ExposuretoCommunityViolence:TraumaInformedCareinthePediatricMedicalHome
JamesDuffee,MD,MPH,FAAPOhioAAPAnnualMeeting
September,2016
MOCII:ExposuretoCommunityViolence
JamesDuffee,MD,MPH,FAAPNationwideChildren’sHospital
TraumaInformedCareinthePediatricMentalHomeMOCII:ExposuretoCommunityViolence
JamesDuffee,MD,MPH,FAAPDaytonChildren’sHospital
TraumaInformedCareinthePediatricMentalHome
Disclosure
IhavenopersonalfinancialrelationshipsinanycommercialinterestrelatedtothisCME.
Idonotplantoreferenceofflabel/unapprovedusesofdrugsordevices.
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LearningObjectives1. Understandthefrequencyandextentofexposureto
differentformsofviolencebychildrenandadolescentsaccordingtodevelopmentalstage.
2. Describepossiblebehavioraloremotionalresponsesbychildrenexposedtocommunityviolence,strategiestoidentifychildrenatriskforprolongedormaladaptivereactions,andinterventionsthataresupportedbyevidence,eitherinpediatricpracticeorwithcommunitypartners.
3. Applytheconceptsoftrauma-informedpediatricpractice,includinginterviewingtechniques,staffdevelopmentandofficepoliciestoavoidrepeatorcontinuedtraumaexperiencedbychildrenpreviouslyexposedtocommunityviolence.
CultureofViolence
• Continuumofviolence– Fromchildabuseandintimatepartnerviolence– throughbullyingandpeerviolence– toyouthviolenceandcriminality
• Eco-bio-developmentalmodelforunderstandingandprevention
• Requiresthepediatricmedicalhometobecometrauma-informed
ShiftingParadigms• Theoriginsoflifelonghealthareinearlychildhood• Considerneuro-developmentaltrajectoriesratherthanbehaviors
• Strength-basedassessment– RiskandProtectiveFactors
• PopulationHealth(upstream)Perspective– Distributionofhealthoutcomes– Healthdeterminantsthatinfluencedistribution– Policiesthataffectdeterminants
• CommunityEngagement
ChildhoodExposuretoViolence• Home
– Childmaltreatment– IntimatePartnerViolence– Siblingassault
• Community– Bullying,non-siblingassault– Sexualassault,datingviolence– Othercommunityorschoolviolencewww.DefendingChildhood.org
ExposureatHome
• 40%ofteensreportexposuretoatleastonetypeofIPVoverlifetime
• 1in6childrenhavebeenexposedtophysicalIPVoverlifetime,about13.6million
• 14%reportpastyearmaltreatmentfromaparentorcaregiver,10millionchildren
ExposureintheCommunity
• 60%ofchildrenandyouthreportthattheyhaveexperiencedorwitnessedviolentvictimizationinthepastyear
• About3in10childrenreportmoderateorfrequentbullying
• Overathirdofgirlsaged14to17reportsexualvictimizationovertheirlifetime
Polyvictimization
• 11%ofchildrenreportexposureto5ormoredifferentkindsofviolenceinthepastyear
• Childrenexposedtoonetypeareathigherriskofothertypes– 4to6timeshigherriskofseriousvictimization,injuryorassaultwithweapon
– Mostlikelytoreportpost-traumasymptoms
RacialandEthnicInequity
• Structuralviolencerelatedtoracismandethnicprejudicecompoundstheriskofexposuretocommunityviolence
• ParticularlyimportantforNativeAmerican,AlaskanNativeandAfricanAmericanchildren
• Spatialracism,criminaljusticeinequities(policing,sentencing)
• Hateorbiascrimes
ConsequencesofExposure
• Youthexposedtoviolenceathigherriskofcriminalbehavior
• Exposureassociatedwithloweracademicachievementandhigherabsenteeism
• AdverseChildhoodExperiencesstudyfoundassociationswithaplethoraofpooradultphysicalandmentalhealthoutcomes
• Racismcompoundspooroutcomes
NationalSurveyofChildren’sExposuretoViolence(NatSCEV)
• 4,549childrenandadolescents,twogroups• Representativesample• Oversampleofexchangesassociatedwithhighdensity(70%)ofAfrican-American,Latinoorlow-incomecommunities
• Telephonesurvey,adultsprovideddemographics,childrensurveyed
• Screeningquestionsincluded48typesofvictimization
ScreeningQuestions
• Conventionalcrime– Assault,robbery,kidnapping
– Hateorbiascrime
• Childmaltreatment• Sexualvictimization• Peerandsiblingvictimization
• Schoolviolenceandthreat
• Internetvictimization• Witnessingandindirectvictimization
ExposurebyDevelopmentalAge
• MiddleChildhood– Assaultwithoutaweapon
– Physicalbullying
• EarlyAdolescence(10to13)– Assaultwithweapon– Kidnapping– Witnessingfamilyassault
• OlderAdolescentsmostlikelytoexperiencemoreseriousformsofviolence– Assaultswithinjury,gangassaults
– Sexualvictimization– Exposuretoshooting,schoolbombthreat
SomeSurveyResults
• 60%pastyear,10%fiveormorepastyear• Morethan70%witnessedviolencetoanotherpersonoverlifetime
• 3.5%preschoolershadwitnessedshooting,morethanoneinfive14to17yearolds
• Boysmorelikelytowitnessmurder,shootingsandotherformsofcommunityviolence
AdverseChildhoodExperiences
• 10originalACEs– Childabuse– Childneglect– Householddysfunction
• Additions– Economicstress– Bullying,schoolviolence– Communityviolence
• MedicalStress• RefugeeStress• NaturalDisasters• Masstraumaevents
– Shootings– Terrorism
SAMHSA’s ConceptofTrauma
• Referstoemotionaltrauma.• Definedasanevent,seriesofevents,orsetofcircumstancesthatisexperiencedasbyanindividualasphysicallyoremotionallyharmfulandthathaslastingadverseeffectsontheperson’sfunctioningandmental,physical,emotionalorspiritualwell-being.
