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Trauma-Informed Care in a Practice Setting – Grand Rounds Episode with MOC and Ethics Credit · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

• 0:01
  Welcome to Pediatrics Now, cases, updates, and discussions for the busy practitioner.
• 0:07
  I'm your host, Holly Wayment. I work for UT Health San Antonio's Department of Pediatrics.
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  In this podcast, we explore how we can provide the best, most cutting-edge,
• 0:17
  compassionate care for children.
• 0:18
  We hope to give you a unique and behind-the-scenes edge from our expert guests.
• 0:23
  After listening, click on the link on this podcast for free credit that may
• 0:28
  include CME, MOC, or ethics credit, depending on the topic.
• 0:31
  Music.
• 0:35
  The topic this morning, trauma-informed care in a practice setting,
• 0:39
  is a relatively new topic for medicine and pediatrics.
• 0:43
  And it was really first introduced in 2001, but initially was applied to adult
• 0:50
  settings, intended to help facilitate recovery of adults who were,
• 0:56
  suffering from addiction and
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  mental health disorders, but who had also had prior trauma experiences.
• 1:03
  It came into the picture in pediatrics in about 2009 when the National Child Trauma Stress Network,
• 1:10
  an organization that offered resources on this, became very active and they
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  were instrumental in providing services at the Sandy Hook Elementary School of Shrewden. them.
• 1:20
  In 2021, the American Academy of Pediatrics published a clinical report and
• 1:26
  a technical report on trauma-informed care.
• 1:30
  So it's a very current topic in our pediatric practice.
• 1:34
  Our objectives today are to describe experiences that may trigger toxic stress responses.
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  So it's not just about child abuse. It's about a lot of other different types
• 1:44
  of stresses that children and families can suffer from or be exposed to.
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  We also want to recognize and respond to children and caregivers that have experienced trauma,
• 1:56
  and understand how trauma-informed principles can be implemented in practice
• 2:00
  setting, not just one that is geared for child abuse, but also for other settings
• 2:06
  as well, and to employ strategies to mitigate secondary trauma,
• 2:11
  in a practice setting.
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  Start off with a patient presentation. So this is Rachel. I met Rachel a few years ago.
• 2:19
  And she presented to Center for Miracles, which is where I work, for a sexual abuse exam.
• 2:24
  And she was very upfront and just said right off the bat that she did not want this exam.
• 2:30
  It would scare her to do it today. It was too immediate.
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  She had touch issues and she had trust issues.
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  And, you know, she came from a long history of CPS involvement,
• 2:40
  had lived in several foster the family, different relatives, and shelters.
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  And so when you have a patient like Rachel, just stop for a minute and think,
• 2:48
  what would you do next? What would you say next?
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  So why is it important to be trauma-informed? Really, the purpose is to minimize
• 2:56
  further trauma, facilitate trust and transparency,
• 3:00
  to optimize empathic communication and listening, and to engage the child and
• 3:05
  family in a cooperative venture towards healing. on.
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  So my response to Rachel, I think some people would say, that's fine. We want you to check up.
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  I decided to try to open the door with her. And I said, what can I do to earn your trust?
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  And she had some very specific answers for this question.
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  She had rule. She said, don't lie to me. Don't talk about my mother.
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  Don't give me shots. And don't tell me to do something immediate or I will be traumatized.
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  And we'll come back to Rachel at the end of the presentation to see how this all worked out.
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  So today, I first want to just give an overview of what the child's world of
• 3:44
  trauma looks like and talk about different prevalence and types of traumatic
• 3:49
  experiences that children experience, the ripple effect.
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  It's not just the child that's affected by trauma, but it's also the caregiver
• 3:57
  as well as the healthcare provider.
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  We'll do a brief overview view of the brain and adversity, and then talk about
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  signs of stress that we may see in children and in others.
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  We'll then move on to what is trauma-informed care and how is it defined.
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  We will include implementation strategies as described by the American Academy
• 4:19
  of Pediatrics clinical report.
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  And then we'll move to some more specific strategies that can be utilized in
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  a clinical setting for children and families that have experienced trauma.
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  So traumatic experiences in childhood are common. When we talk about adverse
• 4:36
  childhood experiences,
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  it is up to 68% of children will
• 4:42
  experience at least one adverse childhood experience during childhood.
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  So the most common experiences include witness to family and peer violence,
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  separation, divorce of parents, and sexual trauma.
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  In about 30% of these children, they were experiencing more than one adverse childhood event.
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  And the relationship, though, between the number of adverse childhood events
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  and the adult health is a dose response.
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  So, in other words, the greater number of adverse childhood events a child has,
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  the higher the risk is for medical and mental health outcomes in adolescence and adulthood.
