September 8, 2023
Trauma informed care can look different for everyone and for every situation. Experts agree that nearly everyone has experienced some form of trauma, so how can we approach our care for pediatric patients using an approach that provides comfort and healing? Joining us is Dr. Heather Forkey, director of foster children evaluation service at UMass Memorial Health.
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the kid experts where the complex is our every day. Each week we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change how you care for kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. We are hearing more and more these days about trauma-informed care, but many of us may not be exactly sure what that means. Trauma-informed care isn’t just for survivors of abuse, though it’s certainly appropriate in those situations. As a general rule, experts agree that it’s safe to assume that nearly everyone has experienced trauma of some kind and to treat people accordingly. Trauma-informed care can look different for everyone and for every situation. Joining us today to learn more about trauma-informed care is Dr. Heather Forkey, Director Foster Children Evaluation Service at UMass Memorial Health, and Professor of Pediatrics at the University of Massachusetts Chan Medical School. Dr. Forkey, thanks for joining me today.
Dr. Heather Forkey: Oh, thanks so much for having me.
Dr. Angela Kade Goepferd: Can you tell us a little bit about your experience with trauma-informed care and maybe a little bit about how you came to be an expert in this area and how it comes up for you in your practice?
Dr. Heather Forkey: Lucky me, I have been taking care of kids who are in foster care for most of my career. And when I started doing that work in the late 1990s, we recognized that most of the kids we cared for seemed to have some of the same outcomes, some of the same symptoms, but we didn’t really appreciate why that was so. And it was only in early 2000s when I became more aware of the adverse childhood experiences study and more of the research around child trauma that we began to put the pieces together. And so recognizing that really revolutionized how I care for the patients that I serve. And it also led me to want to know more and want to know why we in pediatrics didn’t understand what was going on for these kids and how trauma has its impact, particularly the profound impact that it has when trauma is experienced in childhood. And so that led me on an exploration and efforts to discover more, and I teamed up with people around the country who were looking into that. And that’s sort of become a big part of what I do.
Dr. Angela Kade Goepferd: When we think about trauma in kids, we have to understand what the trauma is or what’s going on and figure out a way to ask about that and have those conversations with families. Can you share a little bit about how you approach the topic of trauma or trauma that a family or a child may be experiencing?
Dr. Heather Forkey: Yes, but I’m going to take us back one step before I do that because in medicine, really everything we do is physiology based. We don’t take an action or do anything unless we really understand the physiology. And I think understanding what we’re talking about in terms of trauma physiology is critical. And so humans have at birth really very limited things they can accomplish. They can seek support from other people and they can kind of deal with threats. And that’s really our primitive brain can do those two things. That’s it. And so why would that be? And it has everything to do with the stress response that we have particular ways that we’ve evolved to manage threat as humans. And most of us in medical school or even earlier, learned about the freeze response so that if some threat is coming at you just stand still hoping the threat will pass you by and not notice you. Not that useful for humans, right? We’re too big, we get noticed.
Then there’s fight and flight. Fight and flight are useful in the short term, but they’re not that useful for kids. Kids can’t run away very fast. They can’t fight very effectively. People who are with children can’t, people who are pregnant can’t. And after all, we don’t have claws. We can’t hide underwater. We’re not that good at fight or flight. And so from an evolutionary standpoint, if it was the only those things that humans had, we were not going to evolve to be where we are. We would’ve been kind of wiped out of the gene pool. And so humans had to evolve to have something that was most effective for us.
It turns out that the fourth response, which is called the affiliate response or tend and befriend, is what’s really very effective for humans in most circumstances. It’s actually oxytocin mediated, not cortisol mediated. It means that we look left and we say, “Hey, are there other humans here who can help me deal with this threat?” If I look left and right and identify, “Oh yeah, you can help me,” my cortisol drops, my adrenaline drops, and I gather people to me so we can deal with the threat. I look left and nobody will help me, or those people who are supposed to help me are hurting me, I can’t use what’s most effective for me. And so I get shoved to fight or flight. And when we think about the effects of trauma, what we’re really seeing is the effect of the overuse of fight or flight because of the inability to use affiliate.
Dr. Angela Kade Goepferd: Well, let’s stay there for a second. So in what you’re saying, what makes sense to me is that one of the biggest protective factors then for kids is to have someone who can help them with that oxytocin response, whether that’s a parent or not. That if they can look left or right and have a caring adult or someone who can help them with the traumatic experience, that should theoretically be protective for them.
