#15: Trauma-Informed Care

December 26, 2020 | By Justin Berk

A primer for understanding Trauma-Informed Care in the Pediatric Setting with Dr. Heather Forkey

Summary

Are you interested in implementing Trauma-Informed Care into your pediatric practice but unsure how to start? Join us for our conversation about TIC with Dr. Heather Forkey. Dr. Forkey is the clinical director of the Foster Children Evaluation Services (FaCES), Chief of the Division of Child Protection for the UMass Memorial Children’s Medical Center in Worcester and Associate Professor at the University of Massachusetts Medical School. Dr. Forkey is an expert in childhood trauma, child abuse and the health of foster care children.  She gives us the building blocks to integrate  Trauma-Informed Care into our everyday practice!

Credits

• Written and Produced by Drs. Joan Park and Christle Nwora 
• Cover Art: Dr. Chris Chiu
• Hosts: Drs Justin Berk and Chris Chiu
• Editor: Dr. Justin Berk; Clair Morgan of nodderly.com
• Guest(s): Dr. Heather Forkey

Trauma-Informed Care Pearls

1. No traumatic experiences are the same nor do they impact all children in the same way. Trauma-informed care should stem from relationships and rapport with families. 
2. The caregiver relationship protects children from toxic stress. Trauma-informed care involves helping caregivers find the tools to support themselves and the child. 
3. Most children build resilience every day. The pediatricians’ and caregivers’ role is to help them continue to create this “ordinary magic”.

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Trauma Informed Care Notes 

Definition of Trauma Informed Care 

Trauma Informed Care is an approach to practice that includes “awareness of the prevalence of trauma, understanding the impact of trauma, and commitment to incorporating those understandings in policy, procedure, and practice” (Collin-Vezina, 2020). 

Discussing Trauma in a Clinical Setting 

Dr. Forkey recommends checking in with the patient first, before addressing trauma. These conversations are personal and can be difficult for both practitioner and patient. First ask, “How are you?” and validate the experiences of your patient. Trauma informed care starts with building rapport and relationships. Pediatric providers have an unique opportunity to partner with families towards recovery. 

Screening for Trauma 

Screening for trauma is challenging. There are not any validated and brief screening tools for primary care (The Medical Home Approach to Identifying and Responding to Exposure to Trauma, 2014). In Dr. Forkey’s expert opinion, trauma informed care happens in the setting of relationships. Using a screening tool devoid of personal interaction can limit its success. Not all traumatic experiences are created the same nor do they impact all children in the same way. 

As opposed to screening, surveillance in the setting of a well child exam may be useful. Questions pediatricians can ask include: 

Has anything scary or upsetting happened for you or your child? 

Have there been any changes in school?

How are they functioning at home? 

Are you worried that your child has been exposed to something? 

Has anyone come or gone from the house that is new?  

You can also relate symptoms to trauma: Sometimes abdominal pain can be related to something changing at home, do you think that is true for you?

Adapted Table 1 (The Medical Home Approach to Identifying and Responding to Exposure to Trauma, 2014)

Building Resilience 

Pediatricians can participate in building resilience at every visit. Dr. Ann Masten, Professor at the Institute of Child Development at the University of Minnesota, defines resilience as the capacity to adapt to or in spite of significant difficulties. Dr. Masten refers to this process of building resilience as “ordinary magic” because for most children, resilience is being built every day.  Dr. Forkey says that resiliency skills are the THREADS of childhood:

Thinking and learning brain

Hope

Regulation or self control

Efficacy

Attachment

Developmental skill mastery

Social connectedness

Addressing Trauma in Care with Families

Not all clinical settings are best suited to address trauma (e.g., mom with multiple kids in the clinic room or acute sick visit in the ED). Start with identifying the family’s priorities. Then create space for the patient/caregiver to volunteer information as they feel comfortable. 

When the patient and caregiver are open and ready for a conversation, explore how trauma may be manifested in the child’s life. You can start by asking about sleep patterns. If you are being chased by a bear, being awake is to your advantage. Trauma similarly activates the reticular activating system to keep us awake and disrupt restorative sleeping patterns. Establishing a good sleep routine can benefit both child and family. 

Framing a child’s response to trauma is important. It may help to discuss the fight-flight response as above or walk through a caregiver’s own response to stress and relate it to their child’s. Use the SPLINT mnemonic to communicate how trauma can be connected to symptoms. 

Say that trauma can be the cause.

Problem solve and help families identify things they can implement for their child

Language is important for families and children. “This is a normal response to trauma and stress”

Investigate further and see if the child is in immediate danger. Involve CPS and additional community resources as needed. 

Normalize it and tell families that there is a way forward. 

Therapy or Treatment may be appropriate for families. 

Use the three R’s to guide caregivers through caring for their child: 

Reassure safety: Show the child that they are safe through safe physical spaces in the home and warm affection. 

Rituals and Routines: Removes the stress from making every day decisions. 

Regulating: Work on relaxation skills. This involves naming and managing feelings of stress. Encourage mindfulness, belly breathing or prayer if the family is religious.

These conversations take time and can occur over multiple visits. 

Finally, be aware that medicine has often misdiagnosed children with trauma (ADD/ADHD, Oppositional Defiant Disorder, Conduct Disorder, Developmental Delay). 

Table 2 (The Medical Home Approach to Identifying and Responding to Exposure to Trauma, 2014)

Adverse Childhood Experiences and Social Determinants of Health 

Both Adverse Childhood Experiences (ACEs) and social determinants of health (SDoH) impact a child’s development. How are they different? It depends on where the trauma occurs, Dr. Forkey explains. ACEs occur in the setting of a caregiver relationship, while SDoH occurs outside of the caregiver relationship, as Dr. Forkey explains. 

ACEs can negatively contribute to adult physical and mental health outcomes (Felitti et al, 1998).  This was first defined in a 1998 study from the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente looked at more than 17,000 middle-class Americans.

The original ACEs are: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, mother treated violently, household substance use disorder, household mental illness, parental separation or divorce and incarcerated household members. 

SDoH as defined by the CDC are “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (CDC, 2020). 

In a child’s development, toxic stress occurs when there is not enough buffer between the child and source of stress. The caregiver relationship can build a larger buffer for the child. However, institutional oppression, including racism, stresses the caregiver relationship at multiple levels. Pediatricians can affect both ACEs and SDoHs by strengthening the caregiver relationship and advocating for social changes. 

Supporting Caregivers 

Trauma is an overwhelming experience for all members of the family. For caregivers, ask the ABCs: 

Attune to your body: How are you feeling? How is the child’s behavior impacting you?

Balance: What do you need to self regulate and cope? Who can you turn to for support (i.e. friend, neighbor)?

Connection: Connect with the caregiver to resources and other caregivers in similar situations.

Explain to the caregiver that children need the SAME things:

Safety

Availability of a caregiver that is predictable and compassionate 

Mind in mind or looking at the world through a child’s eye 

Emotional container or being able to hold emotions for the child 

Take Home Points 

Toxic stress and trauma is not just about the bad things that happen to you, but rather how well caregivers can buffer those experiences.

Pediatricians are well suited to address trauma as it presents itself in a child’s life.