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Lisa Black

The core mission statement of pediatric institutions should focus on identifying and alleviating trauma and toxic stress

The American Academy of Pediatrics calls for governmental, institutional and academic leaders to incorporate effective ways to identify and address the effects of trauma on children, families and their healthcare providers in a policy statement, “Trauma-Informed Care in Child Health Systems,” published in the August 2021 Pediatrics.

The policy statement and accompanying clinical report, which will be published online Monday, July 26, observes that when children lack safe, stable, and nurturing relationships, their response to stress over time can result in lifelong impairments in physical, mental, and relational health. The clinical report provides practical tools for pediatricians to embrace this approach when working with children, families and communities.

“Almost half of American children have faced at least one potentially traumatic early childhood experience, and many have been harmed by the confluence of poverty, losses related to the pandemic and racial unrest,” said James Duffee, MD, MPH, FAAP, lead author of the policy statement. Both policy statement and clinical report were written by the Council on Community Pediatrics; Council on Foster Care, Adoption, and Kinship Care; Council on Child Abuse and Neglect; and Committee on Psychosocial Aspects of Child and Family Health.

“Because of differences in temperament and prior life experiences, some children are more vulnerable to long-term effects of trauma than others. We see symptoms that range from changes in eating and sleeping to severe physical and mental health effects that may require treatment,” Dr. Duffee said. “Helping children and their parents and caregivers draw on their close relationships with others can help lessen the harms of trauma and build resilience.”

In surveys, poverty or financial stress is the most reported childhood adversity, second only to loss of a parent, according to the policy statement. Exposure to divorce, child maltreatment, sexual abuse, intimate partner violence, bullying, parental mental illness, parental substance use problems, and community violence are also common and racism is a common cross-cutting factor.

“Trauma-informed care embeds screening or surveillance in the context of comprehensive care, starting with engaging families, building resilience, addressing attachment, and assuring safety at all visits,” said Heather Forkey, MD, FAAP, an author of the statement and clinical report.

The AAP offers clinical recommendations on:

  • Knowledge about trauma and its potential lifelong effects
  • Support for the caregiver-child relationship to build resilience and prevent traumatic stress reactions
  • Screening for trauma history and symptoms
  • Recognition of cultural context of trauma experiences, response, and recovery
  • Anticipatory guidance for families and health care workers
  • Ways to avoid re-traumatization in healthcare settings
  • Processes for responding in the pediatric setting and referral to counseling with evidence-based therapies when indicated
  • Attention to the prevention and treatment of secondary traumatic stress

“These reports also call attention to the fact that caregivers and health care workers can experience stress and burnout as secondary effects of addressing the trauma experienced by others,” Dr. Duffee said. “We are calling on healthcare systems to adopt trauma-informed care as a core mission and for federal and state policy makers to help make that happen.”

An additional resource is a new AAP-published book, “Childhood Trauma & Resilience: A Practical Guide” by Dr. Forkey; Jessica L. Griffin, PsyD; and Moira Szilagyi, MD, PhD, FAAP, that provides guidance on trauma-informed care and the protective power of resilience. Dr. Forkey and Dr. Szilagyi were co-authors of the policy statement and clinical report.

To request an interview with an author or request a review copy of Childhood Trauma & Resilience, contact AAP Public Affairs.


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 infants, children, adolescents and young adults.

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