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  So about 10% of children will experience sexual abuse, serious accident,
• 5:32
  natural disaster, living with anyone with a drug or alcohol problem.
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  And then you see to the right what the increased risk are for experiencing three
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  or more adverse childhood events.
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  It's 46 times more likely that someone will become involved with injection drug
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  use. And suicide thoughts as well as behaviors are increased risk by 12.
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  We also see an increased risk in sexually transmitted infections and COPD of
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  two to three times greater.
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  So here are the original 10 adverse childhood experiences. And you can see that
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  a lot of them involve trauma treatment.
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  So if we look at these, they do not happen in isolation. So many of these are
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  associated with additional adverse childhood events.
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  So, for example, if we look at sexual abuse, there's an increased rate of also
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  experience in physical abuse, exposure to household mental illness,
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  and exposure to intimate partner abuse in the home.
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  If we take a look at exposure to household mental illness, that in turn is associated
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  with emotional abuse, family member being incarcerated, and physical abuse.
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  So you can see how these compound upon one another, and it's very common for
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  children to experience more than one adverse childhood experience.
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  So looking at the world of trauma, it's not just about ACEs.
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  So it is about experiences they see in their world from inside their home and
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  then moving out to the community, society, and unfortunately at school as well.
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  Many of these experiences directly impact the child and others may more indirectly
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  impact the child, but all of them can have very significant and severe,
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  create very significant severe stresses for the child.
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  So here's a ripple of that. And when we look at definitions for trauma-informed care,
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  we find that pretty much most definitions incorporate trauma-informed care,
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  not just for the child, but also
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  for the caregiver and as well for the healthcare provider or clinician.
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  So what we see here is a primary stress experienced by the child.
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  We have secondary trauma stress experienced by the caregiver and the clinician.
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  And in turn, their experiences in the past, their past traumatic experiences,
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  influenced their capability of providing the appropriate support for the child.
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  How would this work in a clinical setting? So if we take, for example,
• 8:15
  a common scenario at Center for Miracles, and we'll have a child that will present with sexual abuse.
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  And what we would see is that the child is first, she's experiencing stress
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  or he's experiencing stress just due to thoughts of, will they believe me? What will happen?
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  So once a child discloses abuse, there's a whole other set of structures that impact the child.
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  Then we move to the caregiver level, and there's a lot of things that caregivers
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  struggle with. So they struggle with the fact that many of these children who
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  are victims of sexual abuse will wait an average of two years to tell.
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  Why didn't they tell me sooner? Why didn't they tell me? Why didn't they tell the teacher?
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  Then there's also a level of grief for loss of the child's innocence, partner, family ties.
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  And then we have sometimes caregivers who simply just don't believe their child
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  or not sure whether to believe the child. And so that creates additional stressors,
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  particularly on the child-caregiver relationship.
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  But then we also have to remember the healthcare provider.
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  And we have both an opportunity, but sometimes we have a struggle of how to
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  handle these situations.
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  So, for example, our opportunity to try to encourage the caregiver to understand
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  that disclosure can take years.
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  It's very common for it to take years. It doesn't mean they did anything wrong or bad as a parent.
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  But then sometimes we're confronted with parents who do not believe their child
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  or do not support who says anger, frustration, sometimes frustration with the
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  lack of a safety response from CPS.
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  So this affects many people. And we have to remember to attend to the needs
• 10:04
  of everybody in order to heal the child appropriately. Right.
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  We'll talk about the types of stress. So there are three types of stress that
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  are described, positive stress, tolerable stress, and toxic stress.
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  So positive stress is supposed to be good stress. So this is something that
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  elicits a mild physiologic response.
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  It resolves quickly. It tends to result in a productive or an adaptive action.
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  So examples of a positive stress would be learning to ride a bike,
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  preparing for an exam or a test.
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  Stress in general, when the brain responds to a positive stress,
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  it's a first-line defense, which we'll look at in the next slide. So it's more of a buoy.
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  It enhances performance, and it resolves very quickly.
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  Palliable stress lasts a little longer. So it elicits a moderate physiologic stress response.
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  Important to note that it can be buffered with supportive, safe,
• 11:01
  nurturing relationships.
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  And we'll see this mentioned a couple of times in the next several slides.
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  Examples of tolerable stress would be a death of a family member or witnessing community violence.
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  This type of stress elicits a first and second line defense,
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  but it tends not to be sustained because the buffer is effective or because
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  the child is able to get through the trauma without difficulty or with less difficulty.
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  Positive stress is the one we need to be most concerned about.
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  So this elicits a severe, frequent, prolonged physical response and an ineffective or absent buffer.
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  So examples of this would be abuse and neglect, of course, and witness and family violence.
