Trauma is a substantial threat to public health. As such, significant effort has been exerted into developing interventions which mitigate the consequences of trauma. Trauma-informed practice (TIP) aims to alleviate the effects of trauma by building policies and practices focused on safety, trust, transparency, support, collaboration, and empowerment. This study investigated how individual-level factors, including readiness for organizational change, perceived benefit of TIP training, and personal trauma history affect one’s ability to apply a TIP lens in a sample (n =100) of members of a graduate-level college. Further, it explored if one’s perceptions of and response to trauma-informed practice training predict changes in well-being, stress, and burnout. Results indicated that perceived benefit and readiness for organizational change are important predictors of post-training outcomes. Participants with a history of trauma performed more poorly on post-training trauma-informed knowledge questions. Results provided initial utility for use of objective measurement of trauma-informed application abilities.

Although previous research identified exposure to significant adverse childhood experiences (ACEs) as harmful to individuals in several psychological and physiological health domains, research examining the mechanisms of action driving this relationship has been lacking. As a result, the current study examined the role that psychological symptoms serve in the relationship between ACEs and substance misuse behaviors. The current study included a sample of 183 participants (i.e., 82 men and 101 women) who completed five questionnaires assessing exposure to ACEs; psychological symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD); and substance misuse behaviors. Correlational analyses indicated significant associations among the variables of interest. Exposure to ACEs was a significant predictor of substance misuse behaviors in both men and women. Additionally, depressive symptoms, anxiety symptoms, and PTSD symptoms were significant predictors of men's substance misuse behaviors, whereas only PTSD symptoms were a significant predictor of women's substance misuse behaviors. Symptoms of depression, anxiety, and PTSD each contributed unique and significant variance to the relationship between ACEs and substance misuse behaviors in men, consistent with partial mediations. A different pattern of prediction was evident for women. Such findings suggested that psychological symptoms of depression, anxiety, and PTSD may serve as a risk factor for substance misuse behaviors in men later in life, especially when they have had a history of ACEs. These results demonstrated the importance of promoting trauma-informed mental health care to remediate negative substance outcomes, particularly in those who have had significant ACEs. The importance of studying the relationships among these variables is discussed further.

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Research has shown that there are a number of risk factors that increase the odds of youth joining gangs, from individual- to family- to neighborhood-level risks. Studies have identified child abuse and other childhood traumatic experiences as influences on gang membership. Adverse childhood experiences (ACEs) provide a framework for how to measure and identify these traumatic events. This dissertation study uses longitudinal data from the Pittsburgh Youth Study (PYS) to inform the relationship between early life events and later gang membership. First, the count of total ACEs experienced by gang involved youth were compared to nongang youth. Then, latent class analysis was used to create groupings of ACEs to determine if particular classes of adverse events are associated with higher odds of gang membership during later adolescence. Using the longitudinal data structure of the PYS, additional latent classes were developed when breaking up the adversity into separate age ranges. ACE categories for the youngest cohort were able to be divided into early school entry (elementary school), early adolescence (middle school), and later adolescence (high school) due to their earlier age of first survey, and then these age-graded categories were added into the latent class model to determine if age specific adversity increased odds of gang membership. Lastly, covariates were added into the model to test if time-stable elements increased odds of belonging to one of the classes identified in the initial latent class analysis. The methods described above produced results, showing that gang involved youth have significantly more childhood adversity than nongang involved youth on average. When the latent class analysis was conducted, a three-class solution was found to be the most appropriate model, with classes with higher odds of adversity leading to greater odds of gang membership. There was no significant difference between two classes that had higher odds of adversity, though both included high rates of community violence experiences and parental separation. There were mixed findings on the impact of age specific adversity. Lastly, covariates were added into the model finding early school achievement plays a large role in predicting class membership, while familial financial strain does not. The findings from this dissertation have important implications for policy and practice around gang prevention and intervention in that they can help pinpoint constellations of risk factors. Evidence-based school intervention programs, such as The Fourth R-- an in-school intervention designed to reduce delinquency through positive relationship building with teachers, parents, and pro-social peers (Crooks et al., 2011)-- are important for reducing the odds of experiencing higher odds of adversity. Additionally, programs that work with youth who experience adversity can help reduce the hurt they perpetrate on others. / Criminal Justice

The aim of this arts-based research study was to experience, analyze, and gain insight into songs written by adolescents who have had adverse childhood experiences and who identify with Hip Hop culture. This study investigated the aesthetic components of eleven songs including their musical elements, the compositional techniques, the affective-intuitive qualities, and the interaction between the music and the lyrics. An arts-based research design, rooted in the ethos of Hip Hop, was employed to gain a holistic understanding of the songs. My artistic encounters and subsequent analyses of the songs revealed the complex inner struggles and developmental challenges for adolescents who have experienced extreme trauma. Three groupings of songs emerged: Songs that Protect Vulnerability, Songs of Abandonment, and Songs of Faith and Love. Each category reflects a different stage of developmental growth for the songwriters. Employing Fowler's (1981/1995) stages of faith development, a music-centered developmental model of therapeutic songwriting with adolescents is proposed in this study. This model consists of three therapeutic songwriting stages: Imitation, Developing Self-Reflection, and Developing Self-Love. The implications for this study include developing an arts-based method of song analysis for students and professionals, developing a music-centered therapeutic songwriting assessment, developing a perspective for music therapy practice and research rooted in the ethos of Hip Hop, and developing longitudinal arts-based research studies that track the life of songs across various stages of developmental growth. / Music Therapy

