C Pediatric care is on the cusp of a transformation, from reactively identifying and treating the H CCHHIILLDHOOD consequences of childhood adversity to proactively building the skills needed for resilience, healing, I L and thriving. Childhood Trauma and Resilience is a must for all pediatric professionals interested D in transforming their practice from “trauma-informed” to “resilience-centered” care. H —Andrew Garner, MD, PhD, FAAP, coauthor of Th inking Developmentally: Nurturing Wellness in Childhood to Promote Lifelong Health O TTTTRRRRAAAAUUUUMMMMAAAA & O CHILDHOOD TRAUMA D T RRREEESSSIIILLLIIIEEENNNCCCEEE R & RESILIENCE A U M A Practical Guide AAA PPPrrraaaccctttiiicccaaalll GGGuuuiiidddeee A & Heather C. Forkey, MD, FAAP • Jessica L. Griffi n, PsyD • Moira Szilagyi, MD, PhD, FAAP R E W S ith this practical guide, pediatricians and other child health professionals will learn to identify, evaluate, and treat I L children and families aff ected by trauma and adversity when they present at the offi ce. In addition to instruction for I E hands-on acute care, the cohesive approach lays out a framework and concrete steps to focus proactively on resilience N and provide the best, most impactful care to all patients. C Childhood Trauma and Resilience includes mnemonics, charts, tables, reproducible handouts, and numerous case E studies to reinforce learning, as well as timely information on physician burnout and secondary traumatic stress. : A P About the Authors r a Heather C. Forkey, MD, FAAP, is a professor of pediatrics and pediatric vice chair for wellness at the University of Massachusetts c t Medical School (UMMS) and division director of the Child Protection Program and Foster Children Evaluation Service of the i c UMass Memorial Children’s Medical Center. She also serves as medical director of Lifeline4Kids at the UMMS. a l Jessica L. Griffi n, PsyD, is a clinical psychologist, an associate professor of psychiatry and pediatrics at the UMMS, and executive G director of the UMMS Child Trauma Training Center. In 2020, she was awarded a multiyear, multimillion-dollar grant to develop u the national Resilience Through Relationships Center, housed at the UMMS, aimed at supporting parents, caregivers, and i d children exposed to trauma. She also serves as executive director of Lifeline4Kids at the UMMS. e Moira Szilagyi, MD, PhD, FAAP, elected to serve as 2021 president-elect and 2022 president of the American Academy of Pediatrics, is a primary care pediatrician, professor of pediatrics, and division chief of developmental-behavioral pediatrics at UCLA, where she is also the Peter Shapiro Term Chair for Enhancing Children’s Developmental and Behavioral Health in F Pediatrics. She is editor of Fostering Health and has worked for 30 years with children and teens in foster care. o r k HHeeaatthheerr CC.. FFoorrkkeeyy,, MMDD,, FFAAAAPP e y • G JJeessssiiccaa LL.. GGrriifffifi nn,, PPssyyDD r if For more pediatric resources, visit the fi n MMMoooiiirrraaa SSSzzziiilllaaagggyyyiii,,, MMMDDD,,, PPPhhhDDD,,, FFFAAAAAAPPP American Academy of Pediatrics at shop.aap.org. • S z ila g y i AAP CCHHIILLDDHHOOOODD TTRRAAUUMMAA -- CCOOVVEERR SSPPRREEAADD..iinndddd AAllll PPaaggeess 55//2277//2211 1111::0044 AAMM Available From the American Academy of Pediatrics AAP Developmental and Behavioral Pediatrics Addressing Mental Health Concerns in Pediatrics: A Practical Resource Toolkit for Clinicians Building Resilience in Children and Teens: Giving Kids Roots and Wings Child Abuse: Medical Diagnosis and Management Managing Behavioral Issues in Child Care and Schools: A Quick Reference Guide Managing Mental Health Concerns in Pediatrics: A Clinical Support Chart Medical Evaluation of Child Sexual Abuse: A Practical Guide Mental Health Care of Children and Adolescents: A Guide for Primary Care Clinicians Pediatric Mental Health: A Compendium of AAP Clinical Practice Guidelines and Policies Pediatric Psychopharmacology for Primary Care Promoting Mental Health in Children and Adolescents: Primary Care Practice and Advocacy Raising Kids to Thrive: Balancing Love With Expectations and Protection With Trust Reaching Teens: Strength-Based, Trauma-Sensitive, Resilience-Building Communication Strategies Rooted in Positive Youth Development Thinking Developmentally: Nurturing Wellness in Childhood to Promote Lifelong Health For additional resources, visit https://shop.aap.org. CCTTAARR BBOOOOKK..iinnddbb 11 55//1166//2211 22::5544 PPMM CCTTAARR BBOOOOKK..iinnddbb 22 55//1166//2211 22::5544 PPMM CCTTAARR BBOOOOKK..iinnddbb 11 55//1166//2211 22::5544 PPMM American Academy of Pediatrics Publishing Staff Mary Lou White, Chief Product and Services Officer/SVP, Membership, Marketing, and Publishing Mark Grimes, Vice President, Publishing Chris Wiberg, Senior Editor, Professional/Clinical Publishing Theresa Wiener, Production Manager, Clinical and Professional Publications Amanda Helmholz, Medical Copy Editor Sara Hoerdeman, Marketing Manager, Consumer Products Published by the American Academy of Pediatrics 345 Park Blvd Itasca, IL 60143 Telephone: 630/626-6000 Facsimile: 847/434-8000 www.aap.org The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of all infants, children, adolescents, and young adults. The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication. The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at the first opportunity. This publication has been developed by the American Academy of Pediatrics. The contributors