• SAMHSA’s GuidanceforaTrauma-InformedApproach(2014)
CumulativeBurdenofRecurrentorPersistentExposuretoTrauma
• Alterationsinbrainarchitecture• Changesingeneexpression• Endocrineandimmuneimbalance• Decreasedexecutivefunctionandaffectregulation
• Interferencewithrelationalhealth• Behavioralallostasis• Chronicillness,healthdisparities,decreasedqualityandlengthoflife
EffectsonBrainArchitecture
• Epigenetic-interactionwithhormonesandinflammatoryfactors
• Neuronsthatfiretogether,wiretogether
• Decreasedgreymattervolume
• Smallerhippocampus• Decreasedprefrontaldendritic proliferationanddecreasedactivity
• Amygdala hypertrophy
EffectsonNEIFunction
• Epigeneticchangeincontrolofchronicstressresponse
• ProlongedactivationFlight-Fight-Freeze(amygdala)
• Alterationsinhormonesthatenhanceandsustainpro-socialbehavior
• Imbalanceofactivationandsuppressionofinflammatorycytokines
Sara B. Johnson et al. Pediatrics 2013;131:319-327
©2013 by American Academy of Pediatrics
NEIMediation
DoseResponseIncreasedRisk• Alcoholismandalcohol
abuse• Liverdisease• Smoking• Chronicobstructive
pulmonarydisease• Illicitdruguse• Ischemicheartdisease• Depression• Suicideattempts
• Intimatepartnerviolence• Earlyinitiationofsexual
activity• Multiplesexualpartners• Sexuallytransmitted
diseases• Unintendedpregnancies• Prematurity,smallfor
gestationalage• Fetaldeath
ACEStudyConclusion
• Adversechildhoodexperiencesmaybeamongthebasicfactorsthatunderliehealthrisks,illness,anddeath,andcanbeidentifiedearlybyroutinescreeningofallchildren.
• Earlyidentificationofchildrenatriskallowsforstratified,targetedinterventioninordertobuffertheeffectsandchangethedevelopmentaltrajectory
FunctionalCorrelatestoStressActivation
• Increasedsympathetictone• Toiletingdifficulties,regressionofmilestones• Enuresis,Encopresis
• Anxietyrelatedinhibitionofsatiety• Foodhording• Lossofappetiteorstuffing
• Overstimulationofreticularactivatingsystem• Difficultywithsleeponset• nightmares
BehavioralReactionstoTrauma
• Normativebehavioralreactions– Resolvewithinafewweeks
• Acutevs.ChronicExposure
• Mediators– Attachment– Resilience
• Maladaptiveresponses– Externalizing
• Non-compliance• Impairedself-regulation
– Internalizing• Depression• Anxiety• Posttraumaticstressdisorder
NormativeResponsestoAcuteTrauma
• Sleepproblems– Nightmares– Nightawakenings
• Eatingproblems• Sadness• Anxiety• Irritability
• Difficultywithconcentration
• Exacerbationofrisk-takingbehavior
• Developmentalregression– Bedwetting– Tantrums
OverviewofAttachment
• JohnBowlby 1907-1990 • Emotionalbondsarebasicforsurvival
• Interactivesystemstomaintainproximityorreadyaccess
• Workingmodelsofselfandotherinmind
• Careseeking/caregivingarecomplementary
AttachmentPatternsSecure• Seeksprimary(secure
base)whendistressed• Curious,exploring
environment• Self-confident• Asksforhelp
Insecure• Avoidant
– Passive,withdrawn– Avoidsfeelings,doesn’t
expressdistress• Resistant
– Maybecharming,clingingoroveractivelikeADHD
– Entertainingtoadults,maybeindiscriminant
• Chaotic
Resilience
• Theabilitytoavoidphysiologicandbehavioraldamagefromexposuretochronicstress
• Theprocessofadaptingwellinthefaceofadversity
• Theresultofusingprotectivefactorstomanagemultiplestressfulcircumstanceswithouttoxiceffects
• Transformstoxicstresstotolerablestress
ResilientChildrenHaveinCommon
• Atleastonestable,caringandsupportiverelationship
• Asenseofself-efficacyormasteryoverlifecircumstances
• Strongexecutivefunctionandself-regulation• Solidgroundinginfaithorculturaltraditions
OtherCharacterTraits
• Senseofhumor• Abilitytoformattachments• Innerpsychologicalspacethatprotects
– Innerlocusofcontrol– Tendencytogrowwhenpresentedwithadversity
• Threeyoucan’tdowithout– Flexibility,abilitytoimprovise– Acceptanceofreality– Strongfaiththatlifehasmeaning
“Wemustneverforgetthatwemayalsofindmeaninginlifeevenwhenconfrontedwithahopelesssituation,whenfacingafatethatcannotbechanged.”– VictorFrankl,MD
HowDoesResilienceDevelop?
