According to the American Psychological Association, trauma is an emotional response to a terrible event: experiencing or witnessing violence, neglect or abuse, just to name a few. Trauma comes in varied sizes and shapes and affects just about everyone. But what happens when our children experience traumas?
We discuss childhood trauma and trauma-informed care with two experts in the field.
Guests:
Khadijia Tribié Reid, MD, MPH, Pediatric Medical Director, MedNorth Health Center, University of North Carolina Chapel Hill School of Medicine Wilmington, North Carolina
Mandy O’Hara, MD, MPH, TCTSY-F, ABOIM, Attending Physician and Trauma Sensitive Yoga Facilitator Montefiore Hospital, New York
Host/Producer: Carol Vassar
TRANSCRIPT
Announcer:
Welcome to Well Beyond Medicine, the world’s top-ranked children’s health podcast produced by Nemours Children’s Health. Subscribe on any platform at NemoursWellBeyond.org or find us on YouTube.
Carol Vassar, podcast host/producer:
Each week we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office. I’m your host, Carole Vassar. And now that you are here, let’s go.
According to the American Psychological Association, trauma is an emotional response to a terrible event experiencing or witnessing violence, neglect, or abuse just to name a few. Trauma comes in varied sizes and shapes and affects just about everyone. But what happens when our children experience traumas?
According to the Substance Abuse and Mental Health Services Association, or SAMHSA, over two-thirds of children report experiencing at least one traumatic event by age 16, and it can be life-altering both emotionally and physically. Today I’m joined by Dr. Khadijia Tribié Reid, Pediatric Medical Director for MedNorth Health Center, part of the University of North Carolina Chapel Hill School of Medicine, and Dr. Mandy O’Hara, attending physician and trauma sensitive yoga Facilitator at Montefiore Hospital in New York to talk about the effects of trauma on the developing brain and the importance of trauma-informed care for children. So let’s dive in with a deeper look at trauma itself. Here’s Dr. Khadijia Tribié Reid
Dr. Khadijia Tribié Reid, UNC-Chapel Hill, NC:
When we use it, the way we’ve been using it in recent years, in the clinical space, we mean those instances, those adversities that we see occurring in children that have an impact on their development and their physiology and their behaviors. So typically when we talk about trauma, we’re talking about any number of category of things like household dysfunction such as domestic violence or neglect or abuse, but there’s a wider range of traumas, of course, including natural disaster. So being a refugee. So there’s a large and wide range of traumas that can impact the development and health of children.
Dr. Mandy O’Hara, Montefiore Hospital, New York:
A trauma I’ve heard defined in various ways, even simply as an extremely stressful experience, but may be associated with pumping life-threatening, fear, helplessness. And what we see, especially in children in the first couple of years of life that are in a critical window of their neurodevelopment, that trauma experiences do change how the brain is wired and can have long-lasting impactful effects that we can get into more.
Carol Vassar, podcast host/producer:
Let’s talk about those effects. How does trauma with a capital T or a small t, specifically affect the brain of a child compared to adults?
Dr. Mandy O’Hara, Montefiore Hospital, New York:
As the brain is actively developing neuron, neuronal pathways are forming in the young infant and early child, there are these critical windows in neurodevelopment. And if trauma occurs in a young child or infant as opposed to adulthood, it can greatly impact how the neurons end up wiring. So for example, in a trauma experience, parts of the brain that are more reactive and emotional take over and our more cognitive reasoning parts of the brain or the neocortex becomes overwhelmed in fear response and shuts down.
And we have the emotional limbic system being the primary driver in the trauma experience. If there are repeat trauma experiences that aren’t buffered, for example, by a supportive nurturing adult, it can become toxic stress and over time rewire the nervous system to expect the world around them to be unsafe and to have increased reactivity to even normal or neutral events in their lives.
Carol Vassar, podcast host/producer:
And this can have effects that are lifelong, correct?
Dr. Khadijia Tribié Reid, UNC-Chapel Hill, NC:
Absolutely. So this is the architecture. This is the foundation for how children develop, how developing minds grow. So when we think about the baseline for cognitive development, hearing speech, all of that is wrapped into these foundational pieces of a early brain development. And so that is why that distinction is made between childhood trauma and the impact versus adult trauma. Certainly adult trauma does have impact. They all are familiar with this term PTSD, so we certainly see that. But in children, we can see long-term cognitive effects, mental health effects, physiologic effects on every part of the body, heart, lungs, et cetera. You see increased suicidal ideation among adults who experienced trauma, these types of traumas, especially four or more at less than 18 years of age. So really a significant public health issue.
