Experiences in childhood, both positive and negative, have an enormous impact on subsequent health and developmental outcome and trajectories. A robust and growing literature has demonstrated that childhood traumas such as abuse, neglect, and extreme household dysfunction can alter children's physiological functioning, damage their developing immunologic, neurologic, emotional, and cognitive systems, and cause poor emotional and physical health.1,2 Trauma leading to the frequent or prolonged activation of the stress response in the relative absence of protective relationships has been termed “toxic stress” in the pediatric literature.1,2 These adversities cause harm at a molecular, cellular, and ultimately organ and system level, placing trauma squarely in the wheelhouse of the medical provider, leading to a call for pediatricians to address this compelling child health issue.2,3 Furthermore, we now have treatment approaches to childhood trauma, and the pediatric provider, because of their role in prevention, health promotion and child development, is in an ideal position to identify and manage stress symptoms, and thus mitigate the devastating impact that trauma can have.
Yet, we cannot treat what we do not see. Pediatric medical care providers are likely to be the first, and sometimes the only, professionals with the opportunity to assess the myriad symptoms demonstrated by children experiencing trauma. For many children, the issues that bring them to pediatric attention are trauma related. For instance, 68% of children seen in a pediatric health care setting have experienced exposure to traumatic events,4,5 and as many as 90% of children in urban pediatric clinics have had a traumatic exposure.6,7 Yet, many children do not benefit from early recognition and intervention because symptoms of child trauma are often missed by the pediatric provider.8 Families may or may not bring a history of exposures to traumatic events to the pediatric provider's attention because the parent does not recognize events as traumatic, is unaware of the extent of the exposure, or fears the consequences of sharing the exposure history or symptoms. Therefore, pediatricians need to be equipped to look at all children through a trauma lens to recognize and respond to the spectrum of symptoms of traumatic stress.
Putting on a trauma lens means that the pediatric provider understands the stress response, and puts that into the context of attachment, resilience, and development. The provider must be familiar with the most common symptoms of trauma and be able to discern which resilience skills might be impacted for a given child. This will make it easier to recognize when a known trauma is impacting a child, or when a history of trauma should be considered as the cause of a constellation of symptoms. The grounding in trauma and resilience provides a framework within which the pediatric provider can routinely identify when trauma has impacted a child and respond most appropriately.
When threat is perceived, there are four behavioral responses that can be activated through the neuroendocrine system: freeze, fight, flight, or affiliative. Freezing is usually a brief response, as the organism alerts to danger; this is usually followed by the fight or flight response.9 The fight or flight responses result from release of epinephrine and cortisol by the adrenal glands. In the short term, these hormones lead to physiological changes, including elevations in heart rate and blood pressure, that allow the threat to be addressed. For children exposed to multiple, severe or prolonged traumas, repeated or prolonged stimulation of these hormones results in their dysregulation, leading to potentially long-lasting effects on the brain, immune system, and even the genome, resulting in later negative health outcomes.
The fourth response, the affiliative response, is also called tend and befriend. Humans, without claws or the ability to hide underwater, are not particularly effective at fight or flight. Coordinated in the higher brain rather than the limbic system, and mediated by oxytocin, the affiliative response allows humans to draw support during threat from relationships with others.10,11 Although the exact mechanisms of action are still being studied, it appears that oxytocin mediates stress within the social context.12,13 Under threat, oxytocin promotes social salience, or the ability to look to others in the environment for support in managing a threat. When support is provided by others and positive social interactions are encountered, the stress response declines.12,14 However, if support is not available, or if those in the environment are hostile, one shifts to less adaptive responses and antisocial behaviors. This may then result in an increased perception of stress, increased cortisol, and further use of fight or flight.12,15–17 The emerging science underlying the affiliative response elucidates how safe, stable, nurturing relationships can buffer adversity and promote resilience, whereas children who are unsupported during traumatic experiences are left most at risk for developmental, behavioral, and health consequences.
The Buffering of a Committed Caregiver
Thus, no discussion of trauma can ignore the impact of attachment. Fundamentally, the predictable compassionate availability of the caregiver enables the secure attachment of the child.18,19 The ability of caregivers to protect children, to mediate the world for them, and soften the impact of stressors is a fundamental feature of attachment. However, it is also in the context of a secure attachment relationship that child resilience and healthy development evolves.20 Security in attachment relationships is the best way for children to learn to regulate emotional distress and develop executive function skills like attention and cognitive flexibility.
