Most children will experience at least one traumatic event in their childhood. According to data from the 2016 National Survey of Children's Health, up to 46% of children are affected by one adverse childhood experience (ACE) by the age of 17, and 35% will experience at least one by the age of 5. Pediatricians with a knowledgeable approach of trauma-informed care can support families and help prevent the physical and emotional harm ACEs may inflict on children. This post will cover what trauma-informed care means for pediatrics, from community outreach to staff training and caring for comorbidities.
This post relies extensively on the comprehensive clinical report published in Pediatrics in 2021 by Dr. Heather Forkey et al, “Trauma-Informed Care”. For detailed information on integrating TIC and the data behind the science that supports TIC, we recommend reviewing this clinical report.
Trauma-informed care (TIC) is a relational approach to healthcare intended to assist physicians and mental health professionals in caring for patients affected by trauma. The National Child Traumatic Stress Network defines trauma-informed care as “medical care in which all parties involved assess, recognize, and respond to the effects of traumatic stress on children, caregivers, and health care providers.”
Many pediatricians report that while they support the idea of TIC, they require further information and guidance on placing proven strategies for support into the workflows of their practices. To help your practice get started, here are some of the basic principles of TIC:
Pediatricians practicing for a length of time in a single community can generally get to know the populations where children may be at the highest risk for ACEs or toxic stress, and therefore where TIC is best applied.
Children in every practice will be affected by ACEs, but it’s still a good practice to identify those at high-risk specific to your community. Consider your community’s poverty rate, demographics, and factors such as immigrant or refugee status. What minority racial, ethnic, or religious groups are prevalent in your practice? You can also consider how minority sexual and gender identities are represented in your community, and whether any of these communities could use support from your practice.
Awareness of your community's specific needs can help prepare pediatricians and staff to detect and assess trauma in patients and enable ready support and guidance for the families who are the best candidates for TIC.
TIC depends heavily on the positive, nurturing relationship between a child and their caregivers, whether those are parents, extended family, or other stable and important relationships such as older siblings or educators.
In the context of healthy relationships with a stable adult, a child can recover from toxic stress and trauma. As pediatricians, there are many opportunities for your practice to support these relationships and identify any challenges that could damage the secure attachments a child should ideally experience with their caregiver.
According to the clinical report by Forkey et al, caregivers can start by empathetically responding to a child’s needs, through which interaction a child learns to regulate emotions. At your practice, this translates to observing the caregiver-child relationship, responding with empathy and support as needed, reframing or guiding caregivers through obstacles.
For example, a parent frustrated by their child’s crying in the office could be observed ignoring the child or alternatively, soothing them with touch or words. Responding to lack of engagement, you might focus on the parent's strengths by asking, “Toddlers sure are tough, I’m sure you’ve been through a lot lately. What’s your strategy for cooling yourself down when you’re upset?” or reframing the situation by saying, “She is very independent lately! This is developmentally appropriate for her age. It can seem like toddlers like to be difficult, but in fact, they’re developing their own identity and sense of independence, which is fun to watch, even if it’s frustrating!”
Likewise, a pediatrician can support the empathic responses from parents and learn more about the relationship with remarks like, “It’s so great to see that she knows Dad is keeping her safe. Does she like to be hugged when she’s upset?”
Supporting the positive and empathetic relationships of caregivers and children helps a child develop or build resiliency, a core tool for responding to stress and trauma.
Research shows that because children with ACEs are likely to have caregivers who have also experienced ACEs, a two-generational approach to TIC is likely to increase benefits for the entire family. Pediatricians can engage caregivers with compassionate discussions of their own trauma histories and address how this could affect their parenting choices and their child’s health. Further treatment can be pursued via the caregiver's PCP or licensed mental health professional.
Clinical care for trauma and ACEs depends on strong relationships with families and on a commitment to detecting trauma where it exists and assessing the best care for the individual family.
Screening is a key tool for the clinical detection of trauma. Screens such as those available with CHADIS can help pediatricians identify kids at risk and determine a care plan. The clinical “Trauma-Informed Care” clinical report in Pediatrics suggests that in addition to screening, surveillance, a less formal assessment tool, can be implemented at every visit to assess for potential trauma. Questions such as “Has anything scary happened to you or your child since the last visit?” can open conversations about potentially traumatic events.
Overlap with other pediatric conditions and the pervasive nature of ACEs means that pediatricians should evaluate whether trauma plays a role in each diagnosis. For example, many behavioral health diagnoses such as ADHD and anxiety might be related to trauma and would benefit from TIC.
Finally, there are many clinical options for children experiencing trauma or toxic stress, including behavioral health visits with a child and adolescent psychiatrist or other professional, group therapies such as play therapy, and even trauma-informed education for older children and teens.
The effects of trauma are spread throughout a child’s life, and as we know, even through their future adulthood and parenting. While pediatricians have amazing opportunities to care for families by dint of their professional experience and voice for advocacy, connecting families to community-based resources can profoundly impact a child’s well-being outside of your practice.
Your practice could choose to support caregiver-parent relationships by referring parents to accessible play or reading sessions, parenting classes or discussion groups, or even group therapy sessions. You could even choose to host these groups at your practice after office hours!
Knowing and cultivating relationships with local resource centers such as women and family shelters, financial assistance programs, childcare resources, and other community aids can help lessen the challenge of accessing help for many families. These relationships can make all the difference. Even small remarks like “Tell them Dr. Jamie/ABC Pediatrics sent you!” or “I have a friend at Baby Resource Center, I can give you his number to call so you don’t have to dial the front desk,” can help reduce stigma and help families connect to the support they need but might hesitate to take.
Awareness of TIC is the first best step for pediatric practices to help families dealing with trauma, whether recent or generational. Further steps include exploring the ways your practice can integrate with the mental health professionals that are a part of a complete medical home. Whether you want to know how to hire a social worker for your practice or need to know how to integrate on a budget, integrating healthcare is possible for any practice committed to supporting kids with the care they need. Check out our ebook, Integrating Behavioral Health: A Guide to Expanding Access to learn more.