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Approach to the mental health
aspects of childhood trauma and
toxic stress for primary care
Rachel Yoder, MD
Georgetown Child Psych
• Review what is known about acute and ongoing
effects of trauma in children and adolescents
• Improve pediatrician comfort and skill in
assessing and responding to mental health
aspects of trauma.
The reduction of toxic stress in young children ought
to be a high priority for medicine as a whole and
for pediatrics in particular.
- AAP Policy Statement
Garber AS, Shonkoff JP, Seigel BS, et al.Early Childhood adversity, toxic stress, and the role of the pediatrician: translating
developmental science into lifelong health. Policy statement of the AAP. Pediatrics. 2012: 129:3224-e231
cc: 7 yo M attempted to choke another student and kick teacher
• Other kid said something about
his mom. Admitted to PIW x 1
week. Started on Concerta and
- Asthma (albuterol prn)
- Evaluated for ADHD 1 year ago,
no f/u
- Speech delay (speech therapy in
- Poor prenatal care but normal
- mother with “drug problems”
- Siblings with ADHD
- Older sibling incarcerated for
SH : Lives with mom, siblings ages
3,5,10,13,15 + multiple older cousins
who use home as “hide out” and “teach
him how to fight.” At times if he is “acting
out” is sent to live with grandparents –
less chaotic environment. Periodic CPS
involvement, never taken from home
School: Daily aggressive incidents against
other children with minimal provocation,
yells, acts out.
Teacher Vanderbilt: 8/9 inattention, 9/9
hyperactivity/impulsivity, 8/8 ODD, 2/3
CD, 1/3 anx, 2/3 depression
Trauma Hx: Denies physical and sexual
abuse when asked alone. Witnessed
shooting resulting in severe injury in
front of house last year.
Trauma Basics
• Trauma is common: 1/4 – 2/3 of children/adolescents
experience a traumatic event before reaching adulthood
• Most individuals who experience a traumatic event have
some degree of post traumatic symptoms immediately
– Children, even if they do not meet full criteria for
PTSD, still often have ongoing functional impairment
Costello et al. The prevalence of potentially traumatic events in childhood and adolescence.
2002. Journal of Traumatic Stress. 15 (2) 99-112.
Bethell C et al. Adverse childhood experiences, resilience and mindfulness-based
approaches. Child Adolesc Psychiatric Clin N Am 2015.
Carrion VG, Weems CF, Ray R, Reiss AL. Toward an empirical definition of pediatric PTSD:
the phenomenology of PTSD in youth. J Am Acad Child Adolesc Psychiatry. 2002;41(2):166173.
Trauma Basics
• Most likely to result in PTSD symptoms:
– Sexual abuse (39.3%)
– physical assault by a romantic partner (29.1%)
– physical abuse by a caregiver (25.2%)
Mclaughlin et al. Trauma exposure and posttraumatic stress disorder in a national
sample of adolescents. 2013 JAACAP: 52 (8): 815-30.
Trauma types
• Acute, single event
– Physical/sexual abuse
– Witnessing DV, shooting
– Car accident
• Chronic/complex/toxic stress
– Neglect
– Repetitive abuse
– Disruptive and Disrupted environments
* Often occur together *
Toxic stress: prenatal, early postnatal
• Fetal exposure to maternal stress can
influence later stress reactions
– Likely due to epigenetic modifications of DNA
• Early postnatal experiences with adversity
affect future reactivity to stress
– Alter developing neural circuits controlling
neuroendocrine responses
Shonkoff et al. 2011. The lifetime effects of early childhood adversity and toxic stress.
Pediatrics Technical report.
Garner et al. 2015. Translating developmental science to address childhood adversity.
Academic Pediatrics
Toxic stress: through ongoing development
• Ongoing stress  prolonged exposure to stress
hormones prolonged exposure to
inflammatory cytokines  changes in immune
– Brain: multiple glucocorticoid receptors in amygdala,
hippocampus, prefrontal cortex (learning and memory).
