Featured topic and speakers
Pediatric experts introduce trauma-informed care (TIC) and how the approach can be incorporated within broader integrated care efforts, covering the developmental aspect of trauma, how to screen, treat and prevent trauma, and its impacts across the lifespan. They also discuss developing engagement strategies and techniques to address trauma symptoms.
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Speakers
- Heather C. Forkey, MD, professor of pediatrics, University of Massachusetts Chan Medical School; director, Foster Children Evaluation Services, UMass Memorial Children’s Medical Center
- W. David Lohr, MD, professor of pediatrics, Division of Child & Adolescent Psychiatry and Pediatric Psychology, Department of Pediatrics, University of Louisville School of Medicine
Host
- Samantha Lewin-Smith, program manager, professional satisfaction and practice sustainability, AMA
Transcript
Lewin-Smith: Welcome to the webinar in the BHI Collaborative’s Overcoming Obstacle Series, Sustaining Behavioral Health Care in Your Practice. This webinar is titled, “Addressing Childhood Trauma Through Trauma-Informed Care.” Before we get started, please note this webinar is for informational purposes only. Please consult a professional advisor for specific medical, legal, financial or other advice. If you have questions or concerns, please send your inquiries to [email protected].
This series is a collective product of the nation’s leading physician organizations dedicated to equipping physicians and their practices with the necessary knowledge to sustain a whole-person, integrated and equitable approach to physical, mental and behavioral health care. This webinar will describe the key elements of trauma-informed care and how it can be incorporated within the broader integrated care efforts. While focusing on the pediatric population, physician experts will cover the developmental aspect of trauma, how to screen, treat and prevent it, highlighting impact across the lifespan.
Joining us today are Dr. Heather Forkey, professor of pediatrics at the University of Massachusetts Chan Medical School and director of the Foster Children Evaluation Services of the UMass Memorial Children’s Medical Center, and Dr. William David Lohr, professor of pediatrics, the Division of Child and Adolescent Psychiatry and Pediatric Psychology, Department of Pediatrics at the University of Louisville School of Medicine. And with that, I will turn the conversation over to Dr. Forkey.
Introduction to trauma-informed care
Dr. Forkey: Thanks so much. We are delighted to be with you to talk about trauma-informed care. I do need to disclose that I receive royalties from AAP Press, and Dr. Lohr has no disclosures.
Our learning objectives today are that upon completion, we hope that you’ll be able to implement some engagement strategies to set the stage for trauma-informed care and create safety in the pediatric hospital or outpatient setting. We hope that you can identify some surveillance and screening strategies that can be easily implemented, and when they are completed, provide some clinical direction for you and for families. And we’ll help you to choose some techniques to address trauma symptoms that can be implemented in a variety of integrated settings.
Trauma-informed care, or TIC, has really kind of become a buzzword lately. People are talking about it in all sorts of venues. And in medicine, it’s particularly important. It’s important because trauma has a role in the development and the presentation and the outcome of a whole bunch of the diagnoses that we deal with every single day.
And this is just a snippet of some of those, and you can see how small the print is. Of course, we understand now that trauma is profoundly impacting physiology, and many of us have really had some introduction to the physiology and maybe a little bit more familiar with some of that physiology, although Dr. Lohr is going to cover some of it briefly for you.
Dr. Lohr: When you think about trauma, it gets to my interest of neuroscience. So you think about what happens when kids are born and their brains are developing. And so much happens in the first five years, and we’ve learned that there’s a process known as DNA methylation that really helps control the production of proteins.
And this DNA methylation is really affected by stresses. And so during the first five years, there’s the greatest number of synapses that are being connected in the brain, and these connections are made. And so, early environment is so important to healthy functioning throughout life. We’re going to be talking a lot about the formation of early relationships and maintaining of those relationships throughout time, but the importance really happens early as well.
There are a few things that happen to cause stress, and a number of stresses, they all have effects on the brain and the body. And so it can include trauma, but it can include mental health or other things. And so when you have stresses, it creates a biologic reaction that involves things like the HPA axis that affects your adrenal glands and the production of those stress hormones, such as cortisol or adrenaline. It can also affect your immunological function. So if you have elevations of this, it may set the stage for some conditions later in life, autoimmune conditions. And there’s also a way of thinking about this is toxicity and stress, trauma, depression can all alter what’s known as the cytokine system, which is basically free radicals, oxidation. And so it helps you understand that trauma stresses not only affect immediate, but they can affect the body long term.
