April 19, 2024 • 44 mins
Episode 31: Trauma-Informed Care in a Practice Setting
Link for MOC or Ethics Credit
https://cmetracker.net/UTHSCSA/Publisher?page=pubOpen#/getCertificate/10095774
Welcome to an enlightening episode of Pediatrics Now, hosted by Holly Wayment, a pediatric health professional at UT Health San Antonio's Department of Pediatrics. This episode deep dives into the critical topic of trauma-informed care in pediatric practice, a revolutionary approach that has been endorsed by the American Academy of Pediatrics. Navigate your way through the toxic stress responses caused by various traumatic experiences in children and learn how to effectively recognize and respond to trauma in your pediatric healthcare settings.
Host and Executive Producer Holly Wayment brings us this fascinating grand rounds talk by Dr. Nancy Kellogg, who has more than thirty years of experience fighting child abuse and helping children. A faculty member at UTHealth San Antonio since 1988 and Professor and Division Chief of Child Abuse in the Department of Pediatrics, she was the first Medical Director of the Christus Santa Rosa Center for Miracles which opened in May 2006, and was the former Medical Director for ChildSafe and CHRISTUS Childrens Sexual Assault Nurse Examiner Program. Dr. Kellogg was the first Program Director for the Child Abuse fellowship, which was one of the first programs to become accredited in the country. Dr. Kellogg has published over 135 articles and book chapters and has been an invited speaker at numerous local, regional, national, and international conferences. She was the Chair of the Texas Pediatric Society Committee on Child Abuse for 10 years and served on the American Academy of Pediatrics Committee on Child Abuse and Neglect for 6 years. In September 2006, the American Board of Pediatrics approved Child Abuse as a new subspecialty in pediatrics, and Dr. Kellogg was appointed as the Medical Editor for the sub-board; she served 17 years in this role and continues to write board questions as a volunteer. Dr. Kellogg has received several honors and awards for teaching, clinical excellence, social work, leadership, and humanism.
Financial Disclosures: Nancy Kellogg, MD has no financial relationships with ineligible companies to disclose.
The Pediatric Grand Rounds Planning Committee (Deepak Kamat MD, PhD, Daniel Ranch, MD and Elizabeth Hanson, MD) has no financial relationships with ineligible companies to disclose. Planning Committee member Steven Seidner, MD has disclosed he receives funding from Draeger Medical for the Clinical Study to Evaluate the Safety and Effectiveness of the Infinity Acute Care System Workstation Neonatal Care Babylog VN500 Device in High-Frequency Oscillatory Ventilation (HFOV) Mode in Extremely Low Birth Weight (ELBW) Neonates for which he is a co-principal investigator.
Credits: AMA PRA Category 1 Credits™ (1.00 hour) Non-Physician Participation Credit (1.00 hour) MOC-2 credit (1.00 hour)
Target Audience: Pediatric Doctors and Providers Faculty, residents, health care providers; medical students and trainees.
Accreditation: The UT Health Science Center San Antonio is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Credit Designation: The UT Health Science Center San Antonio designates this live activity up to a maximum of 1.00 AMA PRA Category 1 Credits™.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:01):
Welcome to Pediatrics Now, cases, updates, and discussions for the busy practitioner.
I'm your host, Holly Wayment. I work for UT Health San Antonio's Department of Pediatrics.
In this podcast, we explore how we can provide the best, most cutting-edge,
compassionate care for children.
We hope to give you a unique and behind-the-scenes edge from our expert guests.
(00:23):
After listening, click on the link on this podcast for free credit that may
include CME, MOC, or ethics credit, depending on the topic.
Music.
The topic this morning, trauma-informed care in a practice setting,
is a relatively new topic for medicine and pediatrics.
(00:43):
And it was really first introduced in 2001, but initially was applied to adult
settings, intended to help facilitate recovery of adults who were,
suffering from addiction and
mental health disorders, but who had also had prior trauma experiences.
It came into the picture in pediatrics in about 2009 when the National Child Trauma Stress Network,
(01:10):
an organization that offered resources on this, became very active and they
were instrumental in providing services at the Sandy Hook Elementary School of Shrewden. them.
In 2021, the American Academy of Pediatrics published a clinical report and
a technical report on trauma-informed care.
(01:30):
So it's a very current topic in our pediatric practice.
Our objectives today are to describe experiences that may trigger toxic stress responses.
So it's not just about child abuse. It's about a lot of other different types
of stresses that children and families can suffer from or be exposed to.
(01:51):
We also want to recognize and respond to children and caregivers that have experienced trauma,
and understand how trauma-informed principles can be implemented in practice
setting, not just one that is geared for child abuse, but also for other settings
as well, and to employ strategies to mitigate secondary trauma,
(02:11):
in a practice setting.
Start off with a patient presentation. So this is Rachel. I met Rachel a few years ago.
And she presented to Center for Miracles, which is where I work, for a sexual abuse exam.
And she was very upfront and just said right off the bat that she did not want this exam.
It would scare her to do it today. It was too immediate.
(02:32):
She had touch issues and she had trust issues.
And, you know, she came from a long history of CPS involvement,
had lived in several foster the family, different relatives, and shelters.
And so when you have a patient like Rachel, just stop for a minute and think,
what would you do next? What would you say next?
So why is it important to be trauma-informed? Really, the purpose is to minimize
(02:56):
further trauma, facilitate trust and transparency,
to optimize empathic communication and listening, and to engage the child and
family in a cooperative venture towards healing. on.
So my response to Rachel, I think some people would say, that's fine. We want you to check up.
I decided to try to open the door with her. And I said, what can I do to earn your trust?
(03:19):
And she had some very specific answers for this question.
She had rule. She said, don't lie to me. Don't talk about my mother.
Don't give me shots. And don't tell me to do something immediate or I will be traumatized.
And we'll come back to Rachel at the end of the presentation to see how this all worked out.
So today, I first want to just give an overview of what the child's world of
(03:44):
trauma looks like and talk about different prevalence and types of traumatic
experiences that children experience, the ripple effect.
It's not just the child that's affected by trauma, but it's also the caregiver
as well as the healthcare provider.
We'll do a brief overview view of the brain and adversity, and then talk about
(04:05):
signs of stress that we may see in children and in others.
We'll then move on to what is trauma-informed care and how is it defined.
We will include implementation strategies as described by the American Academy
of Pediatrics clinical report.
And then we'll move to some more specific strategies that can be utilized in
a clinical setting for children and families that have experienced trauma.
(04:31):
So traumatic experiences in childhood are common. When we talk about adverse
childhood experiences,
it is up to 68% of children will
experience at least one adverse childhood experience during childhood.
So the most common experiences include witness to family and peer violence,
(04:53):
separation, divorce of parents, and sexual trauma.
In about 30% of these children, they were experiencing more than one adverse childhood event.
And the relationship, though, between the number of adverse childhood events
and the adult health is a dose response.
(05:13):
So, in other words, the greater number of adverse childhood events a child has,
the higher the risk is for medical and mental health outcomes in adolescence and adulthood.
So about 10% of children will experience sexual abuse, serious accident,
natural disaster, living with anyone with a drug or alcohol problem.
(05:36):
And then you see to the right what the increased risk are for experiencing three
or more adverse childhood events.
It's 46 times more likely that someone will become involved with injection drug
use. And suicide thoughts as well as behaviors are increased risk by 12.
We also see an increased risk in sexually transmitted infections and COPD of
(06:02):
two to three times greater.
So here are the original 10 adverse childhood experiences. And you can see that
a lot of them involve trauma treatment.
So if we look at these, they do not happen in isolation. So many of these are
associated with additional adverse childhood events.
So, for example, if we look at sexual abuse, there's an increased rate of also
(06:28):
experience in physical abuse, exposure to household mental illness,
and exposure to intimate partner abuse in the home.
If we take a look at exposure to household mental illness, that in turn is associated
with emotional abuse, family member being incarcerated, and physical abuse.
So you can see how these compound upon one another, and it's very common for
(06:53):
children to experience more than one adverse childhood experience.
So looking at the world of trauma, it's not just about ACEs.
So it is about experiences they see in their world from inside their home and
then moving out to the community, society, and unfortunately at school as well.