Carol Vassar, podcast host/producer:
It affects all parts of the body. Does it affect all parts of the brain as well?
Dr. Mandy O’Hara, Montefiore Hospital, New York:
So they found that the trauma experience, because in that moment focus has to be outward on the external environment that is threatening. The more internal sensory perceptions get shut down. That part of the brain is the medial frontal cortex or the insula. That’s where we process what’s called interoception, which are our inner body senses. This may be feeling hungry, feeling the stretch of a muscle, feeling more internal needs that get pushed aside in a child who goes through, for example, developmental trauma or chronic abuse or neglect. And those pathways aren’t wired. Studies have shown that is a targeted therapeutic approach to help heal trauma. So whereby there are long time lasting effects like Dr. Reid, you were saying, if there are four or more adverse childhood experiences, there’s a host of data showing adverse long-term increased morbidity and well into adulthood. Nonetheless, there are treatments that can help. We do have trauma-informed evidence-based treatments that can rewire these parts of the nervous system over time.
Carol Vassar, podcast host/producer:
I did want to ask about that. Are these changes reversible? Dr. Reid.
Dr. Khadijia Tribié Reid, UNC-Chapel Hill, NC:
Yeah, well, of course it’s easier to build strong grains to begin with than to try to reinvigorate and recuperate those skills later. It can be done. It certainly can be costly to educational systems and healthcare systems. So ideally, we don’t have these children experiencing these traumas or we have them experiencing the traumas in the context of a safe, stable, nurturing relationship, in which case they can be more resilient. But certainly we see children, I see children in my clinic all the time who developmentally are not normal, probably due to some trauma they experienced early on. They get into a foster care home or their home situation becomes more stable, and they do start to recuperate those skills over time. So I certainly do believe there is an opportunity to recuperate those social and emotional and cognitive skills.
Carol Vassar, podcast host/producer:
Are there signs, are there symptoms of trauma that parents or pediatrician should be looking for in children?
Dr. Khadijia Tribié Reid, UNC-Chapel Hill, NC:
The way I like to think about this when I’m talking to caregivers, to pediatricians, to teachers is to keep trauma on the differential. I think there was a period of time where children would behave a certain way in the classroom and we say they must have ADHD. That seemed to be the thing of the day. And so as we learned more about trauma, I think we started to realize, well, maybe there’s something else here. So then we had to kind of zoom out and look at the wider context, take the focus off just the child and start looking at some of the socio-ecological framework around them, some of the context around them and saying, well, wait a minute, dad was just incarcerated, or she just lost her grandmother who was her primary caretaker, et cetera, et cetera. And then realizing these things were adding up. But of course, the ACE study helped us a great deal, reverse engineer and really scope out and think about what was happening with these children.
Carol Vassar, podcast host/producer:
Tell me more about that study. I hadn’t heard about that.
Dr. Khadijia Tribié Reid, UNC-Chapel Hill, NC:
ACE study is a really important study in which 17,000, I think, Kaiser Permanente patients were surveyed. And these were adult patients, these were patients who had insurance. And in that survey, they were asked about traumas experienced before 18 years of aid, and this is where we get this number of four or more. So in that study, the conclusion was that individuals who had had four or more childhood adversities were significantly more likely to have both physical and mental health consequences.
Carol Vassar, podcast host/producer:
Talk about the mental health consequences. What do we see in children or even adults who have had a childhood trauma that could lead to or exacerbate a mental health concern?
Dr. Mandy O’Hara, Montefiore Hospital, New York:
So the trauma experience causes a fight or flight or freeze response. So that fight or flight, we consider a form of hyper arousal that might mimic, as was explained, that ADHD kind of picture, where in fact the root cause might actually be trauma exposure. Then there may even be hypo arousal. We may see the child withdrawn, avoiding school, disengaging, experiencing depression, and that’s actually from fatigue and shutdown of parts of our nervous system. So we can see either experience in kids who’ve been traumatized. Sometimes it meets the definitional diagnosis of post-traumatic stress disorder.
But with this criteria for such a psychiatric diagnosis, we may not be capturing every child who’s been exposed to trauma. Many of the kids are appearing like ADHD with hyper vigilance, hyper arousal, increased startle response because they were wired to be outwardly focused because of so much threat in their environment that going forward, they’re wired to experience even normative life as threatening. We also might see the more depressed or withdrawn child. Sometimes this comes out in play in a very young child, so we can be tuned into that. Parents families are often tuned into that if there’s a change in play behavior, increased aggression or withdrawn, less engagement with play.
