Trauma Informed Care: Focus on Pediatric Medical Trauma Stress (PMTS)
There is growing awareness and research to support the need and importance of trauma informed care and trauma sensitive schools. Many of us are educating, treating and raising children that have experienced trauma; and the likelihood is high, that you may have been exposed to or experienced a traumatic event(s) in your own childhood or adulthood. Currently, more than 46% of U.S. children under age 18 (~34 million) have had at least 1 adverse childhood experience (ACE), and more than 20% have had at least 2 ACEs. In addition, each year one in four children will receive medical care for an injury, resulting in millions of emergency department visits and hospitalizations. The statistics are staggering and undeniably support the need for enhanced and effective trauma informed care, particularly when we consider the combination of the current data regarding adverse childhood experiences with the frequency of pediatric medical events.
As both a healthcare professional and parent of a child that experienced a life-threatening medical event, I have experienced the aftermath of traumatic experiences personally and assisted my clients with their journeys professionally. But despite my role as an Occupational Therapist, with experience in physical rehabilitation, pediatrics, and mental health, I still found myself blindsided by the intense behavioral outbursts that occurred with my (then) 5 year old son following his hospitalization. Our family felt unprepared & ill equipped to navigate the journey of emotional healing when his physical health was still our primary focus. We grossly underestimated how long the emotional recovery would take. We felt frustrated that we had not been provided with information regarding post-traumatic “red flags” and resources prior to being discharged from the hospital. His sister had her own unique emotions, fears and confusion related to the experience. His Dad & I returned home still in a state of shock, and yet filled with gratitude that our son had survived a life-threatening illness. But explosive behaviors quickly led to our confusion and overwhelm. We became desperate for resources and strategies that would help him…and us…heal emotionally. We needed to find effective interventions that could help restore a sense of safety and trust after a traumatic medical separation. We were experiencing TOXIC STRESS…and it felt like it was being poured all over us from a big ugly cauldron full of anxious, confused and explosive emotions.
So it is only natural that I find great hope that this growing awareness is taking root across our nation in healthcare organizations, schools and communities. I find great relief that the research is validating what countless parents, children, mental health professionals, and educators have been reporting anecdotally for years. So let’s dig deeper, learn more, and discover effective strategies that help restore emotional regulation after traumatic experiences.
According to the CDC and ACEs Too High, Adverse Childhood Experiences (ACEs) are defined as “stressful or traumatic events, including abuse and neglect. They may also include household dysfunction such as witnessing domestic violence or growing up with family members who have substance use disorders”. Many of the health problems being seen in adult medicine and mental health can be correlated with the toxic stress that was present, but often unseen, in pediatrics. Higher ACE scores are correlated with increased risks of some diseases, as well as social and emotional problems. Although the ACE Study mentions that childhood trauma can include “recovery from a severe accident”, pediatric medical trauma is typically not assessed as part of a person’s ACE Score.
According to the Center for Pediatric Traumatic Stress at the Children’s Hospital of Philadelphia (CHOP), Pediatric Medical Traumatic Stress (PMTS) is defined as “a set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences” (National Child Traumatic Stress Network, 2003). PMTS includes traumatic stress responses, such as arousal, re-experiencing, and avoidance, which can vary in intensity and disrupt functioning (Kazak et al., 2005). With one in four children receiving medical care each year for an injury, there are countless children that must endure painful and frightening procedures and treatments as part of their medical care. The Integrative Model of PMTS (Kazak et al., 2005) emphasizes a family-centered perspective, and need for assessment and intervention, for parents, as well as siblings. It highlights the hallmarks typically present: life threat, and/or the likelihood of an event evoking fear, horror and helplessness (American Psychiatric Association, 1994). It notes, however, that the symptoms of PMTS are more strongly correlated with subjective experiences than objective characteristics of a particular illness or treatment course.
This model advocates that PMTS be addressed in the delivery of acute medical treatment (by changing the subjective experience of Potentially Traumatic Events (PTE), then be assessed after the delivery of medical treatment (to prevent the symptoms of PMTS), and that primary healthcare providers and educators have crucial roles in identifying ongoing concerns & linking families with resources upon community & school re-entry (to reduce the symptoms of PMTS). One of the most hopeful aspects that was referenced in the literature are the positive outcomes that can be possible after a traumatic experience, sometimes called Post-Traumatic Growth (PTG). These positive outcomes can include positive changes in self, in relationships with others, and in plans for the future. So as the research emerges, it is important to note that with greater understanding, prevention, assessment and intervention, we have the potential to help children and families develop adaptive long term outcomes after traumatic experiences.
So with a hopeful mindset ♥ of the resilience can be facilitated, let’s discover strategies that will help children and families impacted by traumatic experiences.
- Slowly re-integrate the child (and family) back into daily routines. They may require more assistance with daily tasks or be unable to tolerate a full day at school, daycare or work. Anticipate inconsistent participation and decreased attention to task.
- Help the child select a small meaningful transitional object that reminds the child of a trusted adult. After establishing expectations about the transitional object (to prevent distraction to peers), allow the child to access it throughout school day transitions, to/from school, etc.
- Collaborate with the school nurse and have a plan of action (some kids may visit too frequently for reassurance, others may avoid). Encourage communication between medical staff & school/daycare staff for improved continuum of care.
- Collaborate with classroom teachers, daycare providers, and childcare providers. Staff needs to be aware that the “Band-Aid Approach” (quick separation of child and parent at drop-off) is not effective if there has been a traumatic separation as part of the traumatic experience.