(07:13):
Many of these experiences directly impact the child and others may more indirectly
impact the child, but all of them can have very significant and severe,
create very significant severe stresses for the child.
So here's a ripple of that. And when we look at definitions for trauma-informed care,
(07:36):
we find that pretty much most definitions incorporate trauma-informed care,
not just for the child, but also
for the caregiver and as well for the healthcare provider or clinician.
So what we see here is a primary stress experienced by the child.
We have secondary trauma stress experienced by the caregiver and the clinician.
(07:58):
And in turn, their experiences in the past, their past traumatic experiences,
influenced their capability of providing the appropriate support for the child.
How would this work in a clinical setting? So if we take, for example,
a common scenario at Center for Miracles, and we'll have a child that will present with sexual abuse.
(08:20):
And what we would see is that the child is first, she's experiencing stress
or he's experiencing stress just due to thoughts of, will they believe me? What will happen?
So once a child discloses abuse, there's a whole other set of structures that impact the child.
(08:41):
Then we move to the caregiver level, and there's a lot of things that caregivers
struggle with. So they struggle with the fact that many of these children who
are victims of sexual abuse will wait an average of two years to tell.
Why didn't they tell me sooner? Why didn't they tell me? Why didn't they tell the teacher?
Then there's also a level of grief for loss of the child's innocence, partner, family ties.
(09:05):
And then we have sometimes caregivers who simply just don't believe their child
or not sure whether to believe the child. And so that creates additional stressors,
particularly on the child-caregiver relationship.
But then we also have to remember the healthcare provider.
And we have both an opportunity, but sometimes we have a struggle of how to
(09:28):
handle these situations.
So, for example, our opportunity to try to encourage the caregiver to understand
that disclosure can take years.
It's very common for it to take years. It doesn't mean they did anything wrong or bad as a parent.
But then sometimes we're confronted with parents who do not believe their child
(09:49):
or do not support who says anger, frustration, sometimes frustration with the
lack of a safety response from CPS.
So this affects many people. And we have to remember to attend to the needs
of everybody in order to heal the child appropriately. Right.
We'll talk about the types of stress. So there are three types of stress that
(10:11):
are described, positive stress, tolerable stress, and toxic stress.
So positive stress is supposed to be good stress. So this is something that
elicits a mild physiologic response.
It resolves quickly. It tends to result in a productive or an adaptive action.
So examples of a positive stress would be learning to ride a bike,
(10:33):
preparing for an exam or a test.
Stress in general, when the brain responds to a positive stress,
it's a first-line defense, which we'll look at in the next slide. So it's more of a buoy.
It enhances performance, and it resolves very quickly.
Palliable stress lasts a little longer. So it elicits a moderate physiologic stress response.
(10:57):
Important to note that it can be buffered with supportive, safe,
nurturing relationships.
And we'll see this mentioned a couple of times in the next several slides.
Examples of tolerable stress would be a death of a family member or witnessing community violence.
This type of stress elicits a first and second line defense,
but it tends not to be sustained because the buffer is effective or because
(11:21):
the child is able to get through the trauma without difficulty or with less difficulty.
Positive stress is the one we need to be most concerned about.
So this elicits a severe, frequent, prolonged physical response and an ineffective or absent buffer.
So examples of this would be abuse and neglect, of course, and witness and family violence.
(11:47):
And this elicits a first and second line of events, but these are sustained
and unmitigated responses.
So these are the types of responses that can result in longer-term changes.
So this is a rather simplified overview of what happens in the brain with adversity.
The amygdala is the alarm system. So as soon as we see something in our environment
(12:12):
that's perceived as a threat, the amygdala is activated.
And it sends signals, of course, to the hypothalamus, which in turn sends signals to the adrenals.
And there's a release of epinephrine.
And when you look at all the red arrows here, what you see is that the response
of the brain is to really increase the individual's capacity to respond effectively to the stress.
(12:38):
So we have more oxygen going to the brain, increased respiratory rate, increased heart rate.
So it could be, again, an effective adaptive response.
But then we get to the second line. And the second line is what we call the HPA axis.
So this is the hypothalamus, the pituitary, and the adrenal HPA.
(12:58):
And when that second line is in place, the purpose is to sustain the alert response
to be able to continue to face the threat and handle it effectively.
And this is the one that really stimulates the fight, flight,
or freeze responses that we see.
So what happens with toxic stress? A lot happens with toxic stress.
(13:21):
That HPA axis is on overdrive, and cortisol is the primary substance release
that leads to several of the changes in the brain.
The changes in the brain are not benign. They include alterations in brain connectivity.
This is all mediated by cortisol and includes reductions in gray matter volume.
(13:43):
It also includes changes in dendrites that are either enhanced or pruned.
So it's a lot of very direct effects from sustained cortisol release.
We also have epigenetic changes. And this, again, cortisol mediates these changes.
Primarily what we see is alterations in DNA through methylation of different face pairs.
(14:07):
So we have altering gene expression and stress reactivity behavior.
And finally, cortisol results in an off-regulated inflammatory response,
which increases the risk for fatigue, mood changes, and chronic inflammation.
And you can see there are several areas of the brain that are affected,
in particular the prefrontal cortex, the hypothalamus, the amygdala is also affected as well.
(14:34):
There's some very interesting studies going on in this field, current studies.
Some of the studies have suggested that different types of trauma treatment
have different effects in different parts of the brain.
For example, one study was looking at heart-corporeal punishment,
which was defined as ongoing for three years, at least 12 times a year,
and noted that there is reduction in prefrontal cortex and cingulate gyrus volume,
(14:59):
reduced blood flow in dopamine-rich areas.
And this basically resulted in changes in threat detection, emotional regulation,
and reward anticipation.
The effect on behavior for all of these tend to be of the nature of a change
in how you perceive your world.
(15:20):
So sensory interpretation of sensory information and how you act on it changes
based on toxic stress responses. So, children will have trouble processing emotion.
For example, it's very common for children to have experienced sustained toxic
stress to look at an individual who perhaps is fearful and misinterpreted as anger.
(15:45):
Oxytocin is another area of research, and it's a very important substance in
the mother-infant bonding.
So there have been some studies that have looked at the fact that child maltreatment
dysregulates the oxytocin system, causing anxiety and dysfunctional attachments.
So how does this play out? So if we have a parent, if we have a mother who has
(16:09):
experienced trauma in her past, she may have trouble bonding with her infant
due to her dysregulation of oxytocin system.
There have been some experiments, there have been some studies that have looked
at using intranasal oxytocin to facilitate that bonding between the mother and the infant.
(16:29):
We also have looked at intranasal oxytocin in children, older children who have
experienced trauma and who are having trouble bonding with their caregivers.
One thing that all of these studies suggest is that the periods of most rapid
development are those that are the most vulnerable times, and that is the early
postnatal period and adolescence.
(16:52):
So what do we see when somebody is experiencing traumatic stress?
Well, we see symptoms of fight, flight, and freeze.
So this just gives you some examples of things that children may say or do that
are reflective of their responses to trauma.
So with the fight response, Rachel was a little bit of a fight response.
(17:15):
She wasn't going to participate. She was putting up walls to not want to cooperate with the examination.
Children, they say, I don't want to do this. I don't feel like talking about it.
We also tend to see these children are sensitive to touch.
They complain about pain and discomfort during various parts of the exam when
(17:37):
there really isn't any pain or discomfort, but they perceive it as such.
When we move to the flight responses, there's a lot of anxiety,
a lot of increased motor movement during the history, during the exam,
wondering what all of this will lead to. So that's more of the flight response.
And then we have freeze. And of course, it's overlap, which have some children
(17:59):
that manifest symptoms of fight and flight or freeze and fight.
But the freeze, these are children that tend to say nothing. They're very quiet.
They look for ways to end the question with short answers.
They have little eye contact. They gaze away. Sometimes they look like they're
actively dissociating as you're talking to them.
(18:23):
Now, there is good news in all this. So it's been found that there are reactive
alleles that can facilitate resilience.
And it's also modifying the environment, changing the social and physical environment
can also redirect that negative trajectory in a positive direction.
Most important is to save, secure, nurture relationships.
(18:45):
I feel like this is a very key role for pediatric providers.
