Pediatricians already understand a lot about trauma-informed care. However, we can all hone more specific knowledge and skills in asking about and identifying trauma, screening, engaging parents and children around difficult topics, educating families about trauma and its impact, and providing responsive care that promotes safe, stable, nurturing caregiving to foster attachment and build child and family resilience and promote healing.
Trauma-informed care should be a universal approach to patient care and not reserved just for those whom we suspect or know have experienced trauma. TIC is resilience informed relationship-based care—that creates a sense of safety for children and families and builds trust and a partnership with families. While we do much of this work as pediatricians every day in our office, TIC provides a framework through which we come to understand family and child strengths, the context of their lives, identify trauma and its impact. and tailor our response to meet those needs and promote healing.
Becoming trauma-informed requires gaining some knowledge about the physiology of trauma, resilience, attachment, engagement and trauma-responsive care and then implementing what we have learned in practice. It cannot occur in isolation though.
TIC needs to occur in an organization that is itself trauma-informed and provides a psychologically safe environment for employees and consumers of care. Employees and parents serve in an advisory capacity at all levels of the organization. A TI-organization is invested in education of all leadership, provider and staff members and the development of a trauma-informed workforce. Policies, procedures and financing are aligned with and support family-centered team-based medical home care. The organization has a network of providers and referral resources through which it can support family needs.
Through an implementation project with five practices across the country, we have found that there are some simple things have come up as good ways to start building a trauma-informed practice:
1. Educating All Providers, Staff, and Leadership About:
ACEs, toxic stress and the physiology of trauma;
patient and parent engagement;
safe stable nurturing caregiving; and,
attachment and resilience promotion.
These topics are highlighted in the course: AAP PATTeR (the Pediatric Approach to Trauma, Treatment and Resilience). The understanding that trauma in the absence of buffering relationships can lead to biological changes that affect lifelong health, mental health and social well-being can be sufficient to "hook" leadership and providers on its importance. It turns out the pediatric professionals are already engaged in a lot of trauma-informed and resilience-promoting practices and just need a framework and some simple tools to move forward. Covering the above topics is often enough to empower teams and leadership to take on this issue.
2. Discovery Shopping
The practice team, or a subset of the practice that includes members from clerical, nursing and providers, can undertake the process of “walking” a patient (real or imagined) through every step of a health visit starting at the front door. The foundational principle of TIC is SAFETY: physical, psychological and emotional. “Discovery shopping” enables the team to see what the practice looks like from the perspective of the patient and their caregiver.
What does the patient and family see at the front door? Is it welcoming? Does it imply safety?
Who greets the family and how? Is the parent addressed as "mom" or by name?
What does the waiting area look like and is it a child and family friendly space? Is there a teen area? Are there messages that convey welcome and inclusion to specific subpopulations—parents of newborns? Teens? LGBTQ youth? Diverse populations? Victims of interpersonal violence?
Does the staff resemble the patient population?
What posters or pictures are on the wall? What messages do they convey? Do they reflect the diversity of the patient population?
Is there adequate privacy at the front desk for families?
How are screeners introduced? Is there a script? What does it say? How is it administered? Who is screened (ideally universal)?
What screeners is the practice using? Are they strengths or deficit focused? Are the screeners designed to get at the information of importance? Who scores the screener? Who shares the results of the screeners with the family?
Who greets and brings child and caregiver back for vitals and what is that process like?
What is the workflow for a teen visit? Does the teen have some private time with the provider? How does the teen learn which parts of a teen visit are confidential?
What does the examination room look like? Is it engaging and friendly or stark? Are there books to read? Is there a coloring book and crayons? Are there other items that are engaging for children/teens and parents?
Check out—walk the real or imagined family through the entire process from leaving the examination room to check-out to going out the door.
Is there a plan for a follow-up or return visit and when?
IF making a referral, is there a warm hand-off in the office or a connection made at the time of the visit person-to-person or in a well-established, family-friendly way?
Do referral resources communicate back? If so, how?
What resources are provided to the family? Are they linguistically and culturally appropriate?
3. Review Office Resources
What do you have? What is the reading level? Language? When was it last updated? Are the resources appropriate to the population served?
