Trauma-Informed Care in Healthcare

What is Trauma-Informed Care?

Trauma-informed care in a healthcare setting is an approach which recognises and responds to the impact of traumatic stress on patients, caregivers, and healthcare professionals. This approach impacts the quality of care delivered to patients and caregivers, considers support for healthcare professionals, and benefits the larger organisational culture.

Trauma-Informed Care in Patient Care

Traumatic experiences can have varying impact on a child. While some children recover naturally from these experiences, others who are in more challenging positions to do so are at an increased risk of developing physical, emotional, social, and behavioural difficulties. This is especially the case when the traumatic experience is repeated, and prolonged over time. This not only negatively impacts physical and mental health outcomes, but has the potential to disrupt their capacity to carry out important day-to-day activities such as attending school. Find out more about Adverse Childhood Experiences and Complex Trauma here!

This highlights the importance for healthcare professionals working with the paediatric population to incorporate the principles of trauma-informed care in their daily practice to mitigate the risk of patients developing traumatic stress, improve health-related quality of life outcomes, and reduce costs required for patients to receive healthcare services. Some of these principles of trauma-informed care include:

• Understanding the impact of trauma
• Recognising and acknowledging the signs and symptoms of trauma
• Considering how a patient’s life experiences may contribute to physical, emotional, social or behavioural difficulties (i.e. considering ‘what happened to the patient?’ instead of ‘what is wrong with the patient?’)
• Integrating the understanding of trauma-informed care into policies, procedures, and practices to reduce risk of further traumatisation of the patient in the hospital setting
• Promoting patient-centred and evidence-based care for wholistic health

Trauma-Informed Care for Professionals

Healthcare professionals, by virtue of their role to provide care for others, can also be at risk of experiencing empathy-based stress, such as secondary traumatic stress, and vicarious traumatisation. When a professional feels weighed down by these experiences, their capacity to provide quality care dips, potentially affecting the physical or mental health outcomes of patients and caregivers.

This underlines the concept of ‘caring for the carers’. While many organisations do provide care to their employees to some capacity, there are benefits to adopting a trauma-informed lens when thinking about how existing structures, policies and workflows can be further bolstered to better protect staff against empathy-based stress. This not only benefits the staff’s overall well-being, but has a knock-on effect on the delivery of care to patients and caregivers. Action steps organisations can take include:

• Understanding the impact of empathy-based stress
• Recognising and acknowledging the signs and symptoms of empathy-based stress a staff might be experiencing
• Being sensitive to the needs of staff by integrating the understanding of trauma into policies, procedures, and practices to reduce risk of further traumatisation in the hospital setting

Find out more about what organisations can do on the ‘Prevention is an Individual and Organisation Effort’ on the Self-care for Professionals page.

The subsequent sections in the sidebar provide more information about providing trauma-informed care to children coming to hospital for illness and injury, and understanding the behaviour of children exposed to adverse childhood events.

References

Center for Health Care Strategies. (2021). What is Trauma-Informed Care? Retrieved from https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/.

Medical Traumatic Stress in Children and Caregivers​

In many instances, children visit, or are admitted to hospitals as a result of an event that is potentially traumatic for themselves and their caregivers. These events include road traffic accidents, falls, burns, or other life-threatening accidents or illnesses. While these are already stressful enough situations for children and caregivers to go through, it may be further compounded by agonising experiences the child faces within the hospital setting, such as:

• Sights and sounds of medical equipment
• Pain or painful procedures
• Being alone or separated from caregivers
• Being in an unfamiliar environment (e.g. hospital ward, operating theatre) 

Depending on their age and development, children may not fully be able to understand the medical procedures they have to undergo, the roles of medical professionals attending to them, the reasons for overnight hospital stays, or even the need for visiting a hospital in the first place. This may lead them to draw inaccurate conclusions about their experiences within the hospital. For example, children may overestimate the risk of death from a medical procedure, or underestimate the likelihood of recovery from their injury or illness. Some children may also have the perception that they are a 'bad' child for having to visit the hospital, or having to burden their parents to take care of them.

The hospitalisation experience can also be stressful for caregivers and parents as well. Some caregivers may have been involved in the same event where their child was injured and hence have their own trauma reactions from the event. Additionally, seeing their child in pain, being uncertain of their child’s recovery, and experiencing the possibility of losing their child in some cases can also be extremely distressing.

Examples of Traumatic Stress Reactions

International researchers have found that up to 80% children and their family members experience some traumatic stress reactions due to the child’s experience of a life-threatening illness, injury, or painful medical procedure. While most recover, about 15 to 25% of children and siblings, and 20 to 30 % of parents still continue to experience persistent post-traumatic stress reactions (see ‘Possible Reactions After a Traumatic Event’ on the About Trauma page for more information) a month after the traumatic event. These reactions may affect their ability to carry out day-to-day activities (e.g. focusing in school or at work), and are associated with decreased adherence to treatment or poorer overall health-related quality of life.

There are several risk factors that increase the likelihood of persistent traumatic stress reactions developing in ill or injured children and their caregivers.

