Trauma

The Substance Abuse and Mental Health Services Administration defines trauma as resulting from “ an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”(1)

The events and circumstances may include the actual or extreme threat of physical of psychological harm or severe, life threatening neglect for a child that imperils healthy development.  The individual’s experience of these events or circumstances helps to determine whether it is a traumatic event.  How the event is experienced may be linked to a range of factors including the individual’s cultural beliefs, availability of social supports, or to the developmental stage of the individual.  The long-lasting adverse effects of the event are a critical component of trauma. These adverse effects may occur immediately or may have a delayed onset.  Unaddressed trauma significantly increases the risk of mental and substance use disorders and chronic physical diseases. (2)

In this way, adverse childhood experiences and burden due to inequitable social determinants of health are a form of trauma.

(CLICK) How does trauma affect health?

Cognitive and neuroscience researchers have examined possible mechanisms that might explain the negative consequences of adverse childhood experiences on adult health.  The research has shown that the trajectory can be explained through an understanding of toxic stress, which is a persistent stress in the absence of protective factors.  This chronic stress can lead to long term changes in the brain structure and therefore development. 

(CLICK) Trauma in our Patients

In public institutions and service systems, there is increasing recognition that many of the individuals have extensive histories of trauma.  The need to address trauma is increasingly viewed as an important component of effective behavioral health service delivery. 

There is now a growing understanding that left unaddressed, trauma can be a barrier to achieving good health and well being.  As a result, it is imperative that we as pediatricians understand the ways in which trauma affects our patients and develop skills to address trauma during our patient visits.

(CLICK) Scope of the Problem

DC Urban ACEs

(CLICK) Trauma in our pediatric patients

The effects of trauma and chronic stress on a child can often be presented in externalizing behaviors such as acting out, school problems and somatic complaints.

What may be behind the DIAGNOSIS? Understanding the Survival Responses associated with Trauma:

Research has shown in the face of overwhelming fear or danger, the body responds in three survival responses: FIGHT, FLIGHT or FREEZE. While these survival responses are highly adaptive when a child is in danger, it is often seen as disruptive behavior in the school or home and a child is often mislabeled and misdiagnosed.  Children and adolescents who have experienced trauma are often diagnosed with oppositional defiant disorder, conduct disorder, depression and anxiety.  While many children who have experienced trauma may have depression or anxiety- it is important to include the impact of trauma.  (Trauma Systems Therapy Training.)

Specific Behaviors and Symptoms Associated with Early Childhood Trauma: (NCTSN)

(CLICK) Trauma and Parenting

Effects of Trauma on Parenting: The majority of caretakers are doing the best they can. Caretakers with a history of trauma or who are experiencing overwhelming daily stress often have difficulty responding to and being available for their child.

Potential Effects of Trauma on Parenting

To understand caretakers through a trauma-informed lens means to recognize the potential challenges those with unaddressed trauma histories may experiences.  

• Chronic illness, (heart disease, obesity, high blood pressure

• Difficulty making decisions under acute stress

• Feeling unsafe and on edge

• Difficulty regulating emotions

• Difficulty forming attachments

• Difficulty being attuned to their child’s emotions and needs

• Trust issues, especially with people in positions of power

•  Depression, anxiety

•  Development of unhealthy coping strategies. 

Rethinking the Non-Compliant, Resistant, Difficult patient/parent with a trauma-informed lens

We may not fully understand one’s behavior however understanding the possible effects trauma and chronic stress have on a person allow us to be more empathetic, patient and manage a situation in a way that can make everyone feel safe.

Understanding Survival Responses associated with Trauma:

Research has shown in the face of overwhelming fear or danger, the body responds in three survival responses: FIGHT, FLIGHT or FREEZE.

Examples of survival responses we may see in clinic: Fight: Argumentative, agitated, raised voice.  Flight: Non-compliance/No shows appointments, changes topics, denial. Freeze: Stare-off, non-responsive.

Examples of survival responses we may see in clinic: Fight: Argumentative, agitated, raised voice.  Flight: Non-compliance/No shows appointments, changes topics, denial. Freeze: Stare-off, non-responsive.

Understanding Survival Responses associated with Trauma:

Research has shown in the face of overwhelming fear or danger, the body responds in three survival responses: FIGHT, FLIGHT or FREEZE.

