Pediatrician Heather Forkey, MD, saw the symptoms of childhood trauma in her patients before she recognized what she was seeing.
At the foster care clinic where she worked early in her career, she and her colleagues noticed that the children “all looked remarkably alike,” she said. “They were getting diagnoses of things like ADHD, oppositional defiance disorder, and bipolar disorder, and having rough outcomes as adolescents.”
At the time — in the 1990s and early 2000s — Forkey felt like they were missing something obvious. It just didn’t make sense that all the kids had these disorders. But as the medical community began to “better understand how the body and the brain are impacted by trauma,” things began to make more sense, she explained.
Since then, “there has been a complete brain shift,” she told Medscape Medical News.
Research, such as the seminal 1998 study on adverse childhood experiences, has shown that childhood exposure to abuse, neglect, or other household challenges has an impact on health and well-being that can continue into adulthood.
What happens in childhood does not stay in childhood.
We now know that “what happens in childhood does not stay in childhood,” said Andrew Garner, MD, PhD, from the Case Western Reserve University School of Medicine in Cleveland, who is a member of the American Academy of Pediatrics (AAP) Committee on Psychosocial Aspects of Child and Family Health.
Not only has this changed our understanding of the body’s response to trauma and toxic stress, it is also changing our whole model of health and disease. “We now see things through an eco-bio-developmental lens,” he told Medscape Medical News.
Research in different fields, including epigenetics and neuroscience, suggests that “the early ecology of childhood becomes — literally — biologically embedded in the way the genome works and the way the brain gets wired,” and this drives change over the course of a lifespan, he explained.
This represents a potential “sea change” in pediatric practice, he said. If we want to affect adult outcomes, “we’ve got to get things right the first time, instead of constantly trying to repair, remediate, and fix what seem like intractable problems down the line.”
“And I think that to move forward, we have to pivot away from toxic stress and adversity,” said Garner, who was involved in the development of the AAP policy statement on childhood toxic stress.
He referred to a recent study that showed that positive childhood experiences can “have lifelong consequences for mental and relational health despite co-occurring adversities such as [adverse childhood experiences].”
This means that although we need to “decrease adversity, we also need to build resilience,” he said.
This is where Forkey comes in. “In the relationship that medical providers have with parents and kids, our role is fairly limited in our ability to stop the adversity,” she said. “But we are the people families turn to to help them be better parents, to help them understand development, and to help them raise their child to be resilient.”
“Supportive relationships play an enormous role in resilience across the lifespan. Close attachment bonds with a caregiver and effective parenting protect a young child in multiple ways that are not located ‘in the child,’ ” write Ann Masten, PhD, and Andrew Barnes, MD, from the University of Minnesota Medical School in Minneapolis, in a commentary on resilience in children. They identify common resilience factors that are crucial for childhood development, including hope, self-regulation skills, and problem-solving skills.
But if a child does not develop these skills within the family, all is not lost, they say. “Resilience studies also suggest that there are windows of opportunity for facilitating resilience through preventive interventions,” they report.
The literature says ‘promote safe, stable, and nurturing relationships.’ But practically, how do you do that?
Forkey currently runs the Foster Children Evaluation Service (FaCES) and the child protection program at the University of Massachusetts Memorial Children’s Medical Center in Worcester. “My career is working with kids who have suffered the most severe adversities,” she said.
An important part of her work is to help other pediatricians recognize the signs of trauma and teach them how they can go beyond treating trauma to promoting resilience.
She admits that she was initially frustrated by the literature she read about resilience. “The literature says ‘promote safe, stable, and nurturing relationships.’ But practically, how do you do that?” she said.
This is the question she set out to answer during her presentation at the AAP 2019 National Conference in New Orleans.
The first step in Building Strong Children Instead of Repairing Broken Adults is for clinicians to be able to recognize symptoms of trauma. When you experience trauma, you are dealing with a threat, you are injured, and your sense of the future or of hope is lost, Forkey explained. In children, this results in the development of a particular set of symptoms that fall into common categories.
To help pediatricians easily identify these categories, Forkey came up with the mnemonic FRAYED, which stands for fits, frets, and fear; restricted development; attachment disorders; yelling and yawning; educational delays; and defeated/dissociation.
When physicians see symptoms that fall into these categories, they should think about the potential for trauma or toxic stress, she said.
Another way of seeing these symptoms is that the “child has had some of their resilience skills challenged,” she added.
Drawing from the work of Masten and Barnes, Forkey developed another mnemonic, this time for resilience skills. THREADS stands for thinking and learning brain; hope; regulation or self-control; efficacy; attachment; developmental skill mastery; and social connectedness.
The Three Rs
If symptoms are identified as stemming from trauma, the question becomes: What can you do? Pediatricians need things they can do quickly in the office, Forkey said.
As with any symptoms, clinicians can start with the basics. For example, if a child comes in with diarrhea, pediatricians will start with the BRAT (bananas, rice, apple sauce, toast) diet. If the child gets better, good; if not, the caregiver should bring the child back.
The same approach can be used for adverse experiences, but instead of BRAT, the first step is the three Rs: reassuring, restoring routines, and regulation.
After a traumatic event, the first thing to do is to reassure the child — again and again — that they are safe, said Forkey. “The second one is restoring routines. Any time there’s a trauma, routines are the first thing out the window, but routines are incredibly regulating; they calm you.”
“The third one is regulation, and that can be many things; for example, we can start with belly breathing,” she said. “Ultimately, regulating is about being able to identify your emotions and then modulate them, and that can start with giving kids the words for what is going on.”
Take the case of a foster child who is unable to visit with a parent so becomes disruptive at school and flips a desk. This child is not angry, said Forkey. “They are disappointed, they have grief, they are worried about their parent, they feel disrespected — there is a host of emotions that these kids don’t have the words for.”
Another piece of the puzzle is educating caregivers so they know how to make children feel safe. For this, Forkey created yet another mnemonic, SEAM, which stands for safety; emotional container; predictable compassionate availability; and keeping the child’s mind in mind.
For example, if a baby is crying and the mother picks the child up and provides comforts, that is being an emotional container, she explained. Predictable compassionate availability means that caregivers are consistent in their responses; that is, the child doesn’t get one response when their caregiver is in a good mood and another when they are in a bad mood.
As for keeping the child’s mind in mind, “we figure ourselves out because people reflect who we are to us,” said Forkey. “If the baby cries and the mother picks it up and says, ‘You’re hungry, let’s do something about that,’ the baby learns this is hunger.”
“But if the mother is impaired or can’t deal with it, and when the child cries, she says, ‘You are so greedy, why do you keep bothering me?’ the baby learns that this feeling I have is being greedy and no one helps you with that.”
What we are trying to do is translate evidence-based science, including cognitive behavioral therapy and attachment literature, into language and concepts that are recognizable for all caregivers, she said.
Need for System Change
These simple interventions can make a difference, said Garner, but we need the time to build relationships with the family.
“As pediatricians, we are essentially forming therapeutic alliances with families,” he explained. “We can’t do that if we are busy documenting so we can bill the insurance company. This is a source of frustration across primary care.”
American Academy of Pediatrics (AAP) 2019 National Conference.