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.
CSM Preview: All You Ever Wanted to Know About MIPS
By Kara Gainer, JD
Value. Quality. Outcomes. Costs. The United States is moving away from the traditional fee-for-service reimbursement structure, one in which providers are rewarded solely for the volume of services provided, to one that holds providers accountable for patient outcomes and costs.
Beginning January 1, 2019, the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP), which offers incentive payments to help eligible clinicians focus on care quality and making patients healthier, will include many physical therapists who participate in Medicare Part B.
While we estimate only about 5% of Medicare-enrolled physical therapists in private practice will be mandated to participate or face a penalty, almost all physical therapists in private practice will be eligible. Considering that there are no more scheduled payment updates to the Medicare physician fee schedule after 2019, QPP participation is something you should seriously think about if you're one of those eligible PTs.
At APTA's Combined Sections Meeting in January, we will answer your most pressing questions about QPP:
- What do these acronyms mean?!
- How does it work?
- If I am not required to participate, what is the benefit to me if I do?
- What is the difference between the Merit-based Incentive Payment System (MIPS) and an Advanced Alternative Payment Model (APM)?
- How can I maximize my incentive payment?
Nothing is simple when it comes to Medicare, and QPP is no different. The devil is in the details—and there are a lot of them.
APTA Director of Quality Heather Smith, PT, MPH, and I will be diving into the nitty gritty of what physical therapists need to know if they want to successfully participate in QPP, whether through MIPS or Advanced APMs.
You may be asking yourself: "Do I really need to attend this session?" Well, here is what one California PT who attended a similar session on Medicare payment said:
So, if you're ready to get out of your comfort zone and transform your practice, join us on Friday, January 25, in downtown Washington, DC, for "Emerging Issues in Medicare: Quality Programs and Alternative Payment Models," where you will learn more about QPP and how you can participate in Medicare payment models that reward value over volume, achieving better patient outcomes.
CSM advance registration discounts end December 5.
Kara Gainer, JD, is APTA's director of regulatory affairs. You can connect with Kara on Twitter at @karagainer.
When Health Decisions Aren’t a Matter of Choice: Addressing Social Determinants of Health
Physical therapists (PTs) and physical therapist assistants (PTAs) focus on both restoring movement in those with decreased function and promoting healthy behaviors to prevent health problems such as obesity or high blood pressure. But in doing so, they also must consider how social determinants of health—economics, education, neighborhood, and other factors—influence the lifestyle choices patients and clients make.
Zachary D. Rethorn, PT, DPT, a home health PT, board-certified orthopaedic clinical specialist, doctoral student in health promotion and wellness, and adjunct professor at the University of Tennessee at Chattanooga, has been giving these ideas careful thought and incorporating them into his practice. In 2018, he co-presented on the topic of social determinants of health at APTA's NEXT Conference and Exposition, and earlier this year he published a blog post that further explored the topic. In the post, he writes:
. . .the narrative in our country is one in which personal responsibility is emphasized so much that we can forget we live in communities and systems which influence the choices we make. Say you have a prized rose bush (like I do). If it doesn't bloom this year am I going to uproot it, chuck it out, and get a new one? Of course not! When a flower doesn't bloom you fix the environment in which it grows. Not the flower.
#PTTransforms interviewed Rethorn to learn how PTs and PTAs can incorporate these concepts at the point of care.
In your blog post, you write about the 5 areas of social determinants of health: economic stability, education, social and community context, health and health care, and neighborhood and built environment. Most of these areas pertain to things that neither the patient nor the provider can change, for the most part. You can't change the fact that your neighborhood isn't safe for you to get more physical activity, for example. How can a clinician use this information? Should we be screening for social needs?
ZR: The first question we have to ask ourselves is are we a profession which delivers health services? Or are we a profession that promotes the health of our neighborhoods, communities, cities, and states? If we believe that our role is to advocate for and improve the health of those we serve, then a good place to start is by considering the social and environmental context in which our patients live.
Screening for social needs can be very different from our typical medical or health screening tools. I want to caution readers that screening must be linked to the ability to provide appropriate referrals and treatment. Screening without the capacity to assist is ineffective and potentially unethical.
To mitigate negative unintended consequences of screening, here are 5 tips:
- Be patient-/family-centered in screening.
- Integrate screening with referral and linkage to community-based resources.
- Perform screening within the context of a comprehensive system that supports early detection.
- Acknowledge and build on strengths of patients, families, and communities.
- Engage the entire practice population, rather than targeted subgroups.
How can a clinician evaluate this information and use it to help with shared decision making to improve the patient's health?