What’s even more interesting to me is that your genetic makeup can be altered by your environment. Now, I trained at a time where I thought the genes were fairly stable and they were set, but we are learning that what happens to a mother during pregnancy can change how much the proteins function. That is affected by DNA methylation or epigenetics, which can influence production of proteins. Often these are the stress systems that are involved. And so if you have alterations at an early stage in life, it may set the stage for adult onset of things like depression or anxiety or other things. And you can even take this generation back that what happens to previous generations may have effects. This sort of intergenerational effects and trauma can be important. But it’s really fascinating to think about how our genes change and they can function more openly based on things like stress.
And a lot of the work that has been done on brain architecture comes from Romania, where children were exposed to pretty horrific conditions in orphanages. But over time, persistent stress can change how active the brain connections are formed and how they’re maintained. And you can imagine all the things that we do that involve expression and very high-level association between brain regions. If you’re working with neurons that have less connections, the brain won’t be functioning as well. So this is an example, I think, of just structural changes that can be seen when you have chronic stress.
Dr. Forkey: So I love the science of how we’ve come to understand what trauma does, affecting the brain and the body. But when we try to translate to what we are supposed to do clinically, a lot of what’s been described, has really been fairly abstract.
I mean, even SAMHSA’s description of, sort of what trauma-informed care should encompass, while having really critical principles, is really far too abstract for us to sort of say, OK, this is what I’m going to do actually clinically.
Some other efforts have really focused around what’s called ACE screening, which is a bit of a misnomer. But it’s also a fairly narrow way to think about trauma-informed care. We’re going to talk a little bit more about that. But if this sub-description is too broad and some other very practical things, maybe too narrow and not that effective, what are we to do?
And I would suggest that, as Dr. Lohr has pointed out, really we need to focus on the stress response. If you think about it from an evolutionary perspective, humans have had a number of stress responses that we’ve evolved to have. So there’s the freeze response, which we share with possums and mice, where you just stand still hoping that the predator doesn’t see you and moves by.
Well, for humans, it’s not that effective. We’re just too big. We get noticed. So then there’s the fight or flight response, which is that HPA axis that Dr. Lohr mentioned. And that’s really effective in the short term, but it is designed to be a short-term fix because you either run away or fight the predator within 20 minutes or you get eaten.
And it’s really designed to sort of be a quick fix. It’s also not particularly effective for children or for people who are pregnant because they can’t run fast or they can’t fight effectively. So humans had to evolve to have something that was much more effective for us as a creature living in stressful conditions.
And as it turns out, we did. And that’s called the affiliate response, which people may not be as familiar with. It’s oxytocin mediated. And what it relies on is what humans have most effectively, which is our brain and each other. You know that under stressful conditions, what you actually do first in many instances is you turn to other people and you decide, are there people here who can help me manage this threat? And if there are people there, you gather them to you and you deal with the danger.
Unfortunately, if you look left and right and the people around you maybe want the same structure or living situation that you do, or they want the same prey that you want, or in our modern world, they’re not able to help a child because of their own mental illness or their substance misuse disorder. There’s a problem because that child can’t gather that support to manage the stress. And all that you’re left with is this overuse of the fight or flight response or the freeze response. And interestingly, it’s there that we begin to understand why we see the symptoms that we see. Dr. Lohr, you were going to mention why we see some of these.
Developmental perspectives on trauma
Dr. Lohr: Yes. And so thank you, Heather. So I work a lot with children in foster care and obviously adults. And so we are faced with troubling behavior. And a lot of what we do in understanding trauma-informed care is to understand things, and understanding of why a person does what they do. And so it changes the lens from asking, “What is wrong with you?” to “What’s happened to you?” Or in some cases, “What’s right with you?” “What’s strong with you; how have you coped?”
