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Childhood Trauma and Toxic Stress: A Primary Care Approach

This resource aims to improve primary care providers' understanding and response to the mental health aspects of childhood trauma and toxic stress. It reviews the effects of trauma in children and provides guidance for assessing and addressing these issues. The reduction of toxic stress in young children is emphasized as a priority for pediatric care.

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Childhood Trauma and Toxic Stress: A Primary Care Approach

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  1. Approach to the mental health aspects of childhood trauma and toxic stress for primary care providers Rachel Yoder, MD DCMAP Georgetown Child Psych

  2. Goals • Review what is known about acute and ongoing effects of trauma in children and adolescents • Improve pediatrician comfort and skill in assessing and responding to mental health aspects of trauma. The reduction of toxic stress in young children ought to be a high priority for medicine as a whole and for pediatrics in particular. - AAP Policy Statement Garber AS, Shonkoff JP, Seigel BS, et al.Early Childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Policy statement of the AAP. Pediatrics. 2012: 129:3224-e231

  3. cc: 7 yo M attempted to choke another student and kick teacher • Other kid said something about his mom. Admitted to PIW x 1 week. Started on Concerta and Guanfacine PMH • Asthma (albuterol prn) • Evaluated for ADHD 1 year ago, no f/u • Speech delay (speech therapy in school) • Poor prenatal care but normal delivery FH • mother with “drug problems” • Siblings with ADHD • Older sibling incarcerated for carjacking SH : Lives with mom, siblings ages 3,5,10,13,15 + multiple older cousins who use home as “hide out” and “teach him how to fight.” At times if he is “acting out” is sent to live with grandparents – less chaotic environment. Periodic CPS involvement, never taken from home School: Daily aggressive incidents against other children with minimal provocation, yells, acts out. Teacher Vanderbilt: 8/9 inattention, 9/9 hyperactivity/impulsivity, 8/8 ODD, 2/3 CD, 1/3 anx, 2/3 depression Trauma Hx: Denies physical and sexual abuse when asked alone. Witnessed shooting resulting in severe injury in front of house last year.

  4. Trauma Basics • Trauma is common: 1/4 – 2/3 of children/adolescents experience a traumatic event before reaching adulthood • Most individuals who experience a traumatic event have some degree of post traumatic symptoms immediately • Children, even if they do not meet full criteria for PTSD, still often have ongoing functional impairment • Costello et al. The prevalence of potentially traumatic events in childhood and adolescence. 2002. Journal of Traumatic Stress. 15 (2) 99-112. • Bethell C et al. Adverse childhood experiences, resilience and mindfulness-based approaches. Child Adolesc Psychiatric Clin N Am 2015. • Carrion VG, Weems CF, Ray R, Reiss AL. Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD in youth. J Am Acad Child Adolesc Psychiatry. 2002;41(2):166-173.

  5. Trauma Basics • Most likely to result in PTSD symptoms: • Sexual abuse (39.3%) • physical assault by a romantic partner (29.1%) • physical abuse by a caregiver (25.2%) Mclaughlinet al. Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. 2013 JAACAP: 52 (8): 815-30.

  6. Trauma types • Acute, single event • Physical/sexual abuse • Witnessing DV, shooting • Car accident • Chronic/complex/toxic stress • Neglect • Repetitive abuse • Disruptive and Disrupted environments * Often occur together *

  7. Toxic stress: prenatal, early postnatal • Fetal exposure to maternal stress can influence later stress reactions • Likely due to epigenetic modifications of DNA • Early postnatal experiences with adversity affect future reactivity to stress • Alter developing neural circuits controlling neuroendocrine responses Shonkoffet al. 2011. The lifetime effects of early childhood adversity and toxic stress. Pediatrics Technical report. www.pediatrics.org/cgi/doi/10.1542/peds.2011-2663. Garner et al. 2015. Translating developmental science to address childhood adversity. Academic Pediatrics

  8. Toxic stress: through ongoing development • Ongoing stress  prolonged exposure to stress hormones prolonged exposure to inflammatory cytokines  changes in immune function • Brain: multiple glucocorticoid receptors in amygdala, hippocampus, prefrontal cortex (learning and memory). Chronic exposure to glucocorticoids alters their function, size • Less organization and control from prefrontal cortex • More anxiety/hyperactivationof amygdala • Limits the ability of the hippocampus to promote context in learning (distinguish between safe/not safe) - Rest of body: higher risk of asthma, metabolic syndrome, infection

