Toxic levels of stress in childhood are an ongoing threat to public health (Garner, Horkey, & Szilagyi, 2015). Every year, more than 3 million children in the United States are reported to authorities for neglect and/or abuse, of which evidence is only found to support 1 million of those reports (van der Kolk, 2005). Approximately 1,500 children die at the hands of caregivers yearly (American Academy of Pediatrics [AAP], 2016). Some of these children are in foster care out-of-home placement. According to the AAP (2016), children who remain in the home following a Child Protective Services home investigation experience many of the same adversities as foster children and therefore have similar health needs.
Traumatized children, including foster children, are classified by the AAP (2016) as having special needs for health care, often predating presentation to primary care clinicians. This classification is due to the high prevalence of ongoing developmental, mental health, and medical problems secondary to traumatic events or imminent threats to safety. Most foster children have a minimum of one chronic medical condition; one fourth have at least three or more conditions (Jee & Szilagyi, 2016).
RNs and nurse practitioners (NPs) from primary care to the emergency department to psychiatric care are in a position to consider enhancing their typical models of care to include the special needs of traumatized children. However, what would that enhancement look like? What practices would help identify a child or adolescent who is experiencing or recovering from trauma? Once identified, what can clinicians do to mitigate or eliminate these effects? The current article examines ways to expand the scope of interactions with traumatized children or adolescents in a health care setting, and explore small changes that capture complications of childhood trauma and adversities.
What Is Trauma?
Trauma is defined by the Substance Abuse and Mental Health Services Administration (2015) as “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects” (para. 1). Examples of trauma include parental rejection, abandonment, parental incapacity, parental impairment, severe neglect, domestic violence, parental substance abuse, sexual abuse, and physical abuse (Deutsch et al., 2015). Adversity is another term used to describe events that, if unmitigated, can cause long-term effects. Adversity is more commonplace and includes poverty, parental unemployment, parental mental illness, witnessing violence, and parental dissension. Adversity also includes separation from a parent, parental incarceration, and violent fighting in the home (Garner et al., 2015).
The field of traumatic stress has adopted the term complex trauma to describe multiple and/or prolonged experiences of adverse events during early life. These events most often occur in a child's immediate caregiving system, and include physical, emotional, and sexual abuse, as well as educational neglect. Isolated incidents of trauma produce conditioned biological and behavioral responses. In contrast, chronic traumatization has a pervasive effect on brain development, thereby limiting health in the long-term. Toxic levels of stress can lead to permanent changes in brain connectivity and epigenetics (Garner et al., 2015).
Why Is Complex Trauma Concerning?
Childhood adversity and trauma can alter connectivity among the prefrontal cortex, hippocampus, and amygdala. These areas are critical for emotional regulation, along with adaptive responses to adversity (Herringa et al., 2016). Childhood trauma and adversity are entrenched biologically in ways that allow children to survive and adapt in the short-term, but are maladaptive over the life course (Herringa et al., 2016).
Developmental trauma leads to dramatic increases in use of medical, social, correctional, and mental health services (van der Kolk, 2005). Adults with histories of childhood trauma comprise approximately the entirety of the criminal justice population (van der Kolk, 2005). A link exists between adults who have experienced neglect and physical abuse to extremely high rates of arrest for committing violent crimes (Stouthamer-Loeber, Loeber, Homish, & Wei, 2001). Seventy-five percent of child sexual abuse perpetrators have reported having been sexually abused themselves as children (van der Kolk, 2005). This repetitive tendency is an integral part of the cycle of violence (van der Kolk, 2005).
Children who are chronically traumatized have a tendency to experience alterations in states of consciousness, including amnesia, dissociation, flash-backs, depersonalization, derealization, and loss of orientation in space and time (van der Hart, Nijenhuis, & Steele, 2005). These children are often out of touch and have no language skills to express their suffering. Children rarely spontaneously reveal their traumas and fears, and have little to no insight into the connection between what they feel and do, and the trauma that has occurred. However, they communicate their traumatic past (or present) in the form of reenactments in their play and fantasy lives (van der Hart et al., 2005). As traumatized children mature into adults, they have great difficulty in relationships with peers and intimate partners (Deutsch & Fortin, 2015).