Chronic exposure to glucocorticoids alters their function,
• Less organization and control from prefrontal cortex
• More anxiety/hyperactivation of amygdala
• Limits the ability of the hippocampus to promote context in
learning (distinguish between safe/not safe)
- Rest of body: higher risk of asthma, metabolic syndrome,
Trauma effects
• Trauma exposure, even if it does not result in PTSD,
places children at risk of:
– Depression
– Suicide attempts (8x more likely in victims of sexual
– Substance abuse
– Learning/academic problems (cognitive delay,
impairments in executive functioning, missed
– Medical problems
– Relationship/career problems
1. Fergusson et al. Childhood sexual abuse and psychiatric disorder in young adulthood II:
psychiatric outcomes of childhood sexual abuse. JAACAP. 1996.35 (10):1365-74.
2. Adverse childhood experiences studies
3. Shonkoff et al. The liffetime effects of early childhood adversity and toxic stress.
Pediatrics Technical report.
Post traumatic stress disorder DSM 5
*(Pediatricians do not have to diagnose this)*
• Exposure to a traumatic event
• Intrusive memories, dreams; distress at reminders
– Often seen as recurrent play (distressing or nondistressing)
• Attempt to avoid external reminders, memories,
thoughts, feelings about event
• Negative alterations in cognition and mood
– Distorted understanding of the event
– Social withdrawal, decreased interests, negative beliefs
about self
• Alterations in arousal and reactivity
– Irritable behavior, angry outbursts
– Hypervigilance
– Sleep disturbance, difficulty with concentration
Trauma presentations
• Somatic complaints
– Poor concentration while avoiding, reexperiencing, being
– Outbursts, irritability if exposed to ongoing trauma
• Panic disorder/other anxiety disorder
– Arousal with trauma reminders, sleep disturbance
• Specific phobia
– Avoid trauma reminders
– Social withdrawal, affective numbing, sleep disturbance
• Substance use disorder
– Use for coping
Risk/protective factors for developing
Risk factors:
• Female gender, multiple traumas, greater exposure to the
index trauma, presence of a preexisting psychiatric disorder
(particularly an anxiety disorder), parental psychopathology,
lack of social support
Protective factors :
• Parental support, lower levels of parental PTSD, resolution of
other parental trauma-related symptoms, parent report of
less parenting stress and more engagement in their child’s life
Caregiver’s capacity and response to the trauma
Pine DS, Cohen JA. Trauma in children and adolescents: risk and treatment of psychiatric sequelae. Biol
Psychiatry. 2002;51(7): 519-531.
Bethell C et al. Adverse childhood experiences, resilience and mindfulness-based approaches. Child
Adolesc Psychiatric Clin N Am 2015.
What can you do in the office/hospital
– Because we know we miss it
– Its not going to get better on its own
– the AAP says you should
Shonkoff et al. 2011. The lifetime effects of early childhood adversity and toxic stress. Pediatrics Technical
AAP Policy Statement: Early childhood adversity, toxic stress, and the role of the pediatrician: translating
developmental science into lifelong health. Pediatrics 2012.
How to assess for trauma:
Normal part of social history each visit
Broad then specific, explicit, very routine, normalize:
“I’m a doctor, I care about you, its my job to make sure I ask about
everything in your health, and now I’d like to ask some important
and serious questions”
• Do you think your child ever has experienced anything very scary to
them, like see someone hurt someone else, or felt like they might
be hurt by someone else? Storm, car accident, fire, been around a
shooting, been in a situation where police/ambulance/fire engine
involved/911 was called?
• Do you have any concern that your child has ever been touched in
their private areas inappropriately by an older child or adult?
Avoid using the words trauma or abuse
How to assess for trauma:
Normal part of social history each visit
• Has anything ever really scary happened to you?
• Has anyone who is older than you touched your
penis/vagina (word for these)?
• Have you seen anyone hurt anyone else really bad on
• Has an adult ever hurt you on purpose?
• Have you ever been around with
policemen/ambulance/fireman came?