Introduction: Factors contributing to the HIV continuum of care (HCC) for adults in Tennessee (TN) have not been studied in depth with known predictors for HIV risk, specifically adverse childhood experiences (ACEs), among low annual income or sexual minority groups [lesbian, gay, bisexual, or transgender (LGBT)]. Methods: A mixed methods study design was used to assess factors related to the HCC. Quantitative analysis used the TN Behavioral Risk Factor Surveillance System data to examine at risk and ever tested for HIV, to (1) investigate ACEs among adults with low-income (<$25,000 annually) in 2016-2017 and (2) among LGBT in 2018. Descriptive statistics and multiple logistic regression (MLR) analysis stratified by TN grand division were performed. Qualitative analysis included 11 interviews with persons living with HIV (PLWH) receiving care at a local clinic to evaluate surveillance questions related to ACEs and the HCC to develop a culturally appropriate survey. Results: Quantitative results found that among LGBT (N=262) and low-income (N=3258) adults living in TN, the proportion at risk for HIV and ever tested for HIV was highest in East TN (LGBT at risk – 45.53%; LGBT ever tested for HIV – 58.32%; low-income at risk – 8.14%; low-income ever tested – 52.05%). Among adults with low-income, MLR revealed 1-3 ACEs decreased the odds of HIV risk in East (aOR: aOR: 0.54, 95% CI: 0.52-0.56) whereas 4+ ACEs increased odds of being at risk in Middle TN by 32 times (aOR: 31.86, 95% CI: 29.83-34.02) compared to adults with no ACEs. Among LGBT, MLR estimated odds of HIV testing were 33 times higher among adults in West TN at risk for HIV compared to those not at risk (West TN, aOR: 33.59; 95% CI: 31.97-35.96). Qualitative analysis results provided a 55-question survey related to ACEs, HIV transmission risk, and barriers to HIV care. Discussion: Regional differences were revealed among LGBT and low-income populations; low-income and ACEs were associated with being at risk and ever tested for HIV. ACEs and HCC surveillance were considered relevant by PLWH at the clinic. Additional research including piloting the survey and longitudinal studies are necessary to improve the HCC and quality of life among PLWH in TN.

<p dir="ltr">Background—Adverse Childhood Experiences (ACEs) are events that occur before age 18, such as abuse and neglect, which are potentially traumatic. ACEs can lead to profound negative impacts on physical and psychological health and social relationships. Despite this, positive social connections can mitigate these effects. However, individuals with ACEs may struggle to form healthy relationships because of mistrust, leading to continued exposure to detrimental social environments. Additionally, ACE-exposed adults often internalize stigma.</p><p dir="ltr">Methods—Utilizing data spanning from 1995 to 2014, Chapter 2 examines 629 adults from the MIDUS II: Biomarker study. Employing counterfactual modeling, the study estimates the treatment effect of ACE exposure on well-being and employs weighted multilevel mixed models to analyze life course changes. Chapter 3 uses 1,243 respondents from the MIDUS II: Biomarker study, employing latent class analysis to identify social relationship patterns and assess their mediation between ACEs and the pursuit/enjoyment of new relationships. Chapter 4 uses experimental data from 493 respondents, employing vignette experiments to gauge perceptions of warmth and competence, with gender and happiness examined as moderators, and threat, status, four stigmatizing descriptions as mediators.</p><p dir="ltr">Results—ACE exposure is associated with increased chronic conditions, lower self-rated health, diminished psychological and social well-being. However, the strength of the treatment effects differs based on the type and number of ACE exposures. Latent Class Analysis of social relationships indicates four classes: healthy, ambivalent, kin-focused, and difficult, with higher ACEs linked to a decreased probability of being in the “healthy” class. ACEs also predict reduced enjoyment of interactions with new people, mediated 41% by the current social relationship class. ACE vignettes are perceived as less warm and competent, with happiness moderating some ACE-related perceptions. Status, “mentally ill”, and “damaged” emerged as strong mediators.</p><p dir="ltr">Conclusion—While ACE exposure is related to lower well-being, the rate of decline does not differ from non-ACE-exposed individuals across time. Those in strained relationships are less likely to enjoy new social interactions, potentially perpetuating ACE-related health consequences. Addressing interpersonal trust issues in ACE-exposed adults through social interventions may mitigate these effects. Additionally, there is stigma against each of the ten ACEs, and the medicalization of ACEs contributes to stigma.</p>

Child centered play therapy (CCPT) is a therapeutic intervention that provides the environment for children to work through and heal from difficult experiences through expression of play and therapeutic relationship. It has been demonstrated effective with multiple types of disruptive behaviors. I conducted single-case research to explore CCPT's influence on children who had four or more adverse childhood experiences (ACEs) and provided analysis of data collected from one assessment administered weekly and one assessment at pre-, mid-, and post-intervention: the Strength and Difficulties Questionnaire and the Trauma Symptoms Checklist for Young Children. The two participants (one 8-year-old White American male and one 9-year-old White American female) demonstrated significant improvement in total difficulties and prosocial behaviors. The study revealed potential therapeutic benefits for utilizing CCPT with children who had four or more ACEs. Encompassed in discussion of study results are implications for practice, suggestions for future research, and limitations.

