patient engagement

Supporting Patients through Adversity

More than two-thirds of children report at least 1 traumatic event before the age of 16. According to the National Child Traumatic Stress Network, a critical part of helping children recover from these traumatic events is by having a secure support system -- which includes their pediatrician and medical home. Learn how to support patients through adverse events and guide families on their way to healing with steps you can take at your practice.

Why Trauma Looks like “Bad” Behavior

Pediatricians recognize and understand the signs and significance of trauma in children and teens. Adverse Childhood Experiences (ACEs) can lead to toxic stress or in resilience -- every patient is different and their journeys are unique. At the forefront of the patient’s medical home, pediatricians have a great opportunity to offer support for both patients and caregivers to support kids through adversity, learning with each family along the way.

Pediatricians are trained to recognize the physical and developmental signs of trauma in young children and teens, and next to teachers, are the primary caregivers poised to help. However, it’s important to remember that trauma is not always acute, manifesting in symptoms like separation anxiety, injuries, or depression. Trauma can sometimes manifest in negative behaviors like aggression, tantrums, poor performance at school, or defying authority. 

These negative behaviors may stem from behaviors that relate to the child’s brain attempting to cope with their trauma, according to Dr. Heather Forkey, MD, Division Chief of the Child Protection Program at the University of Massachusetts, and to Dr. Moira Szilagyi, MD, PhD of UCLA. For example, a child with traumatic experiences who recognizes they are alone and unprotected at night may have trouble sleeping, leading to daytime misbehaviors. Drs. Forkey and Szilagyi presented much of the information on childhood trauma discussed in this post in a course, “Practical Tips to Support Children Exposed to Adversity,” at the AAP’s National Conference & Exhibition in 2020. Both doctors have a careers-long history working with the AAP, as well as children in foster care and adverse circumstances.

“The context of supporting kids through trauma is always healthy, supportive relationships,” says Dr. Forkey. “Focus on these instead of just the adversities.”

Significantly, pediatricians who recognize the long-term effects of trauma for what they are, even and especially when the traumatic event has passed, are better able to interpret and support caregivers and patients, supporting their journey to healing and security. 

Responses to Trauma

Each instinctive response to danger results in a child reacting in a different way. These responses may fall into one of three categories:

  • Freeze. The child freezes to avoid being discovered by the dangerous stimuli.
  • Fight/flight. The child lashes out or flees stressful situations. 
  • Affiliate. The child may look to caregivers or other nurturers to “tend and befriend” them, to protect them from danger.

To briefly summarize, the “freeze,” “fight,” or “flight,” responses are stress-filled and may not resolve easily -- that is, instead of resulting in resilience, a child may experience long-term traumatic effects.  The “affiliate” response, in which a child has a secure caregiver to turn to, allows caregivers to support and protect the child, guiding them to feelings of security that release the brain from stress. Without supportive relationships a child can depend on, they can revert to the stressful “freeze” or “fight/flight” reactions, which according to Forkey and Szilagyi, doesn’t allow them to explore and grow during key periods of brain development.

Supporting Secure, Attached Relationships

Caregivers want to support their children, and pediatricians want to support the health of kids and families. A pediatrician has a unique opportunity to offer families concrete steps as to how they can create secure, attached relationships, especially for families struggling to recover from trauma together. These secure relationships offer a safe base for kids to return to in cases where they would otherwise feel alone and unprotected from stressful situations. 

Secure relationships provide safety, soothe distress, and offer a safe space for the child to explore and grow, according to research in attachment theory. Attachment theory is a broad field in itself, which you can learn the basics of here. One method caregivers can use to promote a secure relationship is by using the SAME acronym, proposed by Forkey and Szilagyi.