We really have to be dedicated to facilitating these SSNRs, by ensuring that
caregivers have their medical and mental health needs addressed,
assisting with challenges relating to social determinants of health,
but also utilizing the trauma-informed approach to identify and manage trauma
(19:07):
symptoms in children and their caregivers.
Believe the hurt, begin the healing.
Heal the caregiver, heal the child. So what is trauma-informed care?
We're looking at two definitions.
There are several organizations that have a couple of definitions,
and I think the common denominator here is that we want to enhance our ability
(19:31):
to recognize and respond to individuals that have experienced stress or are
experiencing traumatic stress,
and also to take measures to reduce or resist re-traumatization.
When is it important to be trauma-informed? And there are several different settings.
(19:53):
We can know that somebody has experienced trauma and we should use trauma-informed
care approach with them.
But also when children begin to talk about their traumatic experiences,
that's another time to utilize trauma-informed strategies.
Strategies but keep in mind there are other situations
where children may have experienced trauma we
(20:14):
don't know yet but in particular when
there are children who have behavioral signs such as hostility withdrawal
anxiety fearfulness defensiveness somatic complaints those may be red flags
for traumatic experiences and toxic stress so here's a 2021 clinical report
that That was published by American Academy of Pediatrics.
(20:37):
And what I'd like to do is to review the strategies they proposed in this clinical report.
The first is awareness, and that is knowing the science and epidemiology of
trauma and understanding, again, the importance of those SSRs for recovery in
the child as well as the caregiver.
(20:57):
Knowing the adverse populations that trauma-informed care is appropriate for.
And it's really a paradigm shift. That's what's meant by readiness.
It's a shift from I must speak to you to I must understand you.
And recognizing, again, that the healing the child involves healing the caregiver.
Identify priorities with the caregiver. I know at Center for Miracles,
(21:21):
I have worked with our social workers there.
When they meet with the caregiver, the most common priority for that caregiver
is that I know I need help, but I need to take care of my child first.
So we have our job at Center for Miracles. is to help the caregivers shift that
priority a little bit and say, yes, but for you to give the best care to your
(21:45):
child, you need help as well.
And so we need to find ways for you to get help at the same time.
Many of the caregivers we deal with are also blaming themselves.
They feel they didn't see the signs of the abuse.
So we do try to identify these priorities and we do discuss them,
recognizing that it's important to provide this care to the caregiver.
(22:09):
We also spend a lot of time identifying the changes that are related to adversity.
When children experience abuse and neglect, it is frequent that families have
to move, that families break up, financial support changes. They may have food insecurity.
They may have legal needs. They may need legal aid or they may need a protection
(22:29):
order to keep the individual away. way.
They may have challenges with transportation.
And we do try, these are just very basic needs, but they can be overwhelming
in terms of the stress that they produce.
Another strategy includes detection and assessment, identifying the emergent
versus non-emergent situations.
(22:49):
So the two emergent situations that come to mind are the situation where a child
is in immediate danger of further harm,
and that may necessitate not just a call to CPS, but perhaps a call to law enforcement as well.
But the other emergent situation that we commonly deal with is self-injurious
(23:12):
thoughts and behaviors, particularly in adolescents, but sometimes in children
as young as 10 in our clinic.
So we do actively ask questions about that, not just to the caregiver,
but also to the child individually.
Then it's to assess symptoms. So symptoms may be functional,
neurodevelopmental, or involve the immune system.
(23:36):
So, a list here, the functional symptoms, sleeping difficulties,
appetite changes, toileting concerns, challenges with school functioning.
Symptoms of ADHD are common in children that are experiencing toxic stress.
You can imagine the fight or flight responses makes it difficult for them to focus on learning.
(23:58):
So, attention deficit disorder is something that is commonly diagnosed in these children. them.
Our neurodevelopmental changes include dysregulation of emotions and behavior,
disruptions in executive control, reactions to trigger, and just a negative
worldview, self-narrative.
We try to ask children what their super strengths are and what they would change about the world.
(24:21):
And it's sad how many of them don't see that they have anything that's very
special about them. So we do try to help them see that as well.
And then the immune system, some chronic inflammation can also be present in these children.
So management, again, basic needs should come first.
I love for children and families to have counseling when it's appropriate,
(24:44):
but we also must realize that the basic needs may be the biggest priority for that family.
And anticipatory guidance to caregivers. So knowing that children don't see
the world the same way when they've been traumatized.
No more, they have trouble interpreting emotions. They may react to triggers and different sounds.
(25:07):
They may have trouble expressing their emotions. So all of these things are
changes that the caregiver should be aware of and realize that these are responses to trauma.
This is not the child trying to be a problem to child.
And also mental health treatment is very important. And it should be convenient
(25:27):
for the family and the child.
Now, let's look a little closer at
how we would apply trauma-informed care strategies in a clinical setting.
So this comes from an article that describes how they taught medical students
how to render trauma-informed care.
It's like a rubric that they use to evaluate the performance of a medical student
(25:52):
in a clinical setting as they apply these principles.
So it could be a useful tool.
It's adaptive. I've adapted it a little bit for purposes of this presentation.
So, you can see that there are several items for before the medical evaluation,
during the evaluation, and after.
(26:12):
So, before the medical evaluation, it's important to state your why or your agenda for the visit.
So, I'm Dr. Kellogg. It's my job to take care of your body and your feelings.
I'm going to ask you some questions to help me do that.
Ask permission before proceeding. Is this okay with you? And then,
of course, it's important to offer choices when possible.
(26:34):
So I let the child choose who they want to be with them in the exam room.
That's just one example of a choice, but it should be offered whenever you can.
During the evaluation, it's important to identify concerns.
So is there anything that you're worried about today that you want me to be sure to check?
Respect the personal space and use understandable language.
(26:59):
I think sometimes when we are confronted with somebody who's experienced horrible
trauma, we forget that they have trouble processing what we're saying to them.
So it's important to check and make sure they understand it.
Physical exam, I tell them everything before I do it.
When I do need to undrape certain parts of the body, I only undrape the part
(27:22):
of the body I'm examining.
I'm also very mindful of what I say during the exam.
So, terms of endearment, like sweetie or move your leg for me,
be careful with that because it does send a possessive message and it can be
misinterpreted. It can be interpreted as a threat for the child.
(27:43):
After the evaluation, I tend to focus first on the child and give them the results
of the the evaluation in terms that they can understand.
I always ask the questions, the question from the child, and then I'll ask the
question from the caregiver.
So now quickly, I thought I would share seven things that children and families
have taught me about trauma-informed care.
(28:06):
First, it's about them. It's not about you. I think sometimes we're very frustrated
by children's responses or behaviors towards us, their resistance,
their lack of communication, or even though perhaps a caregiver is angry,
and questioning everything we're doing.
It's recognizing that this comes from an experience of trauma.
(28:28):
It's not to attack you. It's not to push your button.
It's also important to know that people are not always willing to share their experiences.
We don't say, trust me, I'm a doctor in this business. We have to earn this
trust. We cannot assume it.
This just reiterates an earlier point is that I tell them everything that I'm
(28:49):
doing and why at every point of my evaluation.
So what my job is, why I need to talk to them. because, again,
in my setting, many times children are not used to talking with the clinician alone first.
And then what I would do with the information. So based on what you're telling
me, I think we need to do tests for X, Y, and Z.
(29:11):
Or I think I need to look at your medical records to understand a little more
about this medical problem that you're telling me.
And also to recommend next steps for treatment and management.
But they have to, at every point of the way, it has to be clear they have choices.
The patient has a choice. The caregiver has a choice in what happens.
(29:32):
I think it's very important when you're dealing with a child or a caregiver
who has experienced trauma that you're very alert to cues, verbal and nonverbal,
that indicate that that person may not be hearing or understanding what you're saying.
And so these are some of the cues that I look for. They may ask you point blank what a word means.
I like that when it happens because that means the child is listening to me
(29:56):
and they're being very honest and they don't feel odd asking me,
what do you mean by this word?
So that's actually a good sign when that happens. So they may give you an answer
that's not really responsive to the question.
Children, again, tend not to want to admit when they don't understand, so be an alert to that.
