst of anger) The disturbance needs to last greater than 1 month and cause significant distress and/ or impairment in social, occupational, or other important areas of functioning A hospitalization, especially an unexpected hospitalization can be seen as a traumatic event due to threat of death, disability, disfigurement There are several potential consequences to parental PTSD including marital discord and behavioral problems in children (Peebles-Kleiger, 2000) It is important to explore methods of mitigating parental stress It is also important to recognize that fathers and marginalized populations may cope differently It was found that the highest distress was seen in the lowest educational level, (Holditch-Davis, et al, 2009). Staff is also vulnerable to PTSD due to prolonged exposure to grotesque sights, length of time in crisis and emotional identification with patients (similar in age, gender, temperament with one's own child) In summary, PTSD does occur in the NICU environment and may have long term negative consequences.