Carol Vassar, podcast host/producer:
But there’s hope, and I want to talk about that, and that is trauma-informed care. Dr. Reid, what is trauma-informed care?
Dr. Khadijia Tribié Reid, UNC-Chapel Hill, NC:
It’s providing care with the knowledge of all that we’ve spoken of today. It’s providing care, knowing that this context of trauma and the impact of trauma exists and all of the things that go in there. So you don’t just realize that this child could present with this symptoms, but you also realize that trauma is intergenerational. So when you get that parent who came late to their appointment and they have an attitude and you’re thinking, “Why do you have an attitude? You came late to your appointment,” you realize, oh, they may have trauma symptoms as well, which may be increased irritability or anxiety or defensiveness. And so you practice medicine in this context of realizing that trauma exists.
Now, we do utilize, I love to utilize a public health framework called the Public Health Relational Health Pyramid, in which at the base of the pyramid, which means every child, every family is encouraged to spend time with their children and have strong relationships and create safe, stable, nurturing spaces for their children, read books with their children, sit at the dinner table, those strong relationships that we know help children to flourish.
But at the second level of that pyramid, you say, “Well, what if we see it peaks, that the family does not have the capacity to do that for whatever reason?” Maybe there are social stressors. Maybe there are social determinants of health, mental health issues. How do we help them get there? So in those instances, we provide maybe a little bit more support, maybe we have a relationship with a food pantry, we make sure that they have food. Maybe if they’re stressed, intellectual, we help them fill out their school paperwork. What do we do to fill in the gap so they can be at the base of the pyramid and not at that second level stressed out.
And then at that top or the pyramid, those are the kiddos who are experiencing symptoms of toxic stress. Those kids need treatment. They need perhaps cognitive behavioral therapy or deeper family therapy. So those are the ones that we would treat. So that kind of gives you a general idea of what trauma-informed fear can look like to use that relational health pyramid.
Carol Vassar, podcast host/producer:
Does that help with the healing? I know it might not be a complete healing, because the brain is wired and might just be wired forever, but can it help in healing?
Dr. Khadijia Tribié Reid, UNC-Chapel Hill, NC:
I do believe it does. What it does is create a context where the family, anyone who’s gone to therapy for themselves realizes sometimes it’s just sitting there with that therapist and realizing, “Wow, this thing that happened isn’t your fault,” where you’ve been looking at it from this perspective all your life, and there’s this thing that happened. So in that context, we’re able to explain to families, look, your baby’s fine. Your baby is experiencing some dysregulation. There are some problems. We’d like to turn this around, but stress can pause there. So let’s talk about some of the stressors, and in fact, help families understand what is stressful. Because we have so many families dealing with stress at a base level, they don’t even recognize it as stress. They don’t even realize that that death or that incarceration or that move, even a move to a different home or displacement, they don’t even realize those were the stressors. So just helping families put things into perspective.
Carol Vassar, podcast host/producer:
What roles do factors like resilience and maybe other protective factors play into buffering the brain from damaging effects of trauma, Dr. O’Hara?
Dr. Mandy O’Hara, Montefiore Hospital, New York:
Well, the literature really points to the safe, supportive, nurturing relationship, that foundation that’s been referenced. So knowing that there’s one person in your life that’s dependable, loving, and trustworthy can buffer the long-term consequences of traumatic experiences. So that is foremost, and it may not necessarily be what you think. It might not be that biological parent or primary guardian. It may be a foster parent. It could be even in certain context, the local librarian that that child turns to and knows is dependable in the safety of a library setting. So it could be vast, but studies have shown that that is probably the most important factor to prevent extremely stressful event from being toxic, but rather being tolerable.
In trauma-informed care, we create systems that recognize the biological impact of trauma as we’ve begun to discuss, recognizes it, and then responds accordingly, and refers to evidence-informed trauma-focused treatments that have been shown to be effective about, I think I’ve seen some data, maybe even 75% of the time, trauma-focused cognitive behavioral therapy can help.
And I believe it’s never too late. Though it’s never easy. Additionally, there are some theory that because of the trauma’s effect on the brain, when these experiences come in, as we said that the thinking part of the brain is overwhelmed, it shuts down. That includes areas like the hippocampus where memories are typically stored, that’s shutting down. So when someone has a threatening traumatic event, the memories are stored differently. They’re stored more in the physical body as guttural responses, rapid heart rate, muscle tension, bodily collapse, etc.