• Combinationofinnate,intrinsicandextrinsicfactors
• Alsocombinationofsupportiverelationships,skill-buildingandpositiveexperiences
• Resilienceistheresultofmultipleinteractionsbetweenenvironmentalprotectivefactorsandhighlyresponsivebiologicsystems.
• HarvardCenterontheDevelopingChild
ResilienceCanBeLearned
• Importantrelationshipsvaryoverthelifecourse– Parents,grandparents,siblings,peers,intimatepartners
– Groundedinearlyexperiences• Self-regulationandotherexecutivefunctionsstimulatedinearlychildhood
• Non-cognitiveskills(empathy)canbetaughtaslateasadolescence
• Contemporaryemphasisontwo-generationalinterventions
ResilienceandRelationalHealth
Themostimportantandfrequentcommonalityofchildrenwhosucceedisthattheyhavehadaleastonestableandcommittedrelationshipwithasupportiveparent,caregiverorotheradult.
HarvardUniversityCenterontheDevelopingChildhttp://developingchild.harvard.edu
Inspiration
https://www.youtube.com/watch?v=-LGHtc_D328
PediatricMedicalTrauma
• Pain• Procedures• Sedation/lossofconsciousness
• Separation/Isolation• Exposuretosickness/death
• Life-threateningepisodes/relapse
• Responseandinterventiondependentondevelopmentalage– Pre-existingfactors– Personalresilience
• FamilyCrisis– Culturalunderstanding– Parentalroleadjustment– Siblingreaction
CanHospitalizationPrecipitateToxicStress?
ShahAN,Jerardi KE,AugerKA,BeckAF.PEDIATRICSVolume137,number5,May2016:e 20160204
Trauma-InformedPediatrics
• Family-centered,trauma-informedcare• Complexcaremanagementstrategies
– Applycarecoordination– Screenforsignsoftrauma,alsoforfamilystrengths
– Maintainresourceforlinkingtoservices• Multidisciplinary(multiagency)team• Buildonfamilystrengths
Family-CenteredCare• Respectseachchildandfamily,andhonoringracial,ethnic,cultural,andsocioeconomicbackgroundandexperiences
• Ensuresflexibilityinpolicies,procedures,andpracticesinordertoadaptservicestotheneeds,beliefs,andculturalvalues
• Sharescomplete,unbiasedinformation• Providesformalandinformalsupport• Collaborateswithpatientsandfamiliesatalllevels• Buildsonfamilystrengths,empoweringdecisions
AmericanAcademyofPediatrics(AAP)CommitteeonHospitalCareandInstituteforPatient-andFamily-CenteredCare(2012)
Trauma-InformedCare
§ Understandstheproximalanddistaleffectsofadversechildhoodexperiences
§ Recognizesthesignsandsymptomsoftrauma
§ Integratesknowledgeoftraumaintopoliciesandprocedures,andpracticemanagement
§ Resistsre-traumatization
www.samhsa.gov/nctic/trauma-interventions
www.healthcaretoolbox.org
Trauma-InformedPrimaryCare(TIPC)
• Foundations• Environment• Screening
– HistoryofTrauma– RiskandProtectiveFactor
Machtinger et.al.FromTreatmenttoHealing:ThePromiseofTrauma-InformedPrimaryCare.Women’sHealthIssues.2015;25(3)193-197
• Primaryprevention– StrengtheningFamilies– Promotingrelationalhealth
• Response– Integratedprimarycare– Coordinationwithcommunityprograms
FoundationsofTIPC
• Safety• TrustworthinessandTransparency• PeerSupport• CollaborationandMutuality• Empowerment,VoiceandChoice• Recognitionofhistoricaltrauma,adoptionofpoliciesandprocessesresponsivetocultural,racialandethnicneeds
PhysicalEnvironment
• Healthcaresettingsinwhichchildrenandfamiliesfeelsafe,physicallyandemotionally
• Soothingofficeenvironments– Noiselevel,therapydog– Welcomingarchitecturalfeatures,signage
• Parkinglots,bathroomsmonitored,welllit• Makesurepatients(andstaff)haveclearaccesstotheexamroomdoor
EmotionalEnvironment
• Respectpersonalhistoryandexperience• Ensurestaffmaintainsafeinterpersonalboundariesandcanmanageconflicteffectively
• Maintainopen,compassionatecommunication
• Beawareofculturaldifferencesregardingtrauma,safetyandprivacy
ModificationsofHealthCareDelivery
• Emphasizerelationshipsduringhealthpromotionvisits– StrengtheningFamiliesFramework– Promoterelationalhealth
• CircleofSecurity• PromotingFirstRelationships
• Screen– Historyoftrauma,currentexposure– Riskandprotectivefactors– Traumarelatedsymptoms
StrengtheningFamiliesCenterforStudyofSocialPolicy
• TwoGenerationalApproach• ConsiderationofCulture
– Fromculturalcompetencetoculturalhumility• Strength-basedperspective• BiologyofStress• Resiliencetheory• FocusonWell-being• AwarenessofRiskandProtectiveFactors
ProtectiveFactorsFramework
• Parentalresilience• Knowledgeofparentingandchilddevelopment
• Socialconnections• Concretesupportintimesofneed• Socialandemotionalcompetenceofchildren
PromoteCaretakerResilience
• Identifystrengthsandprotectivefactorsinthefamily,nurtureparentalself-esteem
• Encouragesocialconnectedness• Rememberthatbeingconnectedmeansgivinghelpinadditiontoreceivinghelp
• Provideguidance,mentoringtoimproveself-efficacy
• “puttheoxygenmaskonyourselffirst”• Encourageself-reflectioninparent,childandmutualactivities,keepchildinmind
TheCircleofSecurity
.www.circleofsecuritynetwork.org/the_circle_of_security.htm
PromotingFirstRelationships
http://pfrprogram.org
ScreenforTrauma
• Universalscreeninginprimarycarereducespotentialbias
• Apositivescreenisadisclosureandtheemotionalenvironmentmustbereadytoholdthetrauma.