In cases of severe adversity, abuse, and neglect, as well as lack of protection by a caregiver and caregiver incapacity, traumatized children emerge with emotional self-regulation deficits, which are demonstrated by maladaptive behaviors (Table). A lack of predictability from caregivers and environment inhibits development and, as a result, traumatized children often lack the ability to perceive cause-and-effect; they are unaware of their role in what happens to them in everyday life (i.e., they believe they are the center of a universe that is collapsing). When trauma originates from inside the family structure and the child remains with the family (i.e., not in foster care), he/she will organize his/her reactions to the family environment into behaviors that allow him/her to survive within that family (van der Kolk, 2005).
Examples of Maladaptive Behaviors
Children who are chronically neglected, traumatized by abuse or violence, or otherwise maltreated display a variety of the aforementioned complex disturbances, often with fluctuating presentations. When health care providers and educators are not aware of a child's experiences and subsequent maladaptive behaviors, those behaviors inspire revulsion and rejection of the child. Labeling and stigmatizing children for their maladaptive behaviors may result, following revulsion and rejection, although the behaviors only developed as a means to ensure survival.
Presence of these symptoms does not always immediately indicate trauma/adversity. The goal of compiling a table of behaviors associated with trauma/adversity is to assist providers in identifying the possibility that trauma/adversity may be present in the child's life. In the relatively new field of life course science, research has revealed strong associations between adverse/traumatic experiences in childhood and a range of negative outcomes that may continue decades later (Garner et al., 2015). Longitudinal and retrospective studies link childhood trauma and adversity to academic difficulties, poor health, and low economic productivity in adulthood (Garner et al., 2015). Studies have also demonstrated a clear link among early childhood trauma, neglect, and malnutrition with somatic disease processes, such as high blood pressure, coronary heart disease, and diabetes (van der Kolk, 2005). This link is reflected in increased risk for developing an oncologic process, which includes a decrease in cancer-protective factors such as a robust immune system (Garner et al., 2012). Complex trauma can interrupt children's developing immune systems, such that lifetime risk of cancer is increased (Garner et al., 2012). Families with abused, neglected, or maltreated children harbor additional risk factors. For example, there is an increased risk of parental mental disorders, cramped living environment, poverty, or social isolation (Schmid, Petermann, & Fegert, 2013).
Children who have been traumatized or experience adversity develop highly insecure relationships and show nonselective behavior (i.e., promiscuity or clinging) toward adults. Traumatized children often develop feelings of guilt, shame, and self-reproach. The ability to develop a healthy self-image is heavily impaired. Kim and Cicchetti (2004) reported that experiencing feelings of shame following traumatization were linked to interpersonal problems in adulthood.
How Are Trauma and Adversity Recognized Clinically?
The influential landmark study by the Centers for Disease Control and Prevention (2016), Adverse Childhood Experiences (ACEs), showed a statistically significant and dose-dependent link among categories of childhood adversity. The first category includes five forms of maltreatment: emotional, physical, or sexual abuse, and emotional and physical neglect. The second category includes five forms of dysfunctional households: substance abuse, violent fighting, parental separation, incarceration, and mental illness. The ACEs study produced a scoring system on a scale of 0 to 10, with 10 being the highest score and indicative of multiple ACEs (access http://buncombeaces.org/your-ace-score).
Although the ACEs study revolutionized attempts to quantify trauma and adversity, it is not without flaws. The ACEs study put the association of childhood adversity with poorer health outcomes on the radar for the health care community. However, the study was retrospective and therefore could not be linked to causality. In addition, ACEs are calculated relative to age 18, and the scoring was dependent solely on the child's recall of events. However, other screening tools are available to quickly identify trauma and adversity (Garner et al., 2015).
The Safe Environment for Every Kid (SEEK) parental quiz is useful in quickly identifying adverse conditions, and is direct about whether parents believe their child is living in threatening conditions (access http://seekwellbeing.com/the-seek-parent-questionnaire). For instance, a question on the SEEK quiz asks, “Do you worry that your child may have been physically abused?” Even if parents do not feel comfortable answering honestly, these items would then be recognized by them as being a condition worth addressing with a health care provider (U.S. Preventive Services Task Force, 2013). The screening could conceivably be repeated with every encounter in the health care system to detect changes or trends. According to Flynn et al. (2015), after implementing the SEEK model, primary care pediatric residents increased their screening for trauma from 16% to 88%, compared to approximately no change in a control group. Flynn et al. (2015) discussed that simply implementing the SEEK screening tool resulted in lower rates of maltreatment by parents.