How is it available? Paper or electronic?
Is there a space in the office where the child can safely stay while the provider has a private conversation with the parent?
4. Family Engagement
Is there a family advisory board who reviews resources or practice changes? Does the practice assess parent and youth satisfaction on a periodic basis?
5. Notice and Note
This term applies to the concept of offering specific positive praise, or catching the parent or family being good. All staff and providers can engage in this from the front desk to the provider. It is easy to praise the family everyone enjoys—we greet them with joy, tell them how wonderful they are, how we enjoy seeing them, and how great their kids are. It is the challenging families who are anxious, rude, late, angry, yelling at their children etc. that are more of an issue. Noticing even brief positive moments or reframing a negative moment can change the entire dynamic.
For the chronically late, we can say: "I know that it takes a lot of effort for you to get here. Thank you for coming in today. We are so happy to see you." The surprised parent may thank you or simply feel calmer.
For the parent yelling at their child: offer empathy and redirect. “Parenting is so hard, isn’t it? As much as we love them, we all reach our limits sometimes… Perhaps we can find something for him/her to do with all that energy. Does he prefer to color or read?” By doing this, the staff member has offered empathy, validated and probably de-escalated the caregiver’s frustration or anger, and offered another better option to parent and child.
Even better, notice any small positive interaction between parent and child, no matter how fleeting. Sometimes, it might just be noticing that the child has a nice shirt on that day that the parent probably bought for him/her. Sometimes, we see a moment that we can emphasize and reinforce: "I like the way you reminded him to sit and read. Reading is such a great activity for kids—it is calming and they learn so much. You must read at home with him/her."
Assume the best. Just like children, adults often rise to our expectations.
6. Offer Simple Choices
All staff and providers can do this. It is a wonderful way to give the child some control over the visit, which creates a sense of self-efficacy, and establishes a sense of trust and partnership. Mostly we offer simple choices to children, but also sometimes to parents. For the child: "Do you want me to take your blood pressure in your left or right arm?" “Which ear should I look in first?" "Which of these stickers would you like to take home today?" For the parent: "Would you like to hold your child for his/her shots or would you prefer we put him/her on the table?"
7. Explain What Will Happen At the Visit
Don't just assume children know what to expect during an office visit. Explaining or asking if the family has questions reinforces the sense of partnership and of safety, that your practice is an okay place to ask questions and discuss things.
"We are going to see how well you are growing. You can help me by..."
"Now we are checking your heart rate and then ...." "you are seeing Dr. Leslie today for your physical. He/she is going to ask you and your parent some questions and then examine you to make sure you are healthy. Do you have any questions for me?"
It is okay to say: "Lots of kids want to know what blood pressure means...or why I check their vision...or what shots are for..." This can suggest some topics that the child or parent do indeed have questions about or want information about.
8. Ask Questions
You can also ask the child why they think specific parts of the process are important: “Do you know why we check your blood pressure?” Of course, you need to have a simple child-friendly explanation handy.
For providers in particular, we need to emphasize some particular skills:
We do this in a number of ways.
We greet families and children warmly; we might use a little humor; we can welcome them or make them feel welcome and valued (“I am so happy to see you today.”).
We ask about their agenda rather than follow our own: “How can I help you today?” “Do you have any questions or concerns today?”
Attuned attentive listening to those concerns or to any questions we pose. We demonstrate this though eye contact, leaning in, listening closely, reflecting back what we have heard, summarizing to make sure we heard the concerns or answers correctly NOT focusing on the EMR.
We start with open-ended questions and move to more specific ones depending on the answers.
We can ask what the family has tried and how that worked.
We focus on parent and child strengths through observation or as elicited in the history. We notice and note a positive interaction between parent and child.
We can separate the parent and child briefly to protect the child from hearing things that might be negative or harmful and to allow the parent to discuss things more fully.
We take a social history, and ask some surveillance questions that might help us to determine whether trauma or adversity or social risk factors are present and how they are affecting the family/child: “Has anything bad or scary happened to you, your family or your child since I last saw you?” “Lots of stressful things happen in life. Is there anything stressful that has happened or is happening to your family or your child?” “Does your child have any behavioral issues that concern you?” We scan for symptoms of trauma using the FRAYED acronym.
