In the profession of physical therapy (PT), the word "trauma" typically leads one to think of the physical manifestations of a catastrophic injury, subsequent emergency medical care, and lengthy rehabilitation services. However, the psychological aspects of trauma are not always as visible. Throughout an individual’s lifespan, PTs will provide services to restore function, manage pain, and increase physical activity. We provide education, hands-on care, and therapeutic exercise to improve functional mobility and optimize an individual’s quality of life. Pediatric PTs work with infants and children in schools, homes, clinics, hospitals, and daycares. Although our focus is on expanding a child’s gross motor repertoire and thus increasing their functional independence to walk, run, and play, we have multiple opportunities to model building resilience for children and their families through a trauma-informed approach.
Take for example the concept of “tummy time”. As a PT, I know this is an important developmental milestone which can also reduce the risk of “container baby syndrome” as well torticollis and plagiocephaly. Of course, babies aren’t focusing on milestones. Instead, babies often resist lying on their stomachs, as they have to work to push themselves up against gravity to check out their environment, find their primary caregiver, or reach for their favorite toy. This often leads to crying as the infant is communicating “Hey mom look at ME!”. This position is not only an excellent opportunity for the infant to work on prone extension but to also a time to build positive neural connections in the infant’s developing brain through play with their caregiver.
According to the Center for the Developing Child at Harvard University, an infant’s developing brain makes up to one million neural connections every second. Each time the infant cries during tummy time and then the caregiver responds with a smile, eye contact, or a song, positive neural pathways are built creating a strong foundation for brain development. This quick, positive interaction reinforces safety and consistency to the infant by the caregiver creating a sense of safety during a typical stress response.
Stress is a critical part of development. When a young child’s normal stress response system is disrupted, as in cases of abuse or neglect, children are at greater risk for a toxic stress response. The Center on the Developing Child’s Guide to Toxic Stress defines this concept as when a child experiences ongoing adversity – such as abuse, prolonged neglect, caregiver substance use or mental illness, violence, and/or poverty – without the mitigating supportive presence of an adult. Without a consistent adult presence to buffer the effects of stress, a child’s stress response system is continually activated which can lead to physical changes in a child’s developing brain. These changes in the brain can have long-term effects on an individual’s cognition, social-emotional development, and physical health.
As a pediatric PT who works with families and children with special needs, particular consideration needs to be paid to the circumstances our families and children encounter throughout the lifespan. Starting with their first days of life as patients in the NICU, infants and families interact with a number of different healthcare teams in a myriad of settings (e.g., hospital, early intervention, school, clinics, pediatrician). Infants in the NICU often experience trauma from painful medical procedures, inconsistent caregivers, and frequent but necessary separation from their primary caregivers.
Healthcare team members, including PTs, play a critical role in not only the immediate physical health outcomes for these infants and their families but their future mental health outcomes as well. Sanders and Hall advocate for the NICU team to adopt a universal precautions approach to trauma-informed care and have adapted SAHMSA’s six key principles of trauma-informed care for use in the NICU setting. Healthcare teams in the NICU are encouraged to create a mutually respectful environment focused on social connectedness, parent engagement, stress management, and safety to promote long-term positive outcomes for the infant and family.
The AAP’s Power of Play report outlines the innumerable benefits of regular active play. Play experiences not only help young children build school readiness skills, but improve cardiovascular health, lower BMI, and increase overall coordination. In early childhood classrooms, pediatric PTs prescribe gross motor play to help children of all ability levels meet developmental milestones, gain mobility skills, and be physically active. Play experiences and the environment are adapted by the PT to meet the unique motor and developmental needs of each child. In collaboration with other members of the early childhood team (teachers, OTs, speech therapists, etc.), PTs create opportunities for play in which young children can safely and actively explore their environment, problem-solve, and engage with peers.
The most important ingredient in building resilience is for a child to have an ongoing, committed relationship with a supportive, nurturing adult or caregiver. Due to the frequency in which PTs work collaboratively with caregivers in the home and clinics, we not only design therapeutic interventions, but also model strategies to promote positive parent-child interactions. In family-centered practice within an interprofessional team, PTs also consult with colleagues and caregivers to provide peer and community referrals to address the challenges related to the medical, social-emotional, and developmental needs of their child (FSU Supporting Infant and Early Childhood Mental Health in Physical Therapy).
All individuals working with children who have disabilities need to recognize the increased risk for neglect and abuse this population experiences. Children with a developmental delay can be 3x more likely to experience neglect, physical abuse, or sexual abuse (Jones, 2012). The Hogg Foundation published When Disability is a Disguise to raise awareness of the higher incidence of mental health issues in individuals with disabilities. The Hogg Foundation collaborated with the National Childhood Stress Network to publish a training guide for professionals entitled The Road to Recovery: Supporting Children with Intellectual and Developmental Disabilities Who Have Experienced Trauma. This guide provides training materials centered around SAHMSHA’s 4 R’s of Trauma Informed Care - Realize, Recognize, Respond, and avoiding Re-Traumatization – with specific considerations for this vulnerable population.
When Adverse Childhood Experiences and developmental disabilities intersect, families need comprehensive trauma-informed support to navigate the complex social, health and educational systems. Although PTs are movement experts focused on functional mobility, our ultimate aim is to improve the quality of life for our patients. Due to the amount of time we spend in direct contact with kids and families, pediatric PTs are positioned to help model positive child-caregiver interactions and refer families to other providers to help meet their unique needs. In order to provide patient-centered services for our children and families, we need to work in partnership with social service agencies and mental health providers to provide and create access to high-quality, integrated services. Through ongoing conversations, shared research, and interprofessional continuing development we can develop responsive trauma-informed systems for children and families.
Resources:
American Physical Therapy Association. https://www.choosept.com/Resources/Choose.aspx
Center on the Developing Child. Key Concepts Brain Architecture. https://developingchild.harvar.../brain-architecture/
Center on the Developing Child (2015). The Science of Resilience (InBrief). www.developingchild.harvard.edu.
FSU Center for Prevention and Early Intervention Policy. Supporting Infant and Early Childhood Mental Health in Physical Therapy. https://cpeip.fsu.edu/mma/ther...rapist_resources.cfm
Hogg Foundation. When Disability Is a Disguise. https://hogg.utexas.edu/projec...bility-is-a-disguise
Jones, L., Bellis, M. A., Wood, S., Hughes, K., Mccoy, E., Eckley, L., … Officer, A. (2012). Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. The Lancet, 380(9845), 899–907. doi: 10.1016/s0140-6736(12)60692-8
National Scientific Council on the Developing Child (2005/2014). Excessive Stress Disrupts the Architecture of the Developing Brain: Working Paper No. 3. Updated Edition. Retrieved from www.developingchild.harvard.edu.
Sanders, M. R., & Hall, S. L. (2018). Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness. Journal of Perinatology, 38(1), 3-10.
Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
The National Child Traumatic Stress Network. The Road to Recovery: Supporting Children with IDD who Have Experienced Trauma. Published November 2015. Available at: www.NCTSN.org .
Yogman, M., Garner, A., Hutchinson, J., Hirsh-Pasek, K., Golinkoff, R. M., & Committee on Psychosocial Aspects of Child and Family Health. (2018). The power of play: A pediatric role in enhancing development in young children. Pediatrics, 142(3), e20182058.
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