• Screeningshouldalwaysbenefitthepatient—mustbeaddressedinsomeway
• Ifpositiveforonetypeoftrauma,askaboutothersymptomsandexposures
• Re-screeningshouldbeavoided.
YoungChildren
• ASQ-SE• M-Chat-R• PreschoolPediatricSymptomChecklist• StrengthsandDifficultiesQuestionnaire
SchoolAgethroughAdolescence
• FindyourACEscorehttps://acestoohigh.com• StrengthandDifficultiesQuestionnaire• PediatricSymptomChecklist• Anxiety:SCARED• PTSD:PC-PTSD• SubstanceAbuse:CRAFFT(preferred)orCAGE-AID
Depression
Adolescents• Preferred:
– PHQ-2andPHQ-9– PHQ- A
• ASKsuicidescreen• Alternate:
– BeckDepressionInventory
• Eachyearfrom12to18
MaternalDepression• Preferred:
– PHQ-2andPHQ-9
• Alternate:– Edinburgh– CES-D
• 1,2,4and6months
Author's personal copy
410 N.J. Burke et al. / Child Abuse & Neglect 35 (2011) 408– 413
BOD emaN
laitinI & etaD xH yrogetaC ECA deineD 1. esubA lacisyhP 2. esubA lanoitomE
3. esubA lauxeS tcatnoC
4. Alcohol and/or Drug Abuser in the Household
5. Incarcerated Household Me mbe r
6. So meone Chronically Depressed, Mentally Ill, Institutionalized, or Suicidal
7. yltneloiV detaerT rehtoM
8. One or No Parents, Parental Separation, or Divorce
9. Emotional or Physical Neglect
laitinI & etaD xH seirogetaC 1+ deineD Ho melessness (Hx or Current)
tnedicnI citamuarT Foster Care System (Hx or Current)
esubA/ecneloiV ot ssentiW
laitinI & etaD xH derocS toN/rehtO deineD gnisuoH cilbuP
erusopxE gurD eniretuartnI
Child Protective Services Involve ment
Fig. 1. Trauma Screen.
when the review process follows rigorous standards (Gilbert, Lowenstein, Koziol-McLain, Barta, & Steiner, 1996; Greenspan &Wieder, 1997; Luck, Peabody, Dresselhaus, Lee, & Glassman, 2000; Nagy & Szatmari, 1986; Sartwell, 1974). To minimize errorsin this chart review, we adopted the following approach: all chart documentation was completed by one of two pediatricianswithin the same practice, a standard abstraction form was used, inter rater reliability was calculated, researchers were trainedand monitored by experts, and meetings were held to discuss clinical discrepancies between the research team members.Individual charts were reviewed according to published ACEs guidelines (http://www.acestudy.org) and approved by theprincipal investigators (VC and NB).
The number of experiences endorsed was counted and coded as any of the nine ACE categories. Each category endorsedas a traumatic event received a score of 1, hence potential scores range from 0 to 9. Furthermore, individual participant datawas optimized by including relevant supplementary information from siblings’ charts. All sibling charts were reviewed bythe second author and every fifth chart was reviewed by a research assistant. For each documented case of sibling abuse anote was included on the referenced patient’s chart and all uncertainties were resolved via clinical consensus in consultationwith the principal investigator (NB).
The medical charts were reviewed in entirety. Most information was taken from the “Progress Notes” section, the “Confi-dential” section, “Social Services” section, and records from previous providers. Parameters were ascertained either througha medical history form filled out by the patient or by the MD during patient visits. Patient history obtained by a physicianwas gathered by a single physician (NB) for the first 1 1/2 years (April 2007–November 2008) and then by both NB andanother pediatrician trained by NB from November 2008 to April 2009. History of abuse was determined by caregiver reportof abuse, CPS report of confirmed child abuse or historical medical record report of abuse. Cases of abuse that were suspectedby an MD but unsubstantiated after a CPS investigation were not included.
Documentation of learning/behavior problems and overweight/obesity was taken from the medical charts. Over-weight/obesity was defined as having a BMI ≥ 85%. Classification of learning/behavior problems was obtained from a clinical
• NadineBurke-Harris,MD
• https://www.ted.com/talks/nadine_burke_harris_how_childhood_trauma_affects_health_across_a_lifetime?language=en
Youmayconsider
• SEEKSafeEnvironmentforEveryKid– http://theinstitute.umaryland.edu/frames/seek.cfm
• IntimatePartnerViolence– ParentScreeningQuestionnaire
• Haveyoubeeninarelationshipinwhichyouwerephysicallyhurtorthreatenedbyapartner?
• Inthepastyear,haveyoubeenafraidofapartner?• Inthepastyear,haveyouconsideredgettingacourtorderforprotection?
– Doyoufeelsafeathome?• Hasanythingbad,sadorscaryhappenedsincelasttimewemet?