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  And this elicits a first and second line of events, but these are sustained
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  and unmitigated responses.
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  So these are the types of responses that can result in longer-term changes.
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  So this is a rather simplified overview of what happens in the brain with adversity.
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  The amygdala is the alarm system. So as soon as we see something in our environment
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  that's perceived as a threat, the amygdala is activated.
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  And it sends signals, of course, to the hypothalamus, which in turn sends signals to the adrenals.
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  And there's a release of epinephrine.
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  And when you look at all the red arrows here, what you see is that the response
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  of the brain is to really increase the individual's capacity to respond effectively to the stress.
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  So we have more oxygen going to the brain, increased respiratory rate, increased heart rate.
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  So it could be, again, an effective adaptive response.
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  But then we get to the second line. And the second line is what we call the HPA axis.
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  So this is the hypothalamus, the pituitary, and the adrenal HPA.
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  And when that second line is in place, the purpose is to sustain the alert response
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  to be able to continue to face the threat and handle it effectively.
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  And this is the one that really stimulates the fight, flight,
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  or freeze responses that we see.
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  So what happens with toxic stress? A lot happens with toxic stress.
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  That HPA axis is on overdrive, and cortisol is the primary substance release
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  that leads to several of the changes in the brain.
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  The changes in the brain are not benign. They include alterations in brain connectivity.
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  This is all mediated by cortisol and includes reductions in gray matter volume.
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  It also includes changes in dendrites that are either enhanced or pruned.
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  So it's a lot of very direct effects from sustained cortisol release.
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  We also have epigenetic changes. And this, again, cortisol mediates these changes.
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  Primarily what we see is alterations in DNA through methylation of different face pairs.
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  So we have altering gene expression and stress reactivity behavior.
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  And finally, cortisol results in an off-regulated inflammatory response,
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  which increases the risk for fatigue, mood changes, and chronic inflammation.
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  And you can see there are several areas of the brain that are affected,
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  in particular the prefrontal cortex, the hypothalamus, the amygdala is also affected as well.
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  There's some very interesting studies going on in this field, current studies.
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  Some of the studies have suggested that different types of trauma treatment
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  have different effects in different parts of the brain.
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  For example, one study was looking at heart-corporeal punishment,
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  which was defined as ongoing for three years, at least 12 times a year,
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  and noted that there is reduction in prefrontal cortex and cingulate gyrus volume,
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  reduced blood flow in dopamine-rich areas.
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  And this basically resulted in changes in threat detection, emotional regulation,
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  and reward anticipation.
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  The effect on behavior for all of these tend to be of the nature of a change
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  in how you perceive your world.
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  So sensory interpretation of sensory information and how you act on it changes
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  based on toxic stress responses. So, children will have trouble processing emotion.
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  For example, it's very common for children to have experienced sustained toxic
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  stress to look at an individual who perhaps is fearful and misinterpreted as anger.
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  Oxytocin is another area of research, and it's a very important substance in
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  the mother-infant bonding.
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  So there have been some studies that have looked at the fact that child maltreatment
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  dysregulates the oxytocin system, causing anxiety and dysfunctional attachments.
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  So how does this play out? So if we have a parent, if we have a mother who has
• 16:09
  experienced trauma in her past, she may have trouble bonding with her infant
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  due to her dysregulation of oxytocin system.
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  There have been some experiments, there have been some studies that have looked
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  at using intranasal oxytocin to facilitate that bonding between the mother and the infant.
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  We also have looked at intranasal oxytocin in children, older children who have
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  experienced trauma and who are having trouble bonding with their caregivers.
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  One thing that all of these studies suggest is that the periods of most rapid
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  development are those that are the most vulnerable times, and that is the early
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  postnatal period and adolescence.
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  So what do we see when somebody is experiencing traumatic stress?
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  Well, we see symptoms of fight, flight, and freeze.
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  So this just gives you some examples of things that children may say or do that
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  are reflective of their responses to trauma.
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  So with the fight response, Rachel was a little bit of a fight response.
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  She wasn't going to participate. She was putting up walls to not want to cooperate with the examination.
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  Children, they say, I don't want to do this. I don't feel like talking about it.
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  We also tend to see these children are sensitive to touch.
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  They complain about pain and discomfort during various parts of the exam when
• 17:37
  there really isn't any pain or discomfort, but they perceive it as such.
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  When we move to the flight responses, there's a lot of anxiety,
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  a lot of increased motor movement during the history, during the exam,
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  wondering what all of this will lead to. So that's more of the flight response.
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  And then we have freeze. And of course, it's overlap, which have some children
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  that manifest symptoms of fight and flight or freeze and fight.
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  But the freeze, these are children that tend to say nothing. They're very quiet.