And so those of us working in health care are going to see trouble behaviors. We’re going to see people that don’t seem to have empathy, or they act in a way that just isn’t understandable. And so you think about what’s happened to them in early life and perhaps understanding that perhaps this person never had an early attachment from zero to three. So they never learned that the world is a safe, secure place.
We work with people who have aggression or violence. That’s how they manage or cope with the world or that’s how they express things. And so what if a child has been exposed to this violence from an early age? That’s their learning environment. We work with people who have depression and anxiety. And so imagine if you’ve grown up in a situation where you’ve had repeated scenes of stress, emotional distress, emotional chaos, it can be very challenging.
And then also you see people who just don’t seem to have an easy time learning or regulating their emotions. And so you think back to the early attachment and the early parental regulation, spending quiet time with a young child. That’s so important. So trauma-informed care to me is taking a lens and a perspective of understanding behavior in a different way.
Dr. Forkey: And I think what Dr. Lohr is also pointing out here is that in each of those instances, the child couldn’t use the affiliate response. And so was sort of forced to use fight or flight or freeze response. And when we see that excessive aggressiveness or depression and disassociation, we’re seeing this overuse of freeze or fight or flight instead of being able to use the affiliate response, which is really interesting because Dr. Lohr also mentioned that we call this physiologic response to stress toxic stress.
And it’s not really just what the child has experienced, but it’s whether there was the safe, stable and nurturing relationship to buffer it. So if you could click on my little circles, you’ll see that what makes something tolerable versus toxic is whether it can be buffered by supportive relationships. It’s not entirely dependent on what the stressor itself is. So thinking about it in terms of those stress responses really begins to help you put into context what it is you’re seeing and why you’re seeing it.
And now, we can begin to move into trauma-informed care. And we, in our clinical settings, can really make an effort to promote that affiliate response.
Trauma-informed care is also called relational health care. And interestingly, that is because it allows us to use those relationships, those affiliate supports or tending and befriending, so that we can provide care and so that families can better support the kids that they’re serving. And it’s with this new lens that we want to approach patient care with kids and families. And I’m emphasizing with because that will be our little acronym so we can remember the steps of trauma-informed care.
So WITH will stand for wondering together, investigating using surveillance and screening for both exposure and symptoms, treating where we validate and then do some office-based guidance and referral if needed, either outside or for integrated settings within our own programs. And remembering that throughout this whole process, we want to continue to bring hope to the situation and that positive expectation of recovery that we have in all aspects of medicine. In fact, families come to us all the time looking for that sense of hope.
You know, neuroception is the word that was coined to explain our constant surveillance for danger. Even though you think you’re paying attention to this webinar, if there were a loud noise or a funny smell or flashing lights, your attention would immediately be diverted because you’re constantly scanning the environment for danger. And in fact, in medical settings, we are recognizing that families and kids come in always scanning their environment for danger. And if they’ve experienced trauma, they’re going to be even upregulated over scanning for these things.
In our settings, we have low-pitched hums and low-pitched noises are sounds of danger. You know that the "Jaws" theme―you don’t have to know that that movie’s about something scary when you hear that theme because low-pitched sounds are sounds of danger.
High-pitched musical sounds are sounds of safety. So that’s why when we talk to a scared child, we’ll often raise our voice and say, “Hey, honey, what’s going on with you today?” We are automatically going into what’s called parentese to try to help that child to feel safer because we know that there are these auditory cues for danger.
What we want to do, recognizing this neuroception, is wonder together with kids and families thinking about the issues that they’re bringing to us with curiosity, acceptance, respect and empathy. And when we bring those characteristics, we’re going to bring vocal tone, facial expressions, body language, all that promotes a sense of safety for kids and families. So as we open up the visit, we’re going to invite them to tell us what’s going on. “I’m so glad you’ve come in today. What brings you here to see me?” These are things that we commonly do but recognizing that we’re doing this to promote a physiologic response that is one of safety rather than perceiving threat.
Once we’ve begun to wonder together with the family about what’s going on for them, we need to investigate further and ask some open-ended questions or surveillance questions about what might be an issue for them related to trauma. These open-ended questions are not unlike things where we say, “what do you think might be going on for you,” or “have you been sick lately?” Similarly, we can ask, “has anything bad, scary, upsetting happened since we last met?”