SCAREDhttp://www.psychiatry.pitt.edu/sites/default/files/Documents/assessments/SCARED%20Child.pdf
TraumaSymptomChecklistforChildrenandTraumaSymptomChecklistforYoungChildren(TSCCandTSCYC)http://www4.parinc.com
ChildPTSDSymptomScale(CPSS)[email protected]
Univ.ofCaliforniaatLosAngelesPosttraumaticStressDisorderReactionIndex(UCLA-PTSDRI)http://www.istss.org/UCLAPosttraumaticStressDisorderReactionIndex.htm
ScreeningInstruments
Response:PracticeConsiderations
• Allstaffshouldbetrainedin– Traumainformedcare– Conflictresolution– CulturalHumility
• Maintainreferralresource
• Engagepartners– Homevisitors– Peermentors
• Considerintegratedprimarycare
Response:ManagementofAcuteExposure
• DEFoftraumainformedcare• Guidanceforparentsandfamilies
• Recognizingtraumarelatedsymptoms• Managementofmediaexposure
• Whentorefer• Evidencebasedtherapies• Linktocommunityresources• Attendtosecondarytrauma
Trauma-InformedPediatrics–DEFModel• ReduceDistress
– Providechildasmuchcontrolaspossible– Provideinformation,repeatback
• PromoteEmotional Support– Listen,empower– Respectexperienceandexpertise
• RemembertheFamily– Encourageself-care– Respectculturalandreligioustraditions
IllorInjuredChildren• Reduce Distress
– Assessandmanagepain– Askaboutfearsandworries,– Considergriefandloss
• Promote EmotionalSupport– Askwhoandwhatthepatientneedsnow.Whatdoyouneed?
– Findoutiftherebarrierstomobilizingexistingsupport.• Rememberthe Family
– Assessthedistressofotherfamilymembers.– Gaugepre-existingfamilyprotectiveandriskfactors– Addressotherneeds,socialdeterminantsofhealth
– http://www.nctsn.org
PsychologicalFirstAid
• Acuteinterventiontohelpchildren,youthandfamiliesinimmediateaftermathofdisaster
• Evidencebased• Listen,ProtectandConnect• Fiveprinciples
– Safety -- SelfandCommunityEfficacy– Calming -- Hope– Connectedness
PsychologicalFirstAid:Activities
• Establishhumanconnection
• Providephysicalandemotionalcomfort
• Calmandorient• Offerpracticalassistancetoaddressimmediateneeds
• Connectwithfamily,neighbors,friends
• Supportadaptivecoping,strengths,resilience
• Encourageadults,youthandfamiliestotakeactiverole
• Linktoresponseteamorcommunityresources
GuidanceforParents
• Sleepdisturbance– Consistentbedtime– Noscreentimebeforebed
– Nightlight– Accept,empathizewithfears
– Re-introducetransitionalobject
• EatingDisturbance– Noreprimandsorforce-feeding
– Play
• Toileting– Eliminatenegativeassociations
– Rewardsystem
GuidanceforParents:Emotions
• Modelbylabelingownemotionsandexpressingemotionsinacontrolledmanner
• Givedirectionspositivelyandcalmly• Don’ttakebehaviorpersonally• Practicerelaxationandself-calmingskillswithchild
• Schedulespecialplaytime• Returntousualroutineassoonaspossible
GuidanceforParents:CommunicationandMedia
• Varytheamountofinformationaboutadisasterormassviolenceaccordingtodevelopmentallevel
• Turnoffmediatolimitsecondaryexposureandfurthertrauma(alsoclinicreceptionarea)
• Olderchildrenbenefitfrommoreinformation• Foryoungerchildren,startwithsimple,basicfactsandtaketheleadfromquestions
MaladaptiveResponsetoTrauma
• Internalizing• Dissociation
– Detachment,Numbness– Depression,Anxiety
• Moreoftengirls,youngchildrenorthosewhowerepowerless
• Externalizing• Arousal
– Hypervigilance– Aggression,disorderedconduct
– Exaggeratedresponse
• Moreoftenboys,olderandwitnesstoviolence
WhentoRefer• “Hairtrigger”emotionalresponse,difficultyregulatingarousal
• Reluctancetoturntoothersforhelp• Inabilitytodiscussfeelings• Insecurityorexcessiveanxietyaboutsafetyorsocialconnectedness
• Significantpre-existingrisk– Loss,attachmentdisturbance– Familychaos,parentaldifficultycoping– Natureoftrauma– OtherSDH
PTSD• Conditionedresponsetospecifictrauma• Intrusionsymptoms,avoidance,hyper-reactivity,dissociation,self-injury,triggers
• NEIdysfunction– Increasecatecholamines,increasedCVresponse– Amygdalehyperactivity,fearandanger,failureofregulationbymedialPFC
– PFCvolumelow,lackofexecutivecontrol- inabilitytodistinguishthreatsfromnon-threats
– Hippocampusvolumedecrease- memorydisturbance
PTSDinChildrenUnderSix
• Potentiallytraumaticsituations:childmaltreatment,war,naturaldisasters,dogbites,invasivemedicalprocedures
• Intrusivethoughts,avoidance,exaggeratedreactivity
• DSM5modificationschangetheneedtoremembertheevent
• Sub-corticalmemory,somato-sensory
EBTherapies- EarlyChildhood
ImproveRelationships Decreasedisruptivebehaviors
IncredibleYears +
Triple P- PositiveParentingProgram
+
CircleofSecurity(COS) +
Child ParentPsychotherapy(CPP)
+
Parent ChildInteractionTherapy(PCIT)
+ +
MultidimensionalTreatmentFosterCareforPreschoolers(MTFC-P)
+ +
AdditionalTherapiesforOlderChildrenandAdolescents
ImproveRelationships DecreaseBehaviors
TraumaFocusedCognitiveBehavioral Therapy(TF-CBT)
+ +
FunctionalFamilyTherapy(FFT)
+ +
Dialectical BehavioralTherapy(DBT)
+
Pharmacotherapy
• Nospecifictreatment• Symptommodification,treatco-morbidities
– Depression,othermooddisorders– ADHD,angerdyscontrol– Substanceabuse– Otheranxietydisorders
CareofCaretakers
• Beawarethatcaretakers(includingofficestaff,nurses,doctors)oftenhavetheirowntraumahistories
• BereadytoapplyPFAtoresponders,coworkersandcolleaguesinadditiontoparents
• Bepreparedwithreferraloptions.• Modelproblemfocusedbehaviorandemotionalregulation.
