xi Introduction She stopped me on my way out. I was leaving the presen- tation room at a pediatric conference, having just partici- pated in a session on the physiology of trauma and toxic stress. Her eyes were intense, and her manner was rushed, but the tone of her voice was what arrested my efforts to leave. “Just before you go…what you said, it makes so much sense. I get it. It’s so important, what you talked about…you described my patients,” and more softly she said, “and you described me.” She caught my eye again and queried, “I want to do this work, intervene for my patients…but how?” The cognitive “aha” that this practitioner had when the science of trauma and toxic stress was explained to her was, for her, as it was for us when we first learned about it, intellectually satisfying and profoundly motivating. It can help explain patients, symptoms, and family systems that seemed previously to have a common but invisible thread. For us, it helped make sense of what we had seen clinically for years. But, as this practitioner immediately recognized, knowing what is happening physiologically but not having the practical skills and tools to prevent, recognize, and respond to trauma in the clinical setting can be painfully frustrating. In some circumstances, this combination of improved understanding of the science and helplessness to influence it likely contributes to our own burnout and secondary traumatic stress. Pediatric medical care professionals are likely to be the first, and sometimes only, professionals with the opportu- nity to assess the myriad symptoms demonstrated by chil- dren experiencing trauma. For many children, the issues bringing them to pediatric attention are trauma related. For instance, 68% of children cared for in a pediatric health care setting have experienced exposure to trau- matic events, and as many as 90% of children in urban pediatric clinics have had a trauma exposure.1 We know that these events if unaddressed alter the neuroendocrine and immune systems of our patients in ways that can have lasting consequences. What’s more, the pediatrician is ideally situated for trauma prevention. Like vaccines, resilience skills and attachment are what keep children from experiencing long-term conse- quences from trauma even when there are exposures, and attachment and resilience building are what pediatrics is all about. We use a prevention and developmental framework and our relationships with children and families to pro- mote wellness. Resilience skills develop with attachment— the support of a predictable, compassionate, and available caregiver. With the support of those attachments, children develop regulation skills, executive function, and efficacy (the sense of being able to influence one’s environment). By harnessing our relationships with children and their caregivers, we have the opportunity to provide guidance and practical skills to promote resilience—if only we knew how. This relationship can have impacts in both directions. Studies catalog the myriad possible sources of medical professional burnout. Alarming statistics on depression and suicide in the health professions suggest not just that the work stress is frustration with the electronic medical record but that sharing the traumas of others can have a profound impact on the professional. Understanding the science of the stress response can guide the medical professional as well, but the science needs to be applied to provide practical methods to reduce the effects on our neuroendocrine system. We must take care of ourselves if we are to be at all effective with our patients. Again— if only we knew how. How do we teach families to help their children weave together the threads of resilience? How do we empower parents and caregivers to provide a strong seam to hold those threads in place in the context or fabric of a family’s cultural supports and social risks? How do we recognize the effects of trauma that cause a child or family to become frayed? How do we apply these principles to ourselves and our colleagues so we don’t become frayed as well? How do we weave this together in the medical setting, juggling the time and economic constraints of pediatric practice? That is what this book is about. As the physician I met at the conference recognized, what providers need are the practical tools, guidance, and pathways for us to respond to patients and caregivers and help them and ourselves. So, now, years after the physician I met at that conference asked me the question, we now have an answer. This is how to start. Reference 1. Burke NJ, Hellman JL, Scott BG, Weems CF, Carrion VG. The impact of adverse childhood experiences on an urban pediatric population. Child Abuse Negl. 2011 35(6):408–413 PMID: 21652073 https://doi.org/10.1016/j.chiabu.2011.02.006 CTAR BOOK.indb 11 5/16/21 2:54 PM
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