Understanding Trauma and Chronic Toxic Stress in Your Pediatric Patients
By Jessica Barreca, PT, DPT
In our profession, the word "trauma" typically leads us to think of a catastrophic injury, emergency medical care, and comprehensive rehabilitation services. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), however, trauma also includes "events or circumstances experienced by an individual as physically or emotionally harmful or life-threatening, which result in adverse effects on the individual's functioning and well-being."
ACEs Are More Prevalent Than You Might Think
The first study to examine trauma's long-term health effects was the CDC-Kaiser Permanente Adverse Childhood Experiences Study, which collected confidential surveys of over 17,000 Kaiser Permanente patients. Respondents were asked about their exposure to adverse childhood experiences (ACEs)— neglect, abuse, and "household dysfunction" such as domestic violence—and their current health status, risk behaviors, and disease. The study found that over 50% of participants had experienced at least 1 ACE and 25% had experienced 2 or more.
In 2013, the Philadelphia Urban ACE study (.pdf) surveyed a more racially diverse sample of adults and expanded survey questions to include topics such as community violence, racism, and neighborhood safety. More than 80% of those surveyed had experienced at least 1 ACE and nearly 40% had experienced 4 or more. Children of all ages and backgrounds experience ACEs, but poverty is a risk factor (.pdf).
To achieve optimal health outcomes for children who have or are experiencing trauma, physical therapists (PTs) and physical therapist assistants (PTAs) should practice SAMHSA's "Four Rs" (.pdf):
- Realize trauma's impact
- Recognize signs and symptoms
- Respond by integrating knowledge of trauma-informed care
- Resist retraumatizing patients
Realizing the Impact of Trauma and Toxic Stress
The brain is most plastic and develops most rapidly during early childhood. The influences of the environment and an infant's relationships with adults can significantly impact neural development. Stress plays a large role in all of our lives and is in fact essential to the development of a healthy stress response system, but the presence of a positive, caring adult is what helps a child avoid toxic stress, defined as "strong, frequent, or prolonged activation of the body's stress response systems in the absence of the buffering protection of a supportive, adult relationship."
According to the National Scientific Council on the Developing Child, our bodies respond to stress in different ways. A positive stress response may occur, for example, on a child's first day of kindergarten: The child's heart rate will increase and there will be a minimal rise in stress hormones. Under more challenging circumstances, such as the death of a caregiver or a natural disaster, a child experiences an elevated stress response system for a temporary period of time. In both of these scenarios, children learn to manage stress and regulate their stress response by receiving support from an adult who creates a nurturing environment and models effective coping strategies.
However, when a child is exposed to prolonged, significant, and/or cumulative trauma ranging from abuse, neglect, witnessing violence in their community, or living in poverty—without ongoing support from a caring adult—a toxic stress response occurs.
Research shows that trauma and toxic stress experienced in childhood negatively impacts the physical, mental, social, and emotional development of children, from developmental delays to learning and behavior problems. In the long term, ACEs are linked to risky health and lifestyle behaviors, chronic diseases, and even premature death.
Even when children experience significant trauma, there is still the capacity to develop resilience.
Recognize Signs and Symptoms of Trauma in a Pediatric Patient
The National Child Traumatic Stress Network provides a comprehensive list of signs and symptoms of trauma for individuals from infancy through early adulthood.
Infants and toddlers often don't have the ability to verbally express the events, experiences, and feelings of trauma. Be aware of sudden changes in a young child's behavior—all behavior is communication. Young children who have experienced trauma may exhibit increased separation anxiety, excessive clinginess, crying and/or whining, increased fear and anxiety, regression in global developmental progress, or failure to achieve developmental milestones.
Elementary school students ages 6–12 who have experienced trauma may exhibit a variety of different behaviors, such as increased anxiety, fear, and distress, as well as withdrawal and avoidance. These kids may also demonstrate decreased ability to focus, overreaction to auditory stimuli (a door slamming shut or fire alarm), a change in academic performance, poor impulse control, and challenges with authority figures or constructive criticism. Increased physical complaints (stomachaches and headaches) may be observed as well.
Respond by Integrating Trauma-Informed Principles Into Your Care
SAMHSA's trauma-informed principles can be incorporated into any type of health care setting or organization, and all patients and families, with or without a lived experience of trauma, can benefit from PTs adopting a trauma-informed approach. By adopting these principles, we shift our own internal dialogue from "What is wrong with you?" to "What happened to you?" and view our patients through a trauma-aware lens.
Often a family will miss multiple therapy appointments and will be labeled as a "no-show." By taking a trauma-informed approach, the PT recognizes the multitude of social, economic, and contextual factors that may contribute to missed therapy appointments. Instead of discharging the patient, the PT incorporates trauma-informed principles and meets with administrators, office staff, other team members, and the family to identify pertinent issues and create a solution that allows the child to regularly attend physical therapy. As a next step, the office administrator invites families, office staff, and the therapy team to review policies regarding the clinic's attendance policy. Through this process, policies are amended in a culturally sensitive and collaborative manner with all involved stakeholders to ultimately promote a more inclusive environment for children and their families.
Resist Retraumatizing Patients Inadvertently
PTs working with children and families can take concrete steps to build a culture of emotional and physical safety in their clinical, school, or hospital settings. When the health care team uses trauma-informed principles in partnership with a family-centered approach, it creates a safe environment with reduced potential for retraumatizing children and families. Often individuals who have experienced maltreatment as children are distrustful of authority figures, including health care professionals. By ensuring that families and children have a voice in their plan of care, we can work toward empowering patients through choice.
Jessica Barreca is a physical therapist with over 17 years of experience working with children in a variety of settings including outpatient, early intervention and school systems. She is the community site coordinator in the Center for Interprofessional Education & Research and adjunct instructor of physical therapy at Saint Louis University. Jessica is an ambassador for Alive and Well STL and is passionate about spreading knowledge and awareness regarding the widespread prevalence and impact of childhood trauma on families and children in our communities.
Interested in learning more about this topic? The 2019 APTA Combined Sections Meeting will be holding several presentations related to trauma, including: Sexual Assault and Communities of Color: PT Roles, Pain Science With Vulnerable Populations: Transforming the Human Experience, and A Trauma-Informed Pathway to Caring for Patients and Providers. Register now at www.apta.org/CSM/.
Jessica Barreca will be presenting Using a Trauma Sensitive Lens to Promote Shared Decision Making in Pediatric Practice at the Academy of Pediatric Physical Therapy Annual Conference in November, 2018.