Ill or Injured Children who:

• have more severe early traumatic stress symptoms
• experience more severe levels of pain
• are exposed to scary sights and sounds in the hospital
• are separated from parents or caregivers during/after trauma
• have a history of previous traumatic experiences
• have a history of behavioural or emotional problems
• lack social support

Caregivers who:

• have more severe early traumatic stress symptoms
• have a history of previous traumatic experiences
• have a history of emotional or mental health problems
• are experiencing concurrent life stressors or disruption
• lack social support

It is also important to understand that trauma is a subjective experience. Objective factors such as severity of injury do not necessarily predict whether a patient goes on to develop persistent traumatic stress reactions. Instead, subjective factors such as the level of threat a patient perceives during the event is a better indicator or whether a child would go on to experience persistent traumatic stress reactions. In other words, even though two children may sustain similar severity of injuries from an accident, if Child A felt that he/she was going to die from the accident while Child B perceives it to be simply an unfortunate event, Child A may have an increased risk of developing persistent traumatic stress reactions.

Caregivers are an important resource in helping their children cope with the stress of visiting or being admitted to the hospital. Children often take their cues from their caregivers' reactions to stressful situations to learn how they can in turn cope with the stressful situation themselves. When caregivers are able to provide guidance, and model for their child how to cope with stress in healthy ways, it enables the child to learn better ways of coping with their own distress. This encourages better compliance to medical treatment, which benefits their overall recovery.

What can Healthcare Professionals do to Provide Trauma-Informed Care?

The D-E-F Protocol developed by the National Child Traumatic Stress Network and Children's Hospital of Philadelphia serves as a guide for how healthcare professionals can attend to traumatic stress reactions children or caregivers may have after a child’s visit or admission to a hospital. The framework suggests that after attending to the ABCs (i.e. basics) of the child’s medical and physical needs, healthcare professionals can consider incorporating the ‘D’s, ‘E’s, and ‘F’s in their everyday practice (within the capacity of their role).

Image credit: The National Child Traumatic Stress Network

For more information on how to implement each component, please visit: Paediatric Medical Traumatic Stress Toolkit for Health Care Providers

When to Refer Children for Further Mental Health Support?

Children who are experiencing significant or persistent distress are recommended to be referred to a mental health service (e.g. psychiatry, psychologist) for specialised assessment and intervention.

Referrals should also be made for caregivers who are highly distressed. Alternatively, they may be directed to community agencies for further support. Some of these community agencies can be found on our Resources page under the Where to Get Help tab. 

Additional Readings

The following resources may be useful for healthcare providers who are interested to learn more about trauma-informed practices in a healthcare setting:

1. Beacon House: Freely available resources on trauma and working with patients who present with trauma
2. Blue Knot Foundation: Fact sheets to support safe trauma-informed conversations and individuals with complex trauma experiences
3. Centers for Disease Control and Prevention: Resource to learn more about Adverse Childhood Experiences (ACEs)
4. Health Care Toolbox: Resource for providing trauma-informed and patient-centred care to paediatric patients            
5. The National Child Traumatic Stress Network (NCTSN): Resource to learn more about child trauma           
6. The National Council of Mental Wellbeing: Resources for implementing trauma-informed approaches within primary care settings
7. Trauma-Informed Care Implementation Resource Centre: Resource for becoming a trauma-informed healthcare organisation

References

Ross, L. A. (2016). Psychosocial Care for Injured Children: The Impact of Traumatic Medical Events on Children, Parents, and Healthcare Providers. The Journal of pediatrics, 170, 16-17. doi: 10.1016/j.jpeds.2015.12.022.

Marsac, M. L., Donlon, K. A., Hildenbrand, A. K., Winston, F. K., & Kassam-Adams, N. (2014). Understanding recovery in children following traffic-related injuries: Exploring acute traumatic stress reactions, child coping, and coping assistance. Clinical child psychology and psychiatry, 19(2), 233-243. doi:10.1177/1359104513487000

Meentken, M. G., van Beynum, I. M., Legerstee, J. S., Helbing, W. A., & Utens, E. M. (2017). Medically related post-traumatic stress in children and adolescents with congenital heart defects. Frontiers in Pediatrics, 5, 20. doi: 10.3389/fped.2017.00020.

McGarry, S., Elliott, C., McDonald, A., Valentine, J., Wood, F., & Girdler, S. (2015). “This is not just a little accident”: a qualitative understanding of paediatric burns from the perspective of parents. Disability and rehabilitation, 37(1), 41-50. doi: 10.3109/09638288.2014.892640.

De Young, A. C., Hendrikz, J., Kenardy, J. A., Cobham, V. E., & Kimble, R. M. (2014). Prospective evaluation of parent distress following pediatric burns and identification of risk factors for young child and parent posttraumatic stress disorder. Journal of Child and Adolescent Psychopharmacology, 24(1), 9-17. doi:10.1089/cap.2013.0066.

