July 02, 2016

Five years after Hurricane Katrina, experts reported that at least 20,000 displaced children continued to struggle with storm-related emotional and behavioral problems. Fewer than half had received any psychological help. Since then, dozens of mass shootings and hundreds of natural disasters in the U.S. have left many more children traumatized — often with the same lack of support found in the Gulf Coast just over a decade ago.

To address this problem, the National Child Traumatic Stress Network has advocated that health care systems integrate trauma awareness, knowledge and skills into their practices and policies. It has also developed a toolkit for first responders and emergency department providers — often the first to deal with traumatized kids and their families. The toolkit is based on the D-E-F protocol, which helps providers respond to distress, provide emotional support and ensure family-centered care:

Distress

• Manage pain.
• Ask about fears and worries.
• Consider grief and loss.

Emotional support

• Who and what does the patient need now?
• What are the barriers to mobilizing existing supports?

Family involvement

• Assess the distress of parents, siblings and others.
• Gauge family stressors and resources.
• Address needs other than medical ones.

Daniel R. Hilliker, Ph.D., L.P., a pediatric psychologist at Mayo Clinic's campus in Rochester, Minnesota, says traumatic events and subjective reactions to them are complex, and a wide range of issues fall within this basic framework. For example, identifying distress can be challenging because children's reactions to trauma can vary greatly, depending on their age, developmental level, prior experience with trauma and loss, the nature of the traumatic event, and even the post-traumatic environment.

"Kids can react to trauma in every possible way," he explains. "Some are hyperaroused and hypervigiliant, feeling anxious and fearful about what will happen next. Others may be very shut down and hard to engage. They figuratively and sometimes literally pull the covers over their heads. Differences also occur from one age group to another. Very young children may not have language, so they express their feelings behaviorally — by acting out or trying to get away from the situation. Older kids use language to make sense of what happened, creating a narrative to organize their thinking. Awareness of the range and complexity of reactions is essential to accurately diagnose and support traumatized children."

Dr. Hilliker says at any age, trauma undermines a child's sense of protection and safety, and the most important thing health care providers can do is try to restore feelings of safety and control.

"A medical setting can be threatening, and it's crucial that kids are given reassurance about their safety as well as the opportunity to have some sense of control and choice-making. If it's a nonurgent situation, give them options. For instance, you might say, 'There are a couple of things we need to do. Would you like me to listen to your heart or your lungs first?' Tell them it's a safe place where people will help them, but don't give false reassurance," Dr. Hilliker says. "Instead, give them honest, age-appropriate information about what to expect."

He also suggests talking about the typical responses children might have, such as not being able to calm down or repeatedly replaying the traumatic event in their heads.

"Tell them this is what our brains do when we've been through something scary, threatening and shocking. And let them know that it typically doesn't become a long-term problem," he says.

Involving parents

Parents are vital partners in helping manage children's distress. Health care providers are often meeting a child for the first time and may not have enough information about the family or the family environment to adequately respond to a child's needs. Dr. Hilliker suggests the following:

• Ask parents to share their knowledge of their child. They are the best interpreters for younger children, who don't have as much language and whose behavior may be harder for strangers to understand.
• Give parents some options and sense of control in their child's assessment and treatment. Promote their involvement; sometimes parents feel they should step aside, even when it's not necessary. In these instances, provide concrete suggestions about how to stay engaged in supporting their child.
• Assess the parents' level of stress. "If the parents' response is extreme, then we want to find some support for them before we can expect them to provide meaningful support for the child," Dr. Hilliker says.
• Assume that parents and children have some competence, resilience and coping skills. But keep in mind that despite a certain level of resilience, kids and families are often dealing with pre-existing stressors that already strain the family system. When they are hit with an acute stressor, they may present with significant distress.
• Identify community support for struggling families, such as county case management or help with basics such as food or housing. Ensure access to psychiatric follow-up for those at high risk.

"We assume an underlying resilience in kids and families, but also understand that certain risk factors can interfere with recovery following trauma. So we thoughtfully assess these risks and attempt to provide medical care that is sensitive to the unique needs of the patient and family. In doing so, we can provide a sound foundation for the emotional healing process," Dr. Hilliker says.

For more information

Pediatric Medical Traumatic Stress Toolkit for Health Care Providers. National Child Traumatic Stress Network.