• Helpparentssetclearboundariesforthemselvesandtheirchildren.
RelationalHome
Developmentaltraumaoccurswhen“emotionalpaincannotfindarelationalhomeinwhichitcanbeheld.”
-RobertStolorow.TraumaandHumanExistence.(2007)
WikimediaCommons.commons.wikimedia.org
Question#1TheNationalSurveyofChildrenExposuretoViolence(NatSCEV)surveyedover4,500childrenandadolescentsbyanonymoustelephoneinterviews.Thesurveyrevealedwhatpercentofchildrenwereexposedtoviolenceinthepreviousyear?
A. Lessthan50%B. AboutathirdC. Morethan60%D. Nearly90%
Epidemiology
Question#2TheNatSCEV concludedthatchildrenintheUSaremorelikelytobeexposedtoviolencethanadults.Whichgroupismostlikelytoexperienceexposuretoassaultwithaweapon?
A. LateAdolescenceB. MiddleChildhoodC. ToddlersD. PreteensandEarlyAdolescence
Epidemiology
Question#3Whichofthefollowingstatementsdescribesexposuretocommunityviolenceaccordingtogender,ageortimeframe?
A. Childrenexposedtoonetypeofviolenceareatfargreaterriskofexperiencingothertypesofviolence.
B. Boysandgirlsareequallylikelytowitnesscommunityviolence.
C. Reportsoflifetimeexposureweregenerallythesameasreportsofexposureduringthepreviousyear.
D. Lessthan10%of14to17yearsoldsreportwitnessingashootingovertheirlifetime.
Epidemiology
Question#4Thepatternsofexposurechangeoverchildhoodandadolescence.Whichofthefollowingstatementsdescribestherisksofexposurebyagegroup?
A. Olderadolescentsareleastlikelytoexperiencemoresevereformsofviolence.
B. Kidnappingisathighestriskformiddleadolescents.C. Thereisa25-foldincreaseinratesofwitnessing
communityviolencefromtoddlerstoolderadolescents.
D. Preteensandearlyadolescents(10to13)aremostlikelytobeassaultedwithaweapon.
Epidemiology
Question#5Intheimmediatewakeofacrisis,whiletriagingorexaminingchildren,pediatriciansmayengagewhichofthefollowingstrategiestominimizeexposurebychildrentorepeattrauma?
A. TurnoffTVsinwaitingarea.B. Keepcurtainsopenintriageandtreatmentareas.C. Makesurestaffmaintainopencommunicationwith
familiesaboutmediareportsasithappens.D. Physiciansandotherpediatricprovidersshouldbe
encouragedtoopenlyexpresstheirdistressasajoiningprocedurewithfamilies.
MediaExposure
Question#6Whichofthefollowingismostlikelytobeincludedinanticipatoryguidanceforparentsaboutthemostcommonreactionsbychildrenafteranepisodeofmassviolenceordisaster?
A. Advisethatchildrenshouldbeallowedtosettheirownroutine.
B. Counselthatchildrenmayhavetroublefallingasleeporwakingwithnightmares.
C. Makesurethattheyarewatchingtelevisionaccountssotheyhavealltheinformation.
D. Askthemtonottalkabouteithertheeventortheirfeelingsabouttheevent.
GuidanceforParents
Question#7Whichofthefollowingincreasestheriskofadjustmentproblemsafteracrisis?
A. Preexistinglosses,traumaorattachmentdisturbances
B. ImmediatereunificationwithparentsC. SupportivefamilycommunicationstyleD. Strongconnectionwithcommunitysupport
systems
EarlyIdentification
Question#8PsychologicalFirstAid(PFA)isaninterventionfirstappliedinschoolsbutitusefulforothercommunitymembers,includingstaffofpediatricpractices.WhichofthefollowingisaPFAstrategy?
A. Offerreassuranceeveniffalse.B. Listen,ProtectandConnectC. Isolatefamiliesformnon-involvedfamily
membersinordertolimitfurthertrauma.D. RACE(rescue,alarm,contain,extinguish).E. Suicide
CommunityResponse
Question#9Expandedmediacoverageofmassviolencehasledtoalargerpopulationatriskforbothprimaryandsecondaryexposure. Whichofthefollowingmaybeanticipatoryguidanceforparentsfollowingacatastrophicevent?
