Most children will experience some type of trauma during childhood, and many children suffer from significant adversities. Research in genetics, neuroscience, and epidemiology all provide evidence that these experiences have effects at the molecular, cellular, and organ level, with consequences on physical, emotional, developmental, and behavioral health across the life span. Trauma-informed care translates that science to inform and improve pediatric care and outcomes. To practically address trauma and promote resilience, pediatric clinicians need tools to assess childhood trauma and adversity experiences as well as practical guidance, resources, and interventions. In this clinical report, we summarize current, practical advice for rendering trauma-informed care across varied medical settings.

Experiences in childhood, both positive and negative, have a significant effect on subsequent health, mental health, and developmental trajectories. For many children and adolescents, traumatic experiences are all too common. Almost one-half of American children, or 34 million younger than 18 years, have faced at least 1 potentially traumatic early childhood experience.17  Such traumas may include those originating outside the home, such as community violence, natural disasters, unintentional injuries, terrorism, immigrant or refugee traumas (including detention, discrimination,6,8,9  or racism), and/or those involving the caregiving relationship, such as intimate partner violence, parental substance use, parental mental illness, caregiver death, separation from a caregiver, neglect, or abuse, originally defined as adverse childhood experiences (ACEs).10  For many children, medical events, such as injury, medical procedures, and/or invasive medical treatments, can be traumatic. Given the robust science explaining the physiologic consequences of accumulated trauma experiences on the brain and body,1114  there have been calls for pediatric clinicians to address childhood trauma and child traumatic stress.10,1416  However, practical guidance about how to consider, address, and operationalize this care, although necessary, has been insufficient.

Pediatric clinicians are on the front lines of caring for children and adolescents and, thus, have the greatest potential for early identification of and response to childhood trauma. Data indicate that, although pediatric providers intuitively understand the negative effects of trauma, they report a lack of knowledge, time, and resources as major barriers to providing trauma-informed care (TIC).5,6  Yet, experts believe that the complete assessment of child and adolescent behavioral, developmental, emotional, and physical health requires consideration of trauma as part of the differential diagnosis to improve diagnostic accuracy and appropriateness of care.17,18 

TIC is defined by the National Child Traumatic Stress Network 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. This includes attention to secondary traumatic stress (STS), the emotional strain that results when an individual hears about the first-hand trauma experiences of another. In the clinical setting, TIC includes the prevention, identification, and assessment of trauma, response to trauma, and recovery from trauma as a focus of all services. TIC can be conceptualized in a public health stratification, as summarized in Table 1:

TABLE 1

Range of Trauma Experiences, Symptoms, and Response

Potentially Traumatic ExperiencesTrauma Symptoms (Table 5)Office Response
None None to some Primary prevention: anticipatory guidance; resilience promotion 
Single-incident or minor trauma None or latent or mild Secondary prevention: anticipatory guidance; resilience promotion; trauma- informed guidance; close monitoring: screen for trauma history and symptoms 
Major event or cumulative Mild to moderate Secondary and tertiary prevention: anticipatory guidance; resilience promotion; psychoeducation; trauma-informed guidance, close monitoring, and follow-up; possible referrals to community services, mental health 
Major event or cumulative Moderate to severe Tertiary prevention and treatment: anticipatory guidance; resilience promotion; psychoeducation; trauma-informed guidance, close monitoring, and follow-up; avoidance of retraumatization; referrals to community services; referral to evidence-based and evidence-informed trauma mental health services 
Potentially Traumatic ExperiencesTrauma Symptoms (Table 5)Office Response
None None to some Primary prevention: anticipatory guidance; resilience promotion 
Single-incident or minor trauma None or latent or mild Secondary prevention: anticipatory guidance; resilience promotion; trauma- informed guidance; close monitoring: screen for trauma history and symptoms 
Major event or cumulative Mild to moderate Secondary and tertiary prevention: anticipatory guidance; resilience promotion; psychoeducation; trauma-informed guidance, close monitoring, and follow-up; possible referrals to community services, mental health 
Major event or cumulative Moderate to severe Tertiary prevention and treatment: anticipatory guidance; resilience promotion; psychoeducation; trauma-informed guidance, close monitoring, and follow-up; avoidance of retraumatization; referrals to community services; referral to evidence-based and evidence-informed trauma mental health services 

Adapted from Forkey H, Griffin J, Szilagyi M. Childhood Trauma and Resilience: A Practical Guide. Itasca, IL: American Academy of Pediatrics; 2021.

  • primary prevention of trauma and promotion of resilience;

  • secondary prevention and intervention for those exposed to potentially traumatic experiences, including caregivers, siblings, guardians, and health care workers; and

  • tertiary care for children who display symptoms related to traumatic experiences.

This clinical report and the accompanying policy statement19  address secondary prevention and intervention: practical strategies for identifying children at risk for trauma and/or experiencing trauma symptoms. “Children,” unless otherwise specified, refers to youth from birth to 21 years of age. These clinical strategies and skills include the following16,20 :

  • knowledge about trauma and its potential lifelong effects;

  • support for the caregiver-child relationship to build resilience and prevent traumatic stress reactions;

  • screening for trauma history and symptoms;

  • recognition of cultural context of trauma experiences, response, and recovery;

  • anticipatory guidance for families and health care workers;

  • avoidance of retraumatization;

  • processes for referral to counseling with evidence-based therapies when indicated; and

  • attention to the prevention and treatment of STS and associated sequelae.

Pediatricians have a powerful voice and reach that could promote the policies and procedures necessary to transform pediatric health care into a TIC system. This guidance for pediatric clinicians is organized around 5 strategies for implementation to become trauma informed: awareness, readiness, detection and assessment, management, and integration. The companion policy statement19  outlines broad recommendations for implementing TIC in child health systems.

Pediatric clinicians can promote resilience, identify adversity and trauma, and ameliorate the effects of adversity in their work with children and families. Although the epidemiology and physiology of trauma have been explored in the literature,9,12,13,21,22  few concepts have been translated into the provision of practical TIC in pediatric settings.6,16,23  Awareness of the science and epidemiology of trauma provides the scientific grounding for the practices of TIC.

The most fundamental adaptational mechanism for any child is a secure relationship with a safe, stable, nurturing adult who is continuous over time in the child’s life.24  This is usually the child’s parent or caregiver but can involve extended family and biological or fictive kin. It is in the protective context of this secure relationship that the child develops the varied resilience skills that will prevent or ameliorate the effects of cumulative adversities. The nurturing caregiver protects the child from harm, mediates the world for the child, and helps the child to develop the adaptive skills to manage stressful experiences. Physiology, in addition to psychology, is affected by protective relationships.14,2527 

All children experience some stress and adversity at some point in life, but when it is managed within the context of these nurturing relationships, such events can be weathered and even used for growth. Adverse events that lead to the frequent or prolonged activation of the stress response (see Fig 1) in the relative absence of protective relationships has been termed “toxic stress” in the pediatric literature.14  Toxic stress responses result from events that may be long lasting, severe in intensity, or frequent in occurrence. The available caregiver support is insufficient to turn off the body’s stress response. It is critical to note that the toxic stress response has 2 components: the significant stressors and the relative insufficiency of protective relationships. In sum, there is a marked imbalance between stressors and protective factors.28 

FIGURE 1

Stress responses. HPA, hypothalamic-pituitary-adrenal.

FIGURE 1

Stress responses. HPA, hypothalamic-pituitary-adrenal.

Close modal

Toxic stress responses can result in potentially long-lasting or lifelong impairments in physical and mental health through biological processes that embed developmental, neurologic, epigenetic, and immunologic changes.12,14  The lifelong effects of toxic stress are statistically related to many adult illnesses, particularly those related to chronic inflammation, and causes for early mortality.29  The robust literature on the physiologic effects of toxic stress is beyond the scope of this clinical report yet briefly summarized in Table 2.

TABLE 2

Physiologic Effects of Trauma in Children

AreaImpactSpecificsImplications and Associations
Brain connectivity93  Cortisol acts on rapidly developing brain structures Amygdala overactive; hippocampus underactive; prefrontal cortex not accessible Preliminary association with more severe clinical course in major depressive disorder 
Epigenetic changes21  Methylation patterns impacted by threat, mediated by cortisol Methyl groups attach to promoter region or come off promotor regions of genes, leading to the transcription or lack of transcription of genes Adult stress and reactivity behavior231,232  
Immune function80  Alteration of immune system in response to constant threat Inflammatory system up-regulated; humoral immunity diminished; cytokine-induced “sickness behavior”81  (feeling sick) Symptoms including the following: decreased appetite, fatigue, mood changes including depression and irritability, poor cognitive function 
AreaImpactSpecificsImplications and Associations
Brain connectivity93  Cortisol acts on rapidly developing brain structures Amygdala overactive; hippocampus underactive; prefrontal cortex not accessible Preliminary association with more severe clinical course in major depressive disorder 
Epigenetic changes21  Methylation patterns impacted by threat, mediated by cortisol Methyl groups attach to promoter region or come off promotor regions of genes, leading to the transcription or lack of transcription of genes Adult stress and reactivity behavior231,232  
Immune function80  Alteration of immune system in response to constant threat Inflammatory system up-regulated; humoral immunity diminished; cytokine-induced “sickness behavior”81  (feeling sick) Symptoms including the following: decreased appetite, fatigue, mood changes including depression and irritability, poor cognitive function 

Trauma is a broader term used to describe both a precipitant and a human response. The Substance Abuse and Mental Health Services Administration defines trauma as an event, series of events, or circumstances experienced by a person as physically or emotionally harmful that have long-lasting adverse effects on the person’s functioning and well-being (emotional, physical, or spiritual).16  This definition accounts for the fact that people may respond differently to potentially traumatic events and informs TIC with appreciation that the traumas people experience can result in behavioral changes that may allow them to manage the trauma in the short-term but can have lasting negative effects on conduct. These difficulties should not be viewed as malicious actions or even intentional but as consequences of adversity.30 

Because these epidemiological and physiologic studies provide the background and impetus for TIC, understanding the terminology derived from this literature is important in appreciating the scope, variety, and nuances of TIC and how to actualize them. These are summarized in Table 3.

TABLE 3

Definitions of Terminology in TIC

Terminology of TraumasDefinitions
Acute stress disorder and Post-traumatic stress disorder (PTSD) Psychiatric diagnoses that include having experienced or witnessed a traumatic event and then having persistent symptoms that include the following: reexperiencing (intrusive thoughts, nightmares, or flashbacks); avoidance (feeling numb, refusing to talk about the event); hyperarousal (irritability, exaggerated startle response, always expecting danger); acute stress disorder: symptoms occur 3 d to 1 mo after traumatic exposure81 ; PTSD: symptoms must occur ≥3 mo after the trauma233  
ACEs Stressful or traumatic events, including child abuse and neglect, that occur within the primary caregiving relationship; often breach the parent-child relationship, which is fundamental to nurturing healthy development; linked in population studies to physiologic and behavioral changes impacting the health and well-being of patients over their life course with a wide array of health problems, including associations with substance misuse.10,21,24,80  The original ACEs (from initial study published in 1998) are the following: physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, intimate partner violence, mother treated violently, substance misuse within household, household mental illness, parental separation or divorce, and incarcerated household member. Subsequent studies have expanded the original ACE panel to include other adversities,9,234  including the following: experiencing racism, experiencing bullying, separation from caregiver (resulting from immigration, foster care, incarceration, death, or any other reason), witnessing violence, community violence,49  adverse neighborhood experience,235  and financial insecurity236  
Complex childhood trauma (as defined by the National Child Traumatic Stress Network) Encompasses both a child’s exposure to multiple interpersonal traumatic events, including maltreatment and household dysfunction, and the broad, pervasive, and predictable impact this exposure has on the individual child83,237 ; can disrupt a child’s attachment with caregivers, development, and sense of self 
Developmental trauma disorder (DTD) A proposed diagnosis based on evidence that children exposed to complex trauma are at risk for severe pervasive disruptions in their development in the domains of emotional health, physical health, attention, cognition, learning, behavior, interpersonal relationships, and sense of self; sometimes used interchangeably with complex childhood trauma; describes problems in affect dysregulation, negative self-concept, and difficulty with relationships that occur as a result of trauma-related developmental impairments; symptoms overlap or co-occur with several PTSD symptoms, but DTD includes a fuller spectrum of dysregulation resulting from the insults to multiple pathways in the developing brain when nurturing and is seen as a result of complex childhood trauma; more accurately describes the outcomes of such trauma in children than does the diagnosis PTSD158,238  
Pediatric medical traumatic stress (PMTS) The distress that children and family members experience during hospitalization for a perceived life-threatening diagnosis or while living with or caring for someone with life-altering chronic conditions239241 ; often related to the person’s subjective experience of the medical event rather than its objective severity and is mitigated by SSNRs that promote resilience 
Secondary traumatic stress (STS) A response that may occur in parents, other family members, and health care workers such as physicians, nurses, other hospital staff (including nonclinical staff), first responders, and therapists who are exposed to the suffering of others, particularly children242 ; may have many of the same long-term effects on health that affect children exposed to trauma; individual trauma histories can contribute to the reaction 
Social determinants of health (SDoHs) Conditions of the greater ecology or environment, occurring where people live, learn, work and play, which affect the neuroendocrine stress response and affect a wide range of health risks and outcomes8,22 ; can be mitigated by an SSNR and other protective factors and exacerbated by ACEs and intrafamilial and interpersonal traumas; examples include: poverty, food insecurity, homelessness, and lack of access to health care; examples that also overlap with the expanded ACEs include racism, discrimination, and community violence 
Trauma An event, series of events, or set of circumstances an individual experiences as physically or emotionally harmful that can have lasting adverse effects on the person’s functioning and mental, physical, emotional, or spiritual well-being14 ; can occur outside caregiving relationships (eg, dog bites, natural disasters), within the context of the caregiving relationship (eg, exposure to domestic violence, various forms of abuse or disordered caregiving because of parental mental illness or substance use disorder), or in the context of relationships outside the family (racism, bias, discrimination, bullying) 
Terminology of TraumasDefinitions
Acute stress disorder and Post-traumatic stress disorder (PTSD) Psychiatric diagnoses that include having experienced or witnessed a traumatic event and then having persistent symptoms that include the following: reexperiencing (intrusive thoughts, nightmares, or flashbacks); avoidance (feeling numb, refusing to talk about the event); hyperarousal (irritability, exaggerated startle response, always expecting danger); acute stress disorder: symptoms occur 3 d to 1 mo after traumatic exposure81 ; PTSD: symptoms must occur ≥3 mo after the trauma233  
ACEs Stressful or traumatic events, including child abuse and neglect, that occur within the primary caregiving relationship; often breach the parent-child relationship, which is fundamental to nurturing healthy development; linked in population studies to physiologic and behavioral changes impacting the health and well-being of patients over their life course with a wide array of health problems, including associations with substance misuse.10,21,24,80  The original ACEs (from initial study published in 1998) are the following: physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, intimate partner violence, mother treated violently, substance misuse within household, household mental illness, parental separation or divorce, and incarcerated household member. Subsequent studies have expanded the original ACE panel to include other adversities,9,234  including the following: experiencing racism, experiencing bullying, separation from caregiver (resulting from immigration, foster care, incarceration, death, or any other reason), witnessing violence, community violence,49  adverse neighborhood experience,235  and financial insecurity236  
Complex childhood trauma (as defined by the National Child Traumatic Stress Network) Encompasses both a child’s exposure to multiple interpersonal traumatic events, including maltreatment and household dysfunction, and the broad, pervasive, and predictable impact this exposure has on the individual child83,237 ; can disrupt a child’s attachment with caregivers, development, and sense of self 
Developmental trauma disorder (DTD) A proposed diagnosis based on evidence that children exposed to complex trauma are at risk for severe pervasive disruptions in their development in the domains of emotional health, physical health, attention, cognition, learning, behavior, interpersonal relationships, and sense of self; sometimes used interchangeably with complex childhood trauma; describes problems in affect dysregulation, negative self-concept, and difficulty with relationships that occur as a result of trauma-related developmental impairments; symptoms overlap or co-occur with several PTSD symptoms, but DTD includes a fuller spectrum of dysregulation resulting from the insults to multiple pathways in the developing brain when nurturing and is seen as a result of complex childhood trauma; more accurately describes the outcomes of such trauma in children than does the diagnosis PTSD158,238  
Pediatric medical traumatic stress (PMTS) The distress that children and family members experience during hospitalization for a perceived life-threatening diagnosis or while living with or caring for someone with life-altering chronic conditions239241 ; often related to the person’s subjective experience of the medical event rather than its objective severity and is mitigated by SSNRs that promote resilience 
Secondary traumatic stress (STS) A response that may occur in parents, other family members, and health care workers such as physicians, nurses, other hospital staff (including nonclinical staff), first responders, and therapists who are exposed to the suffering of others, particularly children242 ; may have many of the same long-term effects on health that affect children exposed to trauma; individual trauma histories can contribute to the reaction 
Social determinants of health (SDoHs) Conditions of the greater ecology or environment, occurring where people live, learn, work and play, which affect the neuroendocrine stress response and affect a wide range of health risks and outcomes8,22 ; can be mitigated by an SSNR and other protective factors and exacerbated by ACEs and intrafamilial and interpersonal traumas; examples include: poverty, food insecurity, homelessness, and lack of access to health care; examples that also overlap with the expanded ACEs include racism, discrimination, and community violence 
Trauma An event, series of events, or set of circumstances an individual experiences as physically or emotionally harmful that can have lasting adverse effects on the person’s functioning and mental, physical, emotional, or spiritual well-being14 ; can occur outside caregiving relationships (eg, dog bites, natural disasters), within the context of the caregiving relationship (eg, exposure to domestic violence, various forms of abuse or disordered caregiving because of parental mental illness or substance use disorder), or in the context of relationships outside the family (racism, bias, discrimination, bullying) 

