Scrabble tiles spell out PTSD.

Caring for the Past and Present Patient: The Need for Trauma-Informed Care for Children and Adolescents

COVID-19 has produced fear, social strain, and mental health deterioration across the globe. The indelible marks left by the pandemic on society will furthermore impact younger generations long after this pandemic is deemed “over.” The long-term impact of the pandemic has led researchers to assess its traumatic effects. Trauma in a broader sense can be defined as an event or series of events experienced by an individual or group that has lasting effects on a person’s well-being. Since traumas experienced during childhood can impact long-term health outcomes, it’s imperative to integrate new methods of conversation and care, especially among children, that take into consideration their traumatic experiences. Trauma-informed care (TIC) is an existing framework that should become the standard for providers working with younger populations.

Black and white photo of a man in a suit.
A man described as exhibiting “chronic movements due to shell shock,” 1916. (Courtesy Wikimedia)

TIC emerged historically as an answer to calls for action to address traumas in major patient populations. TIC’s informal roots date back to the American Civil War, when physical and psychological trauma reactions were known as “soldier’s heart.” Following World War I and World War II, terms such as “shell shock” and “battle fatigue” began to define intangible scars. Waves of soldiers returning from war brought renewed calls for specific care plans, sparking the first conversations about implementing TIC in healthcare.

Over the last sixty years, psychologists, sociologists, healthcare professionals, and activists have joined forces to advocate for intersectional trauma support. In the 1960s, the women’s movement amplified issues such as interpersonal violence and crime-related trauma and called for them to be addressed via healthcare and social services. The 1980s brought the creation of the Institute for Traumatic Stress and the National Center for PTSD. The 1994 Dare to Vision conference, convened by the Substance Abuse and Mental Health Administration (SAMHSA), provided a professional space to discuss trauma and the concepts of “re-victimization” and “re-traumatization.” In 1998, SAMHSA launched the longitudinal Women, Co-Occurring Disorders and Violence Study, which resulted in a set of trauma-sensitive guidelines for providers and brought widespread attention to the need for TIC. The evolution of TIC came in waves, focusing on broad populations like veterans and women. However, the conversation about TIC consistently left out one large population: children.

In an effort to address this gap, the new millennium brought the creation of the Donald J. Cohen National Child Traumatic Stress Initiative and National Child Traumatic Stress Network, followed by the National Center for Trauma Informed Care in 2005. More recently, research like the 2016 National Survey of Children’s Health and the Children’s Mental Health Initiative revealed that 46 percent of the nation’s youth aged seventeen or under had reported experiencing at least one trauma. Although the research behind TIC has been decades in the making, the US healthcare system and curricula of healthcare professions as a whole have not integrated TIC as a standard practice, let alone recognized its importance in the care of children and adolescents.

Children and adolescents are one of the most vulnerable patient populations. Many children and adolescents are exposed to traumatic life events that will induce short-term distress responses and that have the potential to leave long-term health issues such as heart disease or depression in their wake. Rates of childhood trauma are alarmingly high, and in the United States alone, more than two-thirds of children report experiencing a traumatic event by age 16, such as a serious accident, natural disaster, or experiencing or witnessing violence. One in four children will experience physical, sexual, or emotional abuse and their various adverse health outcomes – the most tragic being suicide.

The Adverse Childhood Experiences (ACE) Study, conducted by the CDC and Kaiser Permanente Health System, demonstrated a strong correlation between childhood trauma and long-term poor health outcomes and significantly shaped our understanding of childhood trauma. The study identified many different kinds of ACEs classified into broader categories of abuse, household challenges, and neglect. About 61 percent of adults across twenty-five states have experienced at least one kind of ACE, and around one in six have experienced four or more ACEs. The prevalence of ACEs requires treatment protocols to be sensitive to younger patients’ experiences and necessitates the use of TIC.

 

Graphic depicting the lasting impacts of early adversity.
The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study has identified the long-term effects of ACEs. (Courtesy the Centers for Disease Control and Prevention)

TIC considers the pervasive nature of trauma and seeks to foster an environment of healing, while also avoiding practices that may inadvertently retraumatize patients. It is based upon the 4 Rs: realization of trauma, recognition of the signs of trauma, a systemic response to trauma, and resisting retraumatization. For providers, this requires reframing patient history questions like “What’s wrong with you?” to “What happened to you?” This language shifts blame away from the patient and focuses instead on the survivor’s perspective. This trauma-sensitive language ensures that children and adolescents understand that culpability and recovery from traumas doesn’t fall on them alone. TIC also requires communication with the patient about what’s happening during a physical exam, a practice necessary for children with histories of physical or medical-related trauma.

TIC is imperative in adolescent healthcare, since LGBTQ+ youth are known to have an increased risk for depression, posttraumatic stress disorder (PTSD), suicide-related behaviors, substance abuse, and HIV. Under the umbrella of TIC falls gender-inclusive and LGBTQ+ care, such as using preferred names over dead names and correct pronouns, which can prevent triggers that retraumatize the patient. Similarly, TIC supports other at-risk populations, such as survivors of human trafficking, since it fundamentally reshapes the questions asked and focuses first and foremost on building trust between patients and providers.

TIC has never been more necessary, as the COVID-19 pandemic continues. For children, the increased exposure to discussions about death, uncertainty about the future, and developmental challenges posed by social isolation can be considered traumas. Given that COVID-19 has already been found to be a long-term traumatic stressor for adults, capable of eliciting PTSD-like responses and exacerbating mental health problems, the effect on children and their mental health over time is vastly less understood. The application of TIC is necessary to address the unique generational health challenges that stem from this trauma as this population ages.

Historically, the call for TIC has arisen to address the traumas of the times; now, it is ever more essential. TIC provides a foundational basis for mindful clinical practice and would provide organizations and institutions a framework to reduce, or even prevent, a trauma response in individuals. TIC includes principles such as empathy, transparency, sensitivity, and trust that are needed now everywhere from schools to workplaces. A TIC approach can be applied everywhere to accommodate the widespread stress and grief that have emerged from the pandemic. The long-term impact of COVID-19 (and TIC) will only become evident as the child and adolescent population develops, copes, and carries this trauma, in addition to other major stressors over time. Long-term effects of TIC include the improvement of adult health outcomes, the reduction of avoidable healthcare problems, and the curbing of healthcare costs. As a benefit to both the future of the healthcare system and to individual patients, a universal standard for TIC in child healthcare would ensure that one of the most vulnerable patient populations is safe, cared for with sensitivity, and not harmed by the healthcare system meant to help them.

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One Comment

Joyce Morrissette

TIC is indeed needed in the care of younger patients and adult patients as well. We can’t stop there. Nurses and clinicians as an example, are not immune from the impacts of trauma nor are the systems that they’re a part of. Coming out of the collective trauma of the pandemic, perhaps there will be more readiness to become trauma-responsive and healing-centered for the well-being of all, including the planet.

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