The Screen for Child Anxiety Related Disorders (SCARED) tool is available in parent and child versions (access http://pediatricbipolar.pitt.edu/content.asp?id=2333). Children may be administered the child-type questionnaire if they are old enough to comprehend the questions. If not, the parent version is used. The SCARED tool is aimed specifically at anxiety, but if anxiety is identified, this may be a clue to the provider that there is underlying trauma or that the child is living with adversity. This tool has a more complex scoring system and questions are directed at different types of anxiety children may be experiencing. For example, certain questions target social anxiety, whereas others target panic specifically.
Implications for RNs and Nurse Practitioners
The AAP (2016) recommends establishing a medical home in primary care. For specialty clinicians, this could be the first goal after encountering a child or adolescent who is likely to have been psychologically traumatized. For RNs, this could be as simple as communicating with families that establishing primary care is of utmost importance. RNs can assist families in establishing an appointment before they leave the current health care environment. According to the AAP (2016), “Medical care of infants, children, and adolescents ideally should be accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective” (p. 1545). They also further define characteristics of a medical home as having providers who are known to the child and family (or foster caregivers) and should be able to develop a partnership of mutual responsibility and trust. This concept lends more weight to the idea of urging children and families in specialty/psychiatric care to establish a relationship with a primary care provider.
Traumatized children, especially those in foster care, have special health care needs. The AAP (2016) notes that traumatized children and youth require more frequent monitoring from their medical home, and RNs, NPs, social workers, and physicians are critical in assessing and guarding the well-being and health of traumatized and out-of-home (foster) children. Assessing and guarding the well-being and health of traumatized and out-of-home (foster) children is done by providing the highest quality of health services, and by conscientious coordination with psychiatric–mental health care and advocacy (AAP, 2016). These components translate to advocating for traumatized patients to be assessed more frequently, needing encouragement to follow through with follow up, and connecting the child and family to community resources, particularly mental health services.
Implications for Psychiatric-Mental Health Nurse Practitioners
For psychiatric–mental health nurse practitioners (PMHNPs), attention is drawn to considering interventions that mitigate anxiety—a prominent component of behaviors in traumatized individuals. PMHNPs are in the position of expertly establishing pharmacological and nonpharmacological care plans by establishing a trial of anxiolytic or antidepressant agents. This approach may decrease the time it takes to see effectiveness from nonpharmacological interventions (e.g., meditation therapy).
PMHNPs typically work closely with therapists and social services, and are ideal team members for providing oversight of youth who have been psychologically traumatized. PMHNPs' role is perfect for keeping primary care connected and up-to-date on goals set for mental health and/or social services assistance. PMHNPs may be more comfortable establishing a post-traumatic stress disorder (PTSD) diagnosis, and educating other specialties and providers about the risk of misdiagnosing a traumatized individual with attention-deficit/hyperactivity disorder (ADHD).
Implications for the Clinic Environment
Although inquiring about developmental milestones and medical history is standard in clinic examinations, social taboos can prevent providers from obtaining information about abuse, neglect, trauma, and other exposures to violence (van der Kolk, 2005). Previously mentioned screening tools could be administered while patients and families are in the waiting room, awaiting admission, or during transfers, and can quickly be reviewed by nursing staff to identify answers that indicate a problem. In addition, placement of brochures and posters throughout the clinic (or unit) can ease the tension of initiating a conversation about trauma and adversity.
Once trauma or adversity has been identified, RNs, NPs, and unit staff must assist families in connecting with community resources. Many patients and families will not know services exist. Mental health services can often help children and families begin recognizing what indicators of psychological trauma have been identified, and take steps to recover. In addition, educating families about the long-term effects of trauma and adversity can serve as a motivator on an otherwise taboo topic for families, and allow for further assistance in connecting with needed resources. Brochures in simple language can meet this need without consuming staff time. If a child is in foster care and presenting with the foster parent, it is safe to assume a significant traumatic event or series of events may have occurred. Social services can provide the child's medical history in some cases. Sometimes the full history is not known, aside from the precipitating event that led to the child's removal from home. However, nurses should not assume all foster parents understand the effects of trauma on a developing brain just because they are foster parenting. Educating foster parents can assist them in addressing the foster child's major behavioral problems. This education also increases their competence with future foster children they may take in.