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  They look for ways to end the question with short answers.
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  They have little eye contact. They gaze away. Sometimes they look like they're
• 18:19
  actively dissociating as you're talking to them.
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  Now, there is good news in all this. So it's been found that there are reactive
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  alleles that can facilitate resilience.
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  And it's also modifying the environment, changing the social and physical environment
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  can also redirect that negative trajectory in a positive direction.
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  Most important is to save, secure, nurture relationships.
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  I feel like this is a very key role for pediatric providers.
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  We really have to be dedicated to facilitating these SSNRs, by ensuring that
• 18:55
  caregivers have their medical and mental health needs addressed,
• 18:59
  assisting with challenges relating to social determinants of health,
• 19:03
  but also utilizing the trauma-informed approach to identify and manage trauma
• 19:07
  symptoms in children and their caregivers.
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  Believe the hurt, begin the healing.
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  Heal the caregiver, heal the child. So what is trauma-informed care?
• 19:18
  We're looking at two definitions.
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  There are several organizations that have a couple of definitions,
• 19:24
  and I think the common denominator here is that we want to enhance our ability
• 19:31
  to recognize and respond to individuals that have experienced stress or are
• 19:38
  experiencing traumatic stress,
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  and also to take measures to reduce or resist re-traumatization.
• 19:47
  When is it important to be trauma-informed? And there are several different settings.
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  We can know that somebody has experienced trauma and we should use trauma-informed
• 19:58
  care approach with them.
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  But also when children begin to talk about their traumatic experiences,
• 20:04
  that's another time to utilize trauma-informed strategies.
• 20:07
  Strategies but keep in mind there are other situations
• 20:11
  where children may have experienced trauma we
• 20:14
  don't know yet but in particular when
• 20:17
  there are children who have behavioral signs such as hostility withdrawal
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  anxiety fearfulness defensiveness somatic complaints those may be red flags
• 20:26
  for traumatic experiences and toxic stress so here's a 2021 clinical report
• 20:33
  that That was published by American Academy of Pediatrics.
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  And what I'd like to do is to review the strategies they proposed in this clinical report.
• 20:44
  The first is awareness, and that is knowing the science and epidemiology of
• 20:49
  trauma and understanding, again, the importance of those SSRs for recovery in
• 20:55
  the child as well as the caregiver.
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  Knowing the adverse populations that trauma-informed care is appropriate for.
• 21:03
  And it's really a paradigm shift. That's what's meant by readiness.
• 21:07
  It's a shift from I must speak to you to I must understand you.
• 21:11
  And recognizing, again, that the healing the child involves healing the caregiver.
• 21:17
  Identify priorities with the caregiver. I know at Center for Miracles,
• 21:21
  I have worked with our social workers there.
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  When they meet with the caregiver, the most common priority for that caregiver
• 21:30
  is that I know I need help, but I need to take care of my child first.
• 21:35
  So we have our job at Center for Miracles. is to help the caregivers shift that
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  priority a little bit and say, yes, but for you to give the best care to your
• 21:45
  child, you need help as well.
• 21:47
  And so we need to find ways for you to get help at the same time.
• 21:52
  Many of the caregivers we deal with are also blaming themselves.
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  They feel they didn't see the signs of the abuse.
• 21:59
  So we do try to identify these priorities and we do discuss them,
• 22:04
  recognizing that it's important to provide this care to the caregiver.
• 22:09
  We also spend a lot of time identifying the changes that are related to adversity.
• 22:14
  When children experience abuse and neglect, it is frequent that families have
• 22:19
  to move, that families break up, financial support changes. They may have food insecurity.
• 22:25
  They may have legal needs. They may need legal aid or they may need a protection
• 22:29
  order to keep the individual away. way.
• 22:32
  They may have challenges with transportation.
• 22:34
  And we do try, these are just very basic needs, but they can be overwhelming
• 22:39
  in terms of the stress that they produce.
• 22:42
  Another strategy includes detection and assessment, identifying the emergent
• 22:47
  versus non-emergent situations.
• 22:49
  So the two emergent situations that come to mind are the situation where a child
• 22:56
  is in immediate danger of further harm,
• 23:00
  and that may necessitate not just a call to CPS, but perhaps a call to law enforcement as well.
• 23:06
  But the other emergent situation that we commonly deal with is self-injurious
• 23:12
  thoughts and behaviors, particularly in adolescents, but sometimes in children
• 23:17
  as young as 10 in our clinic.
• 23:19
  So we do actively ask questions about that, not just to the caregiver,
• 23:26
  but also to the child individually.
• 23:29
  Then it's to assess symptoms. So symptoms may be functional,
• 23:32
  neurodevelopmental, or involve the immune system.