Dr. Heather Forkey: Yeah, and that is the critical piece. When we’ve talked about trauma, and largely because the Adverse Childhood Experience Study was so informative and so useful for our understanding, we began to really focus on, oh, what are the bad things that can happen to kids and how can we prevent those bad things? Can’t prevent bad things. COVID proved that one more time again, we can’t always prevent them. But the reason we have overwhelming stress responses, the reasons we see trauma have the negative health and behavioral and developmental effects that it has is not related just to the stressor, but it’s related to whether it’s buffered by those caregivers, whether that child can use the affiliate response or not.
Dr. Angela Kade Goepferd: Sure.
Dr. Heather Forkey: And so that becomes the key. That becomes the critical piece. And so interestingly, I think when people think about trauma-informed care, it’s really a misnomer. We’ve begun to talk about it as relational healthcare as opposed to trauma-informed care because it’s the relationships that matter most, not necessarily what the bad things are that occur.
Dr. Angela Kade Goepferd: So that being said, then, how important is the conversation to find out what, if any traumas, a child is experiencing? It seems that you would still want to have that information, but it would be equally as important to understand what the buffers are or what the resilience factors are for a child as well.
Dr. Heather Forkey: And that’s what research is showing now that there is in population studies, findings that the more adversity someone experiences in populations in general, you see more health consequences. But when we look at those studies at the individual level, like they reproduced the ACE study using the original data, and they couldn’t find the link between the number of ACEs and that individual’s health consequences because it didn’t account for all that buffering and all those… whether that person was able to use the affiliate response.
And so when I think about how we do trauma-informed care work, we are first and foremost focusing on what is the relationship of the child in their home setting and how can I promote those relationships? And it starts with the relationships that I have with the families that I’m serving, and that actually becomes my focus. We may eventually get to the bad things that happened and validating that and beginning to talk about that has its place, but the number one thing I’m really focused on is what’s strong with you and who supports you to be strong.
Dr. Angela Kade Goepferd: So let’s take your average pediatrician or pediatric clinician who’s going to be seeing a family, let’s say for a well-child visit. What would it look like to take a trauma-informed or relational approach to that family versus the traditional approach? How would that look or sound different?
Dr. Heather Forkey: Again, focusing on the fact that I’m going to promote the affiliate response in my office setting and I’m going to want to promote that for the child in their home. I’m going to start that visit with a process called engagement where we really are thinking about how am I promoting the safety of this child and the family feeling safe with me? I’m thinking about my tone of voice. I’m thinking about how I open up the questions. I’m using strategies that allow me to sort of, some people call it sharing powers, but what I’m really doing is I’m saying, “You’re an expert on your experiences, your household, your culture, and I have some expertise over here in pediatrics. Let’s work together so that we can address the health of your child.” So I’m welcoming people in.
I’m thinking about my tone of voice because we know people are constantly scanning for danger. That’s a process called neuroception, whether I have a low gravelly voice, which is sounds of danger, versus a sort of high upbeat… Like musical tone in my voice matters. “Hey, I’m so glad you guys came. This is exactly where we should be to be talking about your child’s health. I really want to know how things have been going for you and what’s going on for you and your family.” Really opening it up and sort of saying, “Hey, this is for us to do together.” Certainly we can kind of get down to further questions and I’m happy to talk about where I go next. But you really want to start with people feeling like this is a place where we could come and affiliate so that whatever the threat is, whatever the danger is, and after all, people come to the doctor with the things they are scared about. How can we do that together?
Dr. Angela Kade Goepferd: If you’ve laid that and you have that foundation, then where would you go from there in terms of trying to get more information about what a family may be struggling with or what a child has experienced?
Dr. Heather Forkey: We can ask… we call them surveillance questions. They’re open-ended questions. And if we are doing primary care, I often start with questions like, “How were you parented and how do you want to parent this child?” If the parent’s experience has been good and they’re bringing a wealth of experience of how to do parenting in a healthy way, they usually will say, “Oh, I had a great childhood,” and they move on. But when families recognize that it was a struggle for them, we’ll be able to open up that conversation and talk about how their experience went and what do they want to do differently.
