Why providing care informed by trauma is important

Most people don’t make it through childhood without some degree of trauma. Some people have the resilience to handle this trauma without ongoing effects, but for others it’s more difficult.

Pediatricians are one of the most consistent forces in the lives of many children, and the American Academy of Pediatrics (AAP) has released 2 new guidelines to help them guide families on how to manage and move on from trauma.

“For a long time, pediatrics was trauma informed. We would know what happens, but pediatricians weren’t really sure how to respond,” said Heather Forkey, MD, FAAP, a pediatrician at UMass Memorial Health, in Worcester, Massachusetts.

Forkey helped to write both papers and said there’s a big difference between knowing that trauma has occurred and knowing how to treat it.

In many cases, symptoms of pediatric trauma can be difficult to distinguish from other problems because they can share so many origins. Trauma presents as a spectrum, she explained, and it can look different at every point on that spectrum. Pediatricians are often taught that post-traumatic stress disorder looks like the reaction of a solider returning from war, but trauma can look different in every person—especially in children.

“That’s what you’re trained to look for,” Forkey said. “If a baby has a mom with postpartum depression and can’t interact with baby, the baby will have developmental challenges that don’t really fit the picture of trauma.”

The 2 new papers—a clinical report¹ and policy statement²—cover some things to look for in children in terms of developmental, behavioral, and physical signs of trauma.

“It’s a spectrum of symptoms overlaid on a spectrum of development,” she said. “When you see these symptoms, one of the things you want to be thinking about is, can trauma be a piece of what you are seeing?”

The mnemonic FRAYED that can help with these assessments, Forkey said.

• F: Frets or fears
• R: Regulation difficulties
• A: Attachment problems
• Y: Yawning and sleep problems or yucky feelings
• E: Educational delay
• D: Defeated, depressed, disassociated

These signs can point to trauma, and that is important to acknowledge, Forkey explained. Perhaps the best thing a pediatrician can do when they see trauma is to promote resilience. Resilience can help children move on from trauma and has a protective effect on their overall mental health and functioning. Pediatricians can do this by promoting things like:

1. Self-regulation
2. A sense of home
3. Control over the child’s environment
4. Attachments
5. Social skills

“Those are things we are trying to promote when we see kids who are affected by trauma,” she said.

Pediatricians are used to looking out for developmental and physical delays, but behavioral cues can be more difficult to recognize in these assessments because they can be attributed to so many other causes. What can help is to do regular surveillance, behavioral screenings, and to ask open-ended questions that might encourage a child to share how he or she is feeling. Forkey said she likes to lead with, “has anything scary or difficult happened that’s concerning you?”

“If you don’t let them know that it’s something you can talk about, they might not bring it up,” Forkey said. “Pediatricians normally ask kids historical questions. Has anything bad happened? Have there been illnesses in the family? In those questions, we are opening the door to finding out if something traumatic has happened.”

Some pediatricians talk about using the adverse childhood events (ACE) screening, but these tools haven’t really been validated to use in clinical care, she said. Clinicians shouldn’t be looking at this screening as a diagnostic guide, but more as an opportunity to begin a discussion. The follow-up is key.

“If you’re going to use [ACE], it’s not something the front desk hands somebody and nobody follows up with,” Forkey warned. “If we don’t validate and address that, we are not really doing our job.”

Although the papers provide a detailed guide for pediatricians to use in practice, Forkey said it’s important to remember that first and foremost, connection is key. Engaging and connecting with your patient is the only way to begin.

“Be there for them,” she explained. “Curiosity, respect, and empathy are key. This work requires us to connect at a human level.

The next step is to decide what kind of response is needed. Is there a need for more investigation into what caused the trauma? Having the knowledge and tools to respond are important and can be used to help guide families on continuing care at home, she said. Referrals to behavioral health or trauma specialists can help, too, Forkey added.

Perhaps most important, she noted, is to leave families with a sense of hope.

“One of the things we can be accused of is leaving families overwhelmed,” Forkey stated. “Sometimes with trauma, we forget that our positive expectation of recovery is what families need to hear from us.”

Pediatricians need to be providing validation, too. They need to get the message across to families that trauma is difficult to work through, but it is possible to move forward.

“That is how we promote recovery. Fundamentally, what we are talking about it the fact that in trauma you have a dysregulation of the stress response,” she explained.

Humans rely on the affiliate response as their first stress response, Forkey said. They look for people who can help them with their problems. When that doesn’t happen, the traumatized person will move on to fight-or-flight responses and other stress reactions that have more serious physical and behavioral consequences.

“What we need to do as humans is to reach out and say ‘who can help me?’ And we need to be that affiliate support for them so they can reduce that stress and begin to heal,” Forkey said, adding that recovery happens when relationships that provide that support begin. “It’s so important for kids to get the message that reaching out to others is the things to do. Some kids get the message that reaching out to others isn’t safe, and this leads to a lifelong struggle with taking support and accepting help.”

References

1. Forkey H, Szilagyi M, Kelly E, et al. Trauma-informed care. Pediatrics. 2021;148(2):e2021052580. doi:10.1542/peds.2021-052580

2. Duffee J, Szilagyi M, Forkey H, et al. Trauma-informed care in child health systems. Pediatrics. 2021;148(2):e2021052579. doi:10.1542/peds.2021-052579