ZR: There are a number of evidence-based toolkits that clinicians and health systems can use to screen for social needs, including HealthLeads, PRAPARE, HealthBegins, and the Accountable Health Communities Screening Tool. These tools all provide a starting point with recommended core domains such as food insecurity, housing instability, utility needs, and financial resource strain. Based on a community's needs, additional domains such as child care and social isolation may be added.
Whatever tool you choose to use:
- Make it short and simple—no more than 12 questions, written at a fifth-grade reading level, translated into appropriate languages.
- Choose clinically validated questions designed to open a conversation.
- Integrate the tool into clinical workflows.
- Elicit patient feedback to prioritize screening items.
- Pilot before scaling.
Once a clinician has gathered information about an individual's social context, it is essential to open a conversation with that individual regarding what he or she wants and believes will be most helpful. This is place where the clinician can provide advice and not only refer the individual to other services, but also facilitate access to those services in a sensitive, culturally acceptable, and caring way.
What modifications can a PT make to account for, say, a neighborhood where a patient feels unsafe? Or lack of access to fresh fruits and vegetables?
ZR: The first step to take if individuals are saying that a neighborhood is dangerous or there is no access to fresh fruits and vegetables is to understand what local resources are available. Often, there are resources available that the person may not be aware of.
For the first few years of my practice, I worked in a neighborhood where many of my patients felt unsafe going outside. But as I got to know the neighborhood better, I realized there were opportunities for physical activity outside but perhaps in ways different from what I first envisioned. Instead of coaching individuals to take walks by themselves, I started walking groups. Suddenly, this became a feasible way for many of the older adults I worked with to feel safe and be more social in their neighborhood.
If a creative solution is truly unavailable, this is where advocacy comes into play. My clinic was located in a food desert, where the closest grocery store with fresh produce was 2 miles—but 3 bus changes and 50 minutes—away. As I heard more and more that lack of access to healthy food was a perceived need in my population, I took this to a local farming nonprofit that agreed to begin hosting a mobile market in the neighborhood 2 afternoons per week.
These examples are not extraordinary. They come from carefully listening to the individuals I serve and reimagining my role as a PT from one who simply delivers interventions to one who is invested in and cares about the health of my patients. Caring about the health of my patients necessarily means that I care about the social and environmental context they live in, because the context is what shapes their health behaviors and choices.
When working with a patient, how do you balance empowering the individual to make healthy choices with the knowledge that some things you just cannot control?
ZR: When I work with a patient, I am considering health influences at multiple levels. At purely an individual level, I am examining their health behaviors such as physical activity, diet, stress, and sleep. During my history taking, I will ask about these factors and coach the patient to change their health behaviors based on their desires and resources.
At a wider level, I am cataloguing the individual and systemic barriers that individuals are relating to me. Perhaps a number of individuals are telling me that the sidewalks in their neighborhood are in disrepair. At this point, I can gather more information from a neighborhood association, search for data related to sidewalks in the city, or go to a city councilor to bring up the need related to sidewalk repair.
The goal is to find pain points where social and economic factors present barriers to individuals' ability to engage in health behaviors. From there I can use clinical experience and research evidence to advocate for social change which will improve the health of the population I serve.
Is there a danger of implicit bias here? How can clinicians avoid making assumptions about the relationship between a patient's health and these 5 areas? Or do social determinants of health help us respect the personal, economic, and cultural circumstances our patients face?
ZR: Current data suggest that, first, implicit bias is a real phenomenon. We all hold underlying attitudes and stereotypes toward members of other groups. But not only is it real, health care providers exhibit the same amount as the general population. This bias is shown in positive attitudes toward Whites and negative attitudes toward people of color. Further, this implicit bias may impact the clinical decision making of health care providers toward their patients.
Addressing implicit bias must be a conscious decision. One way to avoid making assumptions is to commit to screening for social determinants of health across your entire patient population and not just for select subgroups. If you target only demographic variables such as age, education, residence, underrepresented minority status—it may reinforce stereotypes and prejudicial presumptions and could stigmatize the screening process.
Another strategy is to improve your understanding of health disparities and bias in health care. Once I understood the daily challenges that my population faced, I became more empathetic and better equipped to facilitate positive changes in the community.
Do you see social determinants of health taking a larger role in health research in the future? How so?
ZR: Research on the social determinants of health is already robust. The influence that the social and environmental context plays on individuals' and populations' health is clear. The question is: Do we have the social will to take what we already know and implement it? Are we willing to address health where it starts, not just where it ends? Can we make the healthy choice the easy choice in culturally sensitive and appropriate ways from neighborhood to neighborhood and city to city?