“What My Bones Know” is a brand new, very poignant memoir written by a journalist who has built her career on sharing the stories of others, both on NPR’s This American Life and in podcasts. Stephanie Foo, the daughter of 1st generation immigrants from Southeast Asia, grew up in a community of Asian immigrant families where the American dream was prized. The outer veneer of stability, achievement, and accumulation of wealth hid the inner experience of families who had experienced untold traumas in their countries of origin and during the journey to a new life. Stephanie relates her experience of extreme physical and psychological abuse at the hands of her parents, which resulted in the manifestation of Complex Post-Traumatic Stress Disorder or C-PTSD. After becoming aware of her diagnosis, which is still somewhat controversial as a diagnosis among trauma experts, Stephanie embarks on her own research, as any good journalist and story-teller would. What I like about the book it that is describes the differences in complex or developmental trauma and PTSD that results from a single event or that begins in adulthood. These are vastly different experiences with effects on brain development, and treatments need to be targeted to the experience of the individual. The author also briefly describes her foray into a wide array of both evidence-based and more controversial interventions, from the alphabet soup of EMDR, IFS, and CBT, to yoga and psychedelics. This should not be taken as medical advice but is a good way to become more familiar with options that exist and for healthcare providers to hear the self-advocate point of view. I also appreciate the discussion of cultural and community factors as well as epigenetic and generational trauma. One of my personal takeaways is to recognize that individuals with C-PTSD should not just be encouraged to self-regulate when triggered but should go on to learn the social dance of repairing relationships after a perceived insult. It can be tempting to calm ones-self and move on to avoid the person who gave an insult in the future. However, the next level of maintaining healthy social relationships is to learn to express what has been hurtful and to navigate giving and receiving apologies or explanations, in order to preserve the relationship. We are made for connection and learning to remain connected is a great healing power. There is also a short discussion of the COVID-19 pandemic and how survivors of childhood trauma may fare better in stressful events, such as this, because they have been wired for survival. I will give warning that the author uses expletives in her vernacular, so take that as you will. Overall, a beautiful book and worth a read or listen!
Laura Shamblin, MD FAAP
Secretary Kevin Corbett,
I was honored to serve the people of Oklahoma on the Board of Directors of the Oklahoma Healthcare Authority at the pleasure of Governor Kevin Stitt. I am proud of the efforts of the Board, and I acted in good faith and with due diligence. I have witnessed incredible efforts by the staff of OHCA to serve our State through a pandemic and many other challenges. As a member of the Rules Advisory Committee, I was blessed to play a small part in making Applied Behavioral Analysis (ABA) therapy available to children with autism spectrum disorder, beginning in 2020. However, the waitlists for diagnosis and treatment remain up to 2 years, and in many parts of the state, ABA, which is the gold standard early intervention for autism, remains inaccessible. Issues such as accessibility of care, early intervention, high quality childcare, and Oklahoma’s rank in the bottom 10 for children with 2 or more Adverse Childhood Experiences, which result in over 40 poor health outcomes, remain for the citizens or our state to advocate for. I hope to serve the state of Oklahoma in the future and am eager to pursue my next professional chapter as a Fellow in Developmental Behavioral Pediatrics.
Laura Shamblin, MD, FAAP
Fellow in Developmental Behavioral Pediatrics
This is because many factors make up characteristics of resilience in each individual. One thing this book provides, which is probably the most unique, is quite a few real stories of families who have lived with RAD. Most of them are disturbing but necessarily honest. Not all of them have a happy ending. The author makes it known that she has tried to provide as many hopeful stories, where the child is doing well following therapy, as possible. She is attempting to provide hope and to emphasize the value of early diagnosis and intervention. What I felt was missing, was more description of the actual interventions that worked. I think the author may have left those descriptions out in order to not provide medical treatment advice without proper credentials. However, many of her pearls of wisdom may be helpful to parents in the trenches. I will include a few of those I thought were likely to be helpful. I apologize in advance to the author, as I will likely not be able to convey everything in the way that she would. These include the following:
Laura Shamblin MD
Do your kids drive you CRAZY with their constant interrupting, fighting, and vying for your attention?
Do your kids drive you CRAZY with their constant interrupting, fighting, and vying for your attention? I know mine have at times! And the way I tend to cope, sometimes, is to look for a book that might give me some new ideas. Whether that’s what you would do or not, I hope this little review gives you a few ideas to restore some peace to your life.