Consider a caregiver tenderly cradling a distressed infant in his or her arms. The caregiver comforts the child through his or her attunement to the child's distress. Secure attachment is built as the infant learns to trust that their caregiver will respond to their distress and help them modulate. Anticipating this, a child knows they can turn to the caregiver for comfort in times of distress. This is critical to prevention and recovery from trauma because there are two things that result from that supportive attachment or the psychological holding the caregiver provides the child: (1) a restoration of a sense of security—expediently shutting down the stress response and restoring emotional regulation; and (2) the provision of a secure base for exploration, as the child trusts he or she can always return for comfort.19 It is here that positive affiliative experiences, oxytocin release, and modulation of the stress response begins.12,21
As pediatric providers in inpatient or outpatient settings, we often assess this aspect of the relationship within the first nanoseconds of any an encounter, noting how attuned, attentive, and developmentally appropriate the parent is, how relaxed, comfortable, and responsive the child is, and the overall quality of the parent-child interaction. When we identify that this relationship is stressed, the pediatric provider will often intuit the vulnerability of the child to trauma. Yet, pediatric providers are in a unique position to ameliorate this stress. Providing a parent with empathy and positive regard is the first step in helping to restore attachment when it has been strained. The active listening and psychological holding of the caregiver by the pediatric provider models predictable compassionate availability and creates a space for parents to then be more empathetic and attuned to their child.19 Thus attuned, the caregiver can help the child develop their own resilience.
Using Attachment to Build Resilience
Resilience is defined as a dynamic process of positive adaptation to or in spite of significant adversities.22 For children, the pathways to resilience are rooted in the give and take of safe, stable, nurturing relationships (SSNRs) that are continuous over time (attachment), and in the growth that occurs through play, exploration, and exposure to a variety of normal activities and resources.22
Resilience promotion is part of almost every pediatric encounter, although it is not always obvious. We take advantage of the fact that resilience is a dynamic process of positive adaptation when we offer anticipatory guidance and promote healthy development and relationships in preventive care. We also assess resilience when we provide medical support around traumatic medical or life events, when we advise parents about child behavior or development, and in the management of complex health problems. The mnemonic THREADS (Thinking & learning brain, with opportunity for continued growth, cognitive development; Hope, optimism, faith, belief in a future for one's self; Regulation (self-regulation, self-control); Efficacy, or knowing one can impact their environment and situation; Attachment, secure; Development, or mastery of age-salient developmental tasks; Social context or the larger network of relationships in which one lives and learns) is a helpful way to remember the positive adaptive mechanisms that lead to resilience.22 Even though attachment is in the middle of the list, it is the foundational thread that is the context in or on which the others develop over time.
How Trauma Impacts Resilience
Trauma can also be described as events that specifically impair these resilience factors. Being alone in unbearable psychological pain is one definition of trauma.19 Trauma, in the absence of nurturing caregiving, can impact each resilience factor: (1) Thinking and learning brain shuts down as the reflexive behaviors and actions of the lower brain take over to manage threat; (2) Hope is lost as all anticipation for the future is abandoned to manage the present danger; (3) Regulation or self-control must be abandoned to respond aggressively and impulsively to unpredictable events; (4) Efficacy cannot be maintained when reacting to situations, not controlling them; (5) Attachment is the fundamental loss as one is alone with no source of security and no base from which to explore the world safely; (6) Developmental skill mastery must be put off as the lower brain is employed to deal with the threat; and (7) Social connectedness is lost in the fear and isolation of trauma.
How Trauma Presents
When the THREADS are woven together through SSNRs, children will present as healthy and happy. But we know that, for many children, these THREADS are frayed, or partially eroded by stressors, so they may present with symptoms. Pediatricians who have a longitudinal relationship with children may notice that trauma symptoms evolve over time. Functional complaints, often related to sleep, eating, toileting, or school functioning may be the first symptoms noted by families dealing with stressors. The trauma from single incidents, such as accidents or natural disasters and medical trauma from serious diagnoses or painful procedures, may also present with functional symptoms. The breach of the parent-child relationship that occurs in the presence of chaotic parenting, intra-familial violence, neglect, or abuse, however, may have a more profound and long-lasting impact due to the lack of safe, stable nurturance.