• 23:36
  So, a list here, the functional symptoms, sleeping difficulties,
• 23:40
  appetite changes, toileting concerns, challenges with school functioning.
• 23:45
  Symptoms of ADHD are common in children that are experiencing toxic stress.
• 23:50
  You can imagine the fight or flight responses makes it difficult for them to focus on learning.
• 23:58
  So, attention deficit disorder is something that is commonly diagnosed in these children. them.
• 24:03
  Our neurodevelopmental changes include dysregulation of emotions and behavior,
• 24:07
  disruptions in executive control, reactions to trigger, and just a negative
• 24:12
  worldview, self-narrative.
• 24:15
  We try to ask children what their super strengths are and what they would change about the world.
• 24:21
  And it's sad how many of them don't see that they have anything that's very
• 24:25
  special about them. So we do try to help them see that as well.
• 24:29
  And then the immune system, some chronic inflammation can also be present in these children.
• 24:35
  So management, again, basic needs should come first.
• 24:40
  I love for children and families to have counseling when it's appropriate,
• 24:44
  but we also must realize that the basic needs may be the biggest priority for that family.
• 24:51
  And anticipatory guidance to caregivers. So knowing that children don't see
• 24:57
  the world the same way when they've been traumatized.
• 25:00
  No more, they have trouble interpreting emotions. They may react to triggers and different sounds.
• 25:07
  They may have trouble expressing their emotions. So all of these things are
• 25:12
  changes that the caregiver should be aware of and realize that these are responses to trauma.
• 25:18
  This is not the child trying to be a problem to child.
• 25:22
  And also mental health treatment is very important. And it should be convenient
• 25:27
  for the family and the child.
• 25:31
  Now, let's look a little closer at
• 25:32
  how we would apply trauma-informed care strategies in a clinical setting.
• 25:38
  So this comes from an article that describes how they taught medical students
• 25:43
  how to render trauma-informed care.
• 25:46
  It's like a rubric that they use to evaluate the performance of a medical student
• 25:52
  in a clinical setting as they apply these principles.
• 25:56
  So it could be a useful tool.
• 25:59
  It's adaptive. I've adapted it a little bit for purposes of this presentation.
• 26:04
  So, you can see that there are several items for before the medical evaluation,
• 26:10
  during the evaluation, and after.
• 26:12
  So, before the medical evaluation, it's important to state your why or your agenda for the visit.
• 26:18
  So, I'm Dr. Kellogg. It's my job to take care of your body and your feelings.
• 26:23
  I'm going to ask you some questions to help me do that.
• 26:27
  Ask permission before proceeding. Is this okay with you? And then,
• 26:31
  of course, it's important to offer choices when possible.
• 26:34
  So I let the child choose who they want to be with them in the exam room.
• 26:40
  That's just one example of a choice, but it should be offered whenever you can.
• 26:44
  During the evaluation, it's important to identify concerns.
• 26:49
  So is there anything that you're worried about today that you want me to be sure to check?
• 26:54
  Respect the personal space and use understandable language.
• 26:59
  I think sometimes when we are confronted with somebody who's experienced horrible
• 27:04
  trauma, we forget that they have trouble processing what we're saying to them.
• 27:09
  So it's important to check and make sure they understand it.
• 27:13
  Physical exam, I tell them everything before I do it.
• 27:17
  When I do need to undrape certain parts of the body, I only undrape the part
• 27:22
  of the body I'm examining.
• 27:24
  I'm also very mindful of what I say during the exam.
• 27:28
  So, terms of endearment, like sweetie or move your leg for me,
• 27:33
  be careful with that because it does send a possessive message and it can be
• 27:38
  misinterpreted. It can be interpreted as a threat for the child.
• 27:43
  After the evaluation, I tend to focus first on the child and give them the results
• 27:48
  of the the evaluation in terms that they can understand.
• 27:51
  I always ask the questions, the question from the child, and then I'll ask the
• 27:56
  question from the caregiver.
• 27:59
  So now quickly, I thought I would share seven things that children and families
• 28:03
  have taught me about trauma-informed care.
• 28:06
  First, it's about them. It's not about you. I think sometimes we're very frustrated
• 28:11
  by children's responses or behaviors towards us, their resistance,
• 28:16
  their lack of communication, or even though perhaps a caregiver is angry,
• 28:22
  and questioning everything we're doing.
• 28:24
  It's recognizing that this comes from an experience of trauma.
• 28:28
  It's not to attack you. It's not to push your button.
• 28:32
  It's also important to know that people are not always willing to share their experiences.
• 28:37
  We don't say, trust me, I'm a doctor in this business. We have to earn this
• 28:42
  trust. We cannot assume it.