(30:17):
They may say, I don't notice several questions, which could also mean I just
don't want to answer that question, or they may not respond at all.
The increased psychomotor activity is something I see frequently.
It generally begins with the very beginning of the interview,
and then I see it slow down as the interview progresses.
(30:37):
Distractive behavior, again, the fight or flight response can also be seen during interviews.
And only nodding or shaking head in response to questions is another non-verbal
cue that maybe they are not quite understanding or receiving the information
we're trying to give them.
Hearing is not the same as listening.
(30:58):
So listening means to understand and respect what they are saying.
And it also means that you are listening and looking for cues of unspoken concerns
or fears that the child may have.
Sometimes they're statements of self-blame, remorse for not telling sooner about
their trauma experiences and anxiety about what will happen with their family.
(31:21):
And just listening carefully to what they're saying and following up on things
that may indicate these unspoken concerns.
No surprises. So remembering that children and caregivers that have experienced
trauma do not receive information, sensory information, in the same way.
(31:41):
So being alert to different triggers. Sometimes we get a loud noise in our interview
room that comes from cars in the garage, and I can see children startled to that sometimes.
But also, especially, be very careful with touch. And I recommend avoid touching
a person during a verbal or during the initial interview or history with them.
(32:04):
The risk of sending the wrong message is much greater than the potential benefit
of trying to show empathy through touch.
There are other ways to show empathy that may be more comfortable.
So really delaying that touch until you absolutely have to during the exam.
In general, that's how I approach it.
So it is common for children and
(32:25):
caregivers to feel devalued and vulnerable it
is common for traumatized individuals to feel that something is wrong with them
and keeping this in mind as you talk to them is important in terms of you know
rendering trauma-informed care so respect can be demonstrated in a lot of different
ways active listening acknowledging strength asking
(32:47):
if they have any questions or concerns,
asking them to help you help them. It's a cooperative venture towards healing.
Respecting their wishes, even if it's different from your recommendations or expectations.
I think this is an important lesson that I've learned through the years,
because in the beginning, I used to be very frustrated with caregivers who didn't
believe their children.
(33:09):
And what I try to do is...
Change your mind, and it may not be possible always to change the caregiver's
mind, but you can give them information to think about.
They're more likely to receive your information if you do this in a respectful way.
Don't tell them how they feel. I think, again, when we see children who have
(33:30):
experienced unspeakable acts, we have a tendency to want to say,
you're brave, you're strong.
They may not feel that way. And when you say things like that to people who
don't feel that way, it may be off-putting.
So Hattie is another patient that I met in 2007. She was a victim of torture.
She was chained and starved with her sister, Krista, who was a year younger, for three years.
(33:55):
She was beaten. She was terrorized. She presented to Center for Miracles the
day after her sister was killed.
This is what she recalled about her visit to Center for Miracles.
That was the first time, the very first time I told anybody the truth about
everything that happened.
She was the first person that I was like, okay, here it is. Here's my story.
(34:17):
And from that point, I wasn't scared, and I didn't feel like I would get hurt
for telling the truth anymore.
It's like over the years, people keep piling rocks on your chest.
And every time you say stop to them, it means more rocks.
And finally, you have that person come along who's there for you.
She said stop, and they stopped.
It was the first time someone listened to me, listened to my story.
(34:40):
The first time nobody spoke for me.
It's frustrating as a kid when you want to say so much, but you're so traumatized
and in so much shock from that moment.
So that was, she had just turned 10 in this picture. It was 24 hours after she had lost her sister.
Me, it was a trauma. Afterwards, I didn't talk about it for a while.
(35:04):
My thoughts ran from the incomprehensible evil she endured for years,
to despair for her sister, the gratefulness that she felt she could share some
of what happened to her during my time with her.
Ultimately, my self-care went to see Kathy in follow-up two weeks and one year
later. So this is a picture one year later.
(35:25):
She's 35 pounds, and I think about three and a half inches taller, 35 pounds heavier.
And so it was at this visit that I could finally let go.
So much to my surprise, 15 years later, Cassie reached out to me.
She wanted to reconnect. And we spent three and a half hours talking about what
(35:47):
happened to her, how she got through that.
And one of the things that really impressed me about this interview is the power
of safe, secure, nurturing relationships.
Kathy had three things that pulled her back, gave her resilience and allowed her to survive.
The first thing was therapy, her therapist. The second was her husband.
(36:12):
So in this picture, she's married and she has three children.
She's happily married. She's a very dedicated mom and is successful.
The third thing that was her SSNR was advocacy.
So she created a website called Crystal Project after his sister,
which is a forum for other adults and children who have experienced trauma like
(36:36):
she has to share their experiences, to share their success stories.
So she's very proud of that. So those are the three things that were her lifelines.
The interesting thing about that is that her lifeline did not come until years after she was rescued.
She had a rough time in foster care.
(36:56):
Nonetheless, the SSNRs, they did save her, but it took years before they were available to her.
So finally, I just wanted to share with you a little bit about the Center for Miracles.
So we are a level one trauma-informed care certified center.
We received that in July of last year.
(37:18):
And I just, the overall process, it took about a year. And we basically looked
at everything we did at Centers for Miracles from beginning,
when the child and family walk in the door, to the end when they leave.
And we looked at it across several major domains. We looked at safety,
physical and interpersonal safety, transparency and trustworthiness,
(37:40):
respect and empowerment,
collaboration and policy, skill building, and emotional intelligence.
In addition to these things, we also wrote a policy guideline for Center for
Miracles, committing ourselves to rendering trauma-informed care.
We do some periodic surveys of trauma-informed climate.
(38:01):
I'm going to share that with you in the next slide because I think it can be
useful in other practice settings.
We do planned staff retreats, and then we offer secondary trauma group sessions. Thank you.
Here's a climate survey, and we try to hand this out at least twice a year.
And this is really, it takes the temperature of the environment you work with or you work in.
(38:25):
So it asks whether you feel safe where you are, whether you have the resources you need.
Who do you trust? Do you have people you know you can trust? What is the leadership?
Does it listen to only certain people? Does it share decision making?
Again, I find these items very useful. And we look at them. They're anonymous.
(38:46):
We try to aggregate the data and look at ways that we can better address the
needs of the people that we work with.
So finally, getting back to racial. So she gave me her rules,
and this is what I said to each rule.
So don't lie to me. I said, I promise not to lie to you.
And I would tell you if I do not know the answer, don't talk about my mother.
(39:09):
I promise not to ask any questions about your mother.
Don't give me shots. We have no shots here. And then perhaps most importantly,
number four, don't tell me to do something immediate or I will be traumatized.
And so what I said to this was, I will not tell you to do anything.
I will explain what I think should be done for your health, but we will make
(39:29):
a decision together on what happens next.
So to my surprise, because when I go into these encounters, I have no expectation
about what a child is willing to do or not willing to do.
But to my surprise, in this situation, she was able to give a full history,
describe how her mother was not supportive.
(39:50):
So she talked about her mother. She gave a full history.
She consented to all parts of the exam.
She underwent the exam without problem, and she was very cooperative throughout.
In summary, traumatic experiences are common in childhood, and they go beyond the ACEs.
You can have short- and long-term medical and mental health consequences from trauma.
(40:13):
Trauma-informed care is a paradigm shift from what is wrong with you to what's
happened to you to what's strong with you.
And remembering that trauma-informed care recognizes, responds,
and manages traumatic stress, but also in that management that it addresses
the needs of the child, the caregiver, and the pediatric clinician.
(40:36):
Caring for one helps them care for all the others as well.
So I would stop at this point and see if there are any questions.
Hi, Dr. Kellogg. This is Dina Tom.
Thank you for your talk today. I have a question about trauma-informed care
training for non-medical providers.
This is very timely because my neighbor actually yesterday asked about any kind
(41:01):
of, she works for wellness.
She does the, she's the wellness director for the San Antonio Community College District.
And she has a bunch of faculty who've asked questions about how to approach
their own students when it comes to trauma-informed care.
And obviously it's a different angle for non-medical providers a little bit,
(41:22):
but do you know if there's any community training or are any resources for those
who work with students or children,
like teachers in the community for having that kind of trauma-informed mindset?
Don't know offhand any resources for community.