In the primary care setting, providers can quickly and easily furnish information about food banks, shelters, prescription drug assistance, social work/case management services, health care services for parents, and mental health services. In other specialty areas, such as psychiatric care or the ED, staff must be familiar with what services are available in the local area. If the child is in foster care, it is important to realize that all foster children are covered by Medicaid until age 26 (Medicaid.gov, 2015). Foster children who have been adopted are also eligible for Medicaid coverage until age 26; however, adoptive families may opt to place children on private insurance or use Medicaid as a secondary source of coverage (Zlotnik, Wilson, Scribano, Wood, & Noonan, 2015). These Medicaid services give health care providers a good idea of scope of coverage.
Flynn et al. (2015) discussed the primary intervention of having resident/intern NPs/RNs visit community agencies in their rotation to learn about developmental and biosocial problems. Residents/interns/RNs would then be required to provide a comprehensive list of local resources and a brief manual of psychosocial issues. This list improves the capacity to make referrals and ensures that referral targets are up to date. Another step is training clinicians to work cooperatively with social workers, and conduct practice dialogue sessions to improve patient and family communication efforts (Flynn et al., 2015).
Flynn et al. (2015) also found that a rotation for physician residents boosted confidence and positivity toward children with traumatic backgrounds and the psychosocial sequelae, and increased confidence in the usefulness of screening tools, community resources, and topics in the handbook they had composed as part of their rotation. In terms of outcomes for parents and children, a systematic review reported reduction in occurrence or risk of trauma, and an increase in community resource referrals from primary care (Flynn et al., 2015).
From an NP standpoint, adding a diagnosis of PTSD to a child's record can indicate a clear connection not previously established, linking his/her traumatic experiences with mental disorders that may be evident or developing (Schmid et al., 2013). According to the American Psychiatric Association (APA; 2013b), traditionally understood PTSD requires one or more of the following to have occurred:
- directly experienced traumatic event;
- witnessed traumatic event in person;
- learned that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); and
- experienced firsthand or repeated exposure to aversive details of the traumatic event (not through media, television, pictures or movies, unless work-related).
The trigger for PTSD must cause clinically significant impairment or distress (Table) in the victim's social interactions or other “important areas of functioning” (APA, 2013a, para. 3). For children younger than 6, there is now PTSD preschool subtype and PTSD dissociative subtype. Of note, ADHD can be misdiagnosed in a traumatized child who exhibits symptomology of inattention and impulsivity (Biederman et al., 2013); the child may instead be experiencing PTSD.
Once trauma has been identified, the child and family should be connected to ongoing mental health services for management of behaviors that may indicate adversity. Many times this connection involves a child therapist who can evaluate the child's development in terms of what therapeutic approach may be appropriate to address the child's behavioral needs. Mental health services can recommend a treatment program type based on each child's needs, and goals that can be reasonably met with the support of therapy. Another approach would be to refer the child directly to a psychiatric provider for evaluation of behavior abnormalities and assessment for medication intervention. Screening tools can serve as a quick reference for behaviors that are suspicious for exposure to trauma/adversity.
There is always the possibility that a child or adolescent may present with a need for the intervention of Child Protective Services. Health care providers are mandated reporters of confirmed or suspected child abuse, neglect, or maltreatment. However, this mandate may present a challenge to those with little or no training (Herendeen, Blevins, Anson, & Smith, 2014). It is likely that those working with pediatric populations in any setting will see a child whose condition raises suspicion. Child abuse experts maintain that education about child abuse and how to report to Child Protective Services is a significant modality for catching childhood trauma as early as possible (Herendeen et al., 2014). Targeting trauma, child abuse, or foster care as a topic for continuing education is another method of establishing expanded practice to include trauma-informed care. NPs and physicians reported greater confidence following appropriate training and education in managing traumatized children (Herendeen, Blevins, Anson, & Smith, 2014). Nurses with education and training targeted at recognition of child abuse demonstrated improved reporting of child abuse (Fraser, Mathews, Walsh, Chen, & Dunne, 2010).
Regarding familiarizing themselves with community resources, it is important for clinicians to consider the specialty of child abuse pediatrics. Child abuse pediatricians have specialized training and have often completed a fellowship in child abuse as part of their education. They are astute in recognizing even the subtlest sequelae of trauma, neglect, and adversity. When considering typical care models, an expert in child abuse is an appropriate community resource to include. If a health care clinician identifies significant trauma or suspected or confirmed child abuse that falls outside the expertise or comfort level of the mainstream pediatric primary care provider, there may be a child abuse pediatrician who is established and appropriate for referring cases of childhood trauma.