• 28:44
  This just reiterates an earlier point is that I tell them everything that I'm
• 28:49
  doing and why at every point of my evaluation.
• 28:52
  So what my job is, why I need to talk to them. because, again,
• 28:57
  in my setting, many times children are not used to talking with the clinician alone first.
• 29:03
  And then what I would do with the information. So based on what you're telling
• 29:07
  me, I think we need to do tests for X, Y, and Z.
• 29:11
  Or I think I need to look at your medical records to understand a little more
• 29:15
  about this medical problem that you're telling me.
• 29:18
  And also to recommend next steps for treatment and management.
• 29:22
  But they have to, at every point of the way, it has to be clear they have choices.
• 29:26
  The patient has a choice. The caregiver has a choice in what happens.
• 29:32
  I think it's very important when you're dealing with a child or a caregiver
• 29:36
  who has experienced trauma that you're very alert to cues, verbal and nonverbal,
• 29:42
  that indicate that that person may not be hearing or understanding what you're saying.
• 29:47
  And so these are some of the cues that I look for. They may ask you point blank what a word means.
• 29:52
  I like that when it happens because that means the child is listening to me
• 29:56
  and they're being very honest and they don't feel odd asking me,
• 30:00
  what do you mean by this word?
• 30:04
  So that's actually a good sign when that happens. So they may give you an answer
• 30:08
  that's not really responsive to the question.
• 30:11
  Children, again, tend not to want to admit when they don't understand, so be an alert to that.
• 30:17
  They may say, I don't notice several questions, which could also mean I just
• 30:21
  don't want to answer that question, or they may not respond at all.
• 30:25
  The increased psychomotor activity is something I see frequently.
• 30:29
  It generally begins with the very beginning of the interview,
• 30:33
  and then I see it slow down as the interview progresses.
• 30:37
  Distractive behavior, again, the fight or flight response can also be seen during interviews.
• 30:43
  And only nodding or shaking head in response to questions is another non-verbal
• 30:48
  cue that maybe they are not quite understanding or receiving the information
• 30:53
  we're trying to give them.
• 30:56
  Hearing is not the same as listening.
• 30:58
  So listening means to understand and respect what they are saying.
• 31:02
  And it also means that you are listening and looking for cues of unspoken concerns
• 31:09
  or fears that the child may have.
• 31:11
  Sometimes they're statements of self-blame, remorse for not telling sooner about
• 31:16
  their trauma experiences and anxiety about what will happen with their family.
• 31:21
  And just listening carefully to what they're saying and following up on things
• 31:25
  that may indicate these unspoken concerns.
• 31:30
  No surprises. So remembering that children and caregivers that have experienced
• 31:35
  trauma do not receive information, sensory information, in the same way.
• 31:41
  So being alert to different triggers. Sometimes we get a loud noise in our interview
• 31:47
  room that comes from cars in the garage, and I can see children startled to that sometimes.
• 31:53
  But also, especially, be very careful with touch. And I recommend avoid touching
• 31:59
  a person during a verbal or during the initial interview or history with them.
• 32:04
  The risk of sending the wrong message is much greater than the potential benefit
• 32:08
  of trying to show empathy through touch.
• 32:11
  There are other ways to show empathy that may be more comfortable.
• 32:14
  So really delaying that touch until you absolutely have to during the exam.
• 32:18
  In general, that's how I approach it.
• 32:22
  So it is common for children and
• 32:25
  caregivers to feel devalued and vulnerable it
• 32:29
  is common for traumatized individuals to feel that something is wrong with them
• 32:33
  and keeping this in mind as you talk to them is important in terms of you know
• 32:38
  rendering trauma-informed care so respect can be demonstrated in a lot of different
• 32:43
  ways active listening acknowledging strength asking
• 32:47
  if they have any questions or concerns,
• 32:49
  asking them to help you help them. It's a cooperative venture towards healing.
• 32:55
  Respecting their wishes, even if it's different from your recommendations or expectations.
• 33:00
  I think this is an important lesson that I've learned through the years,
• 33:03
  because in the beginning, I used to be very frustrated with caregivers who didn't
• 33:07
  believe their children.
• 33:09
  And what I try to do is...
• 33:13
  Change your mind, and it may not be possible always to change the caregiver's
• 33:17
  mind, but you can give them information to think about.
• 33:20
  They're more likely to receive your information if you do this in a respectful way.
• 33:25
  Don't tell them how they feel. I think, again, when we see children who have
• 33:30
  experienced unspeakable acts, we have a tendency to want to say,
• 33:34
  you're brave, you're strong.
• 33:36
  They may not feel that way. And when you say things like that to people who
• 33:40
  don't feel that way, it may be off-putting.