It is important to be aware that the exposures of some child populations and their families put them at particular risk of experiencing trauma but also that the components of TIC can benefit these children and families.3134  More than 7.4 million children, or nearly 1 in 10 children, are reported as potential victims of child abuse and neglect annually.35  In 2019, more than 670 000 children spent time in foster care.36  Children who remain at home after child protective services investigation or are moved to kinship care resemble their peers in foster care in having an extremely high prevalence of significant childhood trauma.3739  Immigrant and refugee children may have left poverty, war, and violence, may have encountered abuse or separation from family members, and can be at risk for deportation, detention, and separation and discrimination.6,40,41  Poverty, or near poverty, affects approximately 43% of US children, and both urban and rural poverty have been linked with multiple stressors and increased risk of trauma.4244  Children of underrepresented racial, ethnic, and religious groups are more likely to be exposed to discrimination.45,46  The psychological, interpersonal, and perhaps physiologic effects of trauma inflicted on a community (particularly because of race, identity, or ethnicity) may be passed to succeeding generations and is referred to as historical trauma.47,48  Community violence and bullying, along with cyberbullying, are experienced by many children and recognized as traumatic exposures included in expanded definitions of ACEs.4951  Lesbian, gay, bisexual, transgender, and queer children and adolescents, children of color, American Indian and Alaskan native children, immigrant children, neurodiverse children and adolescents, and children and adolescents with overweight and obesity are all more likely to experience discrimination, both overt and as a series of microaggressions (small slights, insults, or indignities either intentional or unintentional) that accumulate over time.5254  Additionally, children of military families have a higher prevalence of trauma, abuse, grief, and loss.55  Populations at higher risk for pediatric medical traumatic stress include preterm infants, children with complex and/or chronic medical conditions, and those suffering from serious injury or illness.56  Up to 80% of children and family members experience trauma symptoms after a life-threatening illness, injury, or painful medical procedure.57 

TIC transforms the fundamental questions in medical care from “What is wrong with you?” to “What happened to you?” and, finally, to “What’s strong with you?” A trauma-informed approach acknowledges the biological effects of adversity without suggesting that childhood adversity is destiny. It requires a compassionate approach that does not suggest blame. It requires pediatric health care workers at every level to understand the context of a child’s relationships, especially within the family, and ask, “What are the caregiver’s strengths and challenges?” “What are the child’s strengths and challenges?” and “Who supports you?” This changes the pediatric role from “I must fix you” to “I must understand you (and the relationships that created you and can help you heal).”25,58  Thus, readiness includes an understanding of what provides resilience and how to promote it.

TIC is fundamentally relational health care, the ability to form and maintain safe, stable, and nurturing relationships (SSNRs). Pediatricians are able to support the caregiver-child relationship, the context in which there can be recovery from trauma and the restoration of resilience. Fundamental to these concepts is an understanding of attachment.

Attachment describes the emotionally attuned give-and-take between caregiver and child and the trust, safety, and security provided to the child59  that promotes healthy brain growth, development of accurate mental maps of self and others, development of resilience, and protection from trauma.60  Fundamentally, the predictable compassionate availability of the caregiver promotes the secure attachment of the child.61,62  Recent studies show attachment remains malleable beyond infancy, even into adolescence and adulthood, to some extent.63,64 

Effective parenting encompasses the skills that caregivers bring to the task of parenting and is the context in which secure attachment develops and is relied on during and after traumatic experiences. Although caregivers approach parenting with a range of skills, attitudes, and beliefs rooted in their cultural and family contexts, studies have shown that effective or positive parenting has some universal features.6567 

It is through secure attachment with a predictably empathic caregiver that children learn to regulate their emotions. Children start by turning to a caregiver when upset. The caregiver comforts the child by touch, words, and compassion, which shuts down the stress response and restores emotional regulation. Secure attachment happens as a child predictably receives this sympathetic support from the caregiver when the child is distressed and the child comes to confidently anticipate that support. This relationship becomes a reliable source of safety, and the caregiver is a secure base from which the child can explore their environment.62  Multiple studies have shown that a secure attachment relationship is the best means for building or rebuilding resilience in children; it is also the context for promoting healthy brain growth and development.62,65,68,69  With these positive affiliative experiences, modulation of the stress response begins and includes the release of oxytocin, a potent hormone regulator of the sense of safety and well-being.68,70 

Thus, the first step of TIC is to assess this aspect of the relationship, observing the child-caregiver interaction, including the caregiver’s attention to the child, the caregiver’s ability to read and respond to the child in developmentally appropriate ways, and the child’s ease, comfort, and response to the caregiver. Discussion can begin by focusing on the caregiver’s and child’s strengths and noting the constructive aspects of the relationship while providing the caregiver with empathy. When attachment is strained, caregivers have often lost empathy for the child. The positive regard and attuned attentive listening provided before and while raising concerns supports the caregiver. The empathy provided to the caregiver thus allows the opportunity for them to reattune to the child.62 

Resilience is defined as a dynamic process of positive adaptation to or despite significant adversities.71  This is not a static or innate quality but includes skills children can learn over time with reliable support from attachment figures. The development of resilience includes aptitudes that are attained through play, exploration, and exposure to a variety of normal activities and resources. Studies have shown that development can be robust, even in the face of severe adversity, if certain basic adaptational mechanisms of human development (resilience factors) are protected and in good working order. These mechanisms include attachment to a competent caregiver, cognitive development with opportunity for continued growth, mastery of age-salient developmental tasks, self-control or self-regulation, belief that life has meaning, hope for the future, a sense of self-efficacy, and a network of supportive relationships.71  On the other hand, if those basic adaptational mechanisms or protective factors are absent or impaired before, during, or after the adversity, then the outcomes for children tend to be poorer71  (see Table 4).

TABLE 4

Adaptational Mechanisms of Resilience

Thinking and learning brain, with opportunity for continued growth; cognitive development 
Hope, optimism, faith, belief in a future for oneself 
Regulation (self-regulation, self-control of emotions, behaviors, attention, and impulses) 
Efficacy (self-efficacy) or sense that one can impact their environment or outcomes 
Attachment, secure attachment relationship with safe, stable, and nurturing caregiver or competent caregiver 
Development, mastery of age-salient developmental tasks 
Social context, or the larger network of healthy relationships in which one lives and learns 
Thinking and learning brain, with opportunity for continued growth; cognitive development 
Hope, optimism, faith, belief in a future for oneself 
Regulation (self-regulation, self-control of emotions, behaviors, attention, and impulses) 
Efficacy (self-efficacy) or sense that one can impact their environment or outcomes 
Attachment, secure attachment relationship with safe, stable, and nurturing caregiver or competent caregiver 
Development, mastery of age-salient developmental tasks 
Social context, or the larger network of healthy relationships in which one lives and learns 

Adapted from Masten AS. Ordinary magic. Resilience processes in development. Am Psychol. 2001;56(3)227–238; Forkey H, Griffin J, Szilagyi M. Childhood Trauma and Resilience: A Practical Guide. Itasca, IL: American Academy of Pediatrics; 2021.

Robust implementation of TIC is strength-based, building on family protective factors rather than emphasizing deficits. At almost every encounter, from early childhood through adolescence, pediatric care can include resilience promotion, building on identified strengths. Because resilience is a dynamic process of positive adaptation, routine anticipatory guidance about development or safety can be used to promote relational health and positive childhood experiences, including achievements at home, at school, and in neighborhoods, which enhance resilience.72  When addressing adversities or concerns about development, surmounting the challenges can be framed with resilience and positive experiences as the goal.73  For example, when speaking with a caregiver about a child learning to fall asleep on their own, sleep skills can be framed as building resilience by supporting self-regulation and self-efficacy. Alternatively, when a caregiver expresses concern about a child or teenager who had been sleeping until experiencing a traumatic event, the discussion can be framed around what resilience factors are being challenged (developmental skill mastery, self-efficacy, self-regulation) and which ones can be used to support the child’s recovery (attachment and thinking).

Detection involves both surveillance and formal screening to identify children and families with the history of exposure to potentially traumatic experiences as well as those who exhibit signs and symptoms of trauma. Although TIC is common in social services and other mental health settings, in a health care environment, TIC can be conceptualized by using a medical model. Similar to other medical conditions, TIC includes purposeful triage, engagement, history-taking, surveillance and screening, examination, differential diagnosis, sharing of the diagnosis, and management, which may include office-based anticipatory guidance, referral, psychopharmacology, and/or follow-up or recommendations.

Surveillance for maladaptation after experiencing trauma includes consideration of all those who may be affected by exposure to the direct suffering of the child. Health care workers, such as first responders, nurses, social workers, trainees, physicians, and nonclinical hospital or clinic employees, may be deeply affected by witnessing or hearing about the traumatic experiences of children. Parents (biological, foster, kinship, or adoptive) are particularly at risk for prolonged trauma reactions that may impair their ability to care for and comfort their children. Siblings may also be affected, particularly when there is complex trauma or exposure to suffering, such as having a sibling with cancer or another life-altering disease that involves chronic pain.

Peri-trauma refers to situations in which medical providers are caring for children as the traumatic events are unfolding. One example is pediatric medical traumatic stress. Pediatric medical traumatic stress is a situation in which children experience medical procedures or other aspects of medical care as traumatic events. The effects of such trauma can be mitigated by attending to the child’s and family’s experience of medical care and reducing (as much as possible) frightening or painful aspects of necessary care and procedures. This mitigation can include asking children (and caregivers) about their fears and worries, optimizing pain management and comfort measures, and working with caregivers to increase their ability to provide effective support for their child. The Healthcare Toolbox includes a number of specific suggestions, including assessing distress (D), providing emotional support (E), and addressing the family needs (F)—a D, E, F protocol to follow the A, B, Cs of resuscitation.74 

Another comprehensive strategy used by schools and community agencies when a mass trauma or disaster occurs is Psychological First Aid (PFA).75  Developed by the National Child Traumatic Stress Network, PFA is an evidence-informed program that is designed to help children, families, adults, and other witnesses in the immediate aftermath of a disaster or terror event. Core skills for implementation of PFA are identical to TIC: establish an emotionally safe environment, connect with primary support persons (relational health), link to community resources, and provide psychoeducational materials to help understand the potential responses of children to the exposure.

The first step in medical care is to identify an emergency versus nonemergency situation. When dealing with trauma, its causes, or its consequences, consideration of whether a child may be emergently at risk requires assessment and response as a top priority. In practicing TIC, protocols and practices to identify and address child or family safety issues, both physical and psychological, are integral to care.

Trauma may result from children being in unsafe settings because of abuse, neglect, or impaired caregiving. When the practitioner suspects maltreatment or failure of the caregiver to protect a child at any point in a health encounter, referral to child protective services is necessary and mandated. These issues need to be considered even before screening and addressed with standard protocols to respond to identified risks.7678 

Other immediate safety issues may arise when a consequence of trauma is self-harm or intent to injure others. Screening for suicidality, self-injury, or intent to harm others is included in TIC along with clear protocols for how to address positive endorsement of these issues.

TIC creates a respectful and emotionally safe space in which to engage children, adolescents, and families around the discussion and management of these issues and to prevent retraumatization. Discussion of trauma may raise stress levels, and appropriate engagement reassures the child and family that the setting is safe. Culture can also affect how trauma is experienced and understood by families, and cultural awareness can ease the conversation. Engaging children and families begins with greeting the patient and family and being fully present in the moment while maintaining a balance between professionalism and friendliness. It involves initially asking open-ended questions, followed by more specific and probing questions as needed and that are elicited by caregiver and child or adolescent responses. It involves listening in an active, nonjudgmental, attuned way, reflecting back to the family what is heard for clarification and confirmation, seeking clarification when necessary, paraphrasing, attending to and reflecting on the emotions that accompany the information, and summarizing what is discussed. Implicit bias can affect the provider’s ability to be nonjudgmental in these conversations.46,79  Acceptance, curiosity, and empathy are conveyed to the patient or caregiver in the process of attentive listening.61  Engagement also involves mutual regard between the provider and family. Adolescents and capable children bring their own perspective. Each brings expertise to the TIC of the child or adolescent. The provider has expertise in medicine, whereas the patient and family have expertise about the child, what happened, and their situation, beliefs, strengths, and culture.

When working with families and patients who have experienced trauma, the provider’s body language, affect, and tone of voice can promote or inhibit care. Affect describes the facial and body expressions that reflect our emotional state. Individuals who have experienced trauma are more sensitive to body language, facial expressions, and tone of voice.70  Approaching children slowly and calmly or letting them sit with a caregiver and using higher pitched, more musical speech may ease a child’s tension because these sounds are associated with the release of oxytocin in the amygdala, resulting in calming of this threat-sensitive brain area. A shift to low tones during a discussion may alert a child or caregiver to potential danger and stimulate defensive responses.61 

Much of the information needed to integrate TIC into practice may be obtained as part of the routine health evaluation. Social, developmental, and medical history are all opportunities to identify risks, stressors, and strengths. The health history provides an opportunity to assess child and family resilience factors, social connectedness, parenting attitudes, and skills. The review of systems allows the medical provider to collect symptoms of trauma that may not have been identified in the chief complaint but that can offer valuable insight into the current impact of trauma on the patient.80,81  Symptoms may be functional, neurodevelopmental, or related to immune function.

  1. Functional symptoms: Manifestation of the symptoms of trauma may evolve over time. Functional complaints can result after single- incident traumas (eg, automobile crash, hurricane) or may be early manifestations of complex trauma.8284  Sleep difficulty, changes in appetite, toileting concerns (eg, constipation, abdominal pain or enuresis), and challenges with school functioning (eg, poor attention or attendance) may be the early presentation of ongoing trauma.84,85  Diagnostic criteria for attention-deficit/hyperactivity disorder and adjustment disorder overlap with some of these functional symptoms. When these signs and symptoms are noted, it can be useful to include trauma in the differential diagnosis.17,86,87 

  2. Neurodevelopmental symptoms: Some of the most recognizable manifestations of early trauma result from the effect on areas of the rapidly developing brain of young children. Developmental skill acquisition (higher brain) can be hindered as recognition of and response to threat is prioritized (lower brain).88,89  Specific areas of the brain affected are the limbic system, hippocampus, and prefrontal cortex.12,13,9092  The prefrontal cortex is involved in cognition, emotional regulation, attention, impulse control, and executive function. Consequently, children may have developmental delay and behave as if they are younger than their actual age89,93  (see Table 5 for an easy way to remember these effects). Other observed symptoms may include the following:

    • rapid, reflexive response to stimuli, reminders, or triggers93,94 ;

    • inattention, poor focus, hyperactivity, and difficulty completing tasks86,95 ;

    • difficulty tolerating negative mood so the child seeks ways to defuse the tension through hyperactivity, impulsive behaviors, aggression, self-harm, such as cutting and suicidality, or engagement in health risk behaviors (substance use, sexual activity)89,95,96 ;

    • reactions to stimuli, triggers, or reminders can be transient and flip suddenly back to “normal”; this appears to the observer as emotional lability88,92 ; and

    • negative world view and self-narrative; flat affect; difficulty engaging socially or viewing themselves as worthless.88,92,97 

  3. Immune function symptoms: When a child is exposed to early, severe, or prolonged trauma, the immune system is chronically pressed into action, and, over time, changes can occur in the inflammatory system and humoral immunity.80,89  A persistent inflammatory response can leave children vulnerable to diseases, such as asthma and metabolic syndrome.80,98,99  Humoral immunity may be impaired so that children are more susceptible to infection. Additionally, immune system stimulation may result in the “sick syndrome,” which is a perception of feeling unwell that can include headaches, stomachaches, and lethargy.80,81 

TABLE 5

Most Common Symptoms of Trauma Exposure

Frets (anxiety and worry) and fears 
Regulation difficulties (disorders of behaviors or emotions; hyperactive, impulsive, easily becomes aggressive or emotional; inattentive) 
Attachment challenges (insecure attachment relationships with caregivers); poor peer relationships 
Yawning (sleep problems) and yelling (aggression, impulsivity) 
Educational and developmental delays (especially cognitive, social-emotional, and communication) 
Defeated (hopeless), depressed, or dissociated (separated from reality of moment, lives in own head) 
Frets (anxiety and worry) and fears 
Regulation difficulties (disorders of behaviors or emotions; hyperactive, impulsive, easily becomes aggressive or emotional; inattentive) 
Attachment challenges (insecure attachment relationships with caregivers); poor peer relationships 
Yawning (sleep problems) and yelling (aggression, impulsivity) 
Educational and developmental delays (especially cognitive, social-emotional, and communication) 
Defeated (hopeless), depressed, or dissociated (separated from reality of moment, lives in own head) 

Adapted from Forkey H, Griffin J, Szilagyi M. Childhood Trauma and Resilience: A Practical Guide. Itasca, IL: American Academy of Pediatrics; 2021.