It’s also key for pediatricians to likewise enact these SAME steps for parents and caregivers, who likewise need emotional support in order to offer the same support to their children. Sometimes, caregivers have their own traumas, or a long period of perceived “failures” can result in a lack of parenting confidence. The SAME method is as follows, and aims to offer:

  • Safety. Caregivers can use physical and verbal cues to let their child know they are safe. Pediatricians can use body language and empathy to let parents know they are safe to share their feelings.
  • Availability. Includes practical and emotional availability. Children feel secure when they know when a caregiver will be available and that their needs will be met with compassion. Pediatricians can likewise take time to connect with caregivers to talk about their feelings -- for example, “I’m so glad you came to me with this. What’s on your mind?”
  • Mind in Mind. Being aware of and acknowledging the emotions of the caregiver, and the caregiver of the child. For example, acknowledging when a child is fearful of a stranger or when a caregiver is feeling frustrated with the child’s misbehavior.
  • Emotional Container. Being an emotional “container” allows the child or caregiver to express their emotions so that they can find release and comfort and promote psychological healing. This allows the patient or parent to talk about their feelings and have those feelings acknowledged by a trusted person, validating their thoughts and feelings, rather than “bottling” them. 

While offering support for caregivers who need it, pediatricians can help discuss possible steps for each of the tenants in the SAME method to help parents promote the loving, secure relationships they hope to see at home. Some examples might include helping a child feel safe with soothing words or a hug, instilling routines that reassure a child that their parent is predictably available for them, and learning how to talk about a child’s feelings with age-appropriate language and helping the child express their feelings in constructive ways, such as hugging a comfort object, verbalizing feelings, or taking an elective “time out”.

In It for the Long Haul: Healing Trauma

Healing for some children is a lifelong process, and for others, healing means they gain new resiliency and vibrancy from their healing. The first step is identifying their unique circumstances, including sources of trauma and the child’s reactions. Another key tool is the patient’s support network, a two-fold solution -- it helps a child to grow secure relationships they can depend on, and also allows a caregiver someone to turn to for help. Talking about trauma helps the entire support network, from teachers to step-parents, learn the vocabulary and the responses the child needs for support and security.

For example, a child’s “triggers” are stimuli that re-open the trauma responses in their brain, essentially bringing them back to the feelings and reactions they had during the adverse event. These are different for every child. Some typical scenarios might be the fear of being left alone to sleep, being disciplined, or witnessing anger in an adult.

Once the pediatrician and caregiver have discussed the nature of the trauma, identified the child’s typical reactions and triggers, identified the caregiver’s responses and their triggers, and the family’s support network, the discussion can turn to the three  “Rs” of helping a child heal from trauma: reassurance. restoring routine, and regulation.

Reassurance is a guided response to a child’s reaction to a trauma or trigger. The caregiver by reassuring them, through physical affection and verbal assurances, can help the child recover from their stress response. For example, a child triggered by being left alone can be reassured first by assurances that the caregiver is in the next room or will return at a predictable time, and second by a special toy or charm a caregiver might also possess, allowing them to feel connected to their caregiver.

The next R, restoring routine, allows a child to feel in control or to feel secure in the environment around them. Routines such as these examples outlined by the CDC gives a child predictability, structure, and boundaries around their daily activities as well as predictable consequences for their own positive and negative behaviors. Routines can be especially helpful surrounding the child’s triggers, such as being left alone at school or daycare, or going to bed at night.

Lastly, guiding the child as they learn self-regulation helps them cope with stress and negative emotions in real time. For the example of the child left alone, routines such as waving goodbye, sharing feelings with the remaining caregiver, and occupying themselves with a favorite activity can help them both feel secure in their routine. It also assures them in the moment of stress that they can share their feelings, find comfort, and regulate their feelings themselves by a soothing activity such as drawing, breathing, or play.

Trauma is difficult to witness, and healing is often a long, sometimes arduous process. By allowing both the child and their caregiver to lean on their pediatrician, practices can build the relationships and provide the guidance families need to learn to cope with trauma, support their individual child, and understand negative behaviors in a way that makes responses more compassionate, calm, and constructive. 

When considering options for supportive care, you may be considering behavioral health. Behavioral health resources from a psychologist, counselor, or developmental pediatrician are excellent resources for families, and you can take a part in making these resources accessible for every patient. To learn more about the ways every practice can access behavioral health resources, check out our ebook, Integrated Behavioral Health: A Guide to Expanding Access.

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Allie Squires

Allie Squires is PCC's Marketing Content Writer and editor of The Independent Pediatrician. She holds a master's in Professional Writing from NYU.