Specific areas of the brain are particularly sensitive to trauma including the limbic system, reticular activating system, and prefrontal cortex. These areas of the brain are involved in cognition, rational thought, emotional regulation, activity level, attention, impulse control, and executive function. They are particularly vulnerable in the young child in whom these areas of the brain are rapidly developing. Subsequently, some of the most common symptoms of trauma result from the impact of childhood trauma on these areas of the brain and include (1) Fits (tantrums), Frets (anxiety and worry), and Fear; (2) Regulation disorders (hyperactive, impulsive, easily becomes aggressive or emotional); (3) Attachment problems (insecure attachment relationships with caregivers); (4) Yawning (sleep problems) and Yelling (aggression, impulsivity); (5) Educational and developmental delays (especially cognitive, social-emotional, and communication); and (6) Defeat (depressed, sad) and Dissociation (lives in own head). The fabric of healthy human development becomes FRAYED, the mnemonic that may be useful in remembering these common symptoms of trauma. When more than one of these symptoms are noted, children may even meet diagnostic criteria for adjustment disorder, attention-deficit/hyperactivity disorder, posttraumatic stress disorder, or other behavioral diagnoses. Thus, whenever a child presents with the above symptoms, whether mild or severe, consideration of what has happened to the child in terms of possible traumatic experiences should be part of the differential diagnosis. Failure to include trauma as a consideration may lead to incorrect diagnosis and management.
Putting on the Trauma Lens
Using a trauma lens means that a provider looks at each encounter with children in the context of attachment, seeking to build and weave the THREADS of resilience. By considering the ways children can be FRAYED, the pediatric provider is less likely to miss symptoms of trauma and can provide anticipatory guidance when adverse experiences are reported.
Trauma-informed response and anticipatory guidance provided by pediatricians can help families begin to address the impact of trauma. The positive affiliative reactions by the medical provider can reduce child and parent stress; likewise, the affiliative response of the parent reduces child distress and protects the child from further trauma impact. This affiliative response is promoted by the predictable compassionate availability of the caregiver, and the resultant attachment of the child to that caregiver. When a whole family is experiencing stressors, the caregiver may find that empathy for the child is challenged. When the medical provider can listen to the caregiver with empathy and positive regard, the caregiver develops the psychological space to empathize with the child.18,19
Pediatric providers can offer caregivers advice about three specific interventions to help a child recover from trauma. The “3 Rs” (Reassuring, Restoring routines, and Regulating) are the first steps toward restoring resilience in a child who has become “FRAYED.”
Repeatedly reassuring a child or adolescent that they are safe and allowing the youth to express how they feel can restore a sense of safety. For preverbal or young children, the caregiver can offer extra physical contact with hugs, gentle touch, and rocking to reduce the stress response after a trauma. Children need to know they are safe and protected even when the caregiver is not present, so having the child and caregiver share matched stuffed toys when separated (at bedtime or during parent work hours), having the caregiver provide sticky notes with loving messages, offering the child a picture of the caregiver to keep in their pocket, or talking about how the caregiver and child are connected by an “invisible string” can all be employed to remind the child of those reassuring connections.
Restoring routines is a practical step for caregivers to use after the chaos of a traumatic event. Guiding the caregiver to use verbal prompts and pictorial charts as visual cues of routines and encouraging well-defined mealtimes, sleep times, and standard rituals for bathing and bedtime can restore a sense of order.
Regulating is a larger task and involves helping the child step down the fight or flight stress response. Reassuring and restoring routines start that process, but other methods can be offered in the office setting in the same way anticipatory guidance on other topics is discussed.
Helping caregivers and youth learn relaxation techniques such as belly breathing, guided imagery, meditation, yoga, stretching, and massage can be helpful in reducing stress responses and symptoms.23 Advising about adequate sleep and exercise is also important.
Children who have experienced trauma are wired to respond without checking strong emotions to deal with threats, especially when they are experiencing reminders. Thus, caregivers may be surprised by strong tantrums or unexpected reactions to seemingly innocuous events. Children who have experienced early trauma often don't have the vocabulary or understanding of their own emotional states. Anger is one of the default emotions, but children and caregivers may not understand what underlies this emotion. Indeed, disappointment, fear, and hurt may all manifest as anger. Identifying triggers and working with children after the outburst to identify the underlying emotion can help them learn new ways of coping.24
The pediatric provider can also make referrals to community resources for mindfulness programs, parenting support, and specific caregiver skill training that includes psychoeducation, cognitive coping, relaxation techniques, positive parenting strategies, and reframing. The pediatric provider can have a referral list for community providers, arrange the referral, or provide care coordination to facilitate family engagement with community resources. Achieving regulation can take some time, but often results from children having tools to express how they feel.
Once a pediatric provider has their trauma lens on, it becomes much easier to recognize and respond to children and families who have experienced trauma. We can keep in mind that the THREADS of childhood resilience may become FRAYED by trauma experiences but that we can help families weave children back to health using the 3 Rs.
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