Surveillance or monitoring is the process of recognizing children who might be at risk for being affected by trauma and is modeled after developmental surveillance. Surveillance is less formal than screening and can be conducted at every visit. Asking about caregivers’ concerns, obtaining a trauma history, observing the child, and identifying risk and protective factors provides information about resilience supports and trauma exposure.100  Surveillance requires attention to relationships and engagement. Questions such as “Has anything scary or concerning happened to you or your child since the last visit?” are a way to more specifically explore the possibility of adverse experiences.85  Recognizing that certain symptoms may indicate exposure to childhood adversities, we can ask, “What has happened to you (or your family)?” For adolescents, these questions can be asked as part of the HEADSSS (questions about Home environment, Education and employment, Eating, peer-related Activities, Drugs, Sexuality, Suicide/depression, and Safety) psychosocial interview.101,102  Questions that are considered less threatening are asked first and followed with questions that may be perceived as more intrusive.101  Providers may be concerned that asking questions about a family’s needs, a child’s trauma history, or a child’s symptoms may distress the child or caregiver, but studies in which this topic has been explored indicate that, when the topic is raised, families respond well to having the issues acknowledged and addressed in a supportive setting.85,103,104 

Children only heal from trauma in the context of SSNRs, so it is also necessary to ask about the strengths that are already present in the family. Starting these conversations with questions about child, adolescent, or family strengths frames the conversation in a positive and resilience-focused way.105,106  For instance, a clinician may ask how the child, adolescent, or family copes with stress, what a teenager does well, whether they have frequent family meetings to talk about solving problems, and whether each member of the family has someone to turn to for safety and comfort when they are upset. Trauma that occurs because of problems in the primary attachment relationship represents the greatest threat to the child or adolescent and may be the most challenging for providers to explore. Caregivers may have their own trauma histories or mental health struggles, substance use issues, and/or multiple stressors related to social determinants of health (SDoHs), including poverty, housing instability, and violence exposure that affect their parenting. Exploring parenting stressors, strengths, and attitudes in conversation can help the provider to pinpoint specific leverage points to help children but may also create an opportunity for the caregiver to reflect about the effects of their parenting or stressors on the child. TIC is compassionate and assumes that all caregivers love their children and are doing the best they can. It also assumes that children are doing the best they can.107,108  Adolescents should be included in these conversations and have a role in identifying strengths and challenges. Pediatricians who have cared for a family over time may already have considerable insight into the family’s dynamics and be able to engage the caregivers in an empathic yet open conversation. Furthermore, compassionate surveillance can be combined with use of screeners or questionnaires to elicit more information.

Validated screeners used at preventive health care visits can provide valuable information about child development, mental health, and behavior.109  They can be reassuring when normal or alert the pediatric provider to symptoms or risks when borderline or abnormal. Commonly used tools, such as the Ages and Stages Questionnaire,110  the Pediatric Symptom Checklist,111  the Strengths and Difficulties Questionnaire,112  and the Patient Health Questionnaire-9113  may elicit symptoms that are the possible result of trauma (developmental delays, social-emotional problems, anxiety, etc). Perinatal depression screening may not only identify symptoms of this illness but provide opportunities to explore maternal stressors and strengths.114  Those exposed to known traumas can be evaluated by using standardized posttraumatic stress disorder (PTSD) screening tools such as the PTSD Reaction Index Brief Form,115  and those exposed to medical traumas can be evaluated by using a tool such as the Psychosocial Assessment Tool.116,117  The Pediatric Traumatic Stress Screening Tool in the Intermountain Care Process Model has been recently developed to screen for pediatric traumatic stress in the primary care setting, either as a universal screen or with targeted screening when traumas are known.118  These tools effectively help identify the diagnostic criteria for PTSD, although they are not designed to identify the full spectrum of symptoms of complex trauma (developmental trauma disorder [DTD]).

Screening, per American Academy of Pediatrics (AAP) guidelines, suggests using instruments that are standardized and validated and have defined psychometric properties (sensitivity, specificity, positive predictive value). By that definition, there are currently no screening tools for ACEs and only a few validated screening tools for SDoHs. However, standardized (but not validated) tools are being used in some pediatric settings to assess ACEs and SDoHs and are using aggregate risk scoring to target providing increased support.119121  Many of the available screening tools expanded on the domains included in the original Centers for Disease Control and Prevention/Kaiser ACE study to include additional items applicable to urban and minority populations, including witnessing neighborhood violence and experiencing bullying or discrimination.9  Parental ACE screening may offer the opportunity to align with caregivers and build a partnership to explore issues that may be affecting their parenting. Indeed, several recent studies suggest that parental ACEs can be linked with concerning outcomes for children.122125  Concurrent resilience screening offers the opportunity to identify protective factors that can buffer identified stressors, thus providing more nuanced understanding of a child’s risk. Screening also offers the opportunity to then frame the discussion around promoting strengths in the caregiver-child relationship to protect a child from toxic stress and build adaptive skills.107  Similar to ACE screening, there are few available standardized validated resilience screening tools, although the Connor-Davidson Resilience Scale126  and Brief Resilience Scale127  assess caregiver resilience.128  (Readers are referred to the AAP Screening Technical Assistance Web site at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/About-Us.aspx for developmental and SDoH screening tools.)

A limitation of ACE and SDoH screening tools is their lack of nuance: they identify risk factors that have been derived from epidemiological studies, not outcomes at the individual level.129,130  Those outcomes are the result of the physiologic response to adversities. Although currently only available in the research setting, biomarkers of this physiologic response have the potential to be more accurate measures of the effects of adversity at the individual level.131133  Eventually, clinic-friendly, noninvasive biomarkers could also be used to identify patient-specific response to both stressors and therapeutic interventions.134,135 

Screening health care workers for the effects of hearing about and addressing the trauma experiences of others is most commonly achieved with informal self-assessment strategies to identify symptoms or experiences that may be associated with burnout or STS.136  Substance use disorder, depression, and suicidality may be associated with exposure to secondary trauma, and there appears to be overlap between burnout and STS.137144  An example of a screening tool for health care workers is the Professional Quality of Life Scale,145  which includes subscales for compassion satisfaction, burnout, and STS.

Cultural considerations affect all aspects of TIC, including screening. Instruments that are not normed for the population or translated and validated in the language of the patient and family can result in misleading results. Thus, it is important to consider screening results cautiously with consideration of the family’s culture and ethnicity in relation to the screening tool being used.146 

Blood pressure measurement at preventive health visits or when stress is a potential etiologic factor for concerns is indicated.147  Elevated blood pressure may be the first symptom of childhood traumatic stress, especially as youth age.148,149  Abnormalities in hearing, vision, and growth parameters can be clues to adversities.150,151  Overweight and obesity have been associated with ACEs.152154  Physical examination may reveal signs of neglect or abuse. The immunologic effect of trauma may result in inflammatory or infectious consequences identifiable on examination.1,80,99,155,156  Children who have sustained cumulative ACEs and traumas may exhibit certain common behaviors the provider may witness during physical and mental health evaluation (refer to history and symptoms described earlier).

The provider is encouraged to consider trauma as a possible etiology in the assessment of developmental, mental health, behavioral, and physical symptoms in all pediatric encounters because of the following: (1) the experience of adversity is so common; (2) the symptoms of trauma overlap with the symptoms of other common pediatric conditions87,95 ; and (3) failure to do so might lead to an incorrect or incomplete diagnosis and treatment, enabling the effects of trauma to further embed.17,157,158  Trauma may be mistaken for other conditions, such as attention-deficit/hyperactivity disorder, and includes symptoms that overlap with other diagnostic categories, such as anxiety and depression.86,87,159  It has been proposed that trauma may result in a different “ecophenotype” of common conditions that have a different trajectory and different response to common treatments.93  Children may also have comorbid conditions, such as ADHD, anxiety, depression, or developmental and learning issues, because they frequently accompany childhood trauma. A more detailed description of diagnoses that are commonly confused with trauma or comorbid with it are covered in the AAP clinical report “Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication.”87 

Pediatric providers may encounter children with a wide range of symptoms resulting from trauma. As noted, trauma can result in short-term changes in behavior or have a more lasting impact depending on the child, the trauma itself, and the supports or emotional buffers in a child’s life. When traumatic events are more severe, prolonged, or less buffered by a caregiver, effects on various aspects of functioning can be more severe.1,160163  Children exposed to chaotic households, abuse, or neglect, especially in the early years of life, may have more severe symptoms and symptoms that evolve over time.94,159,164,165  Diagnostically, this may result in children who have functional symptoms (short-term problems with sleeping, eating, toileting), adjustment disorder, PTSD, or complex trauma symptoms.163,166,167 

Some parents and caregivers may come to understand the role of adversities in their child’s symptoms through discussion of the trauma history and symptoms, and others will require the provider to explain this connection before they can appreciate the provider’s advice and recommendations. Psychoeducation is the first step in management of childhood trauma and includes empathic, nonjudgmental sharing of diagnostic information and provider concerns about the etiology of a child’s symptoms The provider’s role is to integrate the child or adolescent and caregiver’s concerns, the child or adolescent’s symptoms, and elements of a thorough history and examination into an explanation of why this raises a concern about trauma exposure or why trauma may be the underlying cause or one of the causes of a child’s symptoms, much as is done for any diagnosis. A simple explanation of the pathophysiology of trauma may help the caregiver to move from frustration with the child or adolescent’s behaviors or symptoms to empathy. In some situations, the explanation may also provide the caregiver with insight into their own history of trauma and its impact on their parenting behaviors or responses to their child’s behaviors, or how an event that affected their child may have traumatized the caregiver as well.

Psychoeducation includes acknowledging that a trauma history can affect behavior and thoughts, with some discussion of how that happens. Table 6 has information on specific psychoeducation. The variable responses of children to trauma can be frustrating or confusing. Discussion of the emerging data on the biological sensitivity to context may be useful to caregivers.168,169  Genetic variations in how a person responds to stress may contribute to a child’s sensitivity to adversity.170  Yet, those with high reactivity who are supported and learn to channel that reactivity to positive activities and passions may have the greatest potential.168  This information, along with specific suggestions about how to support children, can address some of the consternation of caregivers regarding children’s heterogeneous responses to both adversity and interventions.

TABLE 6

Responses to Trauma to Explain to Caregivers: Psychoeducation

Impacts of Trauma on Function and BehaviorClinical Presentation
Changes in auditory processing Children may lose the ability to hear sounds of safety (musical high-pitched voice) and be preferentially attuned to low-pitched sounds that warn of caregiver depression and anger.247  
Changes in how children interpret facial expressions Children may misinterpret the affects and emotions of others, particularly confusing anger and fear.93  
Limited vocabulary for emotions Children may also not accurately recognize or express their own emotions, leading them to act out or respond in ways that seem “off.” What a child (or caregiver) identifies as “anger” may be disappointment, frustration, fear, grief, or anxiety.88  
Negativity Trauma results in children having overactive limbic systems with a focus on safety and a presumption of danger. This can result in strong negative reactions as the first response to a stimulus that might be benign or ambiguous.61  
Triggers Triggers can be physical (smells or sounds that recall details of the trauma) or emotional (feeling embarrassed or shamed, recalling how child felt during abuse). Prevention of exposures to reminders or triggers is the best approach. Triggers may be subtle, so educating and assisting caregivers with their identification is key. This helps caregivers understand a child’s response.167  
Learned Behavior Behaviors that were adaptive for a child in a previous environment may be maladaptive in their current environment. These behaviors can evoke some of the same reactions from caregivers that the child experienced with other adults, reinforcing a familiar pattern of interactions that may not be productive in the new setting.61  
Impacts of Trauma on Function and BehaviorClinical Presentation
Changes in auditory processing Children may lose the ability to hear sounds of safety (musical high-pitched voice) and be preferentially attuned to low-pitched sounds that warn of caregiver depression and anger.247  
Changes in how children interpret facial expressions Children may misinterpret the affects and emotions of others, particularly confusing anger and fear.93  
Limited vocabulary for emotions Children may also not accurately recognize or express their own emotions, leading them to act out or respond in ways that seem “off.” What a child (or caregiver) identifies as “anger” may be disappointment, frustration, fear, grief, or anxiety.88  
Negativity Trauma results in children having overactive limbic systems with a focus on safety and a presumption of danger. This can result in strong negative reactions as the first response to a stimulus that might be benign or ambiguous.61  
Triggers Triggers can be physical (smells or sounds that recall details of the trauma) or emotional (feeling embarrassed or shamed, recalling how child felt during abuse). Prevention of exposures to reminders or triggers is the best approach. Triggers may be subtle, so educating and assisting caregivers with their identification is key. This helps caregivers understand a child’s response.167  
Learned Behavior Behaviors that were adaptive for a child in a previous environment may be maladaptive in their current environment. These behaviors can evoke some of the same reactions from caregivers that the child experienced with other adults, reinforcing a familiar pattern of interactions that may not be productive in the new setting.61  

Adapted from the National Child Traumatic Stress Network. Families and caregivers. Available at: https://www.nctsn.org/audiences/families-and-caregivers. Accessed January 11, 2021;243  US Department of Health and Human Services, Administration for Children and Families. Resources on trauma for caregivers and families. Available at: https://www.childwelfare.gov/topics/responding/trauma/caregivers/. Accessed January 11, 2021244 ; and American Academy of Pediatrics. Parenting After Trauma: Understanding Your Child’s Needs. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/FamilyHandout.pdf. Accessed June 24, 2021245 .

Trauma-informed anticipatory guidance provided by pediatricians can help families promote resilience and begin to address the effects of trauma. If screening for SDoHs is being conducted and/or social needs are identified, referral to applicable community-based services is indicated (eg, food bank, pro bono legal aid, etc). Having a list of community providers, such as Early Head Start, Head Start, evidence-based maternal, infant, and early childhood home visiting programs, state Maternal Child Health Title V programs, and Family to Family Health Information Centers ready for distribution, directly contacting the referral provider with the patient present, or providing formal care coordination all facilitate family engagement and help families connect to needed community resources. For older children and adolescents, trauma-informed schools and teenager crisis centers may be available in the community. In trauma-informed schools, personnel at all levels have a basic realization about trauma and an understanding of how trauma affects student learning and behavior in the school environment.171,172 

Every encounter in an office setting, from those with young children to those with adolescents, is an opportunity to strengthen the attachment between a child and caregiver.173  Through techniques such as reinforcing positive back-and-forth interactions between a parent and a child (serve and return), helping the caregiver to understand the child’s experience (keeping the child’s mind in mind), helping the children to learn words to describe a variety of emotions, and promoting self-reflection concerning the caregiver’s own trauma history, the pediatric clinician can render primary prevention against the development of anxious and maladaptive attachment patterns and promote regulation.82,174  Examples of relevant anticipatory guidance include advice, resources, or referrals to community programs, including Reach Out and Read175177 ; developmentally appropriate play with others178180 ; promoting positive, authoritative (in contrast to punitive or authoritarian) parenting styles181183 ; and mindfulness.184186 Table 7 includes specific advice to promote regulation after trauma.