We can also ask questions specifically about things that might’ve happened. We can say, “Has anything bad, scary or upsetting happened since we last met?” One of the questions that I think is really very effective is, “Has anyone come or gone from the household lately?” And you’d be amazed and surprised at how that opens the door for really the things that disrupt those affiliate relationships for the caregiver, for the parent, for the child, and for that whole familial structure and how they may be challenged. And that usually begins to get us in the door, but it’s also saying, this is a place where we talk about this. This is a place where this matters for your health. And I often will bring in a couple sentences about what we understand now about how that support and those experiences impact a child’s health and development for the longterm.
Dr. Angela Kade Goepferd: Well, what would be a recommended approach for a clinic that is using a paper or electronic screener to get information and then something pops up on that and now you’re having to talk about it in the exam room kind of unexpectedly?
Dr. Heather Forkey: If you’ve decided to use a screening tool like this, it shouldn’t be a surprise when those are screen positive. So one of the things you want to do beforehand is make sure that the staff has a way to respond, but the very first thing to do and the most critical piece is to respond to it. To again, affiliate with the family and say, “wow, I am so happy that you brought this to our attention because this is a really important piece of what’s going on for your child’s health or for your health,” if you’re talking to an adolescent. Taking that moment just to say, “Wow, I’m sorry this happened for you,” or, “I’m so glad you told me about this,” begins that affiliation and support again. And then sort of pointing out, “I’ve noticed, and I would suggest not just having experiences but having symptoms that you identify this thing that has occurred and you are noticing these particular symptoms in your child or these particular symptoms for yourself.”
One of the things that we do is we normalize that and we say, these are really appropriate responses of our body to something scary or upsetting that’s happened. And so bravo, your body’s doing exactly what it’s supposed to do, except it doesn’t feel good, and if we don’t help you to not feel that way, it can have consequences later on. And then having some resources for starting to address that in your office and also for referral if you need to send someone on for more evidence-based trauma therapy or other resources in the community. So I guess what I’m saying too is that we wouldn’t want to start screening unless you were prepared to respond to it. And that response is to validate, to normalize, and then to move on in terms of how to manage it.
Dr. Angela Kade Goepferd: Before we jump into the management piece, which I think is a really important step that we need to talk about, do you have a good way for explaining symptoms of trauma to a family or asking about symptoms of trauma or what would be the most common symptoms? And is there any kind of a tool to screen for those symptoms or recommended way to ask about those?
Dr. Heather Forkey: Trauma presents like every other medical disorder as a spectrum of symptoms. There’s not one thing, and many people think it’s PTSD and that’s all it is, but we know that kids have functional symptoms, impact on sleep and eating and toileting. They can have PTSD symptoms and they can even go on to have more consequential effects of early relational trauma called developmental trauma disorder. If I have to pick one thing that we see most commonly, it’s disrupted sleep, it’s disrupted eating. So those functional symptoms sort of happen first. And what we want to do is explain to families that when something scary has happened, your brain isn’t really thinking about it in modern world terms. Your brain is thinking about this in primitive terms. So when your body is scared, your body thinks that there is a predator or a tiger chasing you. And when that happens, your body’s going to respond the way that would be healthy for that. So your child’s not sleeping.
If your child was being chased by a tiger, it wouldn’t be a really good idea to go to sleep or it wouldn’t be a really great idea to toilet. Or the most common symptom we see is overeating because under constant threat, your body turns down your feeling of satiety because you have to have enough calories to keep running from that tiger. So again, we normalize why we see this symptom in relation to how your brain is understanding the threat and the trauma. And that helps families to see this not as their child’s misbehavior or there’s something very wrong with their child. Again, we reinforce this is the body doing exactly what it’s supposed to do, yay, and then thinking about, but it doesn’t feel really good and we all need to get some sleep. So then how can we address that?
Dr. Angela Kade Goepferd: You mentioned management, and I’m curious to hear from you. If we are someone who has established these relationships with patients, it’s safe enough, we’re hearing about some traumatic events, we’re doing some symptom checking with them, then what next and how can we help them going forward?