While we’re on the topic of sensitive
• Have you ever thought about hurting yourself
on purpose?
• Have you ever thought about killing yourself?
Are there screens?
• Not reliable screens for trauma occurrence compared to
personal interview
Reliable for:
• Social determinants of health (toxic stress)
– SEEK parent questionnaire (risk of maltreatment)
– Bright futures pediatric intake form
– Parenting stress index
ADHD/behavior (Vanderbilt)
Anxiety (SCARED)
Depression (PHQ9)
Development (ASQ, MCHAT)
AAP Mental Health Toolkit
SEEK parent questionnaire
(Safe Environment for Every Kid) ages 0-5
“Being a parent isn’t easy, we want to help everyone have a
safe environment for kids. We are asking everyone these
- Do you need the phone number for poison control?
- In the past year, did you worry that your food would run
out before you got money or Food Stamps to buy more?
- Do you often feel your child is difficult to take care of?
- In the past year, have you been afraid of your partner?
- In the past year, have you felt down, depressed?
- In the past year, have you had a problem with drugs or
Garg, A and Dworkin PH. Surveillance and screening for social determinants of health: the medical home and beyond. JAMA
Pediatrics. Published online Jan 4 2016.
SEEK parent questionnaire:
SEEK evidence
• Randomized, controlled - 18 peds practices associated with
University of Maryland (resident continuity clinics)
• Administered in waiting rooms, added 0-2 minutes to the
• Providers received 4 hrs of training in brief screening and
initially addressing issues
• Social worker available by phone or on site, assist with
• After 1 year:
– 1/3 fewer child protective services calls
– Lower rates of maltreatment by parents
Dubowitz H et al. The SEEK Model of Pediatric primary care: can child maltreatment be prevented
in a low-risk population? Academic Pediatrics. 2012.
Dubowitz, H. et al. The Safe Environment for Every Kid Model: Impact on pediatric primary care
professionals. Pediatrics. 2011.
How to respond to trauma assessment
• If negative: Good teaching opportunity
How to respond to positive trauma
1. Assess current safety/risk of revictimization:
• To parents: Where is the perpetrator now?
Will they ever see the perpetrator again?
• Kids: don’t need to ask anymore questions.
leave details for forensic interview. No more
specific details from parents in child’s hearing
How to respond to positive trauma assessment
If safe and no need for CPS/forensic involvement:
1. Talk with parents about prognosis/what to look
out for
2. Consider informing/involving school for therapy or
just heads up/extra assistance
– In particular if trauma reminders are present in
the school setting. ie: if trauma occurred in school
and perpetrator is still in school
3. Sooner follow up (ideally 2 weeks) and more
frequent visits to check in on progress
– CALL DCMAP!!!!!!! (844) 303 – 2627
How to talk with families about concern for child’s
trauma history and symptoms/prognosis
When scary or upsetting things happen to children, children cope with it in
different ways, and sometimes even when it looks like children are doing
fine on the outside, they might not be fine on the inside.
Sometimes problems that don’t even seem like they should be related to
the thing that happened might be. I wonder if your child’s symptom (trouble
sleeping, trouble paying attention in school, increased temper tantrums)
might be a sign that the event is bothering them
And most people know, that if there’s something going on in the inside and
we don’t get help with it, it can often get worse.
I want to make sure we’re not missing something that’s going on in the
inside that might be causing this problem (symptom). I think it would be
good if someone who is an expert about these things were able to help you
out with this.
Recommended Approach
Treatment in Children:
1. THERAPY: Trauma focused CBT or Parent/child interaction
AND PARENT SUPPORT: Individual therapy, parenting
classes, home visits
2. Consider treatment of comorbid mental health issues
(ADHD, anxiety, depression)
Treatment in Adolescents:
1. THERAPY: Trauma focused cognitive behavioral therapy,
managing parental mental health, parenting support
2. Consider treatment of comorbid mental health issues
(ADHD, anxiety, depression)
3. Consider SSRI for PTSD under conditions (call DCMAP)
How do I explain TFCBT to families?