  9. Trauma effects • Trauma exposure, even if it does not result in PTSD, places children at risk of: • Depression • Suicide attempts (8x more likely in victims of sexual abuse) • Substance abuse • Learning/academic problems (cognitive delay, impairments in executive functioning, missed school) • Medical problems • Relationship/career problems • Fergusson et al. Childhood sexual abuse and psychiatric disorder in young adulthood II: psychiatric outcomes of childhood sexual abuse. JAACAP. 1996.35 (10):1365-74. • Adverse childhood experiences studies • Shonkoff et al. The liffetime effects of early childhood adversity and toxic stress. Pediatrics Technical report. www.pediatrics.org/cgi/doi/10.1542/peds.2011-2663.

  10. Post traumatic stress disorder DSM 5 *(Pediatricians do not have to diagnose this)* • Exposure to a traumatic event • Intrusive memories, dreams; distress at reminders • Often seen as recurrent play (distressing or nondistressing) • Attempt to avoid external reminders, memories, thoughts, feelings about event • Negative alterations in cognition and mood • Distorted understanding of the event • Social withdrawal, decreased interests, negative beliefs about self • Alterations in arousal and reactivity • Irritable behavior, angry outbursts • Hypervigilance • Sleep disturbance, difficulty with concentration

  11. Trauma presentations • Somatic complaints • ADHD • Poor concentration while avoiding, reexperiencing, being hypervigilant • ODD • Outbursts, irritability if exposed to ongoing trauma reminders • Panic disorder/other anxiety disorder • Arousal with trauma reminders, sleep disturbance • Specific phobia • Avoid trauma reminders • MDD • Social withdrawal, affective numbing, sleep disturbance • Substance use disorder • Use for coping

  12. Risk/protective factors for developing PTSD Risk factors: • Female gender, multiple traumas, greater exposure to the index trauma, presence of a preexisting psychiatric disorder (particularly an anxiety disorder),parental psychopathology, lack of social support Protective factors : • Parental support, lower levels of parental PTSD, resolution of other parental trauma-related symptoms, parent report of less parenting stress and more engagement in their child’s life Caregiver’s capacity and response to the trauma • Pine DS, Cohen JA. Trauma in children and adolescents: risk and treatment of psychiatric sequelae. Biol Psychiatry. 2002;51(7): 519-531. • Bethell C et al. Adverse childhood experiences, resilience and mindfulness-based approaches. Child Adolesc Psychiatric Clin N Am 2015.

  13. What can you do in the office/hospital room/ER? • THINK ABOUT IT/ SCREEN FOR IT/DIAGNOSE IT • Because we know we miss it • Its not going to get better on its own • the AAP says you should • TALK WITH THE FAMILY ABOUT IT • REFER, LINK WITH RESOURCES • FOLLOW UP, MANAGE THE LINK • TAKE CARE OF PARENT MENTAL HEALTH/ENGAGEMENT Shonkoff et al. 2011. The lifetime effects of early childhood adversity and toxic stress. Pediatrics Technical report. www.pediatrics.org/cgi/doi/10.1542/peds.2011-2663. AAP Policy Statement: Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics 2012.

  14. How to assess for trauma: Normal part of social history each visit Broad then specific, explicit, very routine, normalize: “I’m a doctor, I care about you, its my job to make sure I ask about everything in your health, and now I’d like to ask some important and serious questions” Parent: • Do you think your child ever has experienced anything very scary to them, like see someone hurt someone else, or felt like they might be hurt by someone else? Storm, car accident, fire, been around a shooting, been in a situation where police/ambulance/fire engine involved/911 was called? • Do you have any concern that your child has ever been touched in their private areas inappropriately by an older child or adult? Avoid using the words trauma or abuse

  15. How to assess for trauma: Normal part of social history each visit Child: • Has anything ever really scary happened to you? • Has anyone who is older than you touched your penis/vagina (word for these)? • Have you seen anyone hurt anyone else really bad on purpose? • Has an adult ever hurt you on purpose? • Have you ever been around with policemen/ambulance/fireman came?

