PolicyLab

Editor’s Note: PolicyLab is proud to feature some of our clinical partners on our blog who are facing first-hand many of the public health issues that we research. To that end, we’re excited to have Dr. Dorothy Novick, a pediatrician from Children’s Hospital of Philadelphia’s South Philly practice, write this post for us as a follow-up to her STAT “First Opinion” article: “Bringing trauma-informed care to children in need can ease toxic stress.”

For decades I have cared for children who suffer repeated traumatic events and struggle to recover. My patients have witnessed their fathers being shot in front of their eyes. They have been abandoned by their mothers and sexually abused by their neighbors.  

Pediatricians know from caring for families over generations that our young patients’ pain often grows into hopelessness as they become adolescents and dysfunction as they become adults. But only recently have we fully appreciated the biologic basis for this evolution. Recent research has shed enormous light on the long-term effects of adverse childhood experiences, allowing us to tailor our clinical care appropriately.

The Effect of Toxic Stress on a Child’s Well-being and Developing Brain

While a limited fight or flight response to trauma can be protective and adaptive, we now understand that a sustained one can be toxic. When children experience significant stress in the absence of appropriate support, persistent elevations in inflammatory mediators and stress hormones result. This physiologic dysregulation results in an over-activation of the stress response itself, creating a self-perpetuating cycle and leading to permanent changes in the architecture of the developing brain and other organ systems.  It is in this way that severe, persistent stress becomes toxic stress, which impacts areas of the brain that control such crucial functions as memory, learning, and executive function.

This is why our young patients who experience abuse, neglect, abandonment and violence in their homes and communities are literally permanently scarred. This is why they are more likely to suffer from learning disorders and school failure, and to exhibit risky health behaviors such as smoking, unprotected sex and unsafe driving. The toxic stress we see in our pediatric practices leads to long-term mental health problems such as depression and suicidality, and to medical problems such as heart disease, cancer, stroke and autoimmune disorders.

These negative health outcomes disrupt not only the life of the individual child, but future generations, entire communities and society as whole. Toxic stress is now understood to be a significant determinant of health disparities among families living in poverty.

The Move Towards Trauma-Informed Care

The implications of this body of research are profound. In order to prevent and mitigate the effects of toxic stress, institutions that work with children around the country are actively revamping their processes to provide trauma-informed care.

Trauma-informed care is by definition a systems wide-approach. It aims to prevent re-traumatization and reduce barriers to appropriate treatment. It requires increased education for those working with children, expanded screening, and integrated approaches to prevention and therapy. By collaborating and combining our efforts across disciplines, we make it possible to care for the whole child – the psychological, medical and cognitive aspects of the child – while improving access to effective care.

Multiple initiatives at Children’s Hospital of Philadelphia are growing out of this new movement. We now have trained mental health professionals working alongside pediatricians in our primary care offices. We have violence prevention counselors initiating community-based care for assault-injured youth in our emergency department. We have intimate partner violence counselors in several of our clinics, at the ready to provide immediate support to patients who are being harmed by their loved ones. Our goal is to incorporate trauma-informed care across our institution and to extend this care to the communities where children live.

Trauma-Informed Initiatives Stretch Far and Wide

Organizations and governmental agencies across our city and state are similarly committed. The city of Philadelphia is implementing a trauma-informed approach throughout its social service and educational agencies. Philadelphia police are working with the schools to divert children who commit nonviolent crimes toward restorative reforms. The PA Department of Human Services now mandates that foster care children who have experienced sexual abuse enter into specialized therapy. The Philadelphia ACE Task Force was developed in 2012 as a network of over 100 professionals working together to do research, educate communities and implement practical interventions to address childhood trauma and adversity.

Nationally the trend is similar. The National Child Traumatic Stress Initiative raises awareness about childhood trauma and offers training for organizations to provide trauma-informed care. The U.S. Department of Health and Human Services has collaborated with several other federal agencies to produce a “Guide to Trauma-informed Human Services.” And the National Council for Behavioral Health, the Substance Abuse and Mental Health Services Administration and the Centers for Diseases Control and Prevention have all made trauma-informed care a backbone of their programming.

It will take time and resources to fully implement and test the wide variety of initiatives rolling out at the local, state and federal levels. But for those of us on the front lines, working with traumatized children every day in our practices, the changes are palpable. The resources we need are increasingly available at our fingertips. Our patients are accessing care in innovative and novel ways, and the results are life-altering. Trauma-informed care for us is not a buzzword, but a path toward saving lives.