• Educate about the traumatic event and common trauma reactions
• Parenting skills: effective parenting interventions such as praise, positive
• Relaxation/emotion modulation skills: use positive self-talk, thought
interruption, positive imagery, problem solving
• Trauma narrative: Write it out, correct cognitive distortions about these
experiences, place these experience in the context of the child’s whole life
• In vivo mastery of trauma reminders: gradual exposure to feared stimuli
• Joint child/parent sessions: child shares the trauma narrative with
parents, help review principles at home, helping parents with their own
symptoms (major risk factor is parents’ reactions to the trauma
TFCBT has been adapted and validated for preschoolers (2) and shown to be effective when
adapted for complex trauma (3)
1. Cohen JA. Ttreating Trauma and Traumatic Grief in Children and Adolescents. 2006
2. Scheeringa MS. Et al. Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three through six yearold children: A randomized clinical trial. J Child Psychol Psychiatry . 2011 August ; 52(8): 853–860
3. Cohen et al. Trauma-focused CBT for youth with complex trauma. Child Abuse Negl. 2012 Jun; 36(6): 528–541.
What is Child-Parent Psychotherapy
(parent-child interaction therapy) ?
Targets younger children (<7) and their parent
with focuses on the attachment relationship,
processing traumatic grief, and emotional and
technical support to both.
- More play based
- More focus on effective parenting skills
(844) 303 – 2627
General advice for families
• Parent mental health addressed if needed. (may have also
experienced trauma)
• Additional family support if applicable
• Importance of REGULAR ROUTINE
• It’s okay and good to talk about what happened. Often kids have
misconceptions of an event that is worse than the real event, may
feel guilty inappropriately
– Parents can invite the kid to talk about it during a time when they’re
not distracted, or be open to talk about it if the kid brings it up
– Take the approach of: “I want to hear what you’re thinking about” and
need to LISTEN
– Parents don’t have to have all of the answers. If they don’t know how
to respond, can be honest, and loving. “you know, I’m not sure of the
answer to that, but I love you and we’re going to figure that out.
– Parents need to be willing to hear the story (may need support for
What about medications?
General recommendation: Begin with TFCBT alone and add an
SSRI only if the child’s symptom severity or lack of response
suggests a need for additional interventions
• While SSRIs have good evidence for PTSD in adults, less so in
children and adolescents (smaller trials)
• No data to support SSRI use alone
1. Cohen JA, Mannarino AP, Perel JM, Staron V. A pilot randomized trial of combined trauma-focused CBT and
sertraline for childhood PTSD symptoms. J Am Acad Child Adolesc Psychiatry. 2007;46(7):811-819
2. Strawn et al. Psychopharmalogical treatment of PTSD in children and adolescents: A Review. J Clin Psych
Can I do something about sleep?
1. Talk about sleep hygiene, SLEEP ROUTINE,
mindfulness activities
2. Melatonin
3. Clonidine/Guanfacine evidence limited
*Call DCMAP!!!!!
• AVOID: sedative hypnotics
DC trauma resources
(844) 30 DC MAP
(844) 303 – 2627
*DC Mental Health Resources Guide*
• Parent-child interaction therapy: DBH Parent Infant
Early Childhood Enhancement (PIECE) Program (SE)
• Wendt Center for Loss and Healing
Home visiting/Parental support
(free services)
• DC Healthy Start: prenatal – age 2
• Family Place: age 3-5
• Mary’s Center Father/Child Program: under 5
Additional resources
• AACAP Facts for Families (general overview of
• Good for all anxiety disorders,
have some videos of patient experiences in all
• Triple P Positive Parenting Program
Resources for Providers
AACAP Practice Parameter on Post Traumatic Stress Disorder
Shonkoff et al. The lifetime effects of early childhood adversity
and toxic stress. Pediatrics Technical report.
AAP Policy Statement: Early childhood adversity, toxic stress, and
the role of the pediatrician: translating developmental science
into lifelong health. 2012
Center on the developing child: