Patient Engagement

Children “At Risk”: Developmental Trauma and the Training Gap

Developmental trauma can be broadly defined as traumatic or adverse experiences that occur chronically to children, within the context of their caregiving environments (families, schools, etc.). Developmental trauma is not a one-off trauma likely to result in Post-Traumatic Stress Disorder – in fact, most traumatized children will never develop the classical signs and symptoms of PTSD. Instead, developmental traumas are the chronic domestic traumas that children encounter in harsh caregiving environments. These include experiences such as having a parent with mental illness or substance abuse, losing a parent due to divorce, abandonment or incarceration, witnessing domestic violence, not feeling loved or that the family was close, or not having enough food or clean clothing. These childhood experiences, as well as experiences of direct verbal, physical or sexual abuse, have been researched extensively. One such body of research comes from a database of over fifteen thousand adults, in a now-famous study known as the ACE, or Adverse Childhood Experiences, study.

This study, which was begun in 1995 in California and is still ongoing, explores the association between developmental trauma and a host of physical and mental health outcomes. Adults were asked about their early life experiences, and assigned an “ACE score” based on the number of these experiences that they endorsed. Adults who endorsed a high number (4 or more) of adverse experiences were found to have exponentially higher rates of serious physical health outcomes, high-risk health behaviours, and early illness and mortality. Fascinatingly, these data and data from thousands of other health measures collected prospectively since 2010 in the United States show that there is a strong dose-response relationship between trauma and poor outcomes. This means that the greater the number of developmental traumas experienced in childhood, the greater the number of illnesses as adults, even after controlling for high-risk health behaviours.

The original ACE data are significant not only for the link between childhood trauma and lifetime poor health, but also because of the remarkably high trauma rates, with a 15% prevalence of adults reporting an ACE score of 3 or more from their childhoods. In data collected each year since 2010 across 33 states, 20% of adults report an ACE score of 3 or more. These data challenge the idea that trauma occurs only within certain marginalized or “at risk” groups. Rather, it seems that children are broadly “at risk” for experiencing developmental trauma, and it matters profoundly to their long-term health and well-being.

The chronic developmental traumas of abuse and neglect afflict children so severely that it alters the course of their lives, impairing their concentration and memory, making it hard for them to succeed in school. It alters their lifelong health, giving them markedly higher risks of heart disease and certain cancers, among other leading causes of death. Yet doctors in Canada tasked with the health care of these children are not required to learn about these traumas. Not pediatricians, not family doctors, not child psychiatrists. We are not taught how to recognize developmental trauma, we are not trained in screening, and we don’t learn how to treat it . A minority of us, out of interest or luck, may receive some training in how to help these children, but there are no systematic training requirements for physicians to learn about this condition, despite it being prevalent, severe, and clearly linked to very poor health outcomes for children.

As pediatric health care providers, what do we need to understand about developmental trauma? Why does our training not require that we learn about the prevalence, presentation, and sequelae of trauma, the way we learn about other toxic exposures such as malnutrition causing failure to thrive? Why are we not taught how to assess and treat traumatized children, given what we now know about how trauma affects physical and mental development?

In many ways, these questions are just beginning to be addressed across the medical system. Many care providers note the frustrations of dealing with chaotic or disordered families, and the challenges of developing a care plan which addresses family functioning. Many of us are not trained how to assess a family’s functioning, so as to better understand the child in front of us. Even if we recognize that there are severe family stressors of the sort described in the ACE study, it can be hard to know where to begin to help, and a sense of burnout or futility may set in. Adding to the complexity, traumatized children often present in a myriad of ways, and there is no single sign or symptom set that we can reliably predict. As a child psychiatrist, I have diagnosed developmental trauma in children who were initially referred with previous diagnoses as diverse as autism, bipolar disorder, learning disabilities and ADHD.

And yet we must find a way to do better. Developmental trauma is prevalent and toxic. Research is now being done on interventions to increase resilience and recovery for these children and their families. There are evidence-based interventions which help. However, until the scale and significance of the problem is recognized and addressed within medical training itself, each new generation of care providers for children will have to grapple with the same knowledge and training gap facing most of us now in practice. Our AMS Phoenix project is one attempt to reduce this gap, by developing an online learning curriculum for family doctors and pediatricians, to help them recognize and address developmental trauma. We’ve included a section on compassion fatigue and burnout as well, in recognition that providing care to traumatized families can be challenging work. Our hope that this project becomes one small part of a much larger curriculum change across training institutions, to better prepare health care providers to assist traumatized children and their families.

One thought on “Children “At Risk”: Developmental Trauma and the Training Gap

  • Does the training include helping the parents find resources for the whole family and include parents in the treatment? Are the parents viewed as part of the solution?

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