TABLE 7

Anticipatory Guidance

Office-Based Guidance to Promote Regulation After Trauma
Restoring safety To reduce the stress response after trauma, caregivers can: repeatedly assure a child or teenager that they are safe now; allow the youth to express how they feel and listen attentively; provide extra physical contact (if appropriate) with hugs, touch, and rocking for younger children. 
Routines Routines or rituals also help reduce the stress response after the unpredictability and chaos of trauma by restoring a sense of order. Caregivers can use visual (pictorial schedule or charts) and verbal cues for well-defined mealtimes, sleep times, and rituals (“Before bed, we are going to brush teeth, read a story, sing a song, and then turn lights out”). Preparing children for changes in routines, or, for the child in foster care or the child of separated or divorced parents, for visitation, can reduce stress responses. 
Relaxation techniques Provide information verbally, with printed instructions or on phone apps that guide relaxation, meditation, and mindfulness. Refer to community programs that provide training in belly breathing, guided imagery, meditation, mindfulness, yoga, stretching, and massage, which can help to reduce the fight-or-flight responses and symptoms.247  
Time-in or special time Dedicated, child-chosen or child-directed play with a caregiver. Caregiver chooses a time that works for them and plans to spend 10 to 30 min with the child in fun activity of child’s choosing. For infant or toddler, reading time is a good example of “time-in.” Recommended for children from early childhood through adolescence. 
Small successes Children who experience trauma may have delays in skill development. Expectations may need to be tailored to the child’s developmental level rather than actual age. It may take lots of repetition and practice before a skill or behavior is learned, so it is useful to celebrate and reward small steps toward desired behaviors. 
Emotional container Child may have strong emotions if reminded of trauma, and the emotions may be directed at the caregiver, although they are usually not about the caregiver. Caregiver needs to remain calm to model self-regulation and avoid retraumatizing the child. 
Cognitive triangle Thoughts impact feelings, which then impact behavior, which then reimpacts thoughts. For example, if children worry they cannot fall asleep, they will then feel nervous and stressed, and then not be able to fall asleep, reinforcing their cognitive belief that they cannot fall asleep. Similarly, if children think no one likes them, they will feel rejected and may lash out at another child, leading to rejection by that child and reinforcing their belief that they are not liked. It can help to identify this triangle and break the link between thoughts and emotions (through new experiences that link thought with different emotions) and/or the link between the emotions and the behavior (“It is ok to feel ___, but it is better to do ___ than to do ____.” This technique involves labeling the emotions and teaching an alternative behavior.) 
Distraction Children who are dysregulating may benefit from distraction from the traumatic thoughts by suggesting a game, music, calling a friend, or deep breathing in a calm environment. 
Positive parenting techniques Positive parenting techniques have to be adapted to the age and developmental stage of the child, but they are principles that are known to work: (1) helping children identify and name their emotions; the next step for the child is to understand the emotion and then to learn healthy ways to express the emotion and build regulation skills; (2) reassuring safety and keeping the child safe both emotionally and physically; (3) attuned, attentive listening, which starts in infancy with “serve and return” but evolves into conversational exchanges over time; (4) setting appropriate boundaries and providing guidance through connecting and listening with children; it is best to teach rather than tell or command; for example, “We draw on paper, not on walls, because it is hard to wash markers off the walls”; (5) catching the child being good and offering the child positive, specific praise for good behaviors; (6) implementing rewards and privileges to create opportunities to develop skills; start small so the child can earn a reward quickly and then build up; (7) using positive language instead of “no” commands: for example, “We color on paper, not on the table,” is a better way to approach a child who is drawing on the table than, “Stop that,” Or, “we use gentle hands—we don’t hit others”; (8) being a good role model as child mimics what they see rather than what they are told; (9) having some fun together as a family (time-in): read, talk, sing, play; (10) reinforcing positive skills as they develop: cooperation, politeness, appropriate assertiveness, kindness, etc; and (11) the law of natural consequences: sometimes the best lesson is letting the consequences play out (not cleaning your room means it will be a mess when your friends come over). 
Office-Based Guidance to Promote Regulation After Trauma
Restoring safety To reduce the stress response after trauma, caregivers can: repeatedly assure a child or teenager that they are safe now; allow the youth to express how they feel and listen attentively; provide extra physical contact (if appropriate) with hugs, touch, and rocking for younger children. 
Routines Routines or rituals also help reduce the stress response after the unpredictability and chaos of trauma by restoring a sense of order. Caregivers can use visual (pictorial schedule or charts) and verbal cues for well-defined mealtimes, sleep times, and rituals (“Before bed, we are going to brush teeth, read a story, sing a song, and then turn lights out”). Preparing children for changes in routines, or, for the child in foster care or the child of separated or divorced parents, for visitation, can reduce stress responses. 
Relaxation techniques Provide information verbally, with printed instructions or on phone apps that guide relaxation, meditation, and mindfulness. Refer to community programs that provide training in belly breathing, guided imagery, meditation, mindfulness, yoga, stretching, and massage, which can help to reduce the fight-or-flight responses and symptoms.247  
Time-in or special time Dedicated, child-chosen or child-directed play with a caregiver. Caregiver chooses a time that works for them and plans to spend 10 to 30 min with the child in fun activity of child’s choosing. For infant or toddler, reading time is a good example of “time-in.” Recommended for children from early childhood through adolescence. 
Small successes Children who experience trauma may have delays in skill development. Expectations may need to be tailored to the child’s developmental level rather than actual age. It may take lots of repetition and practice before a skill or behavior is learned, so it is useful to celebrate and reward small steps toward desired behaviors. 
Emotional container Child may have strong emotions if reminded of trauma, and the emotions may be directed at the caregiver, although they are usually not about the caregiver. Caregiver needs to remain calm to model self-regulation and avoid retraumatizing the child. 
Cognitive triangle Thoughts impact feelings, which then impact behavior, which then reimpacts thoughts. For example, if children worry they cannot fall asleep, they will then feel nervous and stressed, and then not be able to fall asleep, reinforcing their cognitive belief that they cannot fall asleep. Similarly, if children think no one likes them, they will feel rejected and may lash out at another child, leading to rejection by that child and reinforcing their belief that they are not liked. It can help to identify this triangle and break the link between thoughts and emotions (through new experiences that link thought with different emotions) and/or the link between the emotions and the behavior (“It is ok to feel ___, but it is better to do ___ than to do ____.” This technique involves labeling the emotions and teaching an alternative behavior.) 
Distraction Children who are dysregulating may benefit from distraction from the traumatic thoughts by suggesting a game, music, calling a friend, or deep breathing in a calm environment. 
Positive parenting techniques Positive parenting techniques have to be adapted to the age and developmental stage of the child, but they are principles that are known to work: (1) helping children identify and name their emotions; the next step for the child is to understand the emotion and then to learn healthy ways to express the emotion and build regulation skills; (2) reassuring safety and keeping the child safe both emotionally and physically; (3) attuned, attentive listening, which starts in infancy with “serve and return” but evolves into conversational exchanges over time; (4) setting appropriate boundaries and providing guidance through connecting and listening with children; it is best to teach rather than tell or command; for example, “We draw on paper, not on walls, because it is hard to wash markers off the walls”; (5) catching the child being good and offering the child positive, specific praise for good behaviors; (6) implementing rewards and privileges to create opportunities to develop skills; start small so the child can earn a reward quickly and then build up; (7) using positive language instead of “no” commands: for example, “We color on paper, not on the table,” is a better way to approach a child who is drawing on the table than, “Stop that,” Or, “we use gentle hands—we don’t hit others”; (8) being a good role model as child mimics what they see rather than what they are told; (9) having some fun together as a family (time-in): read, talk, sing, play; (10) reinforcing positive skills as they develop: cooperation, politeness, appropriate assertiveness, kindness, etc; and (11) the law of natural consequences: sometimes the best lesson is letting the consequences play out (not cleaning your room means it will be a mess when your friends come over). 

Adapted from Camoirano A. Mentalizing makes parenting work: a review about parental reflective functioning and clinical interventions to improve it. Front Psychol. 2017;8:14; Zuckerman B, Augustyn M. Books and reading: evidence-based standard of care whose time has come. Acad Pediatr. 2011;11(1)11–17; Zuckerman B, Khandekar, A. Reach Out and Read: evidence based approach to promoting early child development. Curr Opin Pediatr. 2010;22(4):539–544; Needlman R, Toker KH, Dreyer BP, Klass P, Medelsohn AL. Effectiveness of a primary care intervention to support reading aloud: a multicenter evaluation. Ambul Pediatr. 2005;5(4)209–215; Mendelsohn AL, Cates CB, Weisleder A, et al. Reading aloud, play, and social-emotional development. Pediatrics. 2018;141(5):e20173393; Shah R, DeFrino D, Kim Y, Atkins M. Sit Down and Play: a preventive primary care-based program to enhance parenting practices. J Child Fam Stud. 2017;26(2):540–547; Chang SM, Grantham-McGregor SM, Powell CA, et al. Integrating a parenting intervention with routine primary health care: a cluster randomized trial. Pediatrics. 2015;136(2)272–280; Girard LC, Doyle O, Tremblay RE. Maternal warmth and toddler development support for transactional models in disadvantaged families. Eur Child Adolesc Psychiatry. 2017;26(4):497–507; Weisleder A, Cates CB, Dreyer BP, et al. Promotion of positive parenting and prevention of socioemotional disparities. Pediatrics. 2016;137(2):e20153239; Shah R, Kennedy S, Clark MD, Bauer SC, Schwartz A. Primary care-based interventions to promote positive parenting behaviors: a meta-analysis. Pediatrics. 2016;137(5)e20153393; Perry-Parrish C, Copeland-Linder N, Webb L, Sibinga EMS. Mindfulness-based approaches for children and youth. Curr Probl Pediatr Adolesc Health Care. 2016;46(6):172–178; Bauer CCC, Caballero C, Scherer E, et al. Mindfulness training reduces stress and amygdala reactivity to fearful faces in middle-school children. Behav Neurosci. 2019;133(6):569–585; Ortiz R, Sibinga EM. The role of mindfulness in reducing the adverse effects of childhood stress and trauma. Children (Basel). 2017;4(3):16; Forkey H, Griffin J, Szilagyi M. Childhood Trauma and Resilience: A Practical Guide. Itasca, IL: American Academy of Pediatrics; 2021.

The presence of complex symptoms, mental health diagnoses, substance abuse, and/or a significant trauma history are indications for referral to evidence-based trauma-informed mental health services.

The most effective therapies are evidence-based treatments (EBTs) with demonstrated efficacy for children who have experienced trauma.85,187,188  Treatments that are designated as evidence based have had the most rigorous evaluation, whereas evidence-informed treatments range from newly emerging practices that are building evidence support to less rigorously studied tools. Sege et al189  published an overview of evidence-based individual and family-based psychotherapeutic interventions. Gleason et al190  specifically outlined services for the treatment of young children. Having these services available on-site or through direct communication with colleagues in mental health (a “warm handoff”) has been revealed to be the most effective approach.191  It is important for caregivers who have their own history of trauma to seek individual therapy, and the pediatric provider may find it useful to have a list of adult mental health providers who address trauma. As research continues to elucidate the neurocognitive basis of trauma symptoms and methods to address those effects, new treatment modalities are being developed and may offer increased therapeutic resources for both adults and children.192194 

Even if therapies are not available on-site, it is useful to familiarize self and staff with evidence-based trauma therapies, how they work, how to refer locally and how to incorporate principals of treatment into pediatric anticipatory guidance. A quick reference for EBTs that includes a brief description of each and the level of evidence can be found on the California Evidence-Based Clearinghouse for Child Welfare (http://www.cebc4cw.org/). Some EBTs have been successfully adapted for telehealth,195,196  and, in the wake of the coronavirus disease 2019 pandemic, opportunities for EBT via telehealth have expanded.197  Telehealth is a mechanism to provide EBT in rural and other underresourced communities.196 

No medication, to date, is approved by the US Food and Drug Administration for trauma-specific symptoms or PTSD in children and adolescents. Medications may be judiciously considered for specific symptoms that are interfering with a child’s ability to function normatively in specific ways.72  Readers are referred to the AAP clinical report “Children Exposed to Maltreatment: Assessment and the Role of Psychotropic Medication” for discussion of medication use in identified comorbid mental health conditions.87 

A commitment to working with the family over time may prevent or reduce feelings of abandonment or rejection, especially when community and mental health resources are in short supply. The pediatric provider who is continuous over time can continue to listen attentively and offer practical trauma-informed advice that reinforces resilience building and healing. Obtaining consent to share information with a mental health provider may also be reassuring to the caregiver or patient even after a referral and linkage to mental health care is established.

Once these aspects of care are part of a provider’s repertoire of care, integrating knowledge about trauma into policies and procedures and daily practice are the next steps in creating a trauma-informed medical setting.198,199 

All staff, from schedulers to billers to nurses and care coordinators, can benefit from training in TIC that is thorough and discipline specific and includes information about physiology, presentation, recognition, and response.15,200,201  This training would ideally promote patient empowerment and include caregiver and patient perspectives.

Implementing TIC in any setting is effective when there is consideration of clinic workflow to maintain efficiency. Specific strategies can include a warm and welcoming waiting room, clear communication of expectations and procedures, and providing choices when possible (eg, do you want blood pressure taken on right arm or left?).201  As noted earlier, the care of a child who has experienced trauma requires an approach that is similar to addressing other health concerns. TIC can include members of the staff, all aware of and empowered to emphasize safety, patient self-efficacy, and a trauma-informed approach.15,201  Use of formalized training in TIC for all staff has been found to be effective in changing staff-reported beliefs and behaviors for caregivers of children in residential care202,203,204  and in improving child functioning and behavioral regulation.204  In pediatrics, training of pediatrics residents caring for substance-exposed infants in TIC was effective at changing attitudes and improving therapeutic relationships.205 

Office personnel may engage with caregivers and patients in ways that trigger strong emotions, especially if they themselves have experienced adversity or trauma. Financial considerations, scheduling, and conflict in the small spaces of an office can also be explored from a TIC perspective. Personnel would ideally engage in some planning about how to handle a crisis or difficult situations that occasionally arise, such as the following: patients or caregivers who are indifferent or shut down, demanding, provocative, rejecting or hostile, or inattentive and distracted; or a child who is out of control and threatening to elope from the office. It is helpful to monitor one’s own response when difficult situations arise and resist the urge to be angry or retaliate. It is less provocative to focus or comment on the emotion than the behavior: “I can see that you are angry, worried, sad, upset, etc,” or “You probably don’t want to be here right now.” These responses are more affiliative and can help to shut down the stress response of the patient or caregiver whose fight-or-flight response may have been triggered by the health care setting, the interaction, or the medical stressor.

Many providers find that the most efficient TIC can be provided by integrating physical and mental health services and social supports. Integrated care has been found to increase social-emotional screening rates206  through colocation of services with clear strategies for medical provider introduction of the patient to the behavioral health consultant in real-time (warm handoff), by reducing the stigma of a mental health referral, or through facilitated or prearranged referral protocols.191,207  Financial and staffing resource issues vary significantly by region, but investigating opportunities for primary care and mental health integration, social work, and/or formal engagement of referral sources and partnering organizations may increase the efficiencies of TIC. Providing case management to address the social modifiers of health (eg, referral to food bank, legal aid) can help to increase family resilience and prevent the consequences of trauma. Referring to resources has been revealed to be associated with increased employment, use of child care, and a decrease in the use of homeless shelters.208 

Growing evidence has linked increasing parental ACE scores and negative effects on child health and development,122,123,125,209  providing compelling evidence that taking a 2-generation approach is important. Families may customarily live in multigenerational family units, and this is a cultural norm for some. The opioid crisis has produced many kinship and grand-families, emphasizing the need for multigenerational care because both children and caregivers have suffered traumatic losses and may be influenced by their own trauma histories.210  Addressing how adversity experienced by a caregiver in childhood may affect their parenting and resilience can have profound effects on a child’s health and outcomes. This approach can include asking these questions in engagement, surveillance, and screening; careful consideration of how the provider or practice can and will respond to elicited issues is important before integrating this into practice flow.

Pediatric offices can develop methods to coordinate trauma-related care with schools, child care, early educators, courts, legal supports, child welfare services, and other community partners (see policy statement19 ).