I would think that, you know, what I mentioned in the beginning was an organization
(41:46):
that has resources in general.
And that's the Child Trauma Stress Network.
And I'm thinking if somebody would look that up, they probably would have some
additional links for adults and for students that could be helpful.
Okay. I think, again, trauma-informed care works best in a one-on-one situation
(42:07):
in terms of trying to help an individual through it.
But that's a very interesting question. I don't know offhand of any specific resources.
It looks like Dr. Hansen put something in the chat that I can refer to.
And I think it came up in light of maybe a couple of teachers that have had
students who were missing class or because they've had to go to court after
(42:32):
being in the foster care system.
And basically teachers not knowing how to handle that from a trauma mindset
of understanding that these children who are now young adults may have different struggles.
So anyway, this is incredible talk. So thank you so much for speaking to me.
(42:53):
Thank you. And I agree with you.
I think, again, there's not much understanding that individuals that have experienced
toxic stress see the world differently.
And being able to understand that behavior is not directed at you,
it is a response to trauma. And oftentimes fits into the fight,
(43:15):
flight, freeze paradigm.
It's one of those or a combination of those. And I think, again,
understanding and recognizing it's the first step in all strategies.
So I think there's just not enough of the recognizing and understanding.
So I think that's the first step for most organizations is just understanding
(43:36):
their trauma responses.
Thanks so much for listening to Pediatrics Now.
Music.
I'm Holly Wayment. Our website is pediatricsnowpodcast.com.
You can email me at pediatricsnow at uthscsa.edu with any questions or topic ideas.
(43:58):
Music.
Welcome to Pediatrics Now, cases, updates, and discussions for the busy practitioner.
I'm your host, Holly Wayment. I work for UT Health San Antonio's Department of Pediatrics.
In this podcast, we explore how we can provide the best, most cutting-edge,
compassionate care for children.
We hope to give you a unique and behind-the-scenes edge from our expert guests.
(00:23):
After listening, click on the link on this podcast for free credit that may
include CME, MOC, or ethics credit, depending on the topic.
Music.
The topic this morning, trauma-informed care in a practice setting,
is a relatively new topic for medicine and pediatrics.
(00:43):
And it was really first introduced in 2001, but initially was applied to adult
settings, intended to help facilitate recovery of adults who were,
suffering from addiction and
mental health disorders, but who had also had prior trauma experiences.
It came into the picture in pediatrics in about 2009 when the National Child Trauma Stress Network,
(01:10):
an organization that offered resources on this, became very active and they
were instrumental in providing services at the Sandy Hook Elementary School of Shrewden. them.
In 2021, the American Academy of Pediatrics published a clinical report and
a technical report on trauma-informed care.
(01:30):
So it's a very current topic in our pediatric practice.
Our objectives today are to describe experiences that may trigger toxic stress responses.
So it's not just about child abuse. It's about a lot of other different types
of stresses that children and families can suffer from or be exposed to.
(01:51):
We also want to recognize and respond to children and caregivers that have experienced trauma,
and understand how trauma-informed principles can be implemented in practice
setting, not just one that is geared for child abuse, but also for other settings
as well, and to employ strategies to mitigate secondary trauma,
(02:11):
in a practice setting.
Start off with a patient presentation. So this is Rachel. I met Rachel a few years ago.
And she presented to Center for Miracles, which is where I work, for a sexual abuse exam.
And she was very upfront and just said right off the bat that she did not want this exam.
It would scare her to do it today. It was too immediate.
(02:32):
She had touch issues and she had trust issues.
And, you know, she came from a long history of CPS involvement,
had lived in several foster the family, different relatives, and shelters.
And so when you have a patient like Rachel, just stop for a minute and think,
what would you do next? What would you say next?
So why is it important to be trauma-informed? Really, the purpose is to minimize
(02:56):
further trauma, facilitate trust and transparency,
to optimize empathic communication and listening, and to engage the child and
family in a cooperative venture towards healing. on.
So my response to Rachel, I think some people would say, that's fine. We want you to check up.
I decided to try to open the door with her. And I said, what can I do to earn your trust?
(03:19):
And she had some very specific answers for this question.
She had rule. She said, don't lie to me. Don't talk about my mother.
Don't give me shots. And don't tell me to do something immediate or I will be traumatized.
And we'll come back to Rachel at the end of the presentation to see how this all worked out.
So today, I first want to just give an overview of what the child's world of
(03:44):
trauma looks like and talk about different prevalence and types of traumatic
experiences that children experience, the ripple effect.
It's not just the child that's affected by trauma, but it's also the caregiver
as well as the healthcare provider.
We'll do a brief overview view of the brain and adversity, and then talk about
(04:05):
signs of stress that we may see in children and in others.
We'll then move on to what is trauma-informed care and how is it defined.
We will include implementation strategies as described by the American Academy
of Pediatrics clinical report.
And then we'll move to some more specific strategies that can be utilized in
a clinical setting for children and families that have experienced trauma.
(04:31):
So traumatic experiences in childhood are common. When we talk about adverse
childhood experiences,
it is up to 68% of children will
experience at least one adverse childhood experience during childhood.
So the most common experiences include witness to family and peer violence,
(04:53):
separation, divorce of parents, and sexual trauma.
In about 30% of these children, they were experiencing more than one adverse childhood event.
And the relationship, though, between the number of adverse childhood events
and the adult health is a dose response.
(05:13):
So, in other words, the greater number of adverse childhood events a child has,
the higher the risk is for medical and mental health outcomes in adolescence and adulthood.
So about 10% of children will experience sexual abuse, serious accident,
natural disaster, living with anyone with a drug or alcohol problem.
(05:36):
And then you see to the right what the increased risk are for experiencing three
or more adverse childhood events.
It's 46 times more likely that someone will become involved with injection drug
use. And suicide thoughts as well as behaviors are increased risk by 12.
We also see an increased risk in sexually transmitted infections and COPD of
(06:02):
two to three times greater.
So here are the original 10 adverse childhood experiences. And you can see that
a lot of them involve trauma treatment.
So if we look at these, they do not happen in isolation. So many of these are
associated with additional adverse childhood events.
So, for example, if we look at sexual abuse, there's an increased rate of also
(06:28):
experience in physical abuse, exposure to household mental illness,
and exposure to intimate partner abuse in the home.
If we take a look at exposure to household mental illness, that in turn is associated
with emotional abuse, family member being incarcerated, and physical abuse.
So you can see how these compound upon one another, and it's very common for
(06:53):
children to experience more than one adverse childhood experience.
So looking at the world of trauma, it's not just about ACEs.
So it is about experiences they see in their world from inside their home and
then moving out to the community, society, and unfortunately at school as well.
(07:13):
Many of these experiences directly impact the child and others may more indirectly
impact the child, but all of them can have very significant and severe,
create very significant severe stresses for the child.
So here's a ripple of that. And when we look at definitions for trauma-informed care,
(07:36):
we find that pretty much most definitions incorporate trauma-informed care,
not just for the child, but also
for the caregiver and as well for the healthcare provider or clinician.
So what we see here is a primary stress experienced by the child.
We have secondary trauma stress experienced by the caregiver and the clinician.
(07:58):
And in turn, their experiences in the past, their past traumatic experiences,
influenced their capability of providing the appropriate support for the child.
How would this work in a clinical setting? So if we take, for example,
a common scenario at Center for Miracles, and we'll have a child that will present with sexual abuse.
(08:20):
And what we would see is that the child is first, she's experiencing stress
or he's experiencing stress just due to thoughts of, will they believe me? What will happen?
So once a child discloses abuse, there's a whole other set of structures that impact the child.
(08:41):
Then we move to the caregiver level, and there's a lot of things that caregivers
struggle with. So they struggle with the fact that many of these children who
are victims of sexual abuse will wait an average of two years to tell.
Why didn't they tell me sooner? Why didn't they tell me? Why didn't they tell the teacher?
Then there's also a level of grief for loss of the child's innocence, partner, family ties.
(09:05):
And then we have sometimes caregivers who simply just don't believe their child
or not sure whether to believe the child. And so that creates additional stressors,
particularly on the child-caregiver relationship.
But then we also have to remember the healthcare provider.