Examples of survival responses we may see in clinic: Fight: Argumentative, agitated, raised voice.  Flight: Non-compliance/No shows appointments, changes topics, denial. Freeze: Stare-off, non-responsive.

(CLICK) Trauma Informed Care

Trauma-informed care requires a shift in how we conceptualize families and how we provide the care. It acknowledges the impact of trauma on development and wellbeing and responds in a way that promotes healing by creating a space that values an individual’s experiences, increases their sense of control and safety and minimizes the potential re-victimization.

“Trauma-informed care is a shift from wondering what is WRONG with a person that would have made them ACT the way they do to WHAT HAPPENED to a person that would have them REACT the way that they do?” (Oregon Pediatric Society, Start Training)  

Insert information on Four R’s as Defined by SAHMSAType your drop-down text here

Quick Tips on Trauma-Informed Care:

• Make no assumptions about how a person has been affected by what seems to be a traumatic event.
• If you learn about a trauma history, it does not mean you have to fix it.  
• The individual’s subjective experience determines whether or not an event is traumatic.
• Even if a person has experienced significant trauma, this may not be the main stressor in their life and/or they may not want or be ready to seek services.

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(CLICK) Universal Screening Questions:

“As pediatricians become more aware of the significant effect that exposure to trauma may have on a child’s health, well-being, and safety, they may consider asking explicitly about exposure to trauma. Given data on the frequency of child exposure to traumatic events, it is not unreasonable to consider trauma during every health visit. Such universal assessment can help remove any sense of stigma or judgment and can reassure the family. The diagnosis cannot be made if it is never considered. Maintaining a high level of suspicion that trauma may be a cause of or contributing factor to the behavior or concern being raised is an important rst step.”

(directly quoted from https://www.aap.org/en-us/Documents/ttb_medicalhomeapproach.pdf)

Universal Screening Questions:

• Since the last time I saw your child, has anything scary or stressful happened to you or your child?

• Scary or traumatic events that may have happened in our past can make it hard to manage our health, take care of ourselves and our family. (Modified from Bread for the City)

• Did you feel love and cared for as a child? (Modified from Bread for the City)

• Are there any behavior problems with the child at home, at child care or school, or in the neighborhood? (American Academy of Pediatrics)

• Do you have goals you would like to achieve and/or goals you would like you child? What might get in the way of achieving these goals? What strengths do you and your child possess that can help? (Kelly McCauley, LSCSW, Trauma Systems Therapy Model)

Additional ways to facilitate discussions without formally using a screening tool:

Even if providers are not ready to assess caretakers for histories of trauma, they can have a conversation about general stress levels. Transition from talking about the child to the parent by asking about:

• Current life stressors. I know we have talked a lot about your child and I wanted to check-in and see how you are doing. We ask all parents about things that may be stressful in their lives so we can best support you and your family.    

• Ways of coping. It sounds like you are really dealing with a lot right now, what helps you get through the day? Are there things that you do when you feel overwhelmed?

• Sources of support. From what you have told me, it looks like there is a lot on your plate. Are there people in your life that you can go to for support- to help you if you need it with your child or just to talk?

• Additional support or services that would be helpful. You are doing a really amazing job managing everything and caring for your child. Can you think of any resources or additional support that may be helpful for you and your family?

• Are there things that are going well for you? Help facilitate conversation by identifying strengths and areas the child is accessing in and attribute to the caretaker.  

Additional Resources and Articles:

•  American Academy of Pediatrics, Trauma Toolbox for Primary Care: Addressing Adverse Childhood Experiences and Other Types of Trauma in the Primary Care Setting, https://www.aap.org/en-us/Documents/ttb_addressing_aces.pdf.

•  Family-Informed Trauma Treatment Center. www.nctsnet.org/sites/default/files/assets/pdfs/understanding_the_impact_of_trauma.pdf.  

(CLICK) Structured screening tools:

Structured screening tools help providers to identify the needs of families and can be used to further facilitate discussion. When looking at screening it may be helpful to consider the following: What are our goals for using this screening tool? How will this screening tool improve the services families receive?  Jump to Structured Screening Tools Table

Acknowledging Pediatrician Identified Barriers:

-        There is not enough TIME to ask about trauma and effectively respond within a short visit time.

