How pediatricians can help patients who’ve experienced trauma

Pediatricians may encounter children who are unable to see the world as a safe, secure place, and others who may have depression, anxiety, problems with learning, or an inability to self-regulate.

By integrating trauma-informed care into a pediatric practice, physicians can go into the exam room searching for an understanding of why a child may have these behaviors. Were they exposed to violence from a young age? Have they grown up surrounded by chaos that resulted in toxic stress?

“Trauma-informed care, to me, is taking a lens and a perspective of understanding behavior in a different way,” said William David Lohr, MD, a professor of pediatrics in the division of child and adolescent psychiatry and pediatric psychology in the pediatrics department at the University of Louisville School of Medicine. “It changes the lens from asking ‘What is wrong with you?’ to ‘What’s happened to you?’ Or, in some cases: ‘What is right with you?’ … How have you coped?’”

During an AMA-hosted Behavioral Health Integration Collaborative webinar, Dr. Lohr joined Heather C. Forkey, MD, professor of pediatrics at the University of Massachusetts (UMass) Chan Medical School and director of the Foster Children Evaluation Service at UMass Memorial Children’s Medical Center. They outlined what trauma does to a developing brain and offered practical ways to incorporate trauma-informed care into the pediatric setting. The webinar is available on demand (registration required).

Providing trauma-informed care is “important because trauma has a role in the development and the presentation and the outcome in a whole bunch of the diagnoses we deal with every day,” Dr. Forkey said.

When children face trauma, the rely on their freeze-or-fight-or-flight response to stressors—in many cases for far longer than the body was designed to operate. This response may have been triggered because the children felt like they couldn’t rely on others to keep them safe or provide a nurturing environment.

Through trauma-informed care, physicians can navigate these situations with an evidence-based approach to engaging children and their families. The acronym WITH spells out how to integrate trauma-informed care:

• Wonder together.
• Investigate.
• Treat.
• Hope.

The approach is detailed below.

Engage with kids and families by bringing curiosity and showing acceptance, respect and empathy. Make sure body language, words and tone put patients and their families at ease.

Ask open-ended questions of the patient such as “Has anything bad, scary or upsetting happened since we last met?” Brief psychosocial interventions such as motivational interviewing may be helpful at this stage.

Once a pediatrician gets to know a parent or caregiver, they can ask additional probing questions on such topics as their own experiences being cared for as a kid, along with things they may want to do differently. It can also be helpful to determine whether there have been any significant changes in the household recently. Trauma often happens around the same time someone is coming to or leaving the household, the experts said.

Once the patient’s experience and related symptoms have been properly identified, the next step is validation. For example: “I’m so sorry that happened to you,” or “I’m so glad you mentioned it; now we can begin to work on this together.”

Pediatricians can then determine what might be the best treatment pathway for the patient. Medication plays a limited role in post-traumatic stress disorder treatment, Dr. Lohr explained. Instead, it’s important to look at therapies such as trauma-focused cognitive behavioral therapy or child-parent psychotherapy.

Wellness behaviors can also go a long way in helping children and adolescents gain more positive experiences and improved self-esteem that allows them to become more resilient. Positive social support from a teacher, relative, neighbor or peer helps build this. Dr. Lohr also suggested writing a prescription for wellness, things such as exercise, music training, mindfulness training, meditation, yoga or tai chi.

Whether it is an ear infection or a more serious diagnosis, pediatricians often give patients and their families hope that things will get better. Trauma-informed care is no different.

It would be wrong to think these situations are ones “that we can’t do anything about,” Dr. Forkey said. “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 heal.”

Learn more with the AMA about behavioral health integration in physician practices.