And we have both an opportunity, but sometimes we have a struggle of how to
(09:28):
handle these situations.
So, for example, our opportunity to try to encourage the caregiver to understand
that disclosure can take years.
It's very common for it to take years. It doesn't mean they did anything wrong or bad as a parent.
But then sometimes we're confronted with parents who do not believe their child
(09:49):
or do not support who says anger, frustration, sometimes frustration with the
lack of a safety response from CPS.
So this affects many people. And we have to remember to attend to the needs
of everybody in order to heal the child appropriately. Right.
We'll talk about the types of stress. So there are three types of stress that
(10:11):
are described, positive stress, tolerable stress, and toxic stress.
So positive stress is supposed to be good stress. So this is something that
elicits a mild physiologic response.
It resolves quickly. It tends to result in a productive or an adaptive action.
So examples of a positive stress would be learning to ride a bike,
(10:33):
preparing for an exam or a test.
Stress in general, when the brain responds to a positive stress,
it's a first-line defense, which we'll look at in the next slide. So it's more of a buoy.
It enhances performance, and it resolves very quickly.
Palliable stress lasts a little longer. So it elicits a moderate physiologic stress response.
(10:57):
Important to note that it can be buffered with supportive, safe,
nurturing relationships.
And we'll see this mentioned a couple of times in the next several slides.
Examples of tolerable stress would be a death of a family member or witnessing community violence.
This type of stress elicits a first and second line defense,
but it tends not to be sustained because the buffer is effective or because
(11:21):
the child is able to get through the trauma without difficulty or with less difficulty.
Positive stress is the one we need to be most concerned about.
So this elicits a severe, frequent, prolonged physical response and an ineffective or absent buffer.
So examples of this would be abuse and neglect, of course, and witness and family violence.
(11:47):
And this elicits a first and second line of events, but these are sustained
and unmitigated responses.
So these are the types of responses that can result in longer-term changes.
So this is a rather simplified overview of what happens in the brain with adversity.
The amygdala is the alarm system. So as soon as we see something in our environment
(12:12):
that's perceived as a threat, the amygdala is activated.
And it sends signals, of course, to the hypothalamus, which in turn sends signals to the adrenals.
And there's a release of epinephrine.
And when you look at all the red arrows here, what you see is that the response
of the brain is to really increase the individual's capacity to respond effectively to the stress.
(12:38):
So we have more oxygen going to the brain, increased respiratory rate, increased heart rate.
So it could be, again, an effective adaptive response.
But then we get to the second line. And the second line is what we call the HPA axis.
So this is the hypothalamus, the pituitary, and the adrenal HPA.
(12:58):
And when that second line is in place, the purpose is to sustain the alert response
to be able to continue to face the threat and handle it effectively.
And this is the one that really stimulates the fight, flight,
or freeze responses that we see.
So what happens with toxic stress? A lot happens with toxic stress.
(13:21):
That HPA axis is on overdrive, and cortisol is the primary substance release
that leads to several of the changes in the brain.
The changes in the brain are not benign. They include alterations in brain connectivity.
This is all mediated by cortisol and includes reductions in gray matter volume.
(13:43):
It also includes changes in dendrites that are either enhanced or pruned.
So it's a lot of very direct effects from sustained cortisol release.
We also have epigenetic changes. And this, again, cortisol mediates these changes.
Primarily what we see is alterations in DNA through methylation of different face pairs.
(14:07):
So we have altering gene expression and stress reactivity behavior.
And finally, cortisol results in an off-regulated inflammatory response,
which increases the risk for fatigue, mood changes, and chronic inflammation.
And you can see there are several areas of the brain that are affected,
in particular the prefrontal cortex, the hypothalamus, the amygdala is also affected as well.
(14:34):
There's some very interesting studies going on in this field, current studies.
Some of the studies have suggested that different types of trauma treatment
have different effects in different parts of the brain.
For example, one study was looking at heart-corporeal punishment,
which was defined as ongoing for three years, at least 12 times a year,
and noted that there is reduction in prefrontal cortex and cingulate gyrus volume,
(14:59):
reduced blood flow in dopamine-rich areas.
And this basically resulted in changes in threat detection, emotional regulation,
and reward anticipation.
The effect on behavior for all of these tend to be of the nature of a change
in how you perceive your world.
(15:20):
So sensory interpretation of sensory information and how you act on it changes
based on toxic stress responses. So, children will have trouble processing emotion.
For example, it's very common for children to have experienced sustained toxic
stress to look at an individual who perhaps is fearful and misinterpreted as anger.
(15:45):
Oxytocin is another area of research, and it's a very important substance in
the mother-infant bonding.
So there have been some studies that have looked at the fact that child maltreatment
dysregulates the oxytocin system, causing anxiety and dysfunctional attachments.
So how does this play out? So if we have a parent, if we have a mother who has
(16:09):
experienced trauma in her past, she may have trouble bonding with her infant
due to her dysregulation of oxytocin system.
There have been some experiments, there have been some studies that have looked
at using intranasal oxytocin to facilitate that bonding between the mother and the infant.
(16:29):
We also have looked at intranasal oxytocin in children, older children who have
experienced trauma and who are having trouble bonding with their caregivers.
One thing that all of these studies suggest is that the periods of most rapid
development are those that are the most vulnerable times, and that is the early
postnatal period and adolescence.
(16:52):
So what do we see when somebody is experiencing traumatic stress?
Well, we see symptoms of fight, flight, and freeze.
So this just gives you some examples of things that children may say or do that
are reflective of their responses to trauma.
So with the fight response, Rachel was a little bit of a fight response.
(17:15):
She wasn't going to participate. She was putting up walls to not want to cooperate with the examination.
Children, they say, I don't want to do this. I don't feel like talking about it.
We also tend to see these children are sensitive to touch.
They complain about pain and discomfort during various parts of the exam when
(17:37):
there really isn't any pain or discomfort, but they perceive it as such.
When we move to the flight responses, there's a lot of anxiety,
a lot of increased motor movement during the history, during the exam,
wondering what all of this will lead to. So that's more of the flight response.
And then we have freeze. And of course, it's overlap, which have some children
(17:59):
that manifest symptoms of fight and flight or freeze and fight.
But the freeze, these are children that tend to say nothing. They're very quiet.
They look for ways to end the question with short answers.
They have little eye contact. They gaze away. Sometimes they look like they're
actively dissociating as you're talking to them.
(18:23):
Now, there is good news in all this. So it's been found that there are reactive
alleles that can facilitate resilience.
And it's also modifying the environment, changing the social and physical environment
can also redirect that negative trajectory in a positive direction.
Most important is to save, secure, nurture relationships.
(18:45):
I feel like this is a very key role for pediatric providers.
We really have to be dedicated to facilitating these SSNRs, by ensuring that
caregivers have their medical and mental health needs addressed,
assisting with challenges relating to social determinants of health,
but also utilizing the trauma-informed approach to identify and manage trauma
(19:07):
symptoms in children and their caregivers.
Believe the hurt, begin the healing.
Heal the caregiver, heal the child. So what is trauma-informed care?
We're looking at two definitions.
There are several organizations that have a couple of definitions,
and I think the common denominator here is that we want to enhance our ability
(19:31):
to recognize and respond to individuals that have experienced stress or are
experiencing traumatic stress,
and also to take measures to reduce or resist re-traumatization.
When is it important to be trauma-informed? And there are several different settings.
(19:53):
We can know that somebody has experienced trauma and we should use trauma-informed
care approach with them.
But also when children begin to talk about their traumatic experiences,
that's another time to utilize trauma-informed strategies.
Strategies but keep in mind there are other situations
where children may have experienced trauma we
(20:14):
don't know yet but in particular when
there are children who have behavioral signs such as hostility withdrawal
anxiety fearfulness defensiveness somatic complaints those may be red flags
for traumatic experiences and toxic stress so here's a 2021 clinical report
that That was published by American Academy of Pediatrics.
(20:37):
And what I'd like to do is to review the strategies they proposed in this clinical report.
The first is awareness, and that is knowing the science and epidemiology of
trauma and understanding, again, the importance of those SSRs for recovery in
the child as well as the caregiver.
(20:57):
Knowing the adverse populations that trauma-informed care is appropriate for.