  16. While we’re on the topic of sensitive questions: Suicide • Have you ever thought about hurting yourself on purpose? • Have you ever thought about killing yourself?

  17. Are there screens? • Not reliable screens for trauma occurrence compared to personal interview Reliable for: • Social determinants of health (toxic stress) • SEEK parent questionnaire (risk of maltreatment) • Bright futures pediatric intake form • Parenting stress index • ADHD/behavior (Vanderbilt) • Anxiety (SCARED) • Depression (PHQ9) • Development (ASQ, MCHAT) AAP Mental Health Toolkit

  18. SEEK parent questionnaire(Safe Environment for Every Kid) ages 0-5 “Being a parent isn’t easy, we want to help everyone have a safe environment for kids. We are asking everyone these questions…” • Do you need the phone number for poison control? • In the past year, did you worry that your food would run out before you got money or Food Stamps to buy more? • Do you often feel your child is difficult to take care of? • In the past year, have you been afraid of your partner? • In the past year, have you felt down, depressed? • In the past year, have you had a problem with drugs or alcohol? Garg, A and Dworkin PH. Surveillance and screening for social determinants of health: the medical home and beyond. JAMA Pediatrics. Published online Jan 4 2016. SEEK parent questionnaire: http://theinstitute.umaryland.edu/seek/seek_pq.cfm

  19. SEEK evidence • Randomized, controlled - 18 peds practices associated with University of Maryland (resident continuity clinics) • Administered in waiting rooms, added 0-2 minutes to the visit • Providers received 4 hrs of training in brief screening and initially addressing issues • Social worker available by phone or on site, assist with support/referrals • After 1 year: • 1/3 fewer child protective services calls • Lower rates of maltreatment by parents Dubowitz H et al. The SEEK Model of Pediatric primary care: can child maltreatment be prevented in a low-risk population? Academic Pediatrics. 2012. Dubowitz, H. et al. The Safe Environment for Every Kid Model: Impact on pediatric primary care professionals. Pediatrics. 2011.

  20. How to respond to trauma assessment • If negative: Good teaching opportunity

  21. How to respond to positive trauma assessment 1. Assess current safety/risk of revictimization: • To parents: Where is the perpetrator now? Will they ever see the perpetrator again? • Kids: don’t need to ask anymore questions. leave details for forensic interview. No more specific details from parents in child’s hearing

  22. How to respond to positive trauma assessment If safe and no need for CPS/forensic involvement: • Talk with parents about prognosis/what to look out for • Consider informing/involving school for therapy or just heads up/extra assistance • In particular if trauma reminders are present in the school setting. ie: if trauma occurred in school and perpetrator is still in school 3. Sooner follow up (ideally 2 weeks) and more frequent visits to check in on progress 4. REFER TO THERAPY • RESOURCES • CALL DCMAP!!!!!!! (844) 303 – 2627

  23. How to talk with families about concern for child’s trauma history and symptoms/prognosis When scary or upsetting things happen to children, children cope with it in different ways, and sometimes even when it looks like children are doing fine on the outside, they might not be fine on the inside. Sometimes problems that don’t even seem like they should be related to the thing that happened might be. I wonder if your child’s symptom (trouble sleeping, trouble paying attention in school, increased temper tantrums) might be a sign that the event is bothering them And most people know, that if there’s something going on in the inside and we don’t get help with it, it can often get worse. I want to make sure we’re not missing something that’s going on in the inside that might be causing this problem (symptom). I think it would be good if someone who is an expert about these things were able to help you out with this.

  24. Recommended Approach Treatment in Children: • THERAPY: Trauma focused CBT or Parent/child interaction therapy AND PARENT SUPPORT: Individual therapy, parenting classes, home visits 2. Consider treatment of comorbid mental health issues (ADHD, anxiety, depression) Treatment in Adolescents: • THERAPY: Trauma focused cognitive behavioral therapy, managing parental mental health, parenting support • Consider treatment of comorbid mental health issues (ADHD, anxiety, depression) • Consider SSRI for PTSD under conditions (call DCMAP)