Addressing the trauma experiences of others can have significant consequences for health providers and staff. Per the National Child Traumatic Stress Network, STS is the emotional distress that results when an individual hears about the first-hand trauma experiences of another.136  The essential act of listening to trauma stories may take an emotional toll that compromises professional functioning and diminishes quality of life. Burnout is a syndrome characterized by a high degree of emotional exhaustion and depersonalization (ie, cynicism) and a low sense of personal accomplishment from work. Burnout refers more to general occupational stress and is not used to describe the effects of indirect trauma exposure specifically.136  At least one meta-analysis concluded that job burnout contributes to, or at least increases the risk of, STS.142  Recent surveys of medical students and residents reveal a high rate of depression (Patient Health Questionnaire-9 score >10) of 25% to 30%.139,211  Some data indicate that more than 50% of the physician workforce in the United States suffers from burnout related to their profession.212214  For the individual physician, burnout can result in increased rates of apathy, depression, substance abuse, and suicide and can affect personal relationships.139,212  STS similarly affects providers, although it is more often discussed in the mental health and child welfare literature rather than the medical literature.144 

Detailed discussion of the response to burnout and STS is beyond the scope of this clinical report. However, effective TIC includes recognition of the effect of indirect trauma exposure on the workforce and safeguards to protect those caring for children and caregivers.136,143  Acknowledgment that these are issues and providing resources to address them, with attention to leadership and supervision, have been cited as the most important first steps.143,212,215  For both burnout and STS, support from the immediate supervisor and organizational leadership have been demonstrated to be effective ways to combat the effects of trauma.143,209  Team-based care, efficiencies in practice, and opportunities to share successes and frustrations with peers can all be helpful.216218  Promoting self-care remains an important part of TIC, with adequate time for rest, distance from the office or hospital, exercise, healthy diet, and prayer, meditation, or mindfulness shown to reduce symptoms of burnout and STS.143,219,220  Such interventions are integral to developing and sustaining a trauma-informed practice and include all members of the health care team.

TIC recognizes that exposure to adversities is common to many, if not most, children and that the developmental, behavioral, and health consequences can be profound and long lasting. Pediatric clinicians with an understanding of the physiology of both resilience and trauma are in a position to promote resilience, recognize and respond to traumas, and promote recovery.

  1. TIC is fundamentally relational health care, the ability to form and maintain SSNRs. Pediatric clinicians are well positioned to use a 2-generation approach, evaluate attachment relationships, and harness these attachments to encourage the caregiver’s role in promoting regulation and resilience.

  2. Providing TIC is achieved through common pediatric practices, starting with engagement and providing a safe setting for patients and families. Obtaining history, using surveillance or screening tools appropriate to the pediatric setting and clinical need, and effecting a response involving the pediatric provider and other community resources is consistent with addressing most health-related issues.

  3. Trauma symptoms can vary, from changes in eating and sleeping to severe physical and mental health effects requiring extensive treatment. Individual differences in trauma symptoms relate to the interplay of exposures and buffering from SSNRs as well as genetic variations impacted by the early environment (biological differential sensitivity to context).

  4. Treatment can begin in the office setting with psychoeducation and brief guidance for caregivers. Facilitating linkages to community resources for families to programs that promote positive parenting skills, regulation, and self-efficacy; address the SDoHs (poverty, housing, food insecurity, etc); or provide EBT further supports those at risk and can effectively treat those who are symptomatic.

  5. Integrating this relational model of care to prevent and mitigate the impact of trauma so that all members of the care team feel supported and valued is integral to TIC. Addressing safety and supporting relationships that promote affiliative responses, decrease stress responses, and promote building resilience are principles of TIC for children, caregivers, and health care personnel.

Lead Authors

  • Heather Forkey, MD, FAAP

  • Moira Szilagyi, MD, PhD, FAAP

  • Erin T. Kelly, MD, FAAP, FACP

  • James Duffee, MD, MPH, FAAP

Council on Foster Care, Adoption, and Kinship Care Executive Committee, 2019–2021

  • Sarah H. Springer, MD, FAAP, Chairperson

  • Moira Szilagyi, MD, PhD, FAAP, Immediate Past Chairperson

  • Heather Forkey, MD, FAAP

  • Kristine Fortin, MD, MPH, FAAP

  • Mary Booth Vaden Greiner, MD, MS, FAAP

  • Todd J. Ochs, MD, FAAP

  • Anu N. Partap, MD, MPH, FAAP

  • Linda Davidson Sagor, MD, MPH, FAAP

  • Deborah L. Shropshire, MD, FAAP

  • Jonathan D. Thackeray, MD, FAAP

  • Douglas Waite, MD, FAAP

  • Lisa Weber Zetley, MD, FAAP

Liaisons

  • Jeremy Harvey – Foster Care Alumni of America

  • Wynne Shepard Morgan, MD – American Academy of Child and Adolescent Psychiatry

  • Camille Robinson, MD, FAAP – Section on Pediatric Trainees

Staff

  • Tammy Piazza Hurley

  • Mary Crane, PhD, LSW

  • Müge Chavdar, MPH

Council on Community Pediatrics Executive Committee, 2019–2021

  • James Duffee, MD, MPH, FAAP, Chairperson

  • Kimberly G. Montez, MD, MPH, FAAP, Vice Chairperson

  • Kimberley J. Dilley, MD, MPH, FAAP

  • Andrea E. Green, MD, FAAP

  • Joyce Javier, MD, MPH, MS, FAAP

  • Madhulika Mathur, MD, MPH, FAAP

  • Gerri Mattson, MD, FAAP

  • Kimberly Montez, MD, MPH, FAAP

  • Jacqueline L. Nelson, MD, FAAP

  • Mikah Owen, MD, MPH, FAAP

  • Kenya Parks, MD, MPH, FAAP

  • Christopher B. Peltier, MD, FAAP

Liaisons

  • Donene Feist – Family Voices

  • Rachel Nash, MD, MPH, MD – Section on Pediatric Trainees

  • Judith Thierry, DO, MPH, FAAP – Committee on Native American Child Health

Staff

  • Dana Bennett-Tejes, MA, MNM

Council on Child Abuse and Neglect Executive Committee, 2019–2021

  • Suzanne B. Haney, MD, MS, FAAP, Chairperson

  • Andrew P. Sirotnak, MD, FAAP, Immediate Past Chairperson

  • Andrea Gottsegen Asnes, MD, FAAP

  • Amy R. Gavril, MD, MSCI, FAAP

  • Amanda Bird Hoffert Gilmartin, MD, FAAP

  • Rebecca Greenlee Girardet, MD, FAAP

  • Nancy D. Heavilin, MD, FAAP

  • Sheila M. Idzerda, MD, FAAP

  • Antoinette Laskey, MD, MPH, MBA, FAAP

  • Lori A. Legano, MD, FAAP

  • Stephen A. Messner, MD, FAAP

  • Bethany A. Mohr, MD, FAAP

  • Shalon Marie Nienow, MD, FAAP

  • Norell Rosado, MD, FAAP

Liaisons

  • Heather Forkey, MD, FAAP – Council on Foster Care, Adoption, and Kinship Care

  • Brooks Keeshin, MD, FAAP – American Academy of Child and Adolescent Psychiatry

  • Jennifer Matjasko, PhD – Centers for Disease Control and Prevention

  • Anish Raj, MD – Section on Pediatric Trainees

  • Elaine Stedt, MSW, ACSW – Administration for Children, Youth and Families, Office on Child Abuse and Neglect

Staff

  • Tammy Piazza Hurley

  • Müge Chavdar, MPH

Committee on Psychosocial Aspects of Child and Family Health, 2019–2020

  • Arthur Lavin, MD, FAAP, Chairperson

  • George L. Askew, MD, FAAP

  • Rebecca Baum, MD, FAAP

  • Evelyn Berger-Jenkins, MD, FAAP

  • Tiffani J. Johnson, MD, MSc, FAAP

  • Douglas Jutte, MD, MPH, FAAP

  • Arwa Abdulhaq Nasir, MBBS, MSc, MPH, FAAP

Liaisons

  • Sharon Berry, PhD, ABPP, LP – Society of Pediatric Psychology

  • Edward R. Christophersen, PhD, FAAP – Society of Pediatric Psychology

  • Kathleen Hobson Davis, LSW – Family Liaison

  • Norah L. Johnson, PhD, RN, CPNP-BC – National Association of Pediatric Nurse Practitioners

  • Abigail Boden Schlesinger, MD – American Academy of Child and Adolescent Psychiatry

  • Rachel Segal, MD, FAAP – Section on Pediatric Trainees

  • Amy Starin, PhD, LCSW – National Association of Social Workers

Staff

  • Carolyn Lullo McCarty, PhD

Drs Forkey, Szilagyi, Kelly, and Duffee were equally responsible for conceptualizing, writing, and revising the manuscript and considering input from all reviewers and the Board of Directors; and all authors approved the final manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