And it's really a paradigm shift. That's what's meant by readiness.
It's a shift from I must speak to you to I must understand you.
And recognizing, again, that the healing the child involves healing the caregiver.
Identify priorities with the caregiver. I know at Center for Miracles,
(21:21):
I have worked with our social workers there.
When they meet with the caregiver, the most common priority for that caregiver
is that I know I need help, but I need to take care of my child first.
So we have our job at Center for Miracles. is to help the caregivers shift that
priority a little bit and say, yes, but for you to give the best care to your
(21:45):
child, you need help as well.
And so we need to find ways for you to get help at the same time.
Many of the caregivers we deal with are also blaming themselves.
They feel they didn't see the signs of the abuse.
So we do try to identify these priorities and we do discuss them,
recognizing that it's important to provide this care to the caregiver.
(22:09):
We also spend a lot of time identifying the changes that are related to adversity.
When children experience abuse and neglect, it is frequent that families have
to move, that families break up, financial support changes. They may have food insecurity.
They may have legal needs. They may need legal aid or they may need a protection
(22:29):
order to keep the individual away. way.
They may have challenges with transportation.
And we do try, these are just very basic needs, but they can be overwhelming
in terms of the stress that they produce.
Another strategy includes detection and assessment, identifying the emergent
versus non-emergent situations.
(22:49):
So the two emergent situations that come to mind are the situation where a child
is in immediate danger of further harm,
and that may necessitate not just a call to CPS, but perhaps a call to law enforcement as well.
But the other emergent situation that we commonly deal with is self-injurious
(23:12):
thoughts and behaviors, particularly in adolescents, but sometimes in children
as young as 10 in our clinic.
So we do actively ask questions about that, not just to the caregiver,
but also to the child individually.
Then it's to assess symptoms. So symptoms may be functional,
neurodevelopmental, or involve the immune system.
(23:36):
So, a list here, the functional symptoms, sleeping difficulties,
appetite changes, toileting concerns, challenges with school functioning.
Symptoms of ADHD are common in children that are experiencing toxic stress.
You can imagine the fight or flight responses makes it difficult for them to focus on learning.
(23:58):
So, attention deficit disorder is something that is commonly diagnosed in these children. them.
Our neurodevelopmental changes include dysregulation of emotions and behavior,
disruptions in executive control, reactions to trigger, and just a negative
worldview, self-narrative.
We try to ask children what their super strengths are and what they would change about the world.
(24:21):
And it's sad how many of them don't see that they have anything that's very
special about them. So we do try to help them see that as well.
And then the immune system, some chronic inflammation can also be present in these children.
So management, again, basic needs should come first.
I love for children and families to have counseling when it's appropriate,
(24:44):
but we also must realize that the basic needs may be the biggest priority for that family.
And anticipatory guidance to caregivers. So knowing that children don't see
the world the same way when they've been traumatized.
No more, they have trouble interpreting emotions. They may react to triggers and different sounds.
(25:07):
They may have trouble expressing their emotions. So all of these things are
changes that the caregiver should be aware of and realize that these are responses to trauma.
This is not the child trying to be a problem to child.
And also mental health treatment is very important. And it should be convenient
(25:27):
for the family and the child.
Now, let's look a little closer at
how we would apply trauma-informed care strategies in a clinical setting.
So this comes from an article that describes how they taught medical students
how to render trauma-informed care.
It's like a rubric that they use to evaluate the performance of a medical student
(25:52):
in a clinical setting as they apply these principles.
So it could be a useful tool.
It's adaptive. I've adapted it a little bit for purposes of this presentation.
So, you can see that there are several items for before the medical evaluation,
during the evaluation, and after.
(26:12):
So, before the medical evaluation, it's important to state your why or your agenda for the visit.
So, I'm Dr. Kellogg. It's my job to take care of your body and your feelings.
I'm going to ask you some questions to help me do that.
Ask permission before proceeding. Is this okay with you? And then,
of course, it's important to offer choices when possible.
(26:34):
So I let the child choose who they want to be with them in the exam room.
That's just one example of a choice, but it should be offered whenever you can.
During the evaluation, it's important to identify concerns.
So is there anything that you're worried about today that you want me to be sure to check?
Respect the personal space and use understandable language.
(26:59):
I think sometimes when we are confronted with somebody who's experienced horrible
trauma, we forget that they have trouble processing what we're saying to them.
So it's important to check and make sure they understand it.
Physical exam, I tell them everything before I do it.
When I do need to undrape certain parts of the body, I only undrape the part
(27:22):
of the body I'm examining.
I'm also very mindful of what I say during the exam.
So, terms of endearment, like sweetie or move your leg for me,
be careful with that because it does send a possessive message and it can be
misinterpreted. It can be interpreted as a threat for the child.
(27:43):
After the evaluation, I tend to focus first on the child and give them the results
of the the evaluation in terms that they can understand.
I always ask the questions, the question from the child, and then I'll ask the
question from the caregiver.
So now quickly, I thought I would share seven things that children and families
have taught me about trauma-informed care.
(28:06):
First, it's about them. It's not about you. I think sometimes we're very frustrated
by children's responses or behaviors towards us, their resistance,
their lack of communication, or even though perhaps a caregiver is angry,
and questioning everything we're doing.
It's recognizing that this comes from an experience of trauma.
(28:28):
It's not to attack you. It's not to push your button.
It's also important to know that people are not always willing to share their experiences.
We don't say, trust me, I'm a doctor in this business. We have to earn this
trust. We cannot assume it.
This just reiterates an earlier point is that I tell them everything that I'm
(28:49):
doing and why at every point of my evaluation.
So what my job is, why I need to talk to them. because, again,
in my setting, many times children are not used to talking with the clinician alone first.
And then what I would do with the information. So based on what you're telling
me, I think we need to do tests for X, Y, and Z.
(29:11):
Or I think I need to look at your medical records to understand a little more
about this medical problem that you're telling me.
And also to recommend next steps for treatment and management.
But they have to, at every point of the way, it has to be clear they have choices.
The patient has a choice. The caregiver has a choice in what happens.
(29:32):
I think it's very important when you're dealing with a child or a caregiver
who has experienced trauma that you're very alert to cues, verbal and nonverbal,
that indicate that that person may not be hearing or understanding what you're saying.
And so these are some of the cues that I look for. They may ask you point blank what a word means.
I like that when it happens because that means the child is listening to me
(29:56):
and they're being very honest and they don't feel odd asking me,
what do you mean by this word?
So that's actually a good sign when that happens. So they may give you an answer
that's not really responsive to the question.
Children, again, tend not to want to admit when they don't understand, so be an alert to that.
(30:17):
They may say, I don't notice several questions, which could also mean I just
don't want to answer that question, or they may not respond at all.
The increased psychomotor activity is something I see frequently.
It generally begins with the very beginning of the interview,
and then I see it slow down as the interview progresses.
(30:37):
Distractive behavior, again, the fight or flight response can also be seen during interviews.
And only nodding or shaking head in response to questions is another non-verbal
cue that maybe they are not quite understanding or receiving the information
we're trying to give them.
Hearing is not the same as listening.
(30:58):
So listening means to understand and respect what they are saying.
And it also means that you are listening and looking for cues of unspoken concerns
or fears that the child may have.
Sometimes they're statements of self-blame, remorse for not telling sooner about
their trauma experiences and anxiety about what will happen with their family.
(31:21):
And just listening carefully to what they're saying and following up on things
that may indicate these unspoken concerns.
No surprises. So remembering that children and caregivers that have experienced
trauma do not receive information, sensory information, in the same way.
(31:41):
So being alert to different triggers. Sometimes we get a loud noise in our interview
room that comes from cars in the garage, and I can see children startled to that sometimes.
But also, especially, be very careful with touch. And I recommend avoid touching
a person during a verbal or during the initial interview or history with them.
(32:04):
The risk of sending the wrong message is much greater than the potential benefit
of trying to show empathy through touch.
There are other ways to show empathy that may be more comfortable.
So really delaying that touch until you absolutely have to during the exam.
In general, that's how I approach it.