-        We do not have enough RESOURCES IN COMMUNITY to refer these families to, both behavioral health and for basic needs.

-        What is my ROLE in this family’s life when so many of the social determinants of health are out of my control? Often feel helpless.

There are many options to consider when thinking about who and when to screen for trauma and adversity and how screening tools and questions can be modified to simply facilitate conversation and introduce the topic of trauma and adversity.  

Who to Screen:

The following is a list of screening options adapted from the American Academy of Pediatrics.

-        Children and caretakers.

-        Everyone during the toddler years (universal assessment).   

-        Children experiencing school problems or failure, somatic symptoms.

-        Children and adolescents with asthma or obesity.

-        Adolescents with mental health concerns.

   (Modified from American Academy of Pediatrics) Structured screening tools help providers to identify the needs of families and can be used to further facilitate discussion. When looking at screening it may be helpful to consider the following: What are our goals for using this screening tool? How will this screening tool improve the services families receive?

Jump to Structured Screening Tools Table

Acknowledging Pediatrician Identified Barriers:

-        There is not enough TIME to ask about trauma and effectively respond within a short visit time.

-        We do not have enough RESOURCES IN COMMUNITY to refer these families to, both behavioral health and for basic needs.

-        What is my ROLE in this family’s life when so many of the social determinants of health are out of my control? Often feel helpless.

There are many options to consider when thinking about who and when to screen for trauma and adversity and how screening tools and questions can be modified to simply facilitate conversation and introduce the topic of trauma and adversity.  

Who to Screen:

The following is a list of screening options adapted from the American Academy of Pediatrics.

-        Children and caretakers.

-        Everyone during the toddler years (universal assessment).   

-        Children experiencing school problems or failure, somatic symptoms.

-        Children and adolescents with asthma or obesity.

-        Adolescents with mental health concerns.

(Modified from American Academy of Pediatrics)

(CLICK) Structured Screening Tools table

Type your drop-down text here.

(CLICK) Provider Script

Introducing a structured screening tool and discuss the results with families

Discussing the PURPOSE of the screen with families:

Key information:

•       Stress not only has negative impacts on a child’s emotional health but physical health as well.

•       Screen enables providers to better support family and connect them to resources and services in the community.

•       Give screen routinely to all families during check-ups however is voluntary.

•       Inform families of who will see the screen and how the information will be stored.

Suggested language and options: Stress in a child’s life has long last effects on his or her overall physical health. We feel it is important to ask you about different stressful events your family may have experienced or are currently experiencing. This screen provides us with a better understanding of some of the challenges your family and your child may be experiencing and allows us to better support you and connect you to resources in the community. We give this screen routinely to all of our families during clinic visits. It asks you about a variety of different things. Your family may have experienced some of these things, or maybe none at all and that’s ok.  

We want to look at all aspects of your child’s health that affect your child’s development and it helps to identify things that may be helpful to talk about today.^xxx

Being a parent is not easy. We want to help you be the best parent you can be and families provide a safe environment for their kids so we routinely ask ALL families questions about the challenges and problems they may be going through. And if there is a problem, we’ll try to help.^xxxi

Quick reminder of the application of trauma-informed care during the screening process:

-        State your role and your relationship to the family

-        Inform family about why you are asking and what you intend to do with the information.

-        Be aware that some of these questions may be uncomfortable or distressing.

-        Recognize that some family members do not feel comfortable discussing some events with other family members present. If they do not want to fill it out at the visit they do not have to. xxxii

Key information:

•       Thank the family for completing the screen

•       Ask the family if they have any questions or concerns and if this is a good time to discuss the screen.

•       Acknowledge an individual’s courage in sharing and talking about their story.

•       Make a follow up plan.

Suggested language: Thank you for taking the time to fill out this screen. We know it asks you about some sensitive things and our aim is to better understand the challenges you face as a family and assist in connecting you to resources you think would be helpful. Is now an ok time to talk about the screen?

Quick follow up questions:

•                  Are you currently receiving any services in the community for you or your child?

•                  Are there resources or supports that would be helpful to have access to?