are expert authorities in the field of pediatrics. No commercial involvement of any kind has been solicited or accepted in the development of the content of this publication. Disclosures: Dr Griffin consults independently as a Trauma-Focused Cognitive Behavioral Therapy trainer. Dr Szilagyi disclosed a president-elect relationship with the American Academy of Pediatrics, a principal investigator relationship with the Substance Abuse and Mental Health Services Administration, an author relationship with UpToDate/Wolters Kluwer, and a spouse/partner’s editor relationship with Wolters Kluwer and with Academic Pediatrics. Every effort has been made to ensure that the drug selection and dosages set forth in this text are in accordance with the current recommendations and practice at the time of publication. It is the responsibility of the health care professional to check the package insert of each drug for any change in indications or dosage and for added warnings and precautions. Every effort is made to keep Childhood Trauma and Resilience: A Practical Guide consistent with the most recent advice and information available from the American Academy of Pediatrics. Please visit www.aap.org/errata for an up-to-date list of any applicable errata for this publication. Special discounts are available for bulk purchases of this publication. Email Special Sales at [email protected] for more information. © 2021 American Academy of Pediatrics All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means— electronic, mechanical, photocopying, recording, or otherwise—without prior written permission from the publisher (locate title at https://ebooks.aappublications.org and click on © Get permissions; you may also fax the permissions editor at 847/434-8780 or email [email protected]). Printed in the United States of America 9-458/0521 1 2 3 4 5 6 7 8 9 10 MA1019 ISBN: 978-1-61002-506-5 eBook: 978-1-61002-507-2 Cover and publication design by LSD DESIGN LLC Library of Congress Control Number: 2020943891 CCTTAARR BBOOOOKK..iinnddbb 22 55//1166//2211 22::5544 PPMM Authors Heather C. Forkey, MD, FAAP Professor of Pediatrics Vice Chair for Wellness Medical Director, Lifeline4Kids University of Massachusetts Medical School Chief, Child Protection Program and Foster Children Evaluation Service UMass Memorial Children’s Medical Center Worcester, MA Jessica L. Griffin, PsyD Associate Professor of Psychiatry and Pediatrics Executive Director, Child Trauma Training Center Executive Director, The Resilience Through Relationships Center Executive Director, Lifeline4Kids University of Massachusetts Medical School Worcester, MA Moira Szilagyi, MD, PhD, FAAP Professor David Geffen School of Medicine Mattel Children’s Hospital Division Chief, Developmental-Behavioral Pediatrics Peter Shapiro Term Chair for Enhancing Children’s Developmental and Behavioral Health in Pediatrics University of California, Los Angeles Los Angeles, CA American Academy of Pediatrics Reviewers Council on Child Abuse and Neglect Council on Community Pediatrics Council on Foster Care, Adoption, and Kinship Care CCTTAARR BBOOOOKK..iinnddbb 33 55//1166//2211 22::5544 PPMM CCTTAARR BBOOOOKK..iinnddbb 44 55//1166//2211 22::5544 PPMM ß To all our patients and their families for making us better at what we do and to our families, our safe harbors in life ß CCTTAARR BBOOOOKK..iinnddbb 55 55//1166//2211 22::5544 PPMM Equity, Diversity, and Inclusion Statement The American Academy of Pediatrics is committed to principles of equity, diversity, and inclusion in its publishing program. Editorial boards, author selections, and author transitions (publication succession plans) are designed to include diverse voices that reflect society as a whole. Editor and author teams are encouraged to actively seek out diverse authors and reviewers at all stages of the editorial process. Publishing staff are committed to promoting equity, diversity, and inclusion in all aspects of publication writing, review, and production. CCTTAARR BBOOOOKK..iinnddbb 66 55//1166//2211 22::5544 PPMM Contents ix Acknowledgments xi Introduction 1 Part 1. Building the Resilient Child 3 Chapter 1. Brain Development: Early Childhood Through Adolescence 11 Chapter 2. Promoting Resilience 19 Chapter 3. Attachment 33 Chapter 4. Parenting 51 Chapter 5. Cultural Connections (Andrea Ocampo Rosales, MA) 57 Part 2. Effects of Adversity and Trauma 61 Chapter 6. Pathophysiology of Trauma 73 Chapter 7. How Trauma Can Manifest in Children and Teens 89 Part 3. Promoting Recovery From Trauma 91 Chapter 8. Engagement 97 Chapter 9. Patient Evaluation and Differential Diagnosis 107 Chapter 10. Surveillance and Screening 123 Chapter 11. Pediatric Management 141 Chapter 12. The Intersection of Trauma and Culture (Andrea Ocampo Rosales, MA) 153 Chapter 13. Supporting the Caregiver 159 Chapter 14. Integrated Care 169 Chapter 15. The Role of Medication 177 Part 4. Supporting the Clinician and Pediatric Settings 179 Chapter 16. Burnout and Secondary Traumatic Stress 187 Chapter 17. Trauma-Informed Systems of Care 199 Conclusion 201 Appendixes. Selected Handouts by Topic 203 Appendix A. Promoting Resilience Handouts 204 Appendix B. Attachment Handouts 206 Appendix C. Parenting Handouts 207 Appendix D. Cultural Connections Handouts 208 Appendix E. Signs and Symptoms of Trauma Handouts 209 Appendix F. Engagement Handouts 210 Appendix G. Pediatric Management Handouts 217 Index vii CCTTAARR BBOOOOKK..iinnddbb 77 55//1166//2211 22::5544 PPMM