So many people, especially our mental health colleagues, believe that trauma is actually stored in the physical body. So while our mental health talk therapies are shown to be very helpful for a complete healing of trauma, there are some studies suggesting that somatic therapies that get into the body complement and are adjunctive to completely heal post-traumatic stress disorder in adults.
Carol Vassar, podcast host/producer:
Are you talking about things like EMDR?
Dr. Mandy O’Hara, Montefiore Hospital, New York:
So EMDR is definitely one of the evidence-informed trauma therapies, and I’m also thinking of things like somatic experiencing. Also trauma-sensitive yoga has been well studied in randomized trials to diminish post-traumatic stress disorder in adults from complex early childhood traumas who’d been in talk therapy for three plus years with resistance-persistent PTSD symptoms. And after 10 weekly sessions of one form of trauma-sensitive yoga study I’m familiar with, it actually reversed the diagnosis of post-traumatic stress disorder and diminished symptoms in something like 52% of participants versus 30% of a control group. The control group who had a regular health education session weekly relapsed. But the trauma-sensitive yoga group specifically did not and had consistence, diminished, and even a resolution of PTSD.
Carol Vassar, podcast host/producer:
You talked about the parent or the caregiver or the librarian or the teacher who could be that one anchor, if you will, for a child who has had trauma in their life, how can they best support this child?
Dr. Khadijia Tribié Reid, UNC-Chapel Hill, NC:
Yeah, I think that’s a great question. I think a lot of people look at themselves and say, “Wait, not me.” And so I always want to remind pediatricians, “Yes, you,” definitely think about teachers and pediatricians and librarians as such. They’re often watching children grow in their communities over years and years. So as a pediatrician, for example, I’ve watched children with their biological parent go into foster care, go into various foster care placements, and maybe even back to a biological parent or to an adopted parent, and I was their pediatrician the entire time. That was literally the safe, stable, nurturing relationship. So it really just means being present, being supported regarding the child, giving the child an opportunity to be, having conversation with the child, giving the child opportunity to know they’re important, and whichever role you play in that, regardless of how small or how large it can mean the world to a developing child.
Dr. Mandy O’Hara, Montefiore Hospital, New York:
I’d like to close on an optimistic note. The brain is plastic, there’s neuroplasticity and with the best approaches that are trauma-informed, there can be healing of even complex trauma throughout one’s lifetime.
Carol Vassar, podcast host/producer:
So there is hope no matter how old you are.
Dr. Khadijia Tribié Reid, UNC-Chapel Hill, NC:
I think there is, I think the thing I would like to add as well is as we think about trauma and trauma-informed systems, really want to focus on their word systems. I think medicine has really made a beautiful progression from blaming things on the child and on the parent where we used to say, “Oh, I know they’re smoking. I can smell it on them. They’re smoking.” And be very judgey. We’ve kind of progressed outside of that and started to think, well, “Why is the parent smoking? Maybe that’s to release an allostatic load on something that’s stressful for that parent. What’s going on in that community? Do they have insurance? Do they have housing? Look how expensive housing is. What are the policies that dictate that? Who is the congressman I need to talk to? And eventually, what is the culture outside of that that allows us to move in these directions? So hopefully you’re increasingly thinking beyond that exam rooms and into beyond the walls of the clinic.
Carol Vassar, podcast host/producer:
Dr. Khadijia Tribié Reid is the Pediatric medical director for MedNorth Health Center, part of the University of North Carolina, Chapel Hill School of Medicine. We also heard from Dr. Mandy O’Hara, attending physician and trauma-sensitive yoga facilitator at Montefiore Hospital in New York. Thanks to both Dr. Reid and Dr. O’Hara for joining us to talk about trauma in children and trauma-informed care. And thanks to you for listening.
It’s a big, wide world of factors that happen outside the doctor’s office and affect children’s health, and we’re out to learn as much as we can about all of them. Your podcast ideas are always helpful in that regard, which is why we give you a couple of different ways to share them with us. You can send an email to [email protected], or you can surf to our website, nemourswellbeyond.org and leave us a voicemail. That’s nemourswellbeyond.org.
While you’re there, you can subscribe to the podcast and leave a review. And don’t forget, the podcast can also be found on your favorite podcast app as well as the Nemours YouTube channel. Our production team for this episode includes Cheryl Munn, Susan Masucci, Lauren Teta, and Steve Savino. Join us next time as we look into how health IT can be leveraged to promote health equity and reduce bias. I’m Carol Vassar. Until then, remember, we can change children’s health for good well beyond medicine.