Early stressors like trauma can lead to developmental changes that have life-long negative health consequences (Merikangas et al., 2010; Anda et al., 2006). Approximately 1 in 4 youth experience substantial trauma during their developmental years (Merikangas et al., 2010; Duke, Pettingell, McMorris, and Borowsky, 2010). Such findings suggest the need for early intervention and treatment for adolescents exposed to traumatic events and adversity. Ideally, adolescents could be treated within primary care settings where parents overwhelmingly seek services for their children. Primary care settings are sought out at a 94% to 97% rate of services as compared to only a 4% to 33% rate of parents seeking out mental health services (Guevara et al., 2001). Unfortunately, no adolescent trauma-informed interventions have yet been adapted for use in primary care (Glowa, Olson, and Johnson, 2016). This study aimed to fill this critical gap between adolescent mental health issues associated with trauma and adverse childhood experiences and the lack of treatment in integrated primary care settings. The need for trauma-informed treatment for adolescents who have experienced trauma and adverse experiences is especially salient as evidence-based treatment for adolescents in this setting is limited. A modified Delphi approach was employed to address this gap in the research. Two rounds of questionnaires and focus groups were utilized with a panel of experts and youth stakeholders to gain consensus on treatment recommendations. Ultimately, expert panelists and youth stakeholders identified 59 recommendations for adolescent trauma treatment to be delivered in integrated primary care settings. / Doctor of Philosophy / Childhood trauma can have negative health, social, and educational outcomes that extend into adulthood and over one’s lifespan (Black, Woodworth, Tremblay, & Carpenter, 2012; Merikangas et al., 2010). Approximately 1 in 4 youth today experience trauma (Duke et al., 2010). Trauma can include a variety of things such as physical, sexual, or emotional abuse; being the victim of a crime; witnessing violence in the home; living through a natural disaster or experiencing an accident (Anda et al., 2006; APA, 2017). The frequency of trauma in adolescence suggests the need for early intervention and treatment. Ideally, adolescents could be treated within primary care settings where parents and adolescents frequently seek care services. Unfortunately, no adolescent trauma interventions have been created for this setting (Glowa, Olson, & Johnson, 2016). This study was designed to improve the treatment of adolescent trauma in primary care settings. For this research study a modified Delphi technique was used. Two rounds of questionnaires and focus groups were utilized with participants that consisted of a panel of experts from the field and youth aged 14-18 years old. Ultimately, the study participants made 59 recommendations for adolescent trauma treatment to be delivered in primary care settings.

Introduction: Adverse Childhood Experiences (ACEs) are known to increase risk of mental health challenges throughout development, and sleep is known to decrease risk of mental health challenges. These have not been studied in tandem in younger cohorts. We investigated whether interactions between sleep duration and sleep regularity would moderate the impact of ACE exposure on risk for the development of mental health disorders. Methods: We conducted secondary cross-sectional analyses on the 2020-2021 waves of the National Survey of Children's Health (NSCH) (n = 92,669). We used logistic and ordinal regression to replicate known main effects of ACEs (total, household, community, and single) and sleep (duration and irregularity) on mental health diagnostic status and symptom severity, and we examined the interaction of ACEs and sleep on mental health diagnostic status. To correct for multiple comparisons, all original models were performed with one half of the dataset and then replicated in the second half. Follow-up analyses by age cohort (0-5, 6-11, 12-17 years) further examined interaction effects across development. Poverty level, parental education status, child age, child sex, neighborhood safety, neighborhood support, and race/ethnicity were included as covariates, as indicated in a priori acyclic graph (DAG) modeling. Results: Known main effects for ACE and sleep on mental health diagnoses were replicated across all models. Interactions between ACE exposure and adequate sleep duration or increased sleep irregularity were not clinically significant, although some were statistically significant due to large sample size, such that adequate sleep duration was associated with marginally increased risk of mental health diagnosis (Omnibus B = 0.048, p < 0.0001) and greater bedtime irregularity was associated with marginally decreased risk of mental health diagnosis (Omnibus B = -0.030, p < 0.001). Discussion: Main effects in this analysis are consistent with previous literature on ACEs, sleep, and mental health. However, interaction effects were largely small and clinically insignificant. Dichotomous and categorical parent-report items assessing sleep health may not be sensitive to interaction effects, compared with continuous data or physiological measurements. Further, examining mental health symptoms (rather than diagnosis status) may also allow for more nuanced understanding of potential interaction effects.