Exposure to Community Violence: Trauma Informed Care …ohioaap.org/wp-content/uploads/2016/09/Exposureto... ·  · 2017-02-28Exposure to Community Violence: Trauma Informed Care

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

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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)

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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