Overview
Definition:
Trauma-informed care (TIC) is an approach to healthcare that recognizes the widespread impact of trauma and understands potential paths for recovery
It involves actively resisting re-traumatization by creating safe, trustworthy, and empowering environments for children and their families
This approach integrates knowledge about trauma into policies, procedures, and practices across all levels of a health system.
Epidemiology:
Adverse Childhood Experiences (ACEs) are common, with studies showing that a significant percentage of children experience one or more forms of trauma, including abuse (physical, sexual, emotional), neglect, household dysfunction (parental mental illness, substance abuse, divorce, domestic violence, incarceration)
The prevalence varies by socioeconomic status and geographic region, but underscores the need for TIC in routine pediatric care.
Clinical Significance:
Children who have experienced trauma are at increased risk for a wide range of physical and mental health problems throughout their lives, including chronic diseases, behavioral issues, learning difficulties, and psychiatric disorders
Pediatricians are often the first point of contact for these children and can play a crucial role in identifying trauma, mitigating its impact, and connecting families to appropriate support services, thereby improving long-term health outcomes.
Principles Of Trauma Informed Care
Safety:
Ensuring physical and emotional safety for the child and family
establishing clear boundaries and consistent routines
This includes creating a physically safe environment and fostering a sense of predictability and trust.
Trustworthiness And Transparency:
Making decision-making processes clear and consistent
building trust through open communication and honest interactions
Pediatricians should be transparent about procedures and expectations.
Peer Support:
Maximizing the use of peer support and involving individuals with lived experience of trauma in service delivery and policy-making
While direct peer support might be limited in a pediatric setting, fostering a sense of community and shared understanding among families can be beneficial.
Collaboration And Mutuality:
Leveling the power differences between providers and children/families
promoting shared decision-making and respecting individual autonomy
This means actively listening to and valuing the child's and family's perspectives.
Empowerment Voice And Choice:
Actively supporting the child's and family's ability to build resilience and self-efficacy
ensuring that individuals have agency and control over their care and lives
Offering choices, where appropriate, is paramount.
Identification And Screening
History Taking:
Inquire about family stressors, changes in household, parental mental health, substance use, and any reported or observed safety concerns
Use open-ended questions in a non-judgmental manner
Ask about sleep disturbances, behavioral changes, and school performance
Screen for exposure to violence or abuse within or outside the home.
Observation:
Observe child's behavior, interaction with caregivers, and signs of distress or withdrawal
Look for non-verbal cues of fear or anxiety
Note any age-inappropriate behaviors or regression.
Screening Tools:
Utilize validated screening tools for ACEs or trauma exposure, adapted for age and developmental stage, such as the ACE Questionnaire, or specific trauma symptom checklists
Discuss the purpose and limitations of screening with families.
Red Flags:
Sudden changes in behavior or academic performance
unexplained physical symptoms
withdrawal or excessive clinginess
aggression or defiance
self-harming behaviors
sleep or eating disturbances
fear of specific individuals or situations.
Clinical Presentation In Children
Infants And Toddlers:
Irritability, difficulty sleeping or feeding, excessive crying, developmental delays, regression in milestones, fearfulness of caregivers, somatic complaints without clear organic cause.
Preschool Children:
Regression in toilet training, increased tantrums, enuresis/encopresis, nightmares, fear of the dark or being alone, clinginess, withdrawal, play themes that reenact trauma, difficulty concentrating.
School Aged Children:
Academic decline, behavioral problems (aggression, defiance, impulsivity), social withdrawal, anxiety, depression, somatic symptoms (headaches, stomachaches), difficulty with peer relationships, somatic complaints, self-blame.
Adolescents:
Risk-taking behaviors (substance use, early sexual activity, self-harm), depression, anxiety, PTSD symptoms, eating disorders, aggression, running away from home, difficulty with identity formation, academic failure, somatic complaints.
Management And Intervention
Creating A Safe Environment:
Ensure the clinic is child-friendly and promotes a sense of calm and safety
Use clear, simple language
Provide choices when possible (e.g., which exam room, position)
Be patient and allow the child time to adjust.
Building Rapport:
Spend time establishing a trusting relationship before delving into sensitive topics
Validate the child's and family's feelings
Avoid judgmental language or assumptions.
Trauma Informed Assessment:
Conduct a thorough psychosocial assessment, including ACEs screening if appropriate and indicated
Document findings sensitively and comprehensively
Refer to mental health professionals for detailed trauma assessment and therapy.
Supportive Care:
Educate families about the impact of trauma and coping strategies
Provide resources for mental health services, social support, and community programs
Encourage self-care for parents/caregivers
Coordinate care with schools and other relevant agencies.
Medical Management:
Address physical symptoms and comorbid conditions
Psychopharmacological interventions may be considered for specific psychiatric symptoms (e.g., SSRIs for anxiety/depression), but should be part of a comprehensive treatment plan supervised by a child psychiatrist.
Key Points
Exam Focus:
Understand the core principles of trauma-informed care
Recognize how trauma impacts child development and presentation
Be prepared to ask sensitive questions during history taking
Know when and how to refer to mental health specialists
Prioritize safety and trust in all patient interactions.
Clinical Pearls:
Always ask about safety at home, even if not explicitly screening for trauma
The "universal precautions" approach means assuming that any child might have experienced trauma and practicing TIC with all children
Empowering children and families is as crucial as medical treatment
Small gestures of respect and validation can make a significant difference.
Common Mistakes:
Re-traumatizing patients by asking intrusive questions without building rapport
dismissing somatic complaints as purely psychological
failing to recognize signs of trauma
not involving caregivers in the assessment and management plan
placing blame on the child or family for behaviors related to trauma.