When a stressor or trauma is identified, it is very important to acknowledge it—otherwise we can add to the trauma experience. Acknowledging what you have heard them say is validating. Even if we feel helpless, we can validate the impact of a stressor or trauma on the child/family—“Thank you for letting me know. Other families have told me how stressful it is when X occurs.” We can also ask how they are coping and whether they have appropriate supports and resources in place. Some families are in fact doing well and do have supports and resources.
10. Partnering with Caregivers/Youth
We might ask what the parent thinks is going on. Or ask the child if old enough.
We can point out strengths we notice in either or both.
We can ask about the meaning of what has happened in their culture and their family.
We can ask what they have tried and if it worked.
We can offer some alternatives and ask them what they think might work best for their family or their child.
For families seeking our help, and depending on the issue(s), we can provide some education, explore some possible approaches based on our diagnosis, and use a motivational interviewing approach to assess readiness for change and next steps.
Some screeners in routine use in pediatrics (developmental, maternal depression, mental health screeners) are used to identify problems for which childhood adversity or trauma may be the underlying etiology. Thus, we should, when we have a positive screen, consider trauma as a potential risk factor and ask if anything bad or scary has happened to the child or family.
Screening for trauma ideally involves screening for risk, symptoms and strengths. Unfortunately, there is not yet a validated screen that adequately addresses all 3 domains although there are some screeners that assess symptoms and risks. ACE screening is gaining in popularity but one has to consider whether the screen is validated for use at the individual level (none are for children), who to screen (parent/child/both), when (once, every WCC visit, annually), how often, what constitutes a positive screen (since there is not widely accepted cut-off score for children), and how to manage a positive screen. It is recommended that practices carefully consider their options and the capacities of their setting when contemplating screening for ACEs or trauma.
12. Differential Diagnosis
Adding trauma and its impact to our differential diagnosis when we see certain symptoms (FRAYED) or hear of adverse or traumatizing experiences is very important. A child with inattention, impulsivity, hyperactivity, and sleep problems, may have ADHD, anxiety, or FASD, etc., but we may also be observing the impact of trauma on the developing brain. If we do not consider trauma as part of our differential diagnosis and ask questions or conduct screening that can help to rule it in or out, we can potentially offer a child the wrong treatment plan and allow trauma to further biologically embed.
Sometimes families recognize the link between trauma and their child’s symptoms, which are often behavioral or developmental, but often they do not. For example, a parent reporting that a child is not sleeping and is hyperactive may not relate that to exposure to parental conflict in the home. We may have to provide some basic education about how trauma and adversity can impact the developing brain resulting in the symptoms we are seeing.
As part of psychoeducation, we should also mention the good news that the developing brain is fairly malleable and, in a healing environment, can heal from the impact of trauma. There are things the parent(s) can do at home every day to help the child heal. We should remind the parent that we are there to help, provide resources, and, potentially refer to additional services. If in addition to trauma, there are social risk factors such as housing or food insecurity, we can also refer families to community resources.
14. Anticipatory Guidance about Healing from Trauma
The pediatric approach to trauma involves first and foremost ensuring that the child is safe, physically and psychologically. If not, we must as mandated reporters notify child welfare. Most of the time, safety is sufficient and we can work on nurturing the parent-child relationship and promoting the resilience of the child and family to help the child heal from trauma. Anticipatory guidance often centers on building safe, stable nurturing caregiving to improve the parent-child relationship. We can promote various positive parenting skills and specific trauma-informed approaches to achieve this. (See: Anticipatory Guidance for Childhood Trauma).
One of the key elements of TIC is maintaining connections with children and families. For some families, we will need to schedule regular follow-up visits to offer guidance and monitor progress. For others, we may refer them to evidence-based, trauma-informed mental health services if available in the pediatric setting or in the community. As the child and family make progress, we can determine when to reduce the frequency of visits.
When families miss appointments, having someone in the office reach out to check on them to see how they are doing can reinforce the connection of the family to the practice. Office staff can ask if they would like to set up time for an office visit, phone call, or telehealth visit.