uring my 22 years as a pediatrician in an urban area, I have seen the worst of what America’s children must sometimes endure. Severe medical illness in children is thankfully rare. But severe adversity in homes and communities is all too common and causes toxic stress that has long-term consequences for my patients and future generations.
A 6-year-old patient of mine called 911 on the third day that she and her younger siblings couldn’t wake their intoxicated mother. We cared for their physical needs by administering medications and intravenous fluids. The Department of Human Services cared for their safety by placing them in foster care. But their psychological needs were not addressed until they grew older and began to act out. What they needed from the outset was trauma-informed care.
Pediatricians know firsthand how challenging it is for a child to recover from serious psychological trauma without therapeutic intervention. Numerous studies over the last two decades have confirmed what my colleagues and I see every day in practice: that significant adverse childhood experiences are common and are well-correlated with negative health consequences later in life.
Far too many children face a multitude of stressors, and the effects are cumulative. Children who are physically abused often witness the same thing happening to their mothers. Children who experience substance abuse in their homes often experience incarceration of family members. Children whose parents suffer from mental health disorders often endure emotional neglect. The more adversity a child endures, the greater the degree of toxic stress.
Toxic stress — stress that is severe, unmanageable, and occurs in the absence of appropriate support — leads to physiologic changes that permanently alter the architecture of the developing brain and other organ systems. It also results in overactivation of the stress response itself, creating a self-perpetuating cycle.
These are not the kind of tough knocks that build resilience. These are the ones that batter you down.
The Centers for Disease Control and Prevention now implicate toxic childhood stress as a significant risk factor for a long list of cognitive, behavioral, psychological, and medical disorders — as well as for early death. To prevent and mitigate these effects, the American Academy of Pediatrics has called for a “new pediatric paradigm to promote health and prevent disease,” one built around a foundation of trauma-informed care.
By definition, care that is trauma informed involves prevention, recognition, and response to trauma-related difficulties. Experts agree that incorporating an awareness of trauma into medical care requires a systems-wide approach.
As the front line in this new paradigm, pediatricians are screening more to identify trauma in children. We are finding out earlier than ever when our patients face bullying, domestic violence, child abuse, maternal depression, community violence, and food insecurity. Early identification of children at risk is an important first step. The next step is treatment.
Unfortunately, accessing appropriate therapy can be a huge obstacle. What happens, for example, when a child is in the custody of the very person responsible for his or her stress? I care for a 4-year-old boy whose mother was recently incarcerated. He’s become withdrawn, cries when it’s time to go to school, and has trouble sleeping. His father berates him for his “softness” and says he’s better off without his mother. I’ve encouraged therapy from the outset, but without cooperation from his father, I have yet to succeed.
Transportation and time can also be significant barriers. I care for a depressed teenage girl who is the sole caretaker for her markedly disabled mother. For years I’ve given her phone numbers and addresses of mental health centers in our area. But her mother’s needs are too great and her transportation options are too limited for her to find her way there.
Even when patients and parents agree with the need for therapy, their options are often limited. Evidence-based methods such as family-based cognitive behavioral therapy and parent-child interaction therapy are in short supply. All too often, my young patients walk into adult facilities, encounter a waiting room full of grown men and women suffering from addiction and other serious psychiatric disorders, and walk back out.
Decades of working to access appropriate mental health care for my patients has made one thing perfectly clear: the only way forward is to bring treatment to the children, not the other way around.
This is why I’ve been thrilled to take part in the Healthy Minds Healthy Kids initiative at the Children’s Hospital of Philadelphia, where I work. This trauma-informed approach integrates behavioral health providers into our pediatric primary care practices. Psychologists and psychiatrists now work alongside me and my colleagues — all day, every day.
When I recognize that a child is suffering, I can now introduce him or her to fully trained mental health experts. There is no delay in treatment, no need for extra bus fare, no extra time missed from school or work, no discomfort in walking into a new facility. Even resistant parents often shrug and say, “Why not?” when I tell them the therapist is right outside the door.
Hospitals and pediatric practices across the country are rolling out similar models. We have a long way to go until we can implement and test a variety of designs for trauma-informed care and establish sustainable payment models. But although the data aren’t yet available, I’ve never felt so optimistic about any single intervention on behalf of my patients. When mental, physical, and behavioral health providers come together under one roof, we have the ability to create the seismic change that trauma-informed care requires. The future is here and we must model it around collaborative care for children in need.
Dorothy Novick, M.D., is a pediatrician at the Children’s Hospital of Philadelphia, a clinical assistant professor of pediatrics at the University of Pennsylvania’s Perelman School of Medicine, and a board member of the Education Law Center.