A. Parentsshouldnotlimitexposuretomediacoverage.B. Olderchildrenshouldfollowreportsonsocialmedia.C. Makesurechildrenviewthetraumaticeventin
graphicdetailsotherealitywillsinkin.D. Turnoffmediaifnofurtherunderstandingcanbe
gained.
AnticipatoryGuidance
Question#10Whenelicitingtraumasymptoms,pediatricianscansupportfamiliesbywhichofthefollowing?
A. Openlyexpressanger,frustrationandgrief.B. Encourageproblem-solvingbuildingon
familystrengths.C. Avoiddirectdiscussionofevents.D. Informfamiliesthattheyarepowerlessand
nothingcanhelpthemnow.
PediatricianSupport
Question#11TraumarelatedsymptomsareexpectedphysiologicresponsesoftheHPAaxisandimmunesystemandmaybemisinterpretedbyfamilies.Whichofthefollowingdescribesatraumarelatedphysiologicresponse?
A. Excessivesleepcausedbyreticularactivatingsystemactivation
B. Increasedordecreasedappetiteresultingfromanxietyanddysregulationofthesatietycenter
C. Increasedordecreasedappetiteresultingfromanxietyanddysregulationofthesatietycenter
D. Encopresisresultingfromdecreasedsympathetictone
ResponsetoExposure
Question#12Behavioralresponsetotrauma,particularlyrecurrentevents,canbeeitherinternalizingorexternalizing.Whichofthefollowingdoesnotdescribethedistributionofbehavioralresponsesamongboysandgirls?
A. Dissociationandpsychicnumbingaremostcommoningirls.
B. Depressionisequallycommoningirlsandboys.C. Hyperactivityandaggressionaremorecommon
inboys.D. Anxietyismorecommoninboys
ResponsetoExposure
Question#13Exposuretoearlychildhoodtraumamayresultinunderdevelopmentofpartsofthebrainresponsibleforexecutivefunction.Whichofthefollowingisnotanactivityoftheprefrontalcortexthatmightaffectschoolperformance?
A. Attention,concentrationB. WorkingmemoryC. ImpulsecontrolD. Flight/Fight/FreezereactionE. Recenttraumaorstress
ResponsetoExposure
Question#14Becausetraumaissocommon,formalscreeningathealthsupervisionvisitsmaybereasonable. Whichofthefollowingisanappropriateresponsetodisclosureoftrauma?
A. Trytoremainbusinesslike,revealingnoemotion.
B. Exploreothersymptomsandotherexposures.C. Recordtheresultsofachecklist,thenmoveon.D. Telltheparentsthattheyhavefailedto
adequatelyprotecttheirchild.
ScreenforTraumaSymptoms
Question#15Parentsmaybetraumatized,frustrated,confusedorangrybyeitheracatastrophiceventordisclosureoftraumabytheirchild. Whichofthefollowingisanappropriatetwo-generationalapproachtocare?
A. Telltheparentsthatyoudon’thavetimetoheartheparent’sproblems.
B. Helpparentsidentifyownsupportsystemandfamilystrengths.
C. Advisethatthechildrenshouldeatontheirownschedule.
D. Encourageparentstostepupandsolveproblemsontheirown.
ParentalExposure
Question#16Parentsmayhavetheirowntraumahistory.Whichofthefollowingfailsasanappropriateresponsebyapediatricianwhenaparentdisclosestrauma?
A. Bepreparedwithreferraloptions.B. Modelproblemfocusedbehaviorandemotional
regulation.C. Tellthemthatyouarethechild'sdoctorand
theirproblemsarenotrelevant.D. Helpparentssetclearboundariesfor
themselvesandtheirchildren.
ParentalExposure
Question#17Whentoreferandtowhomisoftenadifficultquestionforpediatricianswhenassessingchildrenexposedtotrauma.Whichifthefollowingisacorrectstatementaboutassessmentandtreatment?
A. Pre-existingemotionalproblemsarenotsignificantpredictorsforpooroutcomes.
B. Youngerchildrenarehelpedbyatwo-generationalapproachsuchasParent-ChildInteractionTherapy(PCIT).
C. Theintensityofadversityisnotcorrelatedwithseriousorenduringemotionalandphysiologicdisturbance.
D. Themosteffectiveevidence-basedtreatment(EBT)forchildrenyoungerthan5yearsisTraumaFocusedCognitiveBehavioralTherapy.
Evidence-basedTherapies
Question#18Resiliencecanbeconsideredacapacity,outcomeorprocess.Whatisthesinglemostimportantfindingthatisassociatedwithchildrendoingwelldespiteserioushardship?
A. GeneticfactorsinfluencingtemperamentB. Thepresenceofonestable,committed
relationshipwithasupportiveadultC. Familysocio-economicstatusD. Frequentseparationsduringearlychildhood
Resillience
Question#19Whichofthefollowingisakeycapacityorskillsetthatenableschildrentorespondsuccessfullytoadversity?
A. Abilitytomulti-taskB. Capacitytoplan,monitorandregulate
emotionalresponsesC. InsistenceonpredictabilityD. Establishmentofexternallocusofcontrolto
blameforadversity
Resillience
Question#20Resilienceresultsfromaninteractionbetweeninternalpredispositionsandexternalexperiences.Whichphrasebestdescribesthedevelopmentofresilience?
A. Beingafavoredchild,firstinasib-shipB. Interactionofsupportiverelationships,gene
expressionandadaptivebiologicsystemsC. Solelyafunctionofpersonalfactors,commonly
knownas“grit”D. Interactionofzipcodeatbirthandparental
ethnicity
Resillience
Question#21Resiliencecanbestrengthenedatanyage.Whichofthefollowingisatruestatementaboutinterventionsthatmaystrengthenthecapacitytobouncebackafteradversity?
