Why providing care informed by trauma is important

Most people do not get through childhood without some form of trauma. Some people have the resilience to deal with this trauma without lasting consequences, but for others it is more difficult.

Pediatricians are one of the most consistent forces in many children’s lives, and the American Academy of Pediatrics (AAP) has released 2 new guidelines to help them guide families in coping with and processing trauma.

“For a long time, pediatrics knew about trauma. We’d know what’s happening, but pediatricians weren’t quite sure how to respond,” said Heather Forkey, MD, FAAP, a pediatrician at UMass Memorial Health in Worcester, Massachusetts.

Forkey helped write both papers and said there is a big difference between knowing a trauma has occurred and knowing how to treat it.

In many cases, the symptoms of pediatric trauma are difficult to distinguish from other problems because they can have so many different causes. Trauma presents itself as a spectrum, she explained, and it can look different at every point on that spectrum. Pediatricians are often taught that post-traumatic stress disorder looks like the reaction of a soldier returning from war, but trauma can look different for each person, especially children.

“That’s what you should look for,” Forkey said. “If a baby has a mother with postpartum depression and can’t interact with the baby, the baby will have developmental issues that don’t really fit the picture of trauma.”

The 2 new articles – a clinical report1 and a policy statement2 – address a number of issues that children should be aware of in terms of developmental, behavioral and physical signs of trauma.

“It’s a spectrum of symptoms across a spectrum of development,” she said. “When you see these symptoms, one of the things you want to think about is, could trauma be part of what you’re seeing?”

The FRAYED mnemonic that can help with these assessments, Forkey said.

F: Frets or fearsR: Control problemsA: Attachment problemsY: Yawning and sleeping problems or dirty feelingsE: Delay in educationD: Depressed, depressed, dissociated

These signs could indicate trauma, and that’s important to acknowledge, Forkey explained. Perhaps promoting resilience is the best thing a pediatrician can do when he sees a trauma. Resilience can help children overcome trauma and have a protective effect on their overall mental health and functioning. Pediatricians can do this by promoting things like:

Self-regulationA sense of homeControl over the child’s environmentAppendicesSocial skills

“Those are things we try to promote when we see children who have been affected by trauma,” she said.

Pediatricians are used to looking for developmental and physical delays, but behavioral cues can be harder to spot in these assessments because they can be attributed to so many other causes. What can help is to monitor regularly, conduct behavioral surveys, and ask open-ended questions that can encourage a child to share how he or she is feeling. Forkey said she likes to lead with, “Has something scary or difficult happened that concerns you?”

“If you don’t let them know you can talk about it, maybe they won’t bring it up,” Forkey said. “Pediatricians normally ask children historical questions. Did something bad happen? Have there been any illnesses in the family? With those questions, we open the door to find out if something traumatic has happened.”

Some pediatricians talk about using the childhood adverse event screening (ACE), but these tools haven’t really been validated for use in clinical care, she said. Doctors should not view this screening as a diagnostic guide, but more as an opportunity to start a discussion. Succession is key.

“If you are going to use [ACE]”It’s not something the front desk hands someone over and nobody follows up,” Forkey warned. “If we don’t validate and address that, we’re not really doing our job.”

While the articles provide a detailed guide for pediatricians to use in practice, Forkey said it’s important to remember that connection is key in the first place. Engaging and connecting with your patient is the only way to get started.

“Be there for them,” she explained. “Curiosity, respect and empathy are the keywords. This work requires us to connect on a human level.

The next step is to decide what kind of response is needed. Is there a need for more research into the cause of the trauma? Having the knowledge and tools to respond is important and can be used to help families continue home care, she said. Referrals to behavioral health or trauma specialists can also help, Forkey added.

Perhaps most importantly, she noted, is to leave families with a sense of hope.

“One of the things we can be accused of is families being overwhelmed,” Forkey said. “Sometimes with trauma, we forget that our positive expectation of recovery is what families need to hear from us.”

Pediatricians must also provide validation. They need to get the message across to families that trauma is hard to deal with, but it is possible to move forward.

“This is how we promote recovery. Fundamentally, what we’re talking about is the fact that in trauma you have a stress response dysregulation,” she explained.

People rely on the partner’s response as their first stress response, Forkey said. They are looking for people who can help them with their problems. If not, the traumatized person will engage in fight-or-flight and other stress responses that have more severe physical and behavioral consequences.

“What we as humans have to do is reach out and say ‘who can help me?’ And we need to be that partner support for them so they can reduce that stress and start healing,” Forkey said, adding that recovery happens when relationships that provide that support start. “It’s so important for kids to get the message that it’s the things you need to do to reach others. Some children are told that reaching others is not safe, and this leads to a lifelong struggle with accepting support and accepting help.”


1. Forkey H, Szilagyi M, Kelly E, et al. Trauma-informed care. Pediatrics. 2021;148(2):e2021052580. doi:10.1542/peds.2021-052580

2. Duffee J, Szilagyi M, Forkey H, et al. Trauma-informed care in child health systems. Pediatrics. 2021;148(2):e2021052579. doi:10.1542/peds.2021-052579

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