So it is common for children and
(32:25):
caregivers to feel devalued and vulnerable it
is common for traumatized individuals to feel that something is wrong with them
and keeping this in mind as you talk to them is important in terms of you know
rendering trauma-informed care so respect can be demonstrated in a lot of different
ways active listening acknowledging strength asking
(32:47):
if they have any questions or concerns,
asking them to help you help them. It's a cooperative venture towards healing.
Respecting their wishes, even if it's different from your recommendations or expectations.
I think this is an important lesson that I've learned through the years,
because in the beginning, I used to be very frustrated with caregivers who didn't
believe their children.
(33:09):
And what I try to do is...
Change your mind, and it may not be possible always to change the caregiver's
mind, but you can give them information to think about.
They're more likely to receive your information if you do this in a respectful way.
Don't tell them how they feel. I think, again, when we see children who have
(33:30):
experienced unspeakable acts, we have a tendency to want to say,
you're brave, you're strong.
They may not feel that way. And when you say things like that to people who
don't feel that way, it may be off-putting.
So Hattie is another patient that I met in 2007. She was a victim of torture.
She was chained and starved with her sister, Krista, who was a year younger, for three years.
(33:55):
She was beaten. She was terrorized. She presented to Center for Miracles the
day after her sister was killed.
This is what she recalled about her visit to Center for Miracles.
That was the first time, the very first time I told anybody the truth about
everything that happened.
She was the first person that I was like, okay, here it is. Here's my story.
(34:17):
And from that point, I wasn't scared, and I didn't feel like I would get hurt
for telling the truth anymore.
It's like over the years, people keep piling rocks on your chest.
And every time you say stop to them, it means more rocks.
And finally, you have that person come along who's there for you.
She said stop, and they stopped.
It was the first time someone listened to me, listened to my story.
(34:40):
The first time nobody spoke for me.
It's frustrating as a kid when you want to say so much, but you're so traumatized
and in so much shock from that moment.
So that was, she had just turned 10 in this picture. It was 24 hours after she had lost her sister.
Me, it was a trauma. Afterwards, I didn't talk about it for a while.
(35:04):
My thoughts ran from the incomprehensible evil she endured for years,
to despair for her sister, the gratefulness that she felt she could share some
of what happened to her during my time with her.
Ultimately, my self-care went to see Kathy in follow-up two weeks and one year
later. So this is a picture one year later.
(35:25):
She's 35 pounds, and I think about three and a half inches taller, 35 pounds heavier.
And so it was at this visit that I could finally let go.
So much to my surprise, 15 years later, Cassie reached out to me.
She wanted to reconnect. And we spent three and a half hours talking about what
(35:47):
happened to her, how she got through that.
And one of the things that really impressed me about this interview is the power
of safe, secure, nurturing relationships.
Kathy had three things that pulled her back, gave her resilience and allowed her to survive.
The first thing was therapy, her therapist. The second was her husband.
(36:12):
So in this picture, she's married and she has three children.
She's happily married. She's a very dedicated mom and is successful.
The third thing that was her SSNR was advocacy.
So she created a website called Crystal Project after his sister,
which is a forum for other adults and children who have experienced trauma like
(36:36):
she has to share their experiences, to share their success stories.
So she's very proud of that. So those are the three things that were her lifelines.
The interesting thing about that is that her lifeline did not come until years after she was rescued.
She had a rough time in foster care.
(36:56):
Nonetheless, the SSNRs, they did save her, but it took years before they were available to her.
So finally, I just wanted to share with you a little bit about the Center for Miracles.
So we are a level one trauma-informed care certified center.
We received that in July of last year.
(37:18):
And I just, the overall process, it took about a year. And we basically looked
at everything we did at Centers for Miracles from beginning,
when the child and family walk in the door, to the end when they leave.
And we looked at it across several major domains. We looked at safety,
physical and interpersonal safety, transparency and trustworthiness,
(37:40):
respect and empowerment,
collaboration and policy, skill building, and emotional intelligence.
In addition to these things, we also wrote a policy guideline for Center for
Miracles, committing ourselves to rendering trauma-informed care.
We do some periodic surveys of trauma-informed climate.
(38:01):
I'm going to share that with you in the next slide because I think it can be
useful in other practice settings.
We do planned staff retreats, and then we offer secondary trauma group sessions. Thank you.
Here's a climate survey, and we try to hand this out at least twice a year.
And this is really, it takes the temperature of the environment you work with or you work in.
(38:25):
So it asks whether you feel safe where you are, whether you have the resources you need.
Who do you trust? Do you have people you know you can trust? What is the leadership?
Does it listen to only certain people? Does it share decision making?
Again, I find these items very useful. And we look at them. They're anonymous.
(38:46):
We try to aggregate the data and look at ways that we can better address the
needs of the people that we work with.
So finally, getting back to racial. So she gave me her rules,
and this is what I said to each rule.
So don't lie to me. I said, I promise not to lie to you.
And I would tell you if I do not know the answer, don't talk about my mother.
(39:09):
I promise not to ask any questions about your mother.
Don't give me shots. We have no shots here. And then perhaps most importantly,
number four, don't tell me to do something immediate or I will be traumatized.
And so what I said to this was, I will not tell you to do anything.
I will explain what I think should be done for your health, but we will make
(39:29):
a decision together on what happens next.
So to my surprise, because when I go into these encounters, I have no expectation
about what a child is willing to do or not willing to do.
But to my surprise, in this situation, she was able to give a full history,
describe how her mother was not supportive.
(39:50):
So she talked about her mother. She gave a full history.
She consented to all parts of the exam.
She underwent the exam without problem, and she was very cooperative throughout.
In summary, traumatic experiences are common in childhood, and they go beyond the ACEs.
You can have short- and long-term medical and mental health consequences from trauma.
(40:13):
Trauma-informed care is a paradigm shift from what is wrong with you to what's
happened to you to what's strong with you.
And remembering that trauma-informed care recognizes, responds,
and manages traumatic stress, but also in that management that it addresses
the needs of the child, the caregiver, and the pediatric clinician.
(40:36):
Caring for one helps them care for all the others as well.
So I would stop at this point and see if there are any questions.
Hi, Dr. Kellogg. This is Dina Tom.
Thank you for your talk today. I have a question about trauma-informed care
training for non-medical providers.
This is very timely because my neighbor actually yesterday asked about any kind
(41:01):
of, she works for wellness.
She does the, she's the wellness director for the San Antonio Community College District.
And she has a bunch of faculty who've asked questions about how to approach
their own students when it comes to trauma-informed care.
And obviously it's a different angle for non-medical providers a little bit,
(41:22):
but do you know if there's any community training or are any resources for those
who work with students or children,
like teachers in the community for having that kind of trauma-informed mindset?
Don't know offhand any resources for community.
I would think that, you know, what I mentioned in the beginning was an organization
(41:46):
that has resources in general.
And that's the Child Trauma Stress Network.
And I'm thinking if somebody would look that up, they probably would have some
additional links for adults and for students that could be helpful.
Okay. I think, again, trauma-informed care works best in a one-on-one situation
(42:07):
in terms of trying to help an individual through it.
But that's a very interesting question. I don't know offhand of any specific resources.
It looks like Dr. Hansen put something in the chat that I can refer to.
And I think it came up in light of maybe a couple of teachers that have had
students who were missing class or because they've had to go to court after
(42:32):
being in the foster care system.
And basically teachers not knowing how to handle that from a trauma mindset
of understanding that these children who are now young adults may have different struggles.
So anyway, this is incredible talk. So thank you so much for speaking to me.
(42:53):
Thank you. And I agree with you.
I think, again, there's not much understanding that individuals that have experienced
toxic stress see the world differently.
And being able to understand that behavior is not directed at you,
it is a response to trauma. And oftentimes fits into the fight,
(43:15):
flight, freeze paradigm.
It's one of those or a combination of those. And I think, again,
understanding and recognizing it's the first step in all strategies.
So I think there's just not enough of the recognizing and understanding.
So I think that's the first step for most organizations is just understanding
(43:36):
their trauma responses.
Thanks so much for listening to Pediatrics Now.
Music.
I'm Holly Wayment. Our website is pediatricsnowpodcast.com.
You can email me at pediatricsnow at uthscsa.edu with any questions or topic ideas.
(43:58):
Music.
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