     
  • ACE

    adverse childhood experience

  •  
  • DTD

    developmental trauma disorder

  •  
  • EBT

    evidence-based treatment

  •  
  • PFA

    Psychological First Aid

  •  
  • PTSD

    posttraumatic stress disorder

  •  
  • SDoH

    social determinant of health

  •  
  • SSNR

    safe, stable, and nurturing relationship

  •  
  • STS

    secondary traumatic stress

  •  
  • TIC

    trauma-informed care

1
Copeland
WE
,
Keeler
G
,
Angold
A
,
Costello
EJ
.
Traumatic events and posttraumatic stress in childhood
.
Arch Gen Psychiatry
.
2007
;
64
(
5
):
577
584
2
Schilling
EA
,
Aseltine
RH
 Jr
,
Gore
S
.
Adverse childhood experiences and mental health in young adults: a longitudinal survey
.
BMC Public Health
.
2007
;
7
:
30
3
Burke
NJ
,
Hellman
JL
,
Scott
BG
,
Weems
CF
,
Carrion
VG
.
The impact of adverse childhood experiences on an urban pediatric population
.
Child Abuse Negl
.
2011
;
35
(
6
):
408
413
4
Lipschitz
DS
,
Rasmusson
AM
,
Anyan
W
,
Cromwell
P
,
Southwick
SM
.
Clinical and functional correlates of posttraumatic stress disorder in urban adolescent girls at a primary care clinic
.
J Am Acad Child Adolesc Psychiatry
.
2000
;
39
(
9
):
1104
1111
5
Suicide Prevention Resource Center
;
Substance Abuse and Mental Health Services Administration
.
Fact sheet: trauma among American Indians and Alaska natives
.
Missoula, MT
:
National Native Children’s Trauma Center
;
2016
.
6
Miller
KK
,
Brown
CR
,
Shramko
M
,
Svetaz
MV
.
Applying trauma-informed practices to the care of refugee and immigrant youth: 10 clinical pearls
.
Children (Basel)
.
2019
;
6
(
8
):
94
7
Bethell
C
,
Davis
MB
,
Gombojav
N
,
Stumbo
S
,
Powers
K
.
Issue brief: a national and across-state profile on adverse childhood experiences among children and possibilities to heal and thrive
.
2017
.
8
Ellis
WR
,
Dietz
WH
.
A new framework for addressing adverse childhood and community experiences: the building community resilience model
.
Acad Pediatr
.
2017
;
17
(
7S
):
S86
S93
9
Cronholm
PF
,
Forke
CM
,
Wade
R
, et al
.
Adverse childhood experiences: expanding the concept of adversity
.
Am J Prev Med
.
2015
;
49
(
3
):
354
361
10
Garner
AS
,
Shonkoff
JP
;
Committee on Psychosocial Aspects of Child and Family Health
;
Committee on Early Childhood, Adoption, and Dependent Care
;
Section on Developmental and Behavioral Pediatrics
.
Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health
.
Pediatrics
.
2012
;
129
(
1
):
e224
e231
11
American Academy of Pediatrics
.
Adverse Childhood Experiences and the Lifelong Consequences of Trauma
.
Elk Grove Village, IL
:
American Academy of Pediatrics
;
2014
.
Available at: https://www.aap.org/en-us/documents/ttb_aces_consequences.pdf. Accessed January 11, 2021
12
Anda
RF
,
Felitti
VJ
,
Bremner
JD
, et al
.
The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology
.
Eur Arch Psychiatry Clin Neurosci
.
2006
;
256
(
3
):
174
186
13
Heim
C
,
Shugart
M
,
Craighead
WE
,
Nemeroff
CB
.
Neurobiological and psychiatric consequences of child abuse and neglect
.
Dev Psychobiol
.
2010
;
52
(
7
):
671
690
14
Shonkoff
JP
,
Garner
AS
;
Committee on Psychosocial Aspects of Child and Family Health
;
Committee on Early Childhood, Adoption, and Dependent Care
;
Section on Developmental and Behavioral Pediatrics
.
The lifelong effects of early childhood adversity and toxic stress
.
Pediatrics
.
2012
;
129
(
1
):
e232
e246
15
Marsac
ML
,
Kassam-Adams
N
,
Hildenbrand
AK
, et al
.
Implementing a trauma-informed approach in pediatric health care networks
.
JAMA Pediatr
.
2016
;
170
(
1
):
70
77
16
Substance Abuse and Mental Health Services Administration
.
SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach
.
Rockville, MD
:
Substance Abuse and Mental Health Services Administration
;
2014
17
Stein
REK
,
Storfer-Isser
A
,
Kerker
BD
, et al
.
Beyond ADHD: how well are we doing?
Acad Pediatr
.
2016
;
16
(
2
):
115
121
18
Horwitz
SM
,
Storfer-Isser
A
,
Kerker
BD
, et al
.
Barriers to the identification and management of psychosocial problems: changes from 2004 to 2013
.
Acad Pediatr
.
2015
;
15
(
6
):
613
620
19
Duffee
J
,
Szilagyi
M
,
Forkey
H
,
Kelly
ET
;
American Academy of Pediatrics, Council on Community Pediatrics, Council on Foster Care, Adoption, and Kinship Care, Council on Child Abuse and Neglect, Committee on Psychosocial Aspects of Child and Family Health
.
Policy statement: trauma-informed care in child health systems
.
Pediatrics
.
2021
;
148
(
2
):
e2021052579
20
National Child Traumatic Stress Network
.
The 12 Core Concepts: Concepts for Understanding Traumatic Stress Responses in Children and Families
.
Los Angeles, CA
:
National Child Traumatic Stress Network
;
2007
.
21
Houtepen
LC
,
Vinkers
CH
,
Carrillo-Roa
T
, et al
.
Genome-wide DNA methylation levels and altered cortisol stress reactivity following childhood trauma in humans
.
Nat Commun
.
2016
;
7
:
10967
22
Felitti
VJ
,
Anda
RF
,
Nordenberg
D
, et al
.
Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study
.
Am J Prev Med
.
1998
;
14
(
4
):
245
258
23
Flynn
AB
,
Fothergill
KE
,
Wilcox
HC
, et al
.
Primary care interventions to prevent or treat traumatic stress in childhood: a systematic review
.
Acad Pediatr
.
2015
;
15
(
5
):
480
492
24
Centers for Disease Control and Prevention
.
Essentials for childhood: creating Safe, stable, nurturing relationships and environments
.
25
Garner
AS
,
Forkey
H
,
Szilagyi
M
.
Translating developmental science to address childhood adversity
.
Acad Pediatr
.
2015
;
15
(
5
):
493
502
26
Lahey
BB
,
Rathouz
PJ
,
Lee
SS
, et al
.
Interactions between early parenting and a polymorphism of the child’s dopamine transporter gene in predicting future child conduct disorder symptoms
.
J Abnorm Psychol
.
2011
;
120
(
1
):
33
45
27
Whittle
S
,
Simmons
JG
,
Dennison
M
, et al
.
Positive parenting predicts the development of adolescent brain structure: a longitudinal study
.
Dev Cogn Neurosci
.
2014
;
8
:
7
17
28
McEwen
BS
,
Gianaros
PJ
.
Central role of the brain in stress and adaptation: links to socioeconomic status, health, and disease
.
Ann N Y Acad Sci
.
2010
;
1186
:
190
222
29
Merrick
MT
,
Ford
DC
,
Ports
KA
, et al
.
Vital Signs: estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention - 25 states, 2015–2017
.
MMWR Morb Mortal Wkly Rep
.
2019
;
68
(
44
):
999
1005
30
Center for the Developing Child
.
ACEs and toxic stress: frequently asked questions
.
31
McHugo
GJ
,
Kammerer
N
,
Jackson
EW
, et al
.
Women, co-occurring disorders, and violence study: evaluation design and study population
.
J Subst Abuse Treat
.
2005
;
28
(
2
):
91
107
32
Bethell
C
,
Jones
J
,
Gombojav
N
,
Linkenbach
J
,
Sege
R
.
Positive childhood experiences and adult mental and relational health in a statewide sample: associations across adverse childhood experiences levels
.
JAMA Pediatr
.
2019
;
173
(
11
):
e193007
33
Bethell
CD
,
Gombojav
N
,
Whitaker
RC
.
Family resilience and connection promote flourishing among US children, even amid adversity
.
Health Aff (Millwood)
.
2019
;
38
(
5
):
729
737
34
Zeanah
P
,
Burstein
K
,
Cartier
J
.
Addressing Adverse childhood experiences: it’s all about relationships
.
Societies
.
2018
;
8
(
4
):
115
35
US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau
.
Child Maltreatment
.
Washington, DC
:
US Department of Health and Human Services
;
2017
.
36
Child Welfare Information Gateway
.
Foster Care Statistics 2019
.
Washington, DC
:
US Department of Health and Human Services, Children’s Bureau
;
2019
.
Available at: https://www.acf.hhs.gov/cb/report/afcars-report-27. Accessed January 11, 2021
37
Burgess
AL
,
Borowsky
IW
.
Health and home environments of caregivers of children investigated by child protective services
.
Pediatrics
.
2010
;
125
(
2
):
273
281
38
Campbell
KA
,
Thomas
AM
,
Cook
LJ
,
Keenan
HT
.
Longitudinal experiences of children remaining at home after a first-time investigation for suspected maltreatment
.
J Pediatr
.
2012
;
161
(
2
):
340
347
39
Horwitz
SM
,
Hurlburt
MS
,
Cohen
SD
,
Zhang
J
,
Landsverk
J
.
Predictors of placement for children who initially remained in their homes after an investigation for abuse or neglect
.
Child Abuse Negl
.
2011
;
35
(
3
):
188
198
40
Perez
D
,
Sribney
WM
,
Rodríguez
MA
.
Perceived discrimination and self-reported quality of care among Latinos in the United States
.
J Gen Intern Med
.
2009
;
24
(
Suppl 3
):
548
554
41
Wood
LCN
.
Impact of punitive immigration policies, parent-child separation and child detention on the mental health and development of children
.
BMJ Paediatr Open
.
2018
;
2
(
1
):
e000338
42
Johnson
SB
,
Riis
JL
,
Noble
KG
.
State of the art review: poverty and the developing brain
.
Pediatrics
.
2016
;
137
(
4
):
e20153075
43
National Advisory Committee on Rural Health and Human Services
.
Exploring the Rural Context For Adverse Childhood Experiences: Policy Brief and Recommendations
.
Washington, DC
:
US Department of Health and Human Services
;
2018
44
Evans
GW
,
English
K
.
The environment of poverty: multiple stressor exposure, psychophysiological stress, and socioemotional adjustment
.
Child Dev
.
2002
;
73
(
4
):
1238
1248
45
Hackman
DA
,
Farah
MJ
.
Socioeconomic status and the developing brain
.
Trends Cogn Sci
.
2009
;
13
(
2
):
65
73
46
Trent
M
,
Dooley
DG
,
Dougé
J
;
Section on Adolescent Health
;
Council on Community Pediatrics
;
Committee on Adolescence
.
Council on Community Pediatrics
;
Committee on Adolescence
.
The impact of racism on child and adolescent health
.
Pediatrics
.
2019
;
144
(
2
):
e20191765
47
Heard-Garris
NJ
,
Cale
M
,
Camaj
L
,
Hamati
MC
,
Dominguez
TP
.
Transmitting trauma: a systematic review of vicarious racism and child health
.
Soc Sci Med
.
2018
;
199
:
230
240
48
Mohatt
NV
,
Thompson
AB
,
Thai
ND
,
Tebes
JK
.
Historical trauma as public narrative: a conceptual review of how history impacts present-day health
.
Soc Sci Med
.
2014
;
106
:
128
136
49
Wade
R
 Jr
,
Shea
JA
,
Rubin
D
,
Wood
J
.
Adverse childhood experiences of low-income urban youth
.
Pediatrics
.
2014
;
134
(
1
):
e13
e20
50
Nixon
CL
.
Current perspectives: the impact of cyberbullying on adolescent health
.
Adolesc Health Med Ther
.
2014
;
5
:
143
158
51
Finkelhor
D
,
Turner
HA
,
Shattuck
A
,
Hamby
SL
.
Violence, crime, and abuse exposure in a national sample of children and youth: an update. [published correction appears in JAMA Pediatr. 2014;168(3):286]
.
JAMA Pediatr
.
2013
;
167
(
7
):
614
621
52
Roberts
AL
,
Austin
SB
,
Corliss
HL
,
Vandermorris
AK
,
Koenen
KC
.
Pervasive trauma exposure among US sexual orientation minority adults and risk of posttraumatic stress disorder
.
Am J Public Health
.
2010
;
100
(
12
):
2433
2441
53
Carroll
G
.
Mundane extreme environmental stress and African American families: a case for recognizing different realities
.
J Comp Fam Stud
.
1998
;
29
(
2
):
271
284
54
Huynh
VW
.
Ethnic microaggressions and the depressive and somatic symptoms of Latino and Asian American adolescents
.
J Youth Adolesc
.
2012
;
41
(
7
):
831
846
55
Siegel
BS
,
Davis
BE
;
Committee on Psychosocial Aspects of Child and Family Health and Section on Uniformed Services
.
Health and mental health needs of children in US military families
.
Pediatrics
.
2013
;
131
(
6
):
e2002
e2015
56
Marsac
ML
,
Kassam-Adams
N
,
Delahanty
DL
,
Widaman
KF
,
Barakat
LP
.
Posttraumatic stress following acute medical trauma in children: a proposed model of bio-psycho-social processes during the peri-trauma period
.
Clin Child Fam Psychol Rev
.
2014
;
17
(
4
):
399
411
57
Brosbe
MS
,
Hoefling
K
,
Faust
J
.
Predicting posttraumatic stress following pediatric injury: a systematic review
.
J Pediatr Psychol
.
2011
;
36
(
6
):
718
729
58
Garner
AS
.
Thinking developmentally: the next evolution in models of health
.
J Dev Behav Pediatr
.
2016
;
37
(
7
):
579
584
59
Bretherton
I
.
The origins of attachment theory: John Bowlby and Mary Ainsworth
.
Dev Psychol
.
1992
;
28
(
5
):
759
775
60
Feldman
R
.
The adaptive human parental brain: implications for children’s social development
.
Trends Neurosci
.
2015
;
38
(
6
):
387
399
61
Hughes
DA
,
Baylin
J
.
The Neurobiology of Attachment-Focused Therapy: Enhancing Connection and Trust in the Treatment of Children and Adolescents
.
New York, NY
:
W.W. Norton and Co
;
2016
62
Allen
JG
.
Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy
.
Arlington, VA
:
American Psychiatric Publishing
;
2013
63
Cantor
P
,
Osher
D
,
Berg
J
,
Steyer
L
,
Rose
T
.
Malleability, plasticity, and individuality: how children learn and develop in context
.
Appl Dev Sci
.
2019
;
23
(
4
):
307
337
64
Ainsworth
MD
.
Attachments beyond infancy
.
Am Psychol
.
1989
;
44
(
4
):
709
716
65
Perry
RE
,
Blair
C
,
Sullivan
RM
.
Neurobiology of infant attachment: attachment despite adversity and parental programming of emotionality
.
Curr Opin Psychol
.
2017
;
17
:
1
6
66
Hoghughi
M
,
Speight
AN
.
Good enough parenting for all children--a strategy for a healthier society
.
Arch Dis Child
.
1998
;
78
(
4
):
293
296
67
Winnicott
DW
.
The Maturational Process and the Facilitative Environment
.
New York, NY
:
International Universities Press
;
1965
68
Porges
SW
.
Social engagement and attachment: a phylogenetic perspective
.
Ann N Y Acad Sci
.
2003
;
1008
:
31
47
69
Benoit
D
.
Infant-parent attachment: definition, types, antecedents, measurement and outcome
.
Paediatr Child Health
.
2004
;
9
(
8
):
541
545
70
Olff
M
,
Frijling
JL
,
Kubzansky
LD
, et al
.
The role of oxytocin in social bonding, stress regulation and mental health: an update on the moderating effects of context and interindividual differences
.
Psychoneuroendocrinology
.
2013
;
38
(
9
):
1883
1894
71
Masten
AS
.
Ordinary magic. Resilience processes in development
.
Am Psychol
.
2001
;
56
(
3
):
227
238
72
Sege
RD
,
Harper Browne
C
.
Responding to ACEs With HOPE: health outcomes from positive experiences
.
Acad Pediatr
.
2017
;
17
(
7S
):
S79
S85
73
Garner
A
,
Yogman
M
;
American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Section on Developmental and Behavioral Pediatrics, Council on Early Childhood
.
Preventing childhood toxic stress: partnering with families and communities to promote relational health
.
Pediatrics
.
2021
;
148
(
2
):
e2021052582
74
Children’s Hospital of Philadelphia Research Institute
.
Basics of trauma-informed care
.
Available at: https://www.healthcaretoolbox.org/. Accessed January 11, 2021
75
Brymer
M
,
Jacobs
A
,
Layne
C
, et al
.
Psychological First Aid Field Operations Guide
. 2nd ed.
Los Angeles, CA
:
National Child Traumatic Stress Network and National Center for Post-traumatic Stress Disorder
;
2006
76
Finkelhor
D
.
Screening for adverse childhood experiences (ACEs): cautions and suggestions
.
Child Abuse Negl
.
2018
;
85
:
174
179
77
Flaherty
E
,
Legano
L
,
Idzerda
S
;
Council on Child Abuse and Neglect
.
Ongoing pediatric health care for the child who has been maltreated
.
Pediatrics
.
2019
;
143
(
4
):
e20190284
78
Flaherty
EG
,
Stirling
J
 Jr
;
American Academy of Pediatrics. Committee on Child Abuse and Neglect
.
Clinical report—the pediatrician’s role in child maltreatment prevention
.
Pediatrics
.
2010
;
126
(
4
):
833
841
79
Schnierle
J
,
Christian-Brathwaite
N
,
Louisias
M
.
Implicit bias: what every pediatrician should know about the effect of bias on health and future directions
.
Curr Probl Pediatr Adolesc Health Care
.
2019
;
49
(
2
):
34
44
80
Johnson
SB
,
Riley
AW
,
Granger
DA
,
Riis
J
.
The science of early life toxic stress for pediatric practice and advocacy
.
Pediatrics
.
2013
;
131
(
2
):
319
327
81
Dantzer
R
,
O’Connor
JC
,
Freund
GG
,
Johnson
RW
,
Kelley
KW
.
From inflammation to sickness and depression: when the immune system subjugates the brain
.
Nat Rev Neurosci
.
2008
;
9
(
1
):
46
56
82
Jonson-Reid
M
,