I am going to review two of the most prominent books I know of on raising siblings and give a comparison of the two to help you decide which might be most helpful to spend your valuable time with. The first is an oldie but a goodie, Siblings Without Rivalry by Adele Faber and Elaine Mazlish, first published in 1987. If you have not checked out their other titles such as How to Talk So Kids Will Listen and Listen So Kids Will Talk, I definitely recommend it. The other book I want to look at is Peaceful Parent, Happy Siblings by Dr. Laura Markham published in 2015.
In Siblings Without Rivalry the authors build on some of the themes of their other books while focusing specifically on sibling relationships and how parents can influence them. The story is in the context of a parent support group that meets and discusses common issues with their children as well as their own adult sibling relationships and mistakes their parents made with them. In that way, it almost reads like a memoir, and if you like a lot of anecdotes it may keep you more interested. The authors use these situations to teach a few basic but very important and helpful concepts. These include the importance of helping your children express in words what their sibling is doing to upset them. They call this “acting as their interpreter.” When you use words instead of behaviors it puts things into perspective and helps children learn to do this for themselves. Other helpful ideas are helping your child express their wishes or fantasies, helping them let their feelings out through creativity, and showing them acceptable ways to express anger. Other helpful concepts are; learning as a parent to use descriptive words about a child’s activities or accomplishments rather than comparative words about them compared with their sibling, not creating roles for your kids like “the smart one” and “the funny one,” and one that is probably my favorite is remembering to treat children as unique rather than equally. In our modern terms, we call this equity vs. equality. Equity means meeting the needs of each person in a way that helps them to have their best outcome, realizing that some will need more help than others. Equality means giving the same amount of help to each person, assuming that their needs should be the same, or it would be unfair to give more to one than another. Children are unique persons and should be helped and celebrated as unique from their siblings. This book is succinct and has their trademark comic strips to show different situations which you kind of miss when you listen to it on audiobook.
In Peaceful Parent, Happy Siblings, the author includes a lot of the concepts from Siblings Without Rivalry plus a lot more. It is longer but you could focus on chapters that are more relevant to you. I especially like that it has a couple of chapters that focus on preparing to have a second child and how to handle a baby and toddler at the same time. If I was a young mom getting ready to have a second child, I would definitely find these chapters helpful.
Dr. Markham ascribes to the positive parenting movement. The first chapter outlines her thoughts on discipline, and I found her theory to be an amalgamation of other more evidence-based theories. Some of the concepts like “time-ins,” helping children learn to describe their feelings in words, allowing children to express their feelings through crying in a safe way and space, are good concepts. She also emphasizes what she calls “preventative maintenance” which includes establishing routines for young children, having regular special time with each child (which could be 5-10 minutes per day), and encouraging roughhousing and laughter together which are included in a lot of other theories. She expresses a desire to avoid all forms of punishment or consequences and is against “time-out.” “Time-out” used in specific ways, coached by professionals, is one of our more evidence-based interventions for preschool aged children. When I read some of the examples she gives, she describes removing a child who cannot stop himself from splashing others in the face from the pool or bathtub. I would call that a time out or a natural consequence. So, I feel like there is a bit of a difference in semantics rather than an actual difference in methods. As a parent, when reading parenting books, you always have to keep your common-sense hat on and feel free to discuss your concerns with your pediatrician.
So overall, I felt like Peaceful Parent, Happy Siblings had a lot more practical ideas for how to encourage positive sibling relationships in a family. For young families I felt it was more likely to be helpful. Siblings Without Rivalry was a bit shorter and simpler but emphasized a bit more what not to do. The concepts that is does teach are very helpful, though, and may be more helpful if you have older children. If you’re wondering what siblings have to do with trauma, Siblings Without Rivalry will convince you that the way some parents have treated their children in their sibling relationships could be considered emotional abuse.
I hope this is a helpful rundown with a few new ideas thrown in that you can try today. Working on positive family relationships is more of a journey than a destination. As long as we are trying and doing our best with intentionality, I think that is all we can ask of ourselves. No one is without relationship difficulties, but as parents we can teach our children to solve their difficulties with creativity and respect.
The Connected Parent: Real Life Strategies for Building Trust and Attachment
by Karyn Purvis, Ph.D., and Lisa Qualls with Emmelie Pickett
I just finished reading The Connected Parent and I cannot recommend it highly enough! I think it would be most helpful to parents who are in the trenches of raising a child from a hard place. However, the principles and subjects discussed in it would be applicable to anyone who regularly comes in contact with children, including grandparents and extended family and friends, teachers, children and youth pastors, coaches, Sunday school teachers, pediatricians, daycare workers and owners, children’s camp workers, and more. You may be wondering what I mean by children from hard places. That term was coined to represent children who have survived early life adversity of various kinds. This could be a stressful pregnancy, extreme prematurity, adoption, foster care, neglect, abuse, prenatal or postnatal exposure to parents who used drugs or alcohol, domestic violence, or a chaotic home life due to poverty, community violence, family dysfunction, and various other stressors that affect children prenatally or in the first years of life. When these types of difficulties are present in the life of a child, without a healthy attachment to a primary caregiver who can act as a buffer to make the child feel safe and to meet the child’s needs, these difficulties can affect the growing brain of the child often causing developmental delays, behavior issues, and difficulties with social and emotional maturity. Parenting children from hard places is a very difficult undertaking that requires skills, coping mechanisms, and community support.
What I love about this book is that Lisa Qualls and Dr. Purvis focus on teaching a few very practical things that parents and caregivers can do to meet the needs of children from hard places. They teach parents how to be detectives in figuring out the needs of each specific child. Children from hard places have often developed survival skills that worked well in their early, difficult circumstances. When they continue to use these skills in a safe environment it often appears disrespectful or defiant. Sad feelings often look like mad feelings. Sensory avoidance can look like defiance or refusal. Fears can look like refusal to “act their age.” This book gives parents practical advice in how to meet needs, build attachment, allay fears, and encourage growth and maturity in our children. Lisa shares anecdotal stories from her large family and friends to help us see how these things play out in our day to day life, and to reinforce that none of us are perfect and there is always room for grace.
Lisa and Dr. Purvis also share some of the core strategies of the parenting method that Dr. Purvis and her colleague Dr. Cross developed, called Trust Based Relational Intervention (TBRI). These include redos, choices, time ins, and scripts among other things. I especially like the teaching on how to use scripts, as it has saved my sanity a few times. Scripts are short phrases that address behaviors in a way that is positive and easy to understand and remember in the midst of high emotion situations like melt downs. I don’t know about you, but I can get as flustered as my kids in these situations and it gets hard to think of what to say and then spit the words out. Similarly, when kids get upset the rational part of their brain is less accessible and they are responding from the emotional part of the brain. They cannot take in new information, or a lecture. If we learn scripts like “no hurts,” “gentle and kind,” “show respect,” “stick together,” and “listen and mind” when we are calm, we can use them in the middle of an upset and everyone knows what they mean without processing a lot of words. Families can make their own scripts that are culturally acceptable and more appropriate for different aged kids. Lisa gives the example of how teens have used terms like “be cool” instead of “no hurts”, and “check with me” instead of “ask permission.” This is just one example of the way TBRI principles have been helpful to me personally, but there are many more examples in the book along with the rationales for why these things work with kids and teens from hard places. They also spend some time translating how to meet the needs of older kids and teens and how to apply nurturing and correction principles in these challenging age groups.
Finally, something I haven’t seen in many other parenting books, Lisa spends a chapter discussing the importance of self-care for parents and gives lots of practical ideas that parents can use, even in the middle of the hardest times. She understands that telling parents to take better care of themselves is often a fruitless command and speaks from the point of view of a parent who has been there and understands the challenges.
Many of you may have already read The Connected Child by Karyn B. Purvis, Ph. D., David R. Cross, Ph.D., and Wendy Lyons Sunshine and you may be wondering how this book is different. I would say The Connected Child took a higher or more comprehensive view of children from hard places, with more explanation of prenatal growth, brain development, and meeting needs. It includes many of the same parenting techniques, so there is some overlap, but I felt The Connected Parent was a little easier to read, understand, and quickly apply for a parent who is currently in the process of parenting a child from a hard place. It has a lot of practical approaches with explanation of the rationale and then anecdotal stories that make it easier to remember and think about how these things play out in real life. I always like stories, as they keep books interesting. The Connected Parent is only 4 hours and 45 minutes on audiobook, so it’s a pretty quick read. Please check it out if you know and love a child from a hard place!
Laura Shamblin, MD
Fellow, Developmental Behavioral Pediatrics
I just wanted to write a quick check-in. I have been keeping to home with 4 children out of school and my husband working from home since mid-March. I've had thoughts of things I could be writing to put good information out there, but I really wanted to be sure I'm taking care of my own family first, sort of like making sure I don't have a rod in my eye while I point out the speck in others' as the Bible says. Thankfully, I can report we are doing okay. If this had happened a year ago when I had two children with pretty significant behavioral health concerns I would not be saying that. We have come a long way in a year with good therapies. I've written 2 articles which will be linked below about how to cope with stress and how to be the buffer for your child and others during this time and I'd love it if you'd share those with others. I am getting ready to start a fellowship in Development Behavioral Pediatrics this July 1st. I'm really excited to get started (and get out of the house!) but I am also mentally preparing that we are likely to see a major uptick in pediatric mental and behavioral health needs in the next few months and years. Unfortunately, some parents are not prepared to be the buffer for their child in a time of stress and we are likely to see an increase in child abuse going on. It may not be reported right now as kids aren't seeing the adults who normally report, but there will be the consequences to deal with for years to come. What can you do to help? There are a lot of nonprofits who work in this area that need continued funding during economic downturns. But closer to home, I want to encourage you all to be reaching out to family and friends who have kids at home, and if you have the ability to relieve some of their stress, do it. We are supposed to be social distancing, but in times of crisis especially, people should still be able to rely on their circle of support that includes extended family and friends who live close by. Don't be afraid to help those who need it. Get to know your neighbors from a distance and just look out for others.
As a pediatrician and mom of four, I have been following the growing area of research in pediatric mental health over the last few years, including the study of adverse childhood experiences. Given the current information overload, I wanted to share the single biggest way we can help kids through this time without causing long-term consequences.
Think for a minute about a boxer’s glove. The function of the glove is to provide padding for the hand. It is a shock absorber. When a hand with a glove punches a hard surface, the thick padding absorbs a lot of the shock of impact. The glove allows the hand and arm to get stronger while absorbing enough of the impact to prevent breaking bones or other injuries.
In the same way, parents, or primary caregivers like grandparents or foster parents, play the role of buffer or shock absorber for the kids in their care. It’s not that we want to wrap kids in bubble wrap and prevent any stress from reaching them. That would not prepare them for life as an adult. Rather, we want to be present to help them navigate the life stresses they are experiencing in a way that helps them learn they can do hard things, solve problems, learn how to respond better next time or just grieve a loss and move forward in life.
How does a parent do this well? A lot of it is instinct if you have grown up with a nurturing caregiver who did this for you. However, some parents did not grow up in a nurturing home. Sometimes, as adults we have to practice new skills to give our kids a better chance than we had.
For kids and parents who have already suffered traumatic events, especially during childhood, they may be even more affected by this feeling of uncertainty. They may also have less ability to put feelings into words. Supporting adults can help by talking through feelings of uncertainty in a calm way, putting thoughts into words.
Many people also benefit from journaling, artwork and music as a way of processing feelings. Good information for parents and grandparents dealing with their own stress can be found at stresshealth.org and developingchild.harvard.edu/.
Adults who are suffering from big losses such as loss of a family member through death or divorce, or loss of a job may need to put all their energy into processing their own feelings.
When this happens, they may become unable to act as the buffer for their kids. It becomes necessary for other adults to step in and support that parent and their children. In this time of isolation, it’s important to stay socially connected in whatever way we can. It does take a village to raise children especially during difficult times.
If you are an adult who is struggling with your mood right now and you think it may be affecting how you interact with your children, the best thing you can do for your family is to get help for yourself.
You can call your family doctor or the Oklahoma Department of Mental Health and Substance Abuse has a great website as well as phone numbers you can call to get help. You can text TALK to 741741 or call 1-800-273-8255. Nearly half of all adults (46%) will have a mental health diagnosis requiring support during their lifetime.
People who have never needed mental health support before are likely to during this time. It is common and treatable so don’t be afraid to reach out for help so that you can continue to do the best job of buffering for your children.
Dr. Laura Shamblin, MD, is an Oklahoma City pediatrician, founder of TraumaInformedMD.com and sits on the board of directors for the Oklahoma Health Care Authority and the Oklahoma Chapter of the American Academy of Pediatrics.
The above is an op-ed published by the Tulsa World at https://www.tulsaworld.com/opinion/columnists/dr-laura-shamblin-parenting-in-a-pandemic/article_f85b17ef-4029-531b-810d-cdd32a9fecbe.html
I’d like to take a few minutes to highlight some information I hope will be helpful to those who are currently experiencing a prolonged period of increased stress. As a physician I have been watching as my fellow physicians mentally and logistically prepare for what we expect to be a very difficult time. I liked the Washington Post article by Alison Block titled “Doctors and nurses are already feeling the psychic shock of treating the coronavirus.” The medical community is preparing for unprecedented measures in the United States. In the midst of this, we are also making decisions about who will care for our children, how much contact we will have with spouses and children, and how to plan for childcare without exposing our elderly parents. In today’s world of living apart from close family many have to find support from friends and neighbors. In the article Dr. Block refers to this as “pre-trauma.”
This concept is very similar to the concept of secondary post-traumatic stress, which is something healthcare workers also frequently experience. Secondary traumatic stress is the emotional duress that results when an individual hears about the firsthand trauma experiences of another. The essential act of listening to trauma stories may take an emotional toll that compromises professional functioning and diminishes quality of life. When you couple this with the stress of the work environment in healthcare settings right now you can expect that your body is putting out a surge of cortisol. Cortisol is useful for short periods of time under stress. It works to raise blood pressure, shunts blood to essential organs, raises blood sugar, and temporarily suppresses immune system function. Normally a period of intense stress should be short and then over, allowing the body to get back to normal functioning. But when you have a job or life situation that involves frequent traumatic events or hyper-vigilance to danger, cortisol remains high for long periods of time or indefinitely. As you can imagine, this would result in persistent high blood pressure, high blood sugar, immune system suppression, and the resulting organ damage over time.
The good news is there are some things we can do to proactively lower our physiologic stress and cortisol levels on a daily basis. Here is a list of activities you can incorporate into your daily schedule right now to give your body a pause.
2. Mindfulness/Meditation - apps like YouTube, Calm, Headspace, MoodTools, Abide
4. Grounding exercises – sitting with eyes closed and focus on your other senses – feeling the floor, your chair, smells, sounds, breathing, etc.
5. Tactical breathing – breathe in while counting to four, hold for four, breathe out for four, hold for four,etc.
6. Spend time with family
7. Spend time with pets or animals
9. Gardening, hiking, spend time in nature
10. Journaling - If you don't like to write a lot, you can write 3 things you are grateful for, 3 good things that happened today, and 3 things you are looking forward to tomorrow.
11. Connecting with faith communities
12. Talk to a colleague who understands
13. Humor, comedy
14. Create something – draw, paint, craft, knit, carpentry, write, sort photos, etc.
It’s a great idea to schedule a few of these throughout your day even at this difficult time. This is called making a coping strategy.
Morning – prayer or mindfulness app
Work – stop and do tactical breathing for one minute twice during your shift, talk to a colleague about your day at the end of shift, call a friend
Evening – go for a walk/run, spend time with family/pets
Bedtime- prayer, do stretches or yoga, listen to a sleep story on a mindfullness app
I also like the idea of combining these as much as possible. Exercising outside is better than indoors. I like to walk outside while listening to a book or podcast that lowers stress. Walking with a pet, watching a comedy with your kids, or working on a project or hobby outdoors or with family are some ways you can think about combining them.
Being intentional to lower our stress is the best way we have available to function at our best and get through this without adverse consequences to our health. As you begin to use these, share with your colleagues and create a culture of intentional coping strategies.
Laura Shamblin, MD
During her exam he was able to disguise very inappropriate touch as a form of treatment and do it with her mom in the room, not realizing what was going on. This went on for over a year, escalating in nature. At the time, the reputation of Larry as the premier sports doctor for USA gymnastics, as well as a teacher of other physicians at Michigan State University, made it seem impossible to suggest he may be guilty of this evil. Due to the climate of victim-blaming, Rachael and her mother had to wait to see if an opportunity to speak out ever presented itself.
In the meantime, Rachael articulates so well the fallout of being a sexual assault survivor. She describes a heightened state of awareness and fear in public places. A fear of men standing behind her, even in a fast-food line. The inability to verbalize what had happened to her, making it impossible to consider going to see a mental health professional. With her family’s support she attempted to process her feelings through journaling and prayer. This part of the book is, I think, the most enlightening to readers who have not been a victim of abuse. The physiological changes, the emotions, and the way memories, nightmares, and fears resurface time after time for the rest of a survivor’s life is something we need to understand more in order to truly support those we come in contact with who are survivors. She explains every cultural bias against victims, point by point, making it easier to see how these biases are played out around us when we don’t even realize it.
For Rachael, as a person of strong Christian faith, her interactions with her church are also worth learning from. She describes sitting in Sunday School and discussing stories like Bathsheba and Dinah and the messages that can be transmitted to children about issues of sexual assault. If you grew up in church, like I did, it is easy to be desensitized to the horror of these stories. But when you think about them from the perspective of a survivor, it is easier to look at the messages we are often sending our children when we teach these stories, including when inappropriate comments are made by other students and not addressed by the teacher. They are a part of the Word of God and therefore have value in teaching. But it is so helpful to listen to the point of view of a survivor before discussing these issues, to help us avoid the pitfalls of our cultural biases.
Some of the messages of this book that translate to a better understanding of being trauma informed are these: Survivors need as many choices as possible as they deal with the aftermath or reporting of their abuse. Choice is a form of control and abuse always represents a loss of control for the victim. In order to recover, find their voice, and retake control of their lives, it is important to give them as many choices as possible when telling their story or seeking help. (I do want to be sure to say that when the victim is a minor at the time of disclosure, there is no choice in reporting for any adult who becomes aware of the abuse or the victim discloses to. Choices should be given when possible in who they talk to, the setting, who is present, etc. Whether or not it is reported to law enforcement or child protective services, is not a choice. It must be done.)
Something else it’s important to remember for being trauma informed is that a survivor’s perception of safety is more important than leadership’s perception of the safety of their organization. This can be called Felt Safety. If you are in leadership – a teacher, pastor, CEO – and you feel your organization is a safe place, both preventing abuse and open to receiving a disclosure of abuse about a leader or staff member and able to follow best practices in reporting and supporting the victim while investigating the claim, your opinion is secondary to whether a survivor feels safe enough to come forward in your organization. When we discuss outside instances of abuse whether in the news, books, movies, or religious texts, we are sending messages to survivors about how safe they would be discussing their abuse in our presence.
Another message that she grapples with and expresses so well is that God loves justice just as much as He loves forgiveness. The Bible teaches that vengeance belongs to Him, and there will be an eternal judgement for the evil we commit. Whether that justice is meted out in our lifetime or after life is not always in our control. But when it can be meted out by our courts, the message that sends to survivors is important. When considering the punishment for abuse, the sentence reflects the worth of the victim. That is the meaning of the book title, What is a girl worth? The answer should be everything. The punishment for victimizing the innocent should be the maximum the law allows. When we try to minimize or mitigate the evildoing of an abuser, we diminish the perfection and beauty of the goodness of God.
The story of Rachael Denhollander, to me, is an Esther story. Esther is told to use her position in a time of crisis, for "who knows but that you have come to your royal position for such a time as this?" Esther 4:14. Rachael developed the gifts God had given her which included an analytical mind and the ability to become an attorney, her supportive family, and her faith. With these three things she became the one person who could bring a police report against Larry Nassar in such a way that she could withstand the institutional push-back from Michigan State University, and get her story out into the public sector where other survivors could see it and join her in coming forward. Without the support from family and personal faith, as well as a few perfectly placed individuals who also sought truth, including a reporter, a detective, and a prosecutor, her story would not have been able to pierce the public arena and bring the judgement of our courts down on Larry Nassar.
I hope that others will take this opportunity to look at the institutions we are a part of, whether they be schools, churches, clubs, corporations or other spheres, for how we can make sure they are as prepared as they can be to both protect the innocent and to be a safe place for victims to disclose their abuse, seek help in reporting, and get support for healing.
One organization I've seen that provides this expertise is https://ministrysafe.com/ They have some great short videos about this issue on their site as well at https://ministrysafe.com/who-we-are/
By Laura Shamblin, MD FAAP
Most of us have now heard of the Adverse Childhood Experiences Study published by Drs. Felitti and Anda in the American Journal of Preventative Medicine in May of 1998. The study and many follow up studies have shown a direct and dose dependent relationship between adverse childhood experiences, or abuse, neglect, and household dysfunction, and adult risky behaviors and health outcomes. As a Pediatrician and advocate for Trauma Informed Care, I’d like to take this opportunity to address some of the objections to screening for ACEs that I have come across. It is true that some areas of research are still emerging, such as protocols, but in other ways we are twenty years behind using the information we have to make a positive difference in our patients lives and in training new physicians to be more comfortable addressing social and experiential determinants of health.
Myth #1 People don’t want to talk about their personal or family traumas.
In several studies, the vast majority of patients did not mind answering a screening tool at a primary care visit. (1,2) Clinics who have adopted ACEs have found using a cover page with a short explanation of the relationship between childhood traumas and adult health outcomes to be helpful. It has also helped to have ACEs screening papers given to the patient to be filled out either at home before the visit, or in a private patient room before seeing the doctor rather than in the public waiting room. Any adoption of a new screening tool should ideally have input from a patient advisory group before implementation to account for concerns of different patient populations. (3)
Myth #2 Filling out a questionnaire may cause someone to remember suppressed memories of childhood abuse and have a sudden onset or worsening of mental health issues.
This concern has been brought up in a couple of published articles (4), however there are many more articles recording the use of ACEs screening tools in various outpatient settings without reference to this situation actually happening. The ACEs questionnaire has also been given and shown to many, many large audiences at conferences and trainings and again, there has never been a case brought to light of any major mental health consequences, to my knowledge. On the contrary, many people express appreciation and even relief to learn the associations between childhood experiences and adult behaviors and health outcomes. They know there is a problem, and it is helpful to put a name to it and therefore be able to get more information about treatment and recovery steps that can be taken. There is mention of patients being uncomfortable with the information on health outcomes being given without being accompanied by information on resilience, buffering, and positive and compensatory experiences. (5)
Myth #3 There aren’t any truly evidence-based interventions for childhood trauma. We shouldn’t make families aware of the negative health outcomes, because there is nothing proven to help them.
This assumes that all positive screens will need a behavioral health care referral. In a large study of 3 community pediatric clinics in the Chicago area, screening for ACEs only resulted in referral for mental health care in 2% of patients. (6) In a feasibility study in a family medicine practice including adults, no new referrals were made. (1) When those services are needed, there are several modalities of treatment that have good evidence for use in children and are recommended by the AAP. At the top of the list would be Trauma-Focused CBT followed by PCIT and CPP. TBRI is also a growing modality with good results among the adoption community and schools but less research funding nationally. More information about treatment modalities can be found here. https://www.traumainformedmd.com/treatments.html#/
For the many who do not need a referral, parenting resources such as local parenting classes (check with churches, hospitals, and pregnancy centers), as well as anticipatory guidance and education provided by the physician, is likely the most helpful resource and is the most asked for by parents. There is growing evidence that positive experiences in childhood as well as healthy attachment relationships with at least one adult both have a buffering effect on children who experience multiple ACEs. These positive experiences and relationships provide resilience as well as support for healing. (7,8)
Myth #4 There aren’t enough mental health professionals available to provide follow up for all of the positive screens we would get, so it’s better to just not ask the questions.
Behavioral health providers who use evidence-based methods of treatment for childhood trauma may be more available than most providers are aware. If you know the modality you would like to be used such as TF-CBT or CPP it is possible to use several search methods to find the nearest provider to your community. Links to these search sites are listed on the Treatments page of www.TraumaInformedMD.com here https://www.traumainformedmd.com/treatments.html#/. SAMHSA also has a search function you can find here https://findtreatment.samhsa.gov/ and most state Mental Health Departments also have search capabilities and resource lists. Another helpful search website is https://www.psychologytoday.com/us which has a way to filter for therapists that provide different modalities or types of therapy. By searching, you can quickly find what behavioral health resources may be near you, even in a rural location.
Myth #5 If we ask about abuse, we may uncover events that would fall under the mandatory reporting obligation. We may overwhelm the Child Protective Services and kids may be removed from the home who didn’t need to be, further traumatizing them.
First of all, if a child is in an unsafe situation there should be no problem with reporting it, despite the time and effort it may require from the provider. However, situations that are serious enough to involve your local Child Protective Services will be evaluated for safety and many of them will not require removal from the home, but they will give the family the opportunity to receive prevention services. The Family First Prevention Services Act is a federal law that was put into effect on October 1st, 2019. It allows state human services agencies to use federal matching money that was previously only used for out-of-home foster care to be used for preventions services given to the family with the child remaining in the home. This law requires some benchmarks in quality to be reached before using it and most states have not put it into effect yet, however, the national trend is changing toward keeping children in the home and providing services to the biological family when possible. (11)
Myth #6 I’d love to screen for ACEs but there is no way I have time during a patient visit to delve into those issues.
In most feasibility studies, practices have found that using a deidentified screening tool – one that just has the patient list the number of ACEs that are positive for them but not specify which ones – allows the physician to talk to them generally about being intermediate or high risk and what they can do to counteract those factors, rather than needing to hear the story of each one. Of course, if a patient wants to explain a positive answer, this may happen and opens the relationship to be a safe space for talking about these issues at this and future visits. When a deidentified screener was used, the time added to most visits was found to be 5 minutes or less in multiple studies. (1,9)
Myth #7 As a doctor, my focus is on my patients’ health, and knowing how many ACEs they have will not affect my diagnosis and treatment of current health issues.
The number of ACEs may not affect a specific diagnosis directly because there are other genetic and resilience factors that also play a role for each individual. However, universal screening makes it more likely that an environment or history of childhood trauma will come to your attention as you are treating chronic illnesses that have been shown to have direct correlations with childhood trauma and toxic stress, such as failure to thrive, asthma, obesity, ADHD, anxiety/depression, substance use, self-harm, and even things like syncope, headaches and chronic abdominal pain. ACEs are present in families of all socioeconomic backgrounds and you may fail to ask about such influences if the family appears to be well-functioning in your clinic.
I’d like to specifically point out the relationship between ACEs and ADHD diagnosis. Patients seem to have a dose dependent relationship between number of ACEs and likelihood of ADHD diagnosis. (10,12) It is also known that one symptom of PTSD is hypervigilance, which in a child includes behaviors such as inattention, inability to sit still, and other behaviors that mimic those of ADHD. Because the DSM-V does not allow for an ADHD diagnosis if another mental health disorder may explain the symptoms, it seems that a screening for ACEs and PTSD may be warranted in any person being screened for ADHD to further inform the diagnosis. As Guanfacine is an accepted treatment for both PTSD symptoms of hypervigilance and ADHD, it is logical that it may be a better first line treatment for a child with both ACEs and ADHD than a stimulant would be. Further research on this and elucidation of protocols are still being worked on.
Myth # 8 The ACEs screen was developed for adults and should not be used on children.
Depending on your purpose there may be value in screening both parents and children. In the case of parents there is some evidence that increased ACEs are related to developmental delays in their children. Surprisingly, there was even a stronger relationship between fathers’ ACEs and children’s developmental delays. (13) This would suggest that screening parents early on may be a way of knowing which to refer for more supports in parenting such as parenting classes or adult mental health services. Early adopters have suggested the 4-month well check visit as being a good time to screen as there are fewer other concerns at that visit. (3) Screening children, either having parents report for young children or having older children report for themselves, would be most helpful for reference when working up health and mental health conditions as stated above such as asthma, failure to thrive, ADHD, etc. These could be done either at well checks and referred back to during illness or could be done at times of work-up for these chronic conditions.
Given the many demands on physicians’ time and paperwork requirements it can be easy to be so busy in our practices that we wait for government or professional organization mandates to dictate how we practice. I hope this helps to bring some resources and research to the forefront to help us use the information that ACEs screening would provide. We should NOT be screening if we are not comfortable with what we will do with the information. And what we will do is usually just have a conversation with the caregiver or patient about the results and things they can do to combat the effects of ACEs on their child, such as getting parenting support, keeping mom healthy, trying to have high quality, safe childcare, trying out things like mindfulness and exercise in the home, leaning on extended family and friends at times of stress, coordinating with teachers, etc. Of course, we will need to have mental health professionals in place that we can refer to when needed. For help with that look back at Myth #4.