The American Academy of Pediatrics (AAP) released a policy statement that urges governmental, institutional, and academic leaders to identify and address the effects of trauma on children, families, and their health care providers (HCPs).1 The accompanying clinical report provides clinical tools for providers. The full clinical report was published in Pediatrics.2

To explain the intent behind the AAP policy statement, James Duffee, MD, MPH, lead author of the report, noted that approximately half of children in the US have had at least 1 potentially traumatic childhood experience, which may be related to poverty, loss, or racial injustice, or a combination of these. Dr Duffee noted that the long-term effects of trauma may be seen in a variety of symptoms, such as changes in eating and sleeping habits or mental health, and “helping children and their parents and caregivers…can help lessen the harms of trauma and build resilience.”1

Authors of the report highlighted the need to address the effects of childhood adversities within pediatric health care systems, using organized strategies and interventions. They described the principles of trauma-informed care in child health care, which “operationalizes the biological evidence of toxic stress with the insights of attachment and resilience to enhance health care delivery to mitigate the effects of trauma.”2


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According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), some of the common presentations among pediatric patients include developmental trauma disorder, pediatric medical traumatic stress, and secondary traumatic stress, which can be applicable to health care workers, family members, and caregivers.2

Because the impact of early childhood trauma may be felt throughout life, reducing exposure to trauma and addressing post-traumatic effects can potentially decrease the rates of mortality and morbidity.2

This policy statement summarizes actionable items that can be taken by policy makers, academic institutions, and health care organizations regarding infrastructure, resources, and finances to integrate principles of trauma-informed care into clinical pediatric care.

As detailed in the report, the core elements of trauma-informed care include a safe physical and emotional environment, leadership commitment, patient and family empowerment, continuous provision of trauma-informed care, recruitment and training of a workforce, and coordination of care across family-serving systems in the community.

AAP Clinical Recommendations for Implementation of Trauma-Informed Care

Federal and State Governments

  • To understand the underlying causes and developmental effects of trauma, as well as to develop relevant effective interventions, research funding for the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), Substance Abuse and Mental Health Services, and other federal agencies, must be continuously expanded.
  •  Epidemiologic research including at-risk populations should be encouraged to prevent, identify, and mitigate the effects of community trauma.
  • For the provision of streamlined clinical care and data collection for research studies, interdisciplinary and interagency cooperation and data sharing can be facilitated.
  • Engaging with national partners, foundations, and academic institutions to support early relational health may be valuable. 
  • Curriculum development and implementation should be supported.
  •  The AAP highlighted the need for expansion of health care coverage including integrated mental and social care. They noted that government and private payers may consider mandating coverage for trauma-informed care, including screening, management, and counseling.

Large Health Systems and Managed Care Organizations

  • Organizations should commit to integrating trauma-informed care into all their services, and recruit and train workforces accordingly.
  • The expansion and improvement of system-wide strategies can be implemented for the identification and management of children and adolescents affected by trauma.
  • The AAP recommended that seamless referral networks be built in the event that intensive treatment for patients is required.
  • To encourage the implementation of trauma-informed care, fair payment mechanisms should be developed. 
  • Engagement with employees for service planning and quality improvement of trauma-informed care models can be supported, with a focus on addressing cultural, ethnic/racial, and gender challenges.
  • Policies to reduce retraumatization, specifically secondary traumatic stress, should be developed and implemented for the treatment of health care workers with symptoms of traumatic stress.

AAP, AAP Chapters, and Academic Institutions

  • With support from federal agencies, medical societies and academic institutions may collaborate with the community to develop curricula on trauma and resilience for pediatricians and their teams for the management of children and adolescents.
  • Development and quality improvement and maintenance of certification nodules can be shared at the state and national levels.
  •  The AAP recommended the development of a comprehensive research agenda for trauma-informed care in pediatric health systems.
  •  Partnering with organizations, such as the National Child Traumatic Stress Network, may help strategize to develop new models of integrated care with pediatric and psychiatric telenetworks.
  • Questions about trauma-informed care can be included in regular surveys to pediatricians. Workshops and online modules may help in the training of health care professionals about childhood trauma.

Authors of the report stated, “The recommendations in this statement and the clinical report build on other [AAP] policies that address the needs of special populations (such as children and adolescents in foster or kinship care, in immigrant and refugee families, or in poor or homeless families) and are congruent with [AAP] policies and technical reports concerning the role of pediatric clinicians in the promotion of lifelong health.”

References

  1. American Academy of Pediatrics calls for trauma-informed care to be incorporated into children’s health care. News release. American Academy of Pediatrics. Published July 26, 2021. Accessed July 27, 2021. https://services.aap.org/en/news-room/news-releases/aap/2021/american-academy-of-pediatrics-calls-for-trauma-informed-care-to-be-incorporated-into-childrens-health-care/
  2.  Duffee J, Szilagyi M, Forkey H, Kelly ET; Council on Community Pediatrics, Council on Foster Care, Adoption, and Kinship Care, Council on Child Abuse and Neglect, Committee on Psychosocial Aspects of Child and Family Health. Trauma-informed care in child health systems. Pediatrics. 2021;148(2):e2021052579. doi:10.1542/peds.2021-052579