• 33:44
  So Hattie is another patient that I met in 2007. She was a victim of torture.
• 33:50
  She was chained and starved with her sister, Krista, who was a year younger, for three years.
• 33:55
  She was beaten. She was terrorized. She presented to Center for Miracles the
• 34:00
  day after her sister was killed.
• 34:03
  This is what she recalled about her visit to Center for Miracles.
• 34:07
  That was the first time, the very first time I told anybody the truth about
• 34:11
  everything that happened.
• 34:13
  She was the first person that I was like, okay, here it is. Here's my story.
• 34:17
  And from that point, I wasn't scared, and I didn't feel like I would get hurt
• 34:21
  for telling the truth anymore.
• 34:23
  It's like over the years, people keep piling rocks on your chest.
• 34:27
  And every time you say stop to them, it means more rocks.
• 34:31
  And finally, you have that person come along who's there for you.
• 34:35
  She said stop, and they stopped.
• 34:37
  It was the first time someone listened to me, listened to my story.
• 34:40
  The first time nobody spoke for me.
• 34:43
  It's frustrating as a kid when you want to say so much, but you're so traumatized
• 34:47
  and in so much shock from that moment.
• 34:50
  So that was, she had just turned 10 in this picture. It was 24 hours after she had lost her sister.
• 34:58
  Me, it was a trauma. Afterwards, I didn't talk about it for a while.
• 35:04
  My thoughts ran from the incomprehensible evil she endured for years,
• 35:09
  to despair for her sister, the gratefulness that she felt she could share some
• 35:14
  of what happened to her during my time with her.
• 35:17
  Ultimately, my self-care went to see Kathy in follow-up two weeks and one year
• 35:22
  later. So this is a picture one year later.
• 35:25
  She's 35 pounds, and I think about three and a half inches taller, 35 pounds heavier.
• 35:31
  And so it was at this visit that I could finally let go.
• 35:35
  So much to my surprise, 15 years later, Cassie reached out to me.
• 35:40
  She wanted to reconnect. And we spent three and a half hours talking about what
• 35:47
  happened to her, how she got through that.
• 35:50
  And one of the things that really impressed me about this interview is the power
• 35:55
  of safe, secure, nurturing relationships.
• 35:58
  Kathy had three things that pulled her back, gave her resilience and allowed her to survive.
• 36:06
  The first thing was therapy, her therapist. The second was her husband.
• 36:12
  So in this picture, she's married and she has three children.
• 36:15
  She's happily married. She's a very dedicated mom and is successful.
• 36:21
  The third thing that was her SSNR was advocacy.
• 36:25
  So she created a website called Crystal Project after his sister,
• 36:30
  which is a forum for other adults and children who have experienced trauma like
• 36:36
  she has to share their experiences, to share their success stories.
• 36:40
  So she's very proud of that. So those are the three things that were her lifelines.
• 36:45
  The interesting thing about that is that her lifeline did not come until years after she was rescued.
• 36:52
  She had a rough time in foster care.
• 36:56
  Nonetheless, the SSNRs, they did save her, but it took years before they were available to her.
• 37:05
  So finally, I just wanted to share with you a little bit about the Center for Miracles.
• 37:09
  So we are a level one trauma-informed care certified center.
• 37:14
  We received that in July of last year.
• 37:18
  And I just, the overall process, it took about a year. And we basically looked
• 37:23
  at everything we did at Centers for Miracles from beginning,
• 37:26
  when the child and family walk in the door, to the end when they leave.
• 37:31
  And we looked at it across several major domains. We looked at safety,
• 37:36
  physical and interpersonal safety, transparency and trustworthiness,
• 37:40
  respect and empowerment,
• 37:42
  collaboration and policy, skill building, and emotional intelligence.
• 37:47
  In addition to these things, we also wrote a policy guideline for Center for
• 37:53
  Miracles, committing ourselves to rendering trauma-informed care.
• 37:57
  We do some periodic surveys of trauma-informed climate.
• 38:01
  I'm going to share that with you in the next slide because I think it can be
• 38:05
  useful in other practice settings.
• 38:07
  We do planned staff retreats, and then we offer secondary trauma group sessions. Thank you.
• 38:14
  Here's a climate survey, and we try to hand this out at least twice a year.
• 38:19
  And this is really, it takes the temperature of the environment you work with or you work in.
• 38:25
  So it asks whether you feel safe where you are, whether you have the resources you need.
• 38:31
  Who do you trust? Do you have people you know you can trust? What is the leadership?
• 38:35
  Does it listen to only certain people? Does it share decision making?
• 38:41
  Again, I find these items very useful. And we look at them. They're anonymous.