For families where we have a long-term relationship, we want to ask about what their experience of being parented is and how they want to parent this child. Are there things they want to do differently? Often when families have had a history of trauma in childhood, they will immediately say, “yeah, there are things I want to do differently.”
Another question that interestingly gets right at the heart of traumatic experiences is, “has anyone come or gone from the household lately?” So very often when things have happened for kids and families, it is related to someone coming or going from the household. So this is sort of an interesting question, which may at face value not be trauma related, but interestingly will often get you to a discussion about some issues that might be going on.
You know, we in medicine use screening all the time. And it’s important for us to recognize that when we’re screening for trauma-related issues, we’re looking at screening for both exposure and symptoms. And if you’re going to introduce a screening tool, and there are a number of them for a variety of diagnoses like post-traumatic stress disorder or acute stress disorder for a more complicated stress response called developmental trauma disorder or other diagnoses that can be impacted by trauma, you really want to understand what has happened and what are the symptoms that you’re seeing.
It’s important to let families know why you’re asking these questions and asking them to fill out the screening tool. And it’s important that you think about this for your practice and make sure that everybody can respond to those things that are identified.
In a number of states in many settings, there has been an initiative to do what’s called ACE screening, which is the use of a tool that was developed for research purposes in the Adverse Childhood Experiences Study, which asks about exposures or histories of trauma. I always think of the quote from "The Princess Bride." “You keep using that word, I do not think it means what you think it means.” Because interestingly, the questionnaire that is being used was never developed as a screening tool. It actually has no validity at the individual clinical level. And without questions related to symptoms may tell you something about history but doesn’t guide you clinically about what to do for this patient in front of you.
When the ACE study was done, the questionnaire was used to look at populations. And so we know that in a population, the more adverse experiences, the more likely populations are to have poor outcomes.
But that’s not necessarily true at the individual level because of everything we just spoke about. We are not asking about what’s strong with that child. We’re not asking about what kind of buffering was present during that experience. And so it’s very hard to use this tool in a specific clinical situation. So just use that as a caution.
And what we like to say, it’s not about summing the suffering. It’s about building the buffering.
Building resilience, interventions that require awareness and support
Once you have identified what a child or family has experienced and some symptoms that you might be related to that, you really need to stop and take a moment to validate and again affiliate with the family. “Wow, I’m so sorry that happened for you,” or “Boy, I’m so glad that you were able to share that with us today.” Or “I’m so glad you mentioned this to us so that we can begin to work on this together.” That allows us the opportunity to reengage that affiliate response and begin that process of healing in a trauma-informed manner. Dr. Lohr, I think that there’s some very practical things that we can do once we have done that.
Dr. Lohr: Thank you. And so practical advice on what we all do. These are interventions that don’t require a degree. It requires just awareness and support. But as a medical professional, we’re in a very good spot to support these things. And so when you work with families, paying attention to or suggesting looking for this one adult that can offer a source of resilience, a caring adult in a secure home, educating families on the signs and symptoms of maltreatment so that they can hopefully find a safe space to talk.
And looking to promote a positive school environment for children can be very helpful, often very supportive. You’re looking for opportunities to build connections to anything that can improve a map of the self or of the world in individuals. So working with meaningfulness, helping children and adolescents understand what is the meaning of what they’re doing, how can they―often children who have been, gone through a great deal of stress, they want to help others avoid this. And so that can be very powerful.
And I do think that as you get into treatment, thinking about wellness behaviors, just putting money in the bank, so to speak, things that can help children and youth gain more positive experiences and promote self-esteem, like exercise. I’ll have a slide on that later. Or meditation, even children can learn to meditate, and music. All these things can help build resources and get to what I call resilience and wellness.
Dr. Forkey: Dr. Lohr, can I just jump in there? I think what’s really fascinating about that advice is that half of it is about building those affiliate supports. And the other half is about burning off the fight or flight response that kids have been overusing. And so again, I think it’s really fun for us in the clinical realm to be able to bring it back to the physiology for kids and families and to help them to understand that this isn’t something that’s abnormal. This is your body doing exactly what it’s supposed to do under kinds of stress. And we’re going to use that physiology to help you feel better. And I think that’s exactly what you’re talking about.
Write an Rx for wellness
Dr. Lohr: Thank you. Yes. And so this slide gets into more what I start to think of as positive psychiatry, but it’s not just psychiatry, it’s positive health care. And that’s building supports, identifying and trying to help make sure that a child and family have support of a teacher, a relative, a peer support perhaps, encouraging families and youth to involve themselves in music or mindfulness, like we were saying before, meditation or Tai Chi. These are all things that you can specifically encourage or even write. And I love the offices that have little prescription pads that are set up for exercise. And having a physician, a pediatrician tell people to do something can be very powerful. So all these activities, they get to the neuroscience, they build this support through epigenetic changes and they start to address and overcome some of the barriers that we’re seeing in the population.
And so exercise is an activity that I enjoy myself and have been really interested to look at the neuroscience of this and that so exercise and other things can be very helpful with improving depression, memory, self-esteem. And if you get into the neuroscience, it involves these connections that we talked about, encouraging that brain plasticity. And there’s a protein called brain-derived neuro factor that can seem to be more expressed when you’re exercising. And so it helps cope, it helps routine. And this is one thing that not only improves physical but emotional resilience to future stress, can be very helpful to us all.
Dr. Forkey: There’s some other resources that you can download from the website from the American Academy of Pediatrics, which will allow you to have some handouts to provide to kids and families.
One of the easiest ones to use is called the three Rs, which gives families some immediate three steps to do. Just the way we talk about for sprains, we talk about RICE―rest, ice, compress and elevate. Here are three Rs. Reassure the child that they’re safe. Get back to routines, which get that child out of fight or flight and back into a calm state of being. And then some skills around regulation, just the ones that Dr. Lohr talked about—meditation, belly breathing, exercise. And then some skills around learning words for their emotions and so they can express what it is that they’re feeling.
Dr. Lohr: And Heather, I can take this. When you get into treatment, I think that it’s very important to think about the symptoms and the nature of what you’re treating. So trauma-focused cognitive behavioral therapy has been very well described for post-traumatic stress disorder and is a manual-based treatment that can really help. It involves getting into the narrative and helping kids build awareness, mindfulness and retelling the story. And so don’t be afraid of encouraging people to confront this because it really is often the first step is getting people to retell their story.
But there are other forms of evidence-based therapy too, that you should be aware of and be able to refer to. And so it gets into the integrated care. Having people available and knowing folks that can provide child-parent psychotherapy or parent-child interaction therapy really gets at that interaction, that attachment-based relationship to help parents discipline in a appropriate way and teach.
And then some other things include traumatic stress interventions that can be helpful. And emerging evidence is really there for eye movement desensitization, which involves using certain eye movements associated with trauma-related therapy. So sub-evidence-based psychosocial therapies are important to be able to access and resource. But also there’s more developmental support that includes paying attention to things like language and learning and reading. They may need school supports or things like physical or occupational therapy all may be part of this.
And we talked also about, you think about the systems of care. You’re not just the patients and the families that you’re treating are not just coming into you in a vacuum. They have supports in the community that we can build and grow. So more community resources help families do better as well.
Dr. Forkey: I was just going to jump in really quickly. We talk about social supports. We talk about helping families build those. One of the ways that we can practically do that is do some social mapping because sometimes when families come in, they just feel overwhelmed. “There’s no one to help me. There’s nothing that can be done.” And they are failing that fight or flight. They don’t feel that affiliate support. So asking them: Who would you turn to in the middle of the night if there was a disaster? Is there a downstairs neighbor? Is there someone who you’re related to in your neighborhood? Who could you reach out to in the middle of the night?
OK, now, match it if it’s the next day, and who would you turn to in that situation? Do you have a church that you could go to? Do you live near a YWCA? Is there a physician local to you and talking about yourself in that role? And then think about the broader structure and some other community resources that the family may not have thought of. So just as you’re talking about, I think mapping that with the family would be really helpful.
The limited role of medication
Dr. Lohr: And when you start to think about the medication, it is important to realize that there are no FDA-approved medications for PTSD in youths. There are a couple of medications that have been approved for use in adult PTSD, like sertraline and the serotonin reuptake inhibitors, antidepressants. And there’s been some use for prazosin for use in sleep in veterans. But there’s a very limited role of medication. And in the population that I work with, children in foster care, they often have a number of medications that they may be taking.
And so I encourage you as providers to realize that, try to understand what it is that you’re treating, and try to understand that the role of medication and trauma may be secondary and often should not be the first role of treatment. You want to look at psychosocial therapies and looking at social mapping and community and family supports that hopefully can be a lot more effective. And I think Dr. Forkey will…
Dr. Forkey: I think in each one of these pieces of this care, we’ve identified that that family understanding their sense of safety and having that affiliate support comes from us providing a positive expectation of recovery. If you think about what we do in medicine, a family’s up all night with an ear infection and they come in and we say, “Oh, we got this.” “We’ll get you some antibiotics,” or “We can watch and wait, but you’re going to feel better very shortly and you’re all going to get some sleep.” Even when we have serious diagnoses like cancer, we’ll say, “Look, this is a concern, but I have people that I can send you to and people here who can help you to start to get better.” We always provide that sense of recovery and hope.
When we’re talking about the effects of trauma, it is really important that we talk about that as well, that these are not situations that we can’t do anything about. That in fact, we have a number of tools right at our disposal, especially in integrated settings, where we can employ those and begin to help families to heal.
Summary: TIC in the health system
Dr. Lohr: And so this is a bit of a summary slide, but when you are a provider, you are part of the health care system for the most part. And with integration, it’s very important to try to get to a seamless interaction between providers and systems. You don’t want to have to refer a youth or family with a mental illness and lose track of them. You want this warm handoff to really take place. So that can be very traumatic and frightening to a family and youth when you make referrals. So being aware of this and making sure that there’s a lot of interaction and collaboration between the systems.
Also thinking about just having a safe place, making the rooms quiet and approachable to families and youth that have had some difficult experiences, paying attention to what this environment looks like to someone coming in.
And I think that we have to think about prevention because you think about primary prevention, first of all, those are things that we can do that can affect everybody. Things like childcare, access to education, parenting strategies. Those are primary prevention that is very important for us all to be aware of and to promote. And then if you start to get into populations that we think have some risk, like those that have been exposed to trauma but may have not expressed symptoms, that gets into secondary prevention. Those are things like Dr. Forkey talked about, that includes things like surveillance, screening and offering that safe space for further discussion and empathy.
And then finally prevention of tertiary conditions. That includes adequate care and adequate immediate care that can prevent complications down the road. In everything we do, we want to have trauma-informed workforce so that workforce can be compassionate and aware of behaviors. We also have to be aware of each other in our workforce because exposure to trauma in those that we treat can be very difficult and can lead to the term known as burnout or other things.
And so being aware of how this affects us all. We have to be in this together to really help this work. And so throughout the health care system, there are things that we can do as providers.
So some key takeaways here. We’ve reviewed the neuroscience of trauma to help you understand genetics and immunological, hormonal ways to guide the understanding of what we do for trauma-informed care. It’s very important for us to engage families and patients with the words, the language, the tone, the validation of their experiences to promote the sense of safety that’s trauma-informed care. It also includes surveillance and screening for exposure and symptoms that can be included in visits throughout.
The interventions briefly teach families tips such as the three Rs to address trauma symptoms at home. And finally, know to refer to evidence-based trauma therapy with warm handoffs within your integrated setting or within colleagues with your community for evidence-based treatment. And some references for your consideration. And contact information if you have questions or further points to review with us.
Lewin-Smith: Great. Well, thank you both again so much, Dr. Lohr and Dr. Forkey, for sharing your experience and expertise with our viewers today. Be sure to visit our series page on the AMA’s website for more information on upcoming releases. You can also access previous recordings on our YouTube playlist.
Please also check out the collaborative’s BHI compendium for a helpful framework on how you can make BHI effective in your practice, along with other actionable resources and practice case studies. Lastly, access the AMA’s strategic practice guides on the AMA’s website for implementing specific topics associated with effective behavioral health integration. Some of our guidance includes pharmacological treatment, substance use disorder treatment, suicide prevention, workflow design and integrated behavioral health care for older adults.
Thank you so much for joining us.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
