Studies have suggested that more than two-thirds of children experience at least one traumatic event before the age of 16. Merriam Webster defines trauma as “a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury.” Children and adolescents experience numerous kinds of traumas, including:
- Physical, sexual and emotional abuse
- Community or school violence
- Witnessing or experiencing domestic violence
- Sudden or violent loss of a loved one
- Natural disasters
- Refugee or war experiences
- Physical or sexual assault
- Commercial sexual exploitation
- Serious accidents or life-threatening illness
- Military related stressors (deployment, parental loss or injury)
One area of specific importance is pediatric medical traumatic stress, which is the distress experienced by both patients and family members when they go through life-threatening or life-altering illness, injuries or conditions. Studies suggest that up to 80% of children and families experience these reactions after enduring a life-threatening illness, injury or procedure.
The Adverse Childhood Experiences study (ACE) and trauma-informed care
ACE was a landmark research project that clearly demonstrated the long-term impacts of trauma.
This study highlighted the importance of identifying people who have experienced trauma as early as possible for intervention. These conclusions ultimately led to the development of trauma-informed care (TIC), which is defined as:
“A strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma that emphasizes physical, psychological and emotional safety for both providers and survivors; and creates opportunities for survivors to rebuild a sense of control and empowerment.”
TIC proposes a dramatic shift when considering the problematic behaviors that people display. Instead of asking “What’s wrong with you?”, trauma informed individuals ask, “What happened to you?”
Then providers must ask themselves, “How do I do things differently because of what’s happened to you?” Providers must view kids within the context of their trauma histories. If we know what they have experienced, then we can better understand why they are doing what they are doing and intervene more effectively.
The stress response in children
We must recognize that many maladaptive behaviors are a reflexive reaction to trauma reminders. When children experience threatening or dangerous events, it triggers their stress reaction: their brains instantly assess the threat and prepare to act to preserve life. Over time, children who experience trauma develop behaviors that help them to survive.
These behaviors enabled the child to survive threatening or traumatic situations, but they can create problems when they occur in safe situations or last for years after the trauma has ended. It’s important to remember that these behaviors aren’t willful and deliberate. Rather, these reactions are the only way the individual knows to survive and communicate their needs. We have to understand and meet their needs rather than reacting to the behaviors.
All humans have needs ranging from the most basic needs for survival to more complex and abstract concepts such as morality, acceptance and meaning. We need to understand our patients’ and their family’s needs, both globally and when they arrive for an appointment at our offices. Our goal is to figure out how their behaviors are connected to their needs so that we can help meet them. In turn, this understanding can help us be more compassionate and respectful in the face of challenging behaviors.
Trauma-informed healthcare systems
TIC is most effective when implemented from a system-wide level and is incorporated into an organization’s overall culture, not just its practices and policies. At a minimum, this requires provision of TIC training to all employees and ongoing assessment of competencies through continuing education as well as explicit efforts to decrease employee burnout. According to the National Child Traumatic Stress Network, the essential elements of a trauma-informed integrated healthcare system are:
- Creating a trauma-informed office. Meet basic needs by providing food and water. Empower patients and families and allow them to make choices when possible, like letting the patient pick an arm for a scheduled vaccination or assessing the need for changing into a gown. Obtain assent/consent.
- Involving and engaging family in program development, implementation and evaluation. Ask families about barriers to care and social determinants of health and consider these when developing programs and when making treatment recommendations. Be mindful of their health literacy. Consider the impact of their culture and diversity. Clearly communicate your expectations.
- Promoting child and family resilience, enhancing protective factors and addressing parent or caregiver trauma. Provide strengths-based community resources like sports and clubs. Be alert for trauma reactions in parents of kids experiencing medical challenges and other traumas.
- Enhancing staff resilience and addressing secondary traumatic stress. Be on the lookout for trauma reactions in staff. Give staff an opportunity to process difficult situations or stories to gain support from colleagues. Ensure that staff have access to mental health and well-being resources such as employee assistance programs.
- Assessing trauma-related somatic and mental health issues. Ask about safety in the home and at school and consider using evidence-based screeners for trauma exposure or trauma symptoms. Assess children for physical complaints that may have no physiological cause and that might connect to stress symptoms.
- Providing coordinated, integrated care across child- and family-service systems. Connect families to resources in the community, collaborate with mental health providers and communicate with schools.
Intervening with patients and families experiencing a stress response
Despite our best efforts to create trauma-informed offices and systems, patients and families will get triggered and display a stress response at time. The most important thing that we can do in those situations is to help patients and family members move out of survival mode by helping to regulate their emotions. Several strategies can be helpful, including:
- Minimizing additional stimulation by using low tones, involving as few team members as possible and removing other patients and families
- Providing choices and avoiding engaging in power struggles
- Avoiding dialogue or conversations that rely on complex cognitive skills such as abstract reasoning, future-focused thinking and understanding long-term consequences.
- Using the five basic senses: Consider stocking exam rooms with items like scented lotions, fidget toys and hard candies
- Consider the vestibular and proprioceptive systems: Teach team members and parents how to engage in full body activities that provide input into those systems like rocking, swinging, jumping or smaller activities such as chewing gum, using stress balls or clenching your fists.
Promoting these types of regulating activities is a significant shift in paradigm and practice and can feel non-productive. But challenge yourself to stop and reflect the next time you find yourself becoming upset or anxious. Consider these questions:
- What do you do that helps?
- What makes it worse?
- How often do you make a good decision in the heat of the moment?
- If you can’t be at our best when upset, then why do we expect that from your patients and families?
- Why do we judge and label them when they act in the only ways they know how?
Take this knowledge of trauma and the stress response into your practices and use that to better understand your patients and families so that you can do things differently for them.