A. Alternativeandcomplimentaryinterventionssuchasmindfulnesspracticeandyogaareineffective
B. Physicalexerciseisofnoimportanceintheexpressionofstressrelatedinflammatoryfactors
C. Activeskillbuildingprogramsforyoungadultsmayimproveexecutivefunctionsandcognitiveflexibility
D. Improvingparentalresiliencehasnoeffectonthechildren
Resillience
Question#22Inadditiontotheavailabilityofatleastonestablerelationship,factorsthatpredisposechildrentopositiveoutcomesdespitesignificantadversityincludewhichofthefollowing?
A. QuickandstrongemotionalreactionsB. Exposuretoparentalsubstanceabuseormental
illnessC. Identificationwithanaffirmingfaithorcultural
traditionD. Protectionbyfamilyfromexposuretostress
Resillience
Question#23Traumainformedcare(TIC)inamedicalsettingimpliesfullintegrationofknowledgeabouttraumaintopolicies,procedureandpractices,seekingtoresistre-traumatization.Whichofthefollowingstatementsdoesnotdescribetraumainformedcare?
A. Recognitionofhowtraumamayaffectpatients,families,staffandproviders.
B. Abilityofofficestafftomanagefracturesaswellasapplysplintsandcasts
C. Integrationofknowledgeoftraumaintopolicies,proceduresandpracticesforhealthcaredelivery
D. Activeresistanceagainstfurthertraumatochildrenorfamiliesinvolvedinthehealthsystem
Trauma-InformedCare
Question#24Medicaltraumaticstressreferstoemotionalreactionstoinjury,illnessortreatmentinbothpatientsandfamilies.Whatisonewaythatapediatricpracticemightdecreasetheeffectofpotentiallytraumaticevent?
A. Trainonlyphysiciansinpsychologicalfirstaid(PFA).B. Ignorethelevelofdistress,maintainstandardizedtreatmentC. Keeptheparentsinaseparateareaduringpossiblepainful
proceduresD. AdopttheDEFprotocol(reduceDistress,Emotionalsupportand
remembertheFamily)E. Therewasnostatisticallysignificantdifferencebetweenthose
patientstreatedwithCBTalone,fluoxetinealoneandCBT+fluoxetine
Trauma-InformedCare
Question#25Familycenteredcareandtraumainformedcareoverlapinwhatways?
A. Physicianleadershipassumescontroloveralldecisions
B. Communicationlimitedtowhatisnecessarytogetthejobdone
C. Involvementoffamiliesindecisionsandemphasisoncollaborationofcare
D. Providerself-careisirrelevant
Trauma-InformedCare
ReferencesforTrauma-InformedCare• Workingwithchildrenandfamiliesexperiencingmedicaltraumaticstress.CenterforPediatricTraumaticStress.(2015)https://www.healthcaretoolbox.org/images/TherapistResourceGuide.pdf
• SAMHSA’s ConceptofTraumaandGuidanceforaTrauma-InformedApproach.(2014)http://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf
• KeyIngredientsforSuccessfulTrauma-InformedCareImplementation.CenterforHealthcareStrategies.(2016)http://www.chcs.org/media/ATC_whitepaper_040616.pdf
ReferencesforTrauma-InformedCare
• Machtinger EL,etal.FromTreatmenttoHealing:ThePromiseofTrauma-InformedPrimaryCare.Women’sHealthIssues.2015;25(3):193-197
• Marsac ML,etal.ImplementingaTrauma-InformedApproachinPediatricHealthCareNetworks.JAMAPediatrics.2016;170(1):70-77
• OralR,etal.Adversechildhoodexperiencesandtraumainformedcare:thefutureofhealthcare.PediatricResearch.2016;79(1):227-233
PrincipleMOCReferences1. DowdMD(ed).TheMedicalHomeApproachtoIdentifyingandRespondingtoExposureto
Trauma.In:TheTraumaToolboxforPrimaryCare.AmericanAcademyofPediatrics.(2014)https://www.aap.org/en-us/Documents/ttb_medicalhomeapproach.pdfAccessed03/04/2016
2. Finkelhor D,TurnerH,Ormrod R,HambySandKracke K.Children’sExposuretoViolence:AComprehensiveNationalSurvey.(2009).U.S.DepartmentofJustice,OfficeofJuvenileJusticeandDeliquency Prevention.https://www.ncjrs.gov/pdffiles1/ojjdp/227744.pdfAccessed03/04/2016
3. Marsac ML,Kassam-AdamsN,Hildenbrand AK,etal.ImplementingaTrauma-InformedApproachinPediatricHealthCareNetworks.JAMAPediatr.2016;170(1):70-77
4. NationalScientificCouncilontheDevelopingChild.(2015).SupportiveRelationshipsandActiveSkill-BuildingStrengthentheFoundationsofResilience:WorkingPaper13.
http://www.developingchild.harvard.eduAccessed03/04/2016
5. Schonfeld DJ,Demaria T,theDisasterPreparednessAdvisoryCouncilandCommitteeonPsychosocialAspectsofChildandFamilyHealth.ProvidingPsychosocialSupporttoChildrenandFamiliesintheAftermathofDisastersandCrises.Pediatrics.2015;136(4):e1120-e1130
