The COVID-19 pandemic and our nation’s racial reckoning have given new visibility to trauma and its impact on children.
Even before the pandemic, it was understood that the most fundamental threats to health have their roots in adversities experienced by children without sufficient buffering of a caregiver. Behavior, development, relationships and physical health can be affected for a lifetime due to the impacts of adverse experiences on brain development and neurophysiology, immune function and gene expression.
Pediatric clinicians, who are trusted by families and engage with youths throughout the life course, have an opportunity to improve outcomes. But how?
Implementation across settings
While the science underlying toxic stress has been evolving for decades, guidance for policy and practical clinical application in pediatrics has lagged.
A new AAP policy statement and clinical report on trauma-informed care provide guidance for pediatricians, community partners and other child-serving clinicians to move this science out of the lab and into lives.
The policy also includes recommendations for governmental advocacy, large health systems, managed care organizations, academic institutions and children’s hospitals to implement trauma-informed policies and procedures that include care of health care workers, children, youths, family members and other caretakers.
The policy Trauma-Informed Care in Child Health Systems is available at https://doi.org/10.1542/peds.2021-052579. The clinical report Trauma-Informed Care is available at https://doi.org/10.1542/peds.2021-052580. Both will be published in the August issue of Pediatrics and are from the AAP Council on Community Pediatrics; Council on Foster Care, Adoption and Kinship Care; Council on Child Abuse and Neglect; and Committee on Psychosocial Aspects of Child and Family Health.
Importance of relationships
Both documents emphasize the power of safe, secure, nurturing relationships — referred to as relational health — to mitigate the effects of potentially traumatic experiences and promote resilience. Pediatric clinicians have a unique opportunity to promote resilience at every visit and address health and developmental consequences effectively when trauma occurs.
Pediatricians already address the effects of trauma that present as disturbances of developmental, behavioral or physical health. Recovery from post-traumatic stress is facilitated when these concerns are diagnosed appropriately and addressed with evidence-based treatment and within the context of a caregiving relationship.
“Every health encounter in pediatrics is an opportunity to promote parent-child attunement, identify and ameliorate trauma, and promote child resilience,” said AAP President-elect Moira A. Szilagyi, M.D., Ph.D., FAAP, a co-author of the policy and clinical report. “This is trauma-informed care — or what might better be termed resilience- and relationship-informed care. It provides a framework that begins in infancy, or even prenatally with families, and nurtures the parent-child relationship through the ages and stages of development to optimize child health, resilience and well-being.”
Part of comprehensive care
The National Child Traumatic Stress Network (https://www.nctsn.org/) defines trauma-informed care as medical care in which all parties involved assess, recognize and respond to the effects of traumatic stress on children, caregivers and health care providers.
Those struggling with the effects of trauma can present in a variety of ways and with a range of severity. Though screening specifically for exposure to adverse experiences in childhood has been promoted in some states recently, trauma-informed care embeds screening or surveillance in the context of comprehensive care. It starts with engaging families, building resilience, addressing attachment and assuring safety at all visits. The clinical report presents advice for families and guidance for pediatric clinicians in tables, figures and easy-to-remember acronyms.
Governmental, institutional and academic leadership needs to make a commitment to trauma-informed care to make it most effective. A service model that integrates biomedical and behavioral health is a necessary augmentation of current practices and requires new training curricula, proof-of-concept research and payment models to support and promulgate trauma-informed care.
Full implementation of trauma-informed care includes attention to secondary traumatic stress, or the emotional strain that results when an individual hears about another’s traumatic experiences. Thus, a multidisciplinary (and sometimes interagency) team can best address the multiple facets of trauma-informed care, offering the opportunity to share the work and support each other in relationships that buoy medical providers as well as patients and families.
Perhaps the documents’ most important message is that humans build resilience skills and find safety from threat through relationships. Learning to harness a child’s first relationships and all those that follow to provide trauma-informed care allows us to use the best medicine has to offer — science and each other.
Drs. Forkey and Duffee are lead authors of the policy and clinical report. Dr. Forkey is a member of the Council on Foster Care, Adoption and Kinship Care and the Council on Child Abuse and Neglect. Dr. Duffee is chair of the Council on Community Pediatrics Executive Committee.