Dr. Heather Forkey: I think trauma is not very different from all the other diagnoses we deal with in medicine. And I think for almost every diagnosis in pediatrics, we have sort of advice that we give for the short term, what are you going to do right now? And we’ve come up with some for trauma, just the way we have… Like if you have a sprain, we say RICE, rest, ice, compress, elevate. We have three Rs for trauma, which stands for: Reassure. Tell the child that they’re safe, they’re safe, they’re safe. Return to routine, which shuts down the stress response. Routines are something that goes out the window when a threat happens or when a family’s got everything disrupted. For some families under chronic stress, routines were never started. So talk about routines.
And then the third R is regulate. And regulate means two things. One is begin to relax, try and help that child to shut down this fight or flight response. It’s all those things you’ve already learned. Guided meditation and deep breathing and all those things we have apps for. But the other piece is regulation, which is understanding the emotion that you’re having and how to manage it. And many of our kids who are undergoing threat don’t get the words for what they’re feeling. We talk about happy, sad, and angry, but of course sometimes it’s disappointment or grief or many, many emotions. So helping families to use books and TV shows to look at characters, what are their emotions, talk about how to deal with those emotions. And just the way you would handle any issue in medicine is that you might say, “Try this, let’s see how you do, and come on back and see me.”
And when families recover and this is enough, that’s great. Some of your families, they’ll need more. And just as we do for orthopedics or surgery, we have a list of specialists that see our patients when they need more than what we can provide in the office. And so having at your disposal, the people in your community that you can refer to for evidence-based trauma therapy, other resources in the community, if this is a family that needs housing support or food support, thinking about what it is that this family’s identifying and what you can do to move them on.
Dr. Angela Kade Goepferd: I have two questions. One, you mentioned some books or resources to help establish different spectrum of emotions for kids. So my first question is, do you have some that you could recommend or even websites or places where those of us who want to maybe even as parents, help our own kids or as pediatricians help our families develop more language around that?
Dr. Heather Forkey: I think for little kids, there’s the Sesame Street in Communities website. It has really great resources for kids in a whole host of different circumstances. But for older kids, we don’t have to really go outside of what they enjoy really. They could look at the Kardashians and we could talk about the emotion that the Kardashians are having in this particular YouTube post or whatever it is or this Instagram that what we want to do is really just help kids to begin to recognize those emotions, name them and think about their own strategies. What is the strategy that they used in this book? What is the strategy that they used in this movie? We’ve used things like superheroes or all sorts of popular culture tools to help kids to see this is the emotion and this is what I do about it. And often it’s identifying what a kid finds fascinating is far better than us trying to come up with our own version of what they might like because-
Dr. Angela Kade Goepferd: Sure.
Dr. Heather Forkey: … we never get that right.
Dr. Angela Kade Goepferd: And then for clinicians who want to learn more or have been intrigued by this conversation and want to work on honing their own skills around having a trauma-informed practice, what would you recommend?
Dr. Heather Forkey: I think that there’s a couple of resources on the web that are worth looking into. One is the National Child Traumatic Stress Network or nctsn.org, and they have a host of resources on all aspects of child trauma. There’s the Center for the Developing Child, which is from Harvard University. Again, speaks about much of this physiology and some of the basic ways that we can support families to promote resilience and respond to trauma. And then at the American Academy of Pediatrics, we have some videos and trainings as well as other resources that you can download for use in your office. And if you go to AAP and Google trauma and resilience, you’ll come up to that on the AAP website as well.
Dr. Angela Kade Goepferd: And maybe what we’ll close with is if we do learn how to do this better and if we can take a more trauma-informed approach to our care and how we interact with families, what do we know about outcomes? How does this help families? Or how can it make a difference?
Dr. Heather Forkey: We know that at the tertiary level that getting kids to evidence-based trauma therapy is profoundly effective. That’s why it’s called evidence-based trauma therapy. So for kids who are profoundly effective, we know that that works. We also know that brains rewire and that kids can recover from trauma, but we also know that they have to have that support of the caregiver. So we have ample evidence, not only from the trauma researchers, but from resilience researchers, from parenting researchers also showing that when we can put these supports back in place, the kids can recover and the outcomes are much better for our patients.
Dr. Angela Kade Goepferd: Well, I’m definitely sold. Thank you so much for the conversation, and I feel like I’ve learned… Even as someone who’s been doing pediatrics for 17 years and works with a lot of adolescents who are experiencing trauma, I feel like I’ve learned a lot in this conversation today. So thank you so much for joining us, and we really appreciate your time.
Dr. Heather Forkey: Thanks so much for having me. It was a pleasure.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amie Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.