Trauma-Informed Pediatric Care
Trauma-informed pediatric care is medical care in which "all parties involved assess, recognize, and respond to the effects of traumatic stress on children, caregivers, and health care providers" (National Child Traumatic Stress Network).
Almost half of US children experience at least 1 potentially traumatic experience, and many experience repeated trauma.
Repeated or severe trauma may elicit behavioral stress responses as well as adverse physiologic changes. Changes occur in brain connectivity, epigenetic changes in methylation patterns, and in immune up-regulation and decreased humoral immunity. The lifetime effects of toxic stress are correlated with chronic inflammation and early mortality.
Children at higher risk for trauma exposure and for adverse outcomes of traumatic exposure include those who live in poverty, children of underrepresented racial, ethnic or religious groups who experience, or whose communities have historically experienced, discrimination and persecution, immigrant, refugee, lesbian, gay, bisexual, and transgender children, and neurodiverse children. Children with chronic or complex medical conditions, children born premature, and children who have suffered severe injuries are at risk for pediatric medical traumatic stress.
A traumatic stress response after exposure to traumatic stress is not a foregone conclusion. The relationship and risk is mediated by the severity, duration, and chronicity of the stressors and by the child's access to supportive relationships, attachment, and a sense of security.
An event or circumstances experienced as physically or emotionally harmful that can have lasting effects on well-being. These events may occur:
- within a caregiving relationship (abuse, neglect, exposure to domestic violence or disordered caregiving due to parental mental illness or substance use)
- outside of relationships (car crash, natural disasters)
- through relationships outside the family (racism, bullying, bias)
Pediatric Medical Traumatic Stress
Distress experienced by children and families undergoing treatment for life-threatening or life-altering diagnoses. The distress is often related to the individual's subjective experience of the medical event rather than its objective severity.
Complex Childhood Trauma
A child's exposure to multiple interpersonal traumatic events including maltreatment and household dysfunction, and the pervasive and predictable impact the exposure has on the child's development, sense of self, and attachment to caregivers
Acute Stress Disorder and Post-Traumatic Stress Disorder
Psychiatric diagnoses that include the experience or witnessing a traumatic event followed by symptoms of reexperiencing the event, avoidance of memories of the event, and hyperarousal.
Secondary Traumatic Stress
A response that may occur in parents, caregivers, healthcare staff and first responders who are exposed to the suffering of others which may have the same long-term effects as exposure to the traumatic experience.
Adverse Childhood Events (ACES)
Stressful or traumatic events linked to physiologic and behavioral changes that may adversely affect child health and well-being, particularly with increasing severity and number of ACES experienced. ACES include child abuse and neglect, exposure to domestic and community violence, household substance abuse or mental illness, parental separation or divorce, incarcerated family member, separation from caregiver, racism, bullying, and financial insecurity.
Social Determinants of Health (SDoHs)
Environmental or sociological conditions which affect the neuroendocrine stress response and affect a range of health outcomes. SDoHs include poverty, homelessness, food insecurity, lack of access to health care, lack of access to adequate educational or financial opportunity. SDoHs interact with and overlap with ACES.
Elements of Trauma Informed Care
Trauma-informed care seeks to:
- recognize the impact of trauma and understand paths for recovery
- recognize the signs and symptoms of trauma in patients, families and staff
- integrate knowledge about trauma into policies and practices
- actively avoid re-traumatization
Core principles of trauma-informed care include:
- physical and psychological safety
- trustworthiness & transparency
- peer support
- reduce power differences between staff and patients through collaboration
- empowerment through recognizing strengths of patients, families and staff
- humility: recognize and address biases, stereotypes, and historical trauma
Organizational practices and strategies that promote trauma-informed care include:
- Lead and communicate about being trauma-informed
- Engage patients in organizational planning and in the treatment process
- Train clinical and non-clinical staff
- Create a safe physical and emotional environment for all
- Prevent secondary traumatic stress in staff
- Screen for trauma
Preventing Childhood Toxic Stress:Partnering With Families and Communities to Promote Relational Health AAP Policy Statement 2021 (pdf)
Trauma-Informed Care in Child Health Systems AAP Policy Statement 2021 (pdf)
Trauma-Informed Care AAP Clinical Report 2021 (pdf)
Clinical Considerations Related to the Behavioral Manifestations of Child Maltreatment AAP Clinical Report 2017 (pdf)