Carmassi, C., Dell’Oste, V., Foghi, C., Bertelloni, C. A., Conti, E., Calderoni, S., ... & Dell’Osso, L. (2021). Post-traumatic stress reactions in caregivers of children and adolescents/young adults with severe diseases: A systematic review of risk and protective factors. International journal of environmental research and public health, 18(1), 189. doi: 10.3390/ijerph18010189.

Kassam-Adams, N., & Butler, L. (2017). What do clinicians caring for children need to know about pediatric medical traumatic stress and the ethics of trauma-informed approaches?. AMA journal of ethics, 19(8), 793-801. doi: 10.1001/journalofethics.2017.19.8.pfor1-1708.

De Young, A.C., Haag, AC., Kenardy, J.A. et al. Coping with Accident Reactions (CARE) early intervention programme for preventing traumatic stress reactions in young injured children: study protocol for two randomised controlled trials. Trials, 17, 362 (2016). doi: 10.1186/s13063-016-1490-2.

The National Child Traumatic Network, Pediatric Medical Traumatic Stress Toolkit For Health Care Providers, https://www.nctsn.org/resources/pediatric-medical-traumatic-stress-toolkit-health-care-providers

The National Child Traumatic Network, Traumatic Stress in Ill Or Injured Children: After The Abc's Consider The Def's, https://www.nctsn.org/resources/traumatic-stress-ill-or-injured-children-after-abcs-consider-defs

Adverse Childhood Events and the Impact on Children

Adverse Childhood Experiences (ACEs) are potentially traumatic events an individual experiences during childhood. Apart from the increased risk of developing physical and mental health difficulties, children with exposure to ACEs are also more likely to find difficulty managing their own emotions, giving rise to behaviours that can be challenging for adults to manage. The greater the exposure to ACEs, the greater the risks of these negative outcomes.

The section below explains how these behaviours can be understood through a trauma-informed lens, which in turn guides how we can respond in a manner that is helpful to the child. If you'd like to find out more about what defines an ACE, and its prevalence in Singapore, navigate to our Adverse Childhood Experiences & Complex Trauma section for more details.

Understanding Children’s Behaviours Post-Trauma

It is not uncommon for paediatric patients who have experienced trauma to present with challenging behaviours in the hospital. Sometimes, their behaviours may even pose additional challenges for healthcare providers conducting necessary medical procedures.

Patients who have gone through traumatic events, especially ones that are chronic, and interpersonal in nature (e.g. physical, sexual or emotional abuse), experience changes in their bodies, brains, and nervous systems. This is because the body’s protective response, known as fight-flight-freeze response, is activated to help them escape from danger, minimize harm and survive the traumatic event. While helpful in instances of danger, these conditioned responses can become unhelpful in other contexts, and present as increased aggression, tantrums, defiance against authority figures, being overly eager to please others, isolating themselves from others, or numbing themselves from experiencing any emotions.

While the fight-flight-freeze behaviours serve as the body's survival response in the midst of a traumatic event, these reactions may become conditioned from frequent activation, such that even when the danger is no longer present (e.g. the child is admitted into a hospital as a place of safety), a child’s brain and body may fail to recognise that the danger has passed and continue to stay in a heightened alert mode. This is especially so for patients who have had repeated, prolonged exposure to traumatic events, which is common in cases of interpersonal trauma (e.g. abuse by family members). Their fight-flight-freeze response may be unknowingly activated by trauma reminders, which are certain aspects of the trauma event (e.g. elevated tone of voice) that occurs in a different situation but reminds the patient of the original trauma event. 

When patients are overwhelmed by a traumatic memory, their capacity to weigh the consequences of their behaviours and control their reactions is reduced. This may result in them engaging in seemingly unruly and disrespectful behaviours. In such situations, it may be helpful for us to adopt a trauma-informed lens to understand the function behind these behaviours. The ‘tip of the iceberg’ analogy below demonstrates this concept that challenging behaviours are often a "symptom" of an underlying need or emotion. While this does not necessarily make challenging behaviours easier to manage, it is the first step to helping us become more patient and empathetic with our patients. Just as it is a learning process for us to respond more effectively to these behaviours, it also takes time for children to learn that their survival response is no longer needed in the current, safe environment, and how to regulate their brains and bodies so that they can in turn interact with others in more appropriate ways.

Image source: WeHeartCBT

References

Centers for Disease Control and Prevention, Adverse Childhood Experiences Journal Articles by Topic Area, https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/journal.html.

Self-Care for Healthcare Professionals

Providing care and support for paediatric patients and their families can be a fulfilling and rewarding endeavour for many healthcare professionals. However, it can also be emotionally draining especially if we are regularly on the receiving end of a patient’s traumatic stress reactions or challenging behaviour. If we do not take the time to first care for ourselves before striving to deliver the best care possible to our patients, we may be at risk of experiencing empathy-based stress reactions such as secondary traumatic stress, or vicarious traumatisation.

Trauma-informed care principles advocate for us to take care of caregivers’ needs so that caregivers will have more bandwidth to take better care of their children. Similarly, it is essential for healthcare providers to take good care of ourselves so that we can provide the best care we can to our patients and their families.