Wideman
E
.
Trauma and very young children
.
Child Adolesc Psychiatr Clin N Am
.
2017
;
26
(
3
):
477
490
83
Cook
A
,
Spinazzola
J
,
Ford
J
, et al
.
Complex trauma in children and adolescents
.
Psychiatr Ann
.
2005
;
35
(
5
):
390
398
84
Substance Abuse and Mental Health Services Administration
.
Recognizing and Treating Child Traumatic Stress
.
Washington, DC
:
Substance Abuse and Mental Health Services Administration
;
2004
.
85
Cohen
JA
,
Kelleher
KJ
,
Mannarino
AP
.
Identifying, treating, and referring traumatized children: the role of pediatric providers
.
Arch Pediatr Adolesc Med
.
2008
;
162
(
5
):
447
452
86
Siegfried
CB
,
Blackhear
K
;
National Child Traumatic Stress Network and National Resource Center on ADHD
.
Is it ADHD or Child Traumatic Stress? A Guide for Clinicians
.
Los Angeles, CA, and Durham. NC
:
National Center for Child Traumatic Stress
;
2016
87
Keeshin
B
,
Forkey
HC
,
Fouras
G
,
MacMillan
HL
;
American Academy of Pediatrics, Council on Child Abuse and Neglect, Council on Foster Care, Adoption, and Kinship Care, American Academy of Child and Adolescent Psychiatry, Committee on Child Maltreatment and Vioence, Committee on Adoption and Foster Care.
.
Children exposed to maltreatment: assessment and the role of psychotropic medication
.
Pediatrics
.
2020
;
145
(
2
):
e20193751
88
Blaustein
M
,
Kinniburgh
K
.
Treating Traumatic Stress in Children and Adolescents: How to Foster Resilience Through Attachment, Self-Regulation and Competency
, 2nd ed.
New York, NY
:
The Guilford Press
;
2019
89
De Bellis
MD
,
Zisk
A
.
The biological effects of childhood trauma
.
Child Adolesc Psychiatr Clin N Am
.
2014
;
23
(
2
):
185
222
,
vii
90
Bremner
JD
.
Traumatic stress: effects on the brain
.
Dialogues Clin Neurosci
.
2006
;
8
(
4
):
445
461
91
Lupien
SJ
,
McEwen
BS
,
Gunnar
MR
,
Heim
C
.
Effects of stress throughout the lifespan on the brain, behaviour and cognition
.
Nat Rev Neurosci
.
2009
;
10
(
6
):
434
445
92
Penza
KM
,
Heim
C
,
Nemeroff
CB
.
Neurobiological effects of childhood abuse: implications for the pathophysiology of depression and anxiety
.
Arch Women Ment Health
.
2003
;
6
(
1
):
15
22
93
Teicher
MH
,
Samson
JA
,
Anderson
CM
,
Ohashi
K
.
The effects of childhood maltreatment on brain structure, function and connectivity
.
Nat Rev Neurosci
.
2016
;
17
(
10
):
652
666
94
Miller
LE
.
Perceived threat in childhood: a review of research and implications for children living in violent households
.
Trauma Violence Abuse
.
2015
;
16
(
2
):
153
168
95
Teicher
MH
,
Samson
JA
.
Childhood maltreatment and psychopathology: a case for ecophenotypic variants as clinically and neurobiologically distinct subtypes
.
Am J Psychiatry
.
2013
;
170
(
10
):
1114
1133
96
Birn
RM
,
Roeber
BJ
,
Pollak
SD
.
Early childhood stress exposure, reward pathways, and adult decision making
.
Proc Natl Acad Sci USA
.
2017
;
114
(
51
):
13549
13554
97
Syed
SA
,
Nemeroff
CB
.
Early life stress, mood, and anxiety disorders
.
Chronic Stress (Thousand Oaks)
.
2017
;
1
:
2470547017694461
98
Ringeisen
H
,
Casanueva
C
,
Urato
M
,
Cross
T
.
Special health care needs among children in the child welfare system
.
Pediatrics
.
2008
;
122
(
1
):
e232
e241
99
Clougherty
JE
,
Levy
JI
,
Kubzansky
LD
, et al
.
Synergistic effects of traffic-related air pollution and exposure to violence on urban asthma etiology
.
Environ Health Perspect
.
2007
;
115
(
8
):
1140
1146
100
Centers for Disease Control and Prevention
.
Developmental monitoring and screening for health professionals
.
101
Klein
D
,
Goldenring
JM
,
Adelman
WP
.
HEEADSSS 3.0: the psychosocial interview for adolescents updated for a new century fueled by media
.
Contemp Pediatr
.
2014
;
31
(
1
):
16
28
102
Goldenring
JM
,
Rosen
DS
.
Getting into adolescent heads: an essential update
.
Contemp Pediatr
.
2004
;
21
(
1
):
64
90
103
Conn
AM
,
Szilagyi
MA
,
Jee
SH
,
Manly
JT
,
Briggs
R
,
Szilagyi
PG
.
Parental perspectives of screening for adverse childhood experiences in pediatric primary care
.
Fam Syst Health
.
2018
;
36
(
1
):
62
72
104
Colvin
JD
,
Bettenhausen
JL
,
Anderson-Carpenter
KD
,
Collie-Akers
V
,
Chung
PJ
.
Caregiver opinion of in-hospital screening for unmet social needs by pediatric residents
.
Acad Pediatr
.
2016
;
16
(
2
):
161
167
105
Wissow
L
,
Anthony
B
,
Brown
J
, et al
.
A common factors approach to improving the mental health capacity of pediatric primary care
.
Adm Policy Ment Health
.
2008
;
35
(
4
):
305
318
106
Ginsburg
K
.
Viewing our patients through a positive lens
.
Contemp Pediatr
.
2007
;
24
(
1
):
65
76
107
Traub
F
,
Boynton-Jarrett
R
.
Modifiable resilience factors to childhood adversity for clinical pediatric practice
.
Pediatrics
.
2017
;
139
(
5
):
e20162569
108
Greene
R
,
Winkler
J
.
Collaborative and Proactive Solutions (CPS): a review of research findings in families, schools, and treatment facilities
.
Clin Child Fam Psychol Rev
.
2019
;
22
(
4
):
549
561
109
Lipkin
PH
,
Macias
MM
;
Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics
.
Promoting optimal development: identifying infants and young children with developmental disorders through developmental surveillance and screening
.
Pediatrics
.
2020
;
145
(
1
):
e20193449
110
Squires
J
,
Potter
L
,
Bricker
D
.
The ASQ User’s Guide
, 3rd ed.
Baltimore, MD
:
Paul H. Brookes Publishing Co
;
2009
111
Jellinek
MS
,
Murphy
JM
,
Little
M
,
Pagano
ME
,
Comer
DM
,
Kelleher
KJ
.
Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study
.
Arch Pediatr Adolesc Med
.
1999
;
153
(
3
):
254
260
112
Stone
LL
,
Otten
R
,
Engels
RCME
,
Vermulst
AA
,
Janssens
JM
.
Psychometric properties of the parent and teacher versions of the strengths and difficulties questionnaire for 4- to 12-year-olds: a review
.
Clin Child Fam Psychol Rev
.
2010
;
13
(
3
):
254
274
113
Richardson
LP
,
McCauley
E
,
Grossman
DC
, et al
.
Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents
.
Pediatrics
.
2010
;
126
(
6
):
1117
1123
114
Earls
MF
,
Yogman
MW
,
Mattson
G
,
Rafferty
J
;
Committee on Psychosocial Aspects of Child and Family Health
.
Incorporating recognition and management of perinatal depression into pediatric practice
.
Pediatrics
.
2019
;
143
(
1
):
e20183259
115
Rolon-Arroyo
B
,
Oosterhoff
B
,
Layne
CM
,
Steinberg
AM
,
Pynoos
RS
,
Kaplow
JB
.
The UCLA PTSD Reaction Index for DSM-5 Brief Form: a screening tool for trauma-exposed youths
.
J Am Acad Child Adolesc Psychiatry
.
2020
;
59
(
3
):
434
443
116
Kazak
A
,
Schneider
S
,
Didonato
S
,
Pai
ALH
.
Family psychosocial risk screening guided by the Pediatric Preventative Psychosocial Health Model (PPPHM) using the Psychosocial Assessment Tool (PAT)
.
Acta Oncol
.
2015
;
54
(
5
):
574
580
117
Kazak
AE
,
Hwang
WT
,
Chen
FF
, et al
.
Screening for family psychosocial risk in pediatric cancer: validation of the Psychosocial Assessment Tool (PAT) Version 3
.
J Pediatr Psychol
.
2018
;
43
(
7
):
737
748
118
Keeshin
B
,
Byrne
K
,
Thorn
B
,
Shepard
L
.
Screening for trauma in pediatric primary care
.
Curr Psychiatry Rep
.
2020
;
22
(
11
):
60
119
Bethell
CD
,
Carle
A
,
Hudziak
J
, et al
.
Methods to assess adverse childhood experiences of children and families: toward approaches to promote child well-being in policy and practice
.
Acad Pediatr
.
2017
;
17
(
7S
):
S51
S69
120
Purewal
SK
,
Bucci
M
,
Gutiérrez Wang
L
, et al
.
Screening for adverse childhood experiences (ACEs) in an integrated pediatric care model
.
Zero Three
.
2016
;
36
(
3
):
10
17
121
Colvin
JD
,
Bettenhausen
JL
,
Anderson-Carpenter
KD
, et al
.
Multiple behavior change intervention to improve detection of unmet social needs and resulting resource referrals
.
Acad Pediatr
.
2016
;
16
(
2
):
168
174
122
Shah
AN
,
Beck
AF
,
Sucharew
HJ
, et al;
H2O Study Group
.
Parental adverse childhood experiences and resilience on coping after discharge
.
Pediatrics
.
2018
;
141
(
4
):
e20172127
123
Folger
AT
,
Eismann
EA
,
Stephenson
NB
, et al
.
Parental adverse childhood experiences and offspring development at 2 years of age
.
Pediatrics
.
2018
;
141
(
4
):
e20172826
124
Schickedanz
A
,
Halfon
N
,
Sastry
N
,
Chung
PJ
.
Parents’ adverse childhood experiences and their children’s behavioral health problems
.
Pediatrics
.
2018
;
142
(
2
):
e20180023
125
Lê-Scherban
F
,
Wang
X
,
Boyle-Steed
KH
,
Pachter
LM
.
Intergenerational associations of parent adverse childhood experiences and child health outcomes
.
Pediatrics
.
2018
;
141
(
6
):
e20174274
126
Connor
KM
,
Davidson
JRT
.
Development of a new resilience scale: the Connor-Davidson Resilience Scale (CD-RISC)
.
Depress Anxiety
.
2003
;
18
(
2
):
76
82
127
Smith
BW
,
Dalen
J
,
Wiggins
K
,
Tooley
E
,
Christopher
P
,
Bernard
J
.
The brief resilience scale: assessing the ability to bounce back
.
Int J Behav Med
.
2008
;
15
(
3
):
194
200
128
Windle
G
,
Bennett
KM
,
Noyes
J
.
A methodological review of resilience measurement scales
.
Health Qual Life Outcomes
.
2011
;
9
:
8
129
Anda
RF
,
Porter
LE
,
Brown
DW
.
Inside the Adverse Childhood Experience Score: strengths, limitations, and misapplications
.
Am J Prev Med
.
2020
;
59
(
2
):
293
295
130
Dube
SR
.
Continuing conversations about adverse childhood experiences (ACEs) screening: a public health perspective
.
Child Abuse Negl
.
2018
;
85
:
180
184
131
Shonkoff
JP
.
Capitalizing on advances in science to reduce the health consequences of early childhood adversity
.
JAMA Pediatr
.
2016
;
170
(
10
):
1003
1007
132
Boyce
WT
,
Levitt
P
,
Martinez
FD
,
McEwen
BS
,
Shonkoff
JP
.
Genes, environments and time: the biology of adversity and resilience
.
Pediatrics
.
2020
;
147
(
2
):
e20201651
133
Shonkoff
JP
,
Boyce
WT
,
Levitt
P
,
Martinez
F
,
McEwen
B
.
Leveraging the biology of adversity and resilience to transform pediatric practice
.
Pediatrics
.
2020
;
147
(
2
):
e20193845
134
Slopen
N
,
McLaughlin
KA
,
Shonkoff
JP
.
Interventions to improve cortisol regulation in children: a systematic review
.
Pediatrics
.
2014
;
133
(
2
):
312
326
135
Le-Niculescu
H
,
Roseberry
K
,
Levey
DF
, et al
.
Towards precision medicine for stress disorders: diagnostic biomarkers and targeted drugs
.
Mol Psychiatry
.
2020
;
25
(
5
):
918
938
136
National Child Traumatic Stress Network
.
Secondary Traumatic Stress: A Fact Sheet for Child-Serving Professionals
.
Los Angeles, CA
:
National Child Traumatic Stress Network
;
2011
.
137
Cieslak
R
,
Shoji
K
,
Douglas
A
,
Melville
E
,
Luszczynska
A
,
Benight
CC
.
A meta-analysis of the relationship between job burnout and secondary traumatic stress among workers with indirect exposure to trauma
.
Psychol Serv
.
2014
;
11
(
1
):
75
86
138
Cocker
F
,
Joss
N
.
Compassion fatigue among healthcare, emergency and community service workers: a systematic review
.
Int J Environ Res Public Health
.
2016
;
13
(
6
):
618
139
Dyrbye
LN
,
Thomas
MR
,
Massie
FS
, et al
.
Burnout and suicidal ideation among U.S. medical students
.
Ann Intern Med
.
2008
;
149
(
5
):
334
341
140
Oreskovich
MR
,
Shanafelt
T
,
Dyrbye
LN
, et al
.
The prevalence of substance use disorders in American physicians
.
Am J Addict
.
2015
;
24
(
1
):
30
38
141
Robins
PM
,
Meltzer
L
,
Zelikovsky
N
.
The experience of secondary traumatic stress upon care providers working within a children’s hospital
.
J Pediatr Nurs
.
2009
;
24
(
4
):
270
279
142
Shoji
K
,
Lesnierowska
M
,
Smoktunowicz
E
, et al
.
What comes first, job burnout or secondary traumatic stress? Findings from two longitudinal studies from the U.S. and Poland
.
PLoS One
.
2015
;
10
(
8
):
e0136730
143
Sprang
G
,
Craig
C
,
Clark
J
.
Secondary traumatic stress and burnout in child welfare workers: a comparative analysis of occupational distress across professional groups
.
Child Welfare
.
2011
;
90
(
6
):
149
168
144
van Mol
MMC
,
Kompanje
EJ
,
Benoit
DD
,
Bakker
J
,
Nijkamp
MD
.
The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: a systematic review
.
PLoS One
.
2015
;
10
(
8
):
e0136955
145
The Center for Victims of Torture
.
Professional quality of life: elements, theory, and measurement
.
2019
.
Available at: https://proqol.org/. Accessed January 11, 2021
146
Wilson
JP
,
So-Kum Tang
CC
.
Cross-Cultural Assessment of Psychological Trauma and PTSD
.
New York, NY
:
Springer Publishing
;
2007
147
Flynn
JT
,
Kaelber
DC
,
Baker-Smith
CM
, et al;
Subcommittee on Screening and Management of High Blood Pressure in Children
.
Clinical practice guideline for screening and management of high blood pressure in children and adolescents
.
Pediatrics
.
2017
;
140
(
3
):
e20171904
148
Gooding
HC
,
Milliren
CE
,
Austin
SB
,
Sheridan
MA
,
McLaughlin
KA
.
Child abuse, resting blood pressure, and blood pressure reactivity to psychosocial stress
.
J Pediatr Psychol
.
2016
;
41
(
1
):
5
14
149
Su
S
,
Wang
X
,
Pollock
JS
, et al
.
Adverse childhood experiences and blood pressure trajectories from childhood to young adulthood: the Georgia stress and Heart study
.
Circulation
.
2015
;
131
(
19
):
1674
1681
150
Szilagyi
MA
,
Rosen
DS
,
Rubin
D
,
Zlotnik
S
;
Council on Foster Care, Adoption, and Kinship Care
;
Committee on Adolescence
;
Council on Early Childhood
.
Health care issues for children and adolescents in foster care and kinship care
.
Pediatrics
.
2015
;
136
(
4
):
e1142
e1166
151
Davis
L
,
Barnes
AJ
,
Gross
AC
,
Ryder
JR
,
Shlafer
RJ
.
Adverse childhood experiences and weight status among adolescents
.
J Pediatr
.
2019
;
204
:
71
76.e1
152
Javier
JR
,
Hoffman
LR
,
Shah
SI
;
Pediatric Policy Council
.
Making the case for ACEs: adverse childhood experiences, obesity, and long-term health
.
Pediatr Res
.
2019
;
86
(
4
):
420
422
153
Purswani
P
,
Marsicek
SM
,
Amankwah
EK
.
Association between cumulative exposure to adverse childhood experiences and childhood obesity
.
PLoS One
.
2020
;
15
(
9
):
e0239940
154
Heerman
WJ
,
Krishnaswami
S
,
Barkin
SL
,
McPheeters
M
.
Adverse family experiences during childhood and adolescent obesity
.
Obesity (Silver Spring)
.
2016
;
24
(
3
):
696
702
155
Exley
D
,
Norman
A
,
Hyland
M
.
Adverse childhood experience and asthma onset: a systematic review
.
Eur Respir Rev
.
2015
;
24
(
136
):
299
305
156
Gilbert
LK
,
Breiding
MJ
,
Merrick
MT
, et al
.
Childhood adversity and adult chronic disease: an update from ten states and the District of Columbia, 2010
.
Am J Prev Med
.
2015
;
48
(
3
):
345
349
157
Heneghan
A
,
Stein
RE
,
Hurlburt
MS
, et al
.
Mental health problems in teens investigated by U.S. child welfare agencies
.
J Adolesc Health
.
2013
;
52
(
5
):
634
640
158
Ford
JD
,
Grasso
D
,
Greene
C
,
Levine
J
,
Spinazzola
J
,
van der Kolk
B
.
Clinical significance of a proposed developmental trauma disorder diagnosis: results of an international survey of clinicians
.
J Clin Psychiatry
.
2013
;
74
(
8
):
841
849
159
Keeshin
BR
,
Strawn
JR
.
Psychological and pharmacologic treatment of youth with posttraumatic stress disorder: an evidence-based review
.
Child Adolesc Psychiatr Clin N Am
.
2014
;
23
(
2
):
399
411
,
x
160
Carrion
VG
,
Weems
CF
,
Reiss
AL
.
Stress predicts brain changes in children: a pilot longitudinal study on youth stress, posttraumatic stress disorder, and the hippocampus
.
Pediatrics
.
2007
;
119
(
3
):
509
516
161
Gunnar
M
,
Quevedo
K
.
The neurobiology of stress and development
.
Annu Rev Psychol
.
2007
;
58
:
145
173
162
McDonald
MK
,
Borntrager
CF
,
Rostad
W
.
Measuring trauma: considerations for assessing complex and non-PTSD Criterion A childhood trauma
.
J Trauma Dissociation
.
2014
;
15
(
2
):
184
203
163
van der Kolk
B
.
Developmental trauma disorder
.
Psychiatr Ann
.
2005
;
35
(
5
):
401
409
164
Ogle
CM
,
Rubin
DC
,
Siegler
IC
.
The impact of the developmental timing of trauma exposure on PTSD symptoms and psychosocial functioning among older adults
.
Dev Psychol
.
2013
;
49
(
11
):
2191
2200
165
Perry
BD
,
Pollard
RA
,
Blakley
TL
,
Baker
WL
,
Vigilante
D