- Provide the child (and family) with increased time to process information. Provide visuals or written information that they can use as a reference for repeated delivery of needed information. Note that during periods of high anxiety/arousal, comprehension of auditory information is poor. Reduce verbal prompting!
- Use a Get Well Map to facilitate communication between children and adults as children progress towards their meaningful goals. Get Well Maps help children visualize & track progress towards their individualized goals (ex: going home during a hospitalization, re-integrating back to school or a preferred extracurricular activity, or even just a special activity planned with a trusted adult). Using a fun, interactive method, Get Well Maps are child-centered and encourage positive communication in the event of setbacks with use of themed “neutral zones”. Upon re-entry to school and home routines, Educational Maps are helpful tools to encourage positive behaviors.
- Seek the support of a Child Life Specialist that specializes in medical play to help reduce anxiety and normalize pediatric healthcare experiences for patients, siblings and families. Child Life Specialists play an imperative role in prevention and early assessment of medical trauma.
- Children may display hypersensitivity to sensory input, particularly to noises and/or touch, after a traumatic experience. In addition, many children with autism or sensory processing disorder have preexisting sensory needs that can be significantly amplified during and following a traumatic experience. Collaborate with an Occupational Therapist to identify calming sensory strategies that are individualized for the child and their specific needs, and have a sensory toolkit available. Having a classroom sensory break space, and opportunities for proprioceptive input (busy bands, weighted lap pad) can be very helpful. Check out more ideas at The Inspired Treehouse.
- Seek the support of an Occupational Therapist, educator, counselor, and/or mental health professional with knowledge of The Alert Program and The Zones of Regulation. These are frameworks and programs that enhance self-regulation and emotional control. The following visuals (and language associated with these visuals) became imperative in our family’s emotional recovery.
- Do some detective work (with the guidance of a professional) to gain a better awareness and understanding of the child’s triggers. Preventing those triggers, but also having an action plan to help the child develop adaptive responses to those triggers is imperative.
- Provide a safe physical outlet for aggression. Punching a pillow, sit-ups, pull-ups, chair or wall push-ups (or real ones). Don’t expect a child to independently initiate a healthy method of releasing their aggression initially…MODEL IT. I used to get on the floor and do sit-ups in my son’s room in the midst of his explosions. Perplexed, then intrigued…he would ask to lay on top of me to do them too. I needed to encourage a safe release of his anger and frustration, as well as calming proprioceptive (deep pressure) input, so I would position him alongside me and we would do several sit-ups until he was no longer escalated. (Quite frankly it helped me remain calm and prevented me from yelling too:)
- Try to remain as calm as possible during outbursts and behavioral problems (as challenging as this is!). Children need to see that you are a safe place to come to in their moments of difficulty & weakness. But that doesn’t mean that they have permission to mistreat you. Validate their emotions, but keep your prompts simple and direct. “I can see you are angry, but you may not hit me”. As long as they are in a safe space and not hurting themselves, others, or property…give them time to cool down. They are not going to process your verbal directions or any discussion about the behavior while in a state of hyperarousal. Remember CUTL? Check out our 1st blog post to learn about this special acronym:
- Facilitate one on one play opportunities with a trusted adult. Give 2-3 choices of activities (maybe more for an older child) and allow the child to choose. Let them have guided opportunities to control their environment and guide the play. Reduce verbal prompting and listen to what is said or left unsaid. These opportunities provide children with a safe place to talk away from peers and/or siblings.
- Provide opportunities for artwork. Many kids “talk” best through pictures. If something is worrying them, they can write it down or illustrate their “worry”. Check out Worry Eaters that can gobble up their worries. If they are illustrating something that contains content that is upsetting to them, give them permission to crumple or tear their paper. Or even stomp or jump on it and then crumple/tear.
- Seek the expertise of a mental health professional trained in Somatic Experiencing (SE). This method, developed by Peter Levine, is highly effective in dealing with the effects of overwhelm on our nervous system. SE is based upon an appreciation of why animals in the wild are not traumatized by routine threats to their lives, while humans, on the other hand, are readily overwhelmed and often subject to the traumatic symptoms of hyper arousal, shutdown and dysregulation. Find his book, Trauma-Proofing Your Kids, here on Amazon. This is a mental health approach that is very different from traditional Cognitive Behavioral Therapy, but gets to the underlying neurological impact of the traumatic experience. I personally found the results to be overwhelmingly effective in resolving the post-traumatic symptoms I was exhibiting as a parent, and move towards Post-Traumatic Growth. The simultaneous education & strategies for supporting my child was crucial in restoring our parent/child trust bond after traumatic separation.
- There are excellent resources for healthcare professionals, educators and families available at The National Child Traumatic Stress Network. Make sure you check out valuable information & educational resources under the products tab (including downloadable pdf’s).
There is hope!!! With prevention, and effective assessments, strategies and interventions, there are opportunities to help children and families navigate the road to emotional healing after traumatic experiences. If you are struggling personally with toxic stress or professionally to make a meaningful impact with those in your care, please find reassurance that healing takes time and there is no linear path. Just as traumatic experiences are subjective to those that experience them, so too is the path to healing an individualized experience♥.
Christina Connors, OTR/L received her degree in Occupational Therapy from Towson University in Baltimore, MD, and has been working as an Occupational Therapist with children and adults since 2002. Inspired by her son’s medical journey, and her desire to ease anxiety and improve age-appropriate communication for children and families facing medical challenges, Christina developed Child Inspired in collaboration with artist John Donato. Child Inspired is working to bring a blend of Art, Therapy and Functional Communication to healthcare and education settings in order to bridge the needs of children, families and healthcare & education professionals.