When considering toxic levels of stress and ACEs, RNs, NPs, and other providers may encounter the effects well into the patient's adult life (Massetti, Thomas, & Ragan, 2016). Holman et al. (2016) reiterated that a major connection was made between ACEs and lifelong health disparities, stating that a “strong, graded relationship [exists] between the breadth of exposure to ACEs and multiple risk factors for several of the leading causes of death in adults” (p. S82).
A good beginning to enhancing practice for identifying childhood trauma is to take interest in typical behaviors and presentations of traumatized children and adolescents. A broad range of care specialties could target trauma-informed care as a staff education topic yearly or more frequently. Nurse leadership should take the opportunity to become aware of and invest time and interest in advocacy programs that exist at the local, state, and federal level (Block, 2016).
Connecting with available resources in the local area can boost providers and staff confidence in referring traumatized children and families for assistance in recovery. An updated list of local/regional services available (updated yearly) ensures that referrals to outside/specialty resources do not become lost to follow up. Communication between agencies, from mental health to social services, helps manage special needs of traumatized children. According to Block (2016), the key to meeting the needs of traumatized children lies mostly in knowing where to turn for individualized, expert care on the spectrum of psychosocial, economic, and medical health. The path to this level of understanding of community resources is the heart of enhancing care to include the needs of traumatized children and families, whose needs may never be evident to the untrained provider (Block, 2016).
It may be helpful to consider how referrals and handoffs are conducted in individual settings. Are there any barriers to the clerical process of referring a patient? What would make a clinic's referral process go more smoothly from the clinician's point of view? What does a referral to community resources look like from the patient's/parent's point of view? Is there any point in the referral and resource-seeking process that the child/adolescent (or now adult) is likely to be lost? These questions are important to consider when thinking of enhancing care to identify and accommodate presenting traumatized children, adolescents, and families.
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Examples of Maladaptive Behaviors
|Alerts that Trauma May be Present||Increasingly Intense Maladaptive Behaviors||Consider Prompt Referral to Therapy||Consider Immediate Psychiatric or Therapy Referral||Immediate Intervention Needed|
|Immature speech||Constantly chattering||Deviant affiliations||Falsely accusing caregiver of abuse||Suicidal behavior|
|Lack of remorse for actions||Impaired ability to initiate or sustain goal-directed behavior||Being overly dependent, overly needy for age||Attempts to be emotionally hurtful to family members||Early substance abuse|
|Charming and engaging with strangers/outsiders||Showing attention-seeking/nuisance behaviors||Destructive behavior toward self or property||Having instantaneous shifts in mood and personality||Habitual/increasingly serious episodes of self-harm|
|Often getting through situations by cheating||Lack of cause-and-effect thinking||Having little regard for boundaries and rules||Early promiscuous sexual behavior||Inability to tolerate or recover from fear, anger, or shame|
|Lack of reciprocal behavior in close relationships with adults or peers||Demonstrating poor organizational skills||Disciplinary problems/conflicts with school personnel||Having a preoccupation or fascination with violence, death, blood, and gore||Threatening homicidal behavior|
|Having a poor sense of time and space||Frequently disrupting the classroom||Shoplifting or stealing||Preoccupation with sexuality, or overly sexualized behavior||Repeated interactions with law enforcement|
|Impulsivity that is not age appropriate||Mistrusting adults||Profound sense of shame||Being passive aggressive or defiant/raging|
|Over- or underreactive to sound and touch||Playing victim||Demonstrating a large ego with low self-esteem||Prolonged, extreme tantrums, or immobilization (“freezing”)|
|Hostility toward parents||Being bossy with adults and peers||Hoarding food/gorging on food||Being highly manipulative|
|Somatic complaints that are not otherwise explained||Non-fulfillment of responsibilities within the family||Being affectionate with strangers||Persistent sense of self-loathing, worthlessness, or defectiveness|
|Disturbances of bodily functions (e.g., sleep, eating)||Inappropriate attempts to make intimate contact/excessive reliance on adults for reassurance||Lack of empathy/ intolerance of others' expressions of distress||Dissociation from or lack of awareness of sensations/emotions|