.
Childhood trauma, the neurobiology of adaptation, and “use-dependent” development of the brain: how “states” become “traits.”
.
Infant Ment Health J
.
1995
;
16
(
4
):
271
291
166
Scheeringa
MS
.
Developmental considerations for diagnosing PTSD and acute stress disorder in preschool and school-age children
.
Am J Psychiatry
.
2008
;
165
(
10
):
1237
1239
167
Treisman
K
.
Working with Relational and Developmental Trauma in Children and Adolescents
.
New York, NY
:
Routledge
;
2017
168
Obradović
J
,
Bush
NR
,
Stamperdahl
J
,
Adler
NE
,
Boyce
WT
.
Biological sensitivity to context: the interactive effects of stress reactivity and family adversity on socioemotional behavior and school readiness
.
Child Dev
.
2010
;
81
(
1
):
270
289
169
Boyce
WT
,
Ellis
BJ
.
Biological sensitivity to context: I. An evolutionary-developmental theory of the origins and functions of stress reactivity
.
Dev Psychopathol
.
2005
;
17
(
2
):
271
301
170
Kennedy
E
.
Orchids and dandelions: how some children are more susceptible to environmental influences for better or worse and the implications for child development
.
Clin Child Psychol Psychiatry
.
2013
;
18
(
3
):
319
321
171
Cole
SF
,
Eisner
A
,
Gregory
M
,
Ristuccia
J
.
Creating and Advocating for Trauma-Sensitive Schools
.
Cambridge, MA
:
Trauma and Learning Policy Initiative
;
2013
172
Overstreet
S
,
Chafouleas
SM
.
Trauma-informed schools: introduction to the special issue
.
School Ment Health
.
2016
;
8
(
1
):
1
6
173
Allen
B
,
Timmer
SG
,
Urquiza
AJ
.
Parent–child interaction therapy as an attachment-based intervention: theoretical rationale and pilot data with adopted children
.
Child Youth Serv Rev
.
2014
;
47
(
Part 3
):
334
341
174
Camoirano
A
.
Mentalizing makes parenting work: a review about parental reflective functioning and clinical interventions to improve it
.
Front Psychol
.
2017
;
8
:
14
175
Zuckerman
B
,
Augustyn
M
.
Books and reading: evidence-based standard of care whose time has come
.
Acad Pediatr
.
2011
;
11
(
1
):
11
17
176
Zuckerman
B
,
Khandekar
A
.
Reach Out and Read: evidence based approach to promoting early child development
.
Curr Opin Pediatr
.
2010
;
22
(
4
):
539
544
177
Needlman
R
,
Toker
KH
,
Dreyer
BP
,
Klass
P
,
Mendelsohn
AL
.
Effectiveness of a primary care intervention to support reading aloud: a multicenter evaluation
.
Ambul Pediatr
.
2005
;
5
(
4
):
209
215
178
Mendelsohn
AL
,
Cates
CB
,
Weisleder
A
, et al
.
Reading aloud, play, and social-emotional development
.
Pediatrics
.
2018
;
141
(
5
):
e20173393
179
Shah
R
,
DeFrino
D
,
Kim
Y
,
Atkins
M
.
Sit Down and Play: a preventive primary care-based program to enhance parenting practices
.
J Child Fam Stud
.
2017
;
26
(
2
):
540
547
180
Chang
SM
,
Grantham-McGregor
SM
,
Powell
CA
, et al
.
Integrating a parenting intervention with routine primary health care: a cluster randomized trial
.
Pediatrics
.
2015
;
136
(
2
):
272
280
181
Girard
LC
,
Doyle
O
,
Tremblay
RE
.
Maternal warmth and toddler development: support for transactional models in disadvantaged families
.
Eur Child Adolesc Psychiatry
.
2017
;
26
(
4
):
497
507
182
Weisleder
A
,
Cates
CB
,
Dreyer
BP
, et al
.
Promotion of positive parenting and prevention of socioemotional disparities
.
Pediatrics
.
2016
;
137
(
2
):
e20153239
183
Shah
R
,
Kennedy
S
,
Clark
MD
,
Bauer
SC
,
Schwartz
A
.
Primary care-based interventions to promote positive parenting behaviors: a meta-analysis
.
Pediatrics
.
2016
;
137
(
5
):
e20153393
184
Perry-Parrish
C
,
Copeland-Linder
N
,
Webb
L
,
Sibinga
EMS
.
Mindfulness-based approaches for children and youth
.
Curr Probl Pediatr Adolesc Health Care
.
2016
;
46
(
6
):
172
178
185
Bauer
CCC
,
Caballero
C
,
Scherer
E
, et al
.
Mindfulness training reduces stress and amygdala reactivity to fearful faces in middle-school children
.
Behav Neurosci
.
2019
;
133
(
6
):
569
585
186
Ortiz
R
,
Sibinga
EM
.
The role of mindfulness in reducing the adverse effects of childhood stress and trauma
.
Children (Basel)
.
2017
;
4
(
3
):
16
187
Foa
EBKT
,
Friedman
MJ
,
Cohen
JA
.
Effective Treatments for Posttraumatic Stress Disorder: Practice Guidelines From the International Society for Traumatic Stress Studies
, 2nd ed.
New York, NY
:
Guilford Press
;
2008
188
Dorsey
S
,
McLaughlin
KA
,
Kerns
SEU
, et al
.
Evidence base update for psychosocial treatments for children and adolescents exposed to traumatic events
.
J Clin Child Adolesc Psychol
.
2017
;
46
(
3
):
303
330
189
Sege
RD
,
Amaya-Jackson
L
;
American Academy of Pediatrics Committee on Child Abuse and Neglect, Council on Foster Care, Adoption, and Kinship Care; American Academy of Child and Adolescent Psychiatry Committee on Child Maltreatment and Violence; National Center for Child Traumatic Stress
.
Clinical considerations related to the behavioral manifestations of child maltreatment
.
Pediatrics
.
2017
;
139
(
4
):
e20170100
190
Gleason
MM
,
Goldson
E
,
Yogman
MW
;
Council on Early Childhood
;
Committee on Pyschosocial Aspects of Child and Family Health
;
Section on Developmental and Behavioral Pediatrics
.
Addressing early childhood emotional and behavioral problems
.
Pediatrics
.
2016
;
138
(
6
):
e20163025
191
Asarnow
JR
,
Rozenman
M
,
Wiblin
J
,
Zeltzer
L
.
Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis
.
JAMA Pediatr
.
2015
;
169
(
10
):
929
937
192
Dunsmoor
JE
,
Kroes
MCW
,
Li
J
,
Daw
ND
,
Simpson
HB
,
Phelps
EA
.
Role of human ventromedial prefrontal cortex in learning and recall of enhanced extinction
.
J Neurosci
.
2019
;
39
(
17
):
3264
3276
193
Giustino
TF
,
Fitzgerald
PJ
,
Ressler
RL
,
Maren
S
.
Locus coeruleus toggles reciprocal prefrontal firing to reinstate fear
.
Proc Natl Acad Sci USA
.
2019
;
116
(
17
):
8570
8575
194
Sloan
DM
,
Marx
BP
,
Lee
DJ
,
Resick
PA
.
A brief exposure-based treatment vs cognitive processing therapy for posttraumatic stress disorder: a randomized noninferiority clinical trial
.
JAMA Psychiatry
.
2018
;
75
(
3
):
233
239
195
Jones
AM
,
Shealy
KM
,
Reid-Quiñones
K
, et al
.
Guidelines for establishing a telemental health program to provide evidence-based therapy for trauma-exposed children and families
.
Psychol Serv
.
2014
;
11
(
4
):
398
409
196
Bashshur
RL
,
Shannon
GW
,
Bashshur
N
,
Yellowlees
PM
.
The empirical evidence for telemedicine interventions in mental disorders
.
Telemed J E Health
.
2016
;
22
(
2
):
87
113
197
Conrad
R
,
Rayala
H
,
Diamon
R
,
Busch
B
,
Kramer
N
.
Expanding telemental health in response to the COVID-19 pandemic
.
2020
.
198
Menschner
C
,
Maul
A
,
Center for Health Care Strategies
.
Key Ingredients for Successful Trauma-Informed Care Implementation
.
Hamilton, NJ
:
Center for Health Care Strategies
;
2016
,
199
Schulman
M
,
Menschner
C
.
Laying the Groundwork for Trauma Informed Care
.
Hamilton, NJ
:
Center for Health Care Strategies
;
2018
.
200
American Academy of Pediatrics
.
Trauma Toolbox for Primary Care
.
Elk Grove Village, IL
:
American Academy of Pediatrics
;
2014
.
201
Pediatric Integrated Care Collaborative
.
Improving the Capacity of Primary Care to Serve Children and Families Experiencing Trauma and Chronic Stress: A Toolkit
.
Baltimore, MD
:
Pediatric Integrated Care Collaborative
;
2016
.
Available at: https://picc.jhu.edu/the-toolkit.html. Accessed January 11, 2021
202
Brown
SM
,
Baker
CN
,
Wilcox
P
.
Risking connection trauma training: a pathway toward trauma-informed care in child congregate care settings
.
Psychol Trauma
.
2012
;
4
(
5
):
507
515
203
Bryson
SA
,
Gauvin
E
,
Jamieson
A
, et al
.
What are effective strategies for implementing trauma-informed care in youth inpatient psychiatric and residential treatment settings? A realist systematic review
.
Int J Ment Health Syst
.
2017
;
11
:
36
204
Murphy
K
,
Moore
KA
,
Redd
Z
,
Malm
K
.
Trauma-informed child welfare systems and children’s well-being: a longitudinal evaluation of KVC’s bridging the way home initiative
.
Child Youth Serv Rev
.
2017
;
75
:
23
34
205
Schiff
DM
,
Zuckerman
B
,
Hutton
E
,
Genatossio
C
,
Michelson
C
,
Bair-Merritt
M
.
Development and pilot implementation of a trauma-informed care curriculum for pediatric residents
.
Acad Pediatr
.
2017
;
17
(
7
):
794
796
206
Substance Abuse and Mental Health Services Administration
.
The Integration of Behavioral Health into Pediatric Primary Care Settings
.
Washington, DC
:
Substance Abuse and Mental Health Services Administration
;
2017
207
Kolko
DJ
,
Perrin
E
.
The integration of behavioral health interventions in children’s health care: services, science, and suggestions
.
J Clin Child Adolesc Psychol
.
2014
;
43
(
2
):
216
228
208
Garg
A
,
Toy
S
,
Tripodis
Y
,
Silverstein
M
,
Freeman
E
.
Addressing social determinants of health at well child care visits: a cluster RCT
.
Pediatrics
.
2015
;
135
(
2
):
e296
e304
209
Sun
J
,
Patel
F
,
Rose-Jacobs
R
,
Frank
DA
,
Black
MM
,
Chilton
M
.
Mothers’ adverse childhood experiences and their young children’s development
.
Am J Prev Med
.
2017
;
53
(
6
):
882
891
210
Feder
KA
,
Letourneau
EJ
,
Brook
J
.
Children in the opioid epidemic: addressing the next generation’s public health crisis
.
Pediatrics
.
2019
;
143
(
1
):
e20181656
211
West
CP
,
Tan
AD
,
Habermann
TM
,
Sloan
JA
,
Shanafelt
TD
.
Association of resident fatigue and distress with perceived medical errors
.
JAMA
.
2009
;
302
(
12
):
1294
1300
212
Shanafelt
TD
,
Noseworthy
JH
.
Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout
.
Mayo Clin Proc
.
2017
;
92
(
1
):
129
146
213
Shanafelt
TD
,
Boone
S
,
Tan
L
, et al
.
Burnout and satisfaction with work-life balance among US physicians relative to the general US population
.
Arch Intern Med
.
2012
;
172
(
18
):
1377
1385
214
Shanafelt
TD
,
Hasan
O
,
Dyrbye
LN
, et al
.
Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014 [published correction appears in Mayo Clin Proc. 2016;91(2):276]
.
Mayo Clin Proc
.
2015
;
90
(
12
):
1600
1613
215
Shanafelt
TD
,
Gorringe
G
,
Menaker
R
, et al
.
Impact of organizational leadership on physician burnout and satisfaction
.
Mayo Clin Proc
.
2015
;
90
(
4
):
432
440
216
Shanafelt
TD
,
Dyrbye
LN
,
Sinsky
C
, et al
.
Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction
.
Mayo Clin Proc
.
2016
;
91
(
7
):
836
848
217
Sinsky
CA
,
Willard-Grace
R
,
Schutzbank
AM
,
Sinsky
TA
,
Margolius
D
,
Bodenheimer
T
.
In search of joy in practice: a report of 23 high-functioning primary care practices
.
Ann Fam Med
.
2013
;
11
(
3
):
272
278
218
Wallace
JE
,
Lemaire
J
.
On physician well being-you'll get by with a little help from your friends
.
Soc Sci Med
.
2007
;
64
(
12
):
2565
2577
219
Horn
DJ
,
Johnston
CB
.
Burnout and self care for palliative care practitioners
.
Med Clin North Am
.
2020
;
104
(
3
):
561
572
220
Ofei-Dodoo
S
,
Cleland-Leighton
A
,
Nilsen
K
,
Cloward
JL
,
Casey
E
.
Impact of a mindfulness-based, workplace group yoga intervention on burnout, self-care, and compassion in health care professionals: a pilot study
.
J Occup Environ Med
.
2020
;
62
(
8
):
581
587
221
Forkey
H
,
Griffin
J
,
Szilagyi
M
.
Childhood Trauma and Resilience: A Practical Guide
.
Itasca, IL
:
American Academy of Pediatrics
;
2021
222
Roelofs
K
.
Freeze for action: neurobiological mechanisms in animal and human freezing
.
Philos Trans R Soc Lond B Biol Sci
.
2017
;
372
(
1718
):
20160206
223
Shonkoff
JP
,
Boyce
WT
,
McEwen
BS
.
Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention
.
JAMA
.
2009
;
301
(
21
):
2252
2259
224
Taylor
SE
,
Klein
LC
,
Lewis
BP
,
Gruenewald
TL
,
Gurung
RA
,
Updegraff
JA
.
Biobehavioral responses to stress in females: tend-and-befriend, not fight-or-flight
.
Psychol Rev
.
2000
;
107
(
3
):
411
429
225
Taylor
SE
.
Tend and befriend: biobehavioral bases of affiliation under stress
.
Curr Dir Psychol Sci
.
2006
;
15
(
6
):
273
277
226
Bartz
JA
,
Zaki
J
,
Bolger
N
,
Ochsner
KN
.
Social effects of oxytocin in humans: context and person matter
.
Trends Cogn Sci
.
2011
;
15
(
7
):
301
309
227
Romano
A
,
Tempesta
B
,
Micioni Di Bonaventura
MV
,
Gaetani
S
.
From autism to eating disorders and more: the role of oxytocin in neuropsychiatric disorders
.
Front Neurosci
.
2016
;
9
:
497
228
Cardoso
C
,
Valkanas
H
,
Serravalle
L
,
Ellenbogen
MA
.
Oxytocin and social context moderate social support seeking in women during negative memory recall
.
Psychoneuroendocrinology
.
2016
;
70
:
63
69
229
Shamay-Tsoory
SG
,
Abu-Akel
A
.
The social salience hypothesis of oxytocin
.
Biol Psychiatry
.
2016
;
79
(
3
):
194
202
230
Bethlehem
RAI
,
Baron-Cohen
S
,
van Honk
J
,
Auyeung
B
,
Bos
PA
.
The oxytocin paradox
.
Front Behav Neurosci
.
2014
;
8
:
48
231
Chen
J
,
Evans
AN
,
Liu
Y
,
Honda
M
,
Saavedra
JM
,
Aguilera
G
.
Maternal deprivation in rats is associated with corticotrophin-releasing hormone (CRH) promoter hypomethylation and enhances CRH transcriptional responses to stress in adulthood
.
J Neuroendocrinol
.
2012
;
24
(
7
):
1055
1064
232
Weaver
ICG
,
Cervoni
N
,
Champagne
FA
, et al
.
Epigenetic programming by maternal behavior
.
Nat Neurosci
.
2004
;
7
(
8
):
847
854
233
American Psychiatric Association
.
Diagnostic and Statistical Manual of Mental Disorders
, 5th ed.
Washington, DC
:
American Psychiatric Publishing
;
2013
234
Koita
K
,
Long
D
,
Hessler
D
, et al
.
Development and implementation of a pediatric adverse childhood experiences (ACEs) and other determinants of health questionnaire in the pediatric medical home: a pilot study
.
PLoS One
.
2018
;
13
(
12
):
e0208088
235
Wade
R
 Jr
,
Cronholm
PF
,
Fein
JA
, et al
.
Household and community-level adverse childhood experiences and adult health outcomes in a diverse urban population
.
Child Abuse Negl
.
2016
;
52
:
135
145
236
Child and Adolescent Health Measurement Initiative
.
2019 National Survey of Children’s Health: guide to topics and questions
.
Data Resource Center for Child and Adolescent Health supported by the US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau
.
2020
.
237
National Child Traumatic Stress Network
.
Complex trauma
.
Available at: www.nctsn.org/trauma-types/complex-trauma. Accessed January 11, 2021
238
Schmid
M
,
Petermann
F
,
Fegert
JM
.
Developmental trauma disorder: pros and cons of including formal criteria in the psychiatric diagnostic systems
.
BMC Psychiatry
.
2013
;
13
:
3
.
DOI: https://doi.org/10.1186/1471-244X-13-3
239
Shah
AN
,
Jerardi
KE
,
Auger
KA
,
Beck
AF
.
Can hospitalization precipitate toxic stress?
Pediatrics
.
2016
;
137
(
5
):
e20160204
240
Rzucidlo
SE
,
Campbell
M
.
Beyond the physical injuries: child and parent coping with medical traumatic stress after pediatric trauma
.
J Trauma Nurs
.
2009
;
16
(
3
):
130
135
241
National Child Traumatic Stress Network
.
Effects
.
242
US Department of Health and Human Services, Administration for Children and Families
.
Secondary traumatic stress
.
243
The National Child Traumatic Stress Network
.
Families and caregivers
.
Available at: https://www.nctsn.org/audiences/families-and-caregivers. Accessed January 11, 2021
244
US Department of Health and Human Services, Administration for Children and Families
.
Resources on trauma for caregivers and families
.
245
American Academy of Pediatrics
.
Parenting After Trauma: Understanding Your Child’s Needs
246
Porges
S
,
Lewis
GF
.
The polyvagal hypothesis: common mechanisms mediating autonomic regulation, vocalizations and listening
. In:
Brudzynski
SM
, ed.
Handbook of Mammalian Vocalization: An Integrative Neuroscience Approach
.
New York, NY
:
Elsevier
;
2009
:
255
264
247
Bethell
C
,
Gombojav
N
,
Solloway
M
,
Wissow
L
.
Adverse childhood experiences, resilience and mindfulness-based approaches: common denominator issues for children with emotional, mental, or behavioral problems
.
Child Adolesc Psychiatr Clin N Am
.
2016
;
25
(
2
):
139
156

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.