Trauma Informed Care in Pediatrics

A child may experience trauma when there is a catastrophic event in the absence of a secure attachment. Further retraumatization may happen when internal and external resources to cope with the threat are absent. Pediatricians can mitigate the effects of trauma by identifying trauma and responding to it. Trauma-informed care in pediatric head trauma is multidimensional, from carrying out primary and secondary examinations, laboratory studies, surgical procedures, pharmacological interventions, to restoring psychological safety and addressing stigma.

Events that are dangerous, evoke fear, or are violent are threats to a “child’s life or body integrity” (American Academy of Pediatrics, 2023). Such traumatic events may occur during natural disasters, terrorism, injury, community violence, racism, intimate partner violence, substance abuse, adverse experiences with caregivers, or other adverse childhood experiences (ACEs).

Children recover from mild stress without problems, and secure attachment relationships increase resilience in children. A catastrophic event in the absence of a secure attachment puts the child at risk of trauma. An inadequacy of internal and external resources to cope with the threat leads to retraumatization (Fisher, n.d.). Pediatricians are the first contact point and responsible for early identification and response to trauma (American Academy of Pediatrics, 2023).

Implementing Trauma-Informed Care in Pediatrics

Trauma informed care (TIC) in pediatrics relates to the “ability to form safe, stable, and nurturing relationships” (American Academy of Pediatrics, 2023). The pediatrician supports the child-caregiver bond to recover from trauma and restore resilience.

According to the National Child Traumatic Stress Network, trauma-informed care (TIC) is defined as medical care which recognizes the effects of traumatic stress on providers, children, and caregivers, and all stakeholders assess, recognize, and respond to trauma (American Academy of Pediatrics, 2023). In a clinical setting that is trauma-informed, trauma is the focus of all services, and all efforts are directed towards its “prevention, identification, and assessment”.

The principles of trauma-informed care are “strength-based philosophies” such as recognizing the nature of trauma, carrying thoughtful assessments, identifying re-traumatizing variables, and providing ongoing training to staff (Fisher, n.d.). The family of the child is involved in all aspects of care, neutral and supportive language is used making sure no pathologization occurs, and staff is educated to ensure non-coercive techniques, careful observation, impulse control is implemented and sarcasm, threats, criticism, or ridicule is not perpetuated.

Several organizations are involved in implementing the standards of trauma informed care (TIC):

• The National Child Traumatic Stress Network (NCTSN) increases care standards and improves access to care for children who have experienced trauma, and for their families and communities residing in the United States. NCTSN functions include disseminating effective and evidence-based treatments, collecting systematic study data, educating the public on trauma impact, and providing information on current treatment and best practices (Fisher, n.d.).
• The American Academy of Pediatrics (AAP) facilitates the implementation of TIC in pediatric settings through its Pediatric Approach to Trauma, Treatment, and Resilience (PATTeR) project (American Academy of Pediatrics, 2023).

Trauma Informed care in Pediatric Head Trauma

Pediatric head trauma includes contusions, concussions, skull fractures, scalp injury, epidural or subdural hematoma, intraventricular hemorrhage, penetrating injuries, diffuse axonal injuries, and intracranial or subarachnoid hemorrhage. Head trauma leads to 80% or more lethal injuries in the United States due to falls, accidents, recreational activities, child abuse or vehicle accidents (Verive, 2023). Head trauma is accompanied by multiple organ injuries. A physician may perform a primary examination consisting of airway, breathing, circulatory status, and neurologic status examination, and a secondary examination (consisting of evaluating the head, neurologic state, and respiratory patterns).

A physician may complete laboratory studies including arterial blood gas, urine and blood toxicology, coagulation profile, and blood chemistry. In addition, radiological studies such as CT scan or MRI may be required. Patients with severe TBI or neurologic deterioration are monitored for intracranial pressure, requiring lumbar or external ventricular drains. Seizures, bleeding and other life-threatening conditions may need to be monitored and a neurosurgeon may need to be consulted (Verive, 2023). Surgical decompression, craniotomy, or surgical debridement may need to be performed in certain cases. In addition, pharmacological interventions may be administered (diuretics, anticonvulsants, anesthetics, neuromuscular blockers).

Trauma Informed Care for Concussion and Brain Injury

Trauma being a complex phenomenon, is multidimensional and beyond the fight-flight-freeze model. Trauma is induced as a result of interpersonal trauma, developmental trauma, intergenerational trauma, historical trauma, and system-induced trauma. Trauma-informed care in brain injury addresses the elements of negative stigma, inequity, and lack of acknowledgement about trauma histories and ongoing trauma among vulnerable patients (Gill, 2023). TIC is important as triggers exist in care settings, and trauma survivors are less compliant with their healthcare providers. TIC does not treat symptoms or require any disclosure from survivors, rather it provides safety. It identifies triggers that re-traumatize, such as forced medication, seclusion, verbal and physical cues, coercion, and restraint.

TIC consists of five pillars: trust, safety, collaboration, choice, and empowerment. Trauma is characterized by loss of control, and restorative strategies consist of respectful and honest relationships (Gill, 2023). The four Rs of TIC recognized by SAMHSA are Realizing widespread trauma impact and understanding potential recovery paths, Recognizing trauma signs and symptoms in families, clients, and people involved in the healthcare system, Responding by integrating trauma knowledge into policy, procedure, and practice, and Resisting Re-traumatization through TIC practice implementation.

References

American Academy of Pediatrics. (2023). Trauma-Informed Care. www.aap.org. https://www.aap.org/en/patient-care/trauma-informed-care/

Fisher, J. (n.d.). Trauma Informed Care. In Commonwealth of Massachusetts. https://www.mass.gov/doc/chapter-four-trauma-informed-care/download

Gill, H. (2023). Exploring trauma-informed care with the Acquired Brain Injury and Concussion Services program. https://doi.org/10.24124/2023/59359

Verive, M. J. (2023). Pediatric Head Trauma: Practice Essentials, Background, Anatomy. EMedicine. https://emedicine.medscape.com/article/907273-overview