Follow up questions if provider has more time/family is open to discussing experiences further:

•                  In what ways can your child’s functioning improve? And the family as a whole?  How did that affect you later in life?

Let’s Take a Look at a more detailed script based on LEVEL of families’ responses

Ø Family reports no stressors or things they would like assistance with today

Key information:

•             Provide information on impacts of stress and health.

•             If issues do arise, make an action plan with family and follow up. 

•             Use clinical judgment regardless of screen results.

Suggested language:

It looks like your family and your child have not experienced any of the stressful things listed in the screen. If you do find that that issues come up or you DO have concerns, please schedule an appointment with me. This is a place you can talk about these things.

Additional follow up questions:

- Are there things that do cause stress in your family’s life that were not listed in the screen?

- Do you have any concerns about your child or your family?

Ø Family reports stressors and would like to discuss them further

Key information:

•             Use clinical judgment regardless of screen results

•             Provide family with resource guide and discuss services that may be helpful

•             Schedule follow up appointment with primary care provider

Suggested language:

It looks like your family has experienced or are currently experiencing some stressful things. We do have a list of community- based resources and I can refer you to people who can further assist you in getting connected to resources and services. “Let’s talk about some ways to get help that might work for you.” I do feel it is important to schedule a follow up appointment with me to check-in. If you find things get worse or something comes up, you can also schedule an appointment to see me or do a walk-in visit in the clinic.  Note* If a child is referred for a mental health evaluation and possible treatment, it is important a caretaker know- “A key role they play is supporting the child: “One of the most important factors in helping children heal is your support. Treatment will help you better understand your child’s responses and know how to help. It can help you feel better as a parent.” ^xxxiii

Additional follow up questions:

•             Are there services you or your family is currently receiving?

•             In what ways can things with your child improve? And the family as a whole?

Ø Family is unsafe to leave w/o emergency plan. Need for immediate services

Key information:

•             Think safety first

•             Take the time to consult with available staff and other supports

Suggested language:

Thank you for sharing with me today. It takes a lot of courage. From what you told me it sounds like you are going through some really tough times. We want to make sure you and your family are safe. I think it is important to work together to come up with a plan so we can ensure your safety today. How does this sound to you? I’m thinking these may be some good steps to take today so we can best support you. Do you have any questions? Let’s plan together to identify what you need to feel comfortable and safe.

(CLICK) Building Resilience

Taking a strengths-based approach to highlight and build upon caregiver strengths

Taking a strength-based approach is the first step in installing hope and building caregiver resilience. “A strengths-based approach focuses on what is working well to support the growth of individuals and communities. It is based on the assumption that people have existing competencies and resources for their own empowerment. It assumes that people are capable of solving problems and learning new skills; they are a part of the process rather than just being guided by a professional.” (Center for Child Wellbeing)

Encourage Self-Care Strategies for Caretakers

It is important to acknowledge the stress many caretakers face and to encourage self-care strategies. Traditional self-care strategies such as going for a walk or finding time for leisure activities may not be as accessible to some of the vulnerable families we work with due to issues such as community violence, housing instability, being a single parent, and working long hours. Despite this, providers can work with caretakers to help identify and encourage meaningful self-care strategies.

Key things to remember:

• Acknowledging a caretaker’s stress and providing a safe space to share their experiences is therapeutic.

• Value a caretaker’s support systems and community networks you may not know of.

• Recognize family can be both a source of support and stress. Ask the caretaker about relationships with family members and the influence of extended family on parenting and expectations.

• Help the caretaker to identify things that they already do to manage stress. What has worked? Are there times you don’t drink?

• Recognize self-care techniques will resonate with some caretakers while not with others. Ask caretakers what they do.

• Identify small goals to practice.

• Assist caretakers in recognizing their stress level and how to cope in the moment.^xvi

Additional Resources for Caretakers

• American Academy of Pediatrics, Trauma Toolbox for Primary Care: When Things Aren’t Perfect- Caring for Yourself and your Children, https://www.aap.org/enus/Documents/ttb_caring_for_yourself.pdf.

• Building Resilience on Sesame Street, http://www.sesamestreet.org/toolkits/challenges.

• Grief, http://www.sesamestreet.org/content/grief.

• Child Witness to Violence Project, Boston Medical Center, http://www.childwitnesstoviolence.org/.