• 38:46
  We try to aggregate the data and look at ways that we can better address the
• 38:52
  needs of the people that we work with.
• 38:54
  So finally, getting back to racial. So she gave me her rules,
• 38:59
  and this is what I said to each rule.
• 39:00
  So don't lie to me. I said, I promise not to lie to you.
• 39:04
  And I would tell you if I do not know the answer, don't talk about my mother.
• 39:09
  I promise not to ask any questions about your mother.
• 39:12
  Don't give me shots. We have no shots here. And then perhaps most importantly,
• 39:17
  number four, don't tell me to do something immediate or I will be traumatized.
• 39:21
  And so what I said to this was, I will not tell you to do anything.
• 39:26
  I will explain what I think should be done for your health, but we will make
• 39:29
  a decision together on what happens next.
• 39:33
  So to my surprise, because when I go into these encounters, I have no expectation
• 39:38
  about what a child is willing to do or not willing to do.
• 39:42
  But to my surprise, in this situation, she was able to give a full history,
• 39:47
  describe how her mother was not supportive.
• 39:50
  So she talked about her mother. She gave a full history.
• 39:53
  She consented to all parts of the exam.
• 39:56
  She underwent the exam without problem, and she was very cooperative throughout.
• 40:02
  In summary, traumatic experiences are common in childhood, and they go beyond the ACEs.
• 40:08
  You can have short- and long-term medical and mental health consequences from trauma.
• 40:13
  Trauma-informed care is a paradigm shift from what is wrong with you to what's
• 40:18
  happened to you to what's strong with you.
• 40:21
  And remembering that trauma-informed care recognizes, responds,
• 40:25
  and manages traumatic stress, but also in that management that it addresses
• 40:31
  the needs of the child, the caregiver, and the pediatric clinician.
• 40:36
  Caring for one helps them care for all the others as well.
• 40:40
  So I would stop at this point and see if there are any questions.
• 40:45
  Hi, Dr. Kellogg. This is Dina Tom.
• 40:48
  Thank you for your talk today. I have a question about trauma-informed care
• 40:53
  training for non-medical providers.
• 40:56
  This is very timely because my neighbor actually yesterday asked about any kind
• 41:01
  of, she works for wellness.
• 41:04
  She does the, she's the wellness director for the San Antonio Community College District.
• 41:08
  And she has a bunch of faculty who've asked questions about how to approach
• 41:14
  their own students when it comes to trauma-informed care.
• 41:18
  And obviously it's a different angle for non-medical providers a little bit,
• 41:22
  but do you know if there's any community training or are any resources for those
• 41:27
  who work with students or children,
• 41:29
  like teachers in the community for having that kind of trauma-informed mindset?
• 41:36
  Don't know offhand any resources for community.
• 41:40
  I would think that, you know, what I mentioned in the beginning was an organization
• 41:46
  that has resources in general.
• 41:49
  And that's the Child Trauma Stress Network.
• 41:52
  And I'm thinking if somebody would look that up, they probably would have some
• 41:56
  additional links for adults and for students that could be helpful.
• 42:02
  Okay. I think, again, trauma-informed care works best in a one-on-one situation
• 42:07
  in terms of trying to help an individual through it.
• 42:11
  But that's a very interesting question. I don't know offhand of any specific resources.
• 42:17
  It looks like Dr. Hansen put something in the chat that I can refer to.
• 42:21
  And I think it came up in light of maybe a couple of teachers that have had
• 42:27
  students who were missing class or because they've had to go to court after
• 42:32
  being in the foster care system.
• 42:34
  And basically teachers not knowing how to handle that from a trauma mindset
• 42:40
  of understanding that these children who are now young adults may have different struggles.
• 42:47
  So anyway, this is incredible talk. So thank you so much for speaking to me.
• 42:53
  Thank you. And I agree with you.
• 42:56
  I think, again, there's not much understanding that individuals that have experienced
• 43:01
  toxic stress see the world differently.
• 43:05
  And being able to understand that behavior is not directed at you,
• 43:09
  it is a response to trauma. And oftentimes fits into the fight,
• 43:15
  flight, freeze paradigm.
• 43:19
  It's one of those or a combination of those. And I think, again,
• 43:23
  understanding and recognizing it's the first step in all strategies.
• 43:27
  So I think there's just not enough of the recognizing and understanding.
• 43:31
  So I think that's the first step for most organizations is just understanding
• 43:36
  their trauma responses.
• 43:40
  Thanks so much for listening to Pediatrics Now.
• 43:41
  Music.
• 43:44
  I'm Holly Wayment. Our website is pediatricsnowpodcast.com.
• 43:49
  You can email me at pediatricsnow at uthscsa.edu with any questions or topic ideas.
• 43:58
  Music.