  25. How do I explain TFCBT to families? HELPS KIDS GET CONTROL OVER THE TRAUMA • Educateabout the traumatic event and common trauma reactions • Parenting skills: effective parenting interventions such as praise, positive attention • Relaxation/emotion modulation skills: use positive self-talk, thought interruption, positive imagery, problem solving • Trauma narrative: Write it out, correct cognitive distortions about these experiences, place these experience in the context of the child’s whole life • In vivo mastery of trauma reminders: gradual exposure to feared stimuli • Joint child/parent sessions: child shares the trauma narrative with parents, help review principles at home, helping parents with their own symptoms (major risk factor is parents’ reactions to the trauma TFCBT has been adapted and validated for preschoolers (2) and shown to be effective when adapted for complex trauma (3) 1. Cohen JA. Ttreating Trauma and Traumatic Grief in Children and Adolescents. 2006 2. Scheeringa MS. Et al. Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three through six year-old children: A randomized clinical trial. J Child Psychol Psychiatry . 2011 August ; 52(8): 853–860 3. Cohen et al. Trauma-focused CBT for youth with complex trauma. Child Abuse Negl. 2012 Jun; 36(6): 528–541.

  26. What is Child-Parent Psychotherapy (parent-child interaction therapy) ? Targets younger children (<7) and their parent with focuses on the attachment relationship, processing traumatic grief, and emotional and technical support to both. • More play based • More focus on effective parenting skills

  27. DCMAP DC MENTAL HEALTH ACCES IN PEDIATRICS (844) 303 – 2627

  28. General advice for families • Parent mental health addressed if needed. (may have also experienced trauma) • Additional family support if applicable • Importance of REGULAR ROUTINE • It’s okay and good to talk about what happened. Often kids have misconceptions of an event that is worse than the real event, may feel guilty inappropriately • Parents can invite the kid to talk about it during a time when they’re not distracted, or be open to talk about it if the kid brings it up • Take the approach of: “I want to hear what you’re thinking about” and need to LISTEN • Parents don’t have to have all of the answers. If they don’t know how to respond, can be honest, and loving. “you know, I’m not sure of the answer to that, but I love you and we’re going to figure that out. • Parents need to be willing to hear the story (may need support for this)

  29. What about medications? General recommendation: Begin with TFCBT alone and add an SSRI only if the child’s symptom severity or lack of response suggests a need for additional interventions • While SSRIs have good evidence for PTSD in adults, less so in children and adolescents (smaller trials) • No data to support SSRI use alone * KNOW THAT PTSD IN CHILDREN AND ADOLESCENTS CAN LOOK LIKE SYMPTOMS OF DISEASES THAT YOU FEEL MORE COMFORTABLE TREATING AND THAT YOU WILL WANT TO TREAT* 1. Cohen JA, Mannarino AP, Perel JM, Staron V. A pilot randomized trial of combined trauma-focused CBT and sertraline for childhood PTSD symptoms. J Am Acad Child Adolesc Psychiatry. 2007;46(7):811-819 2. Strawn et al. Psychopharmalogical treatment of PTSD in children and adolescents: A Review. J Clin Psych 2010.

  30. Can I do something about sleep? 1. Talk about sleep hygiene, SLEEP ROUTINE, mindfulness activities 2. Melatonin 3. Clonidine/Guanfacine evidence limited *Call DCMAP!!!!! • AVOID: sedative hypnotics

  31. DC trauma resources DCMAP!!!!!!!!!!!! www.dcmap.org (844) 30 DC MAP (844) 303 – 2627 • DC HEALTH CHECKLIST www.dchealthcheck.net *DC Mental Health Resources Guide* • Parent-child interaction therapy: DBH Parent Infant Early Childhood Enhancement (PIECE) Program (SE) • Wendt Center for Loss and Healing

  32. Home visiting/Parental support (free services) • DC Healthy Start: prenatal – age 2 • Family Place: age 3-5 • Mary’s Center Father/Child Program: under 5

  33. Additional resources • AACAP Facts for Families (general overview of PTSD, CBT) • Anxietybc.org. Good for all anxiety disorders, have some videos of patient experiences in all types. • Triple P Positive Parenting Program

  34. Resources for Providers AACAP Practice Parameter on Post Traumatic Stress Disorder Shonkoff et al. The lifetime effects of early childhood adversity and toxic stress. Pediatrics Technical report. www.pediatrics.org/cgi/doi/10.1542/peds.2011-2663. AAP Policy Statement: Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. 2012 Center on the developing child: developingchild.harvard.edu

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