1. Childhood Trauma
Heather Forkey, M.D.

2. Child Trauma
Trauma has very obvious
physical effects.
Trauma has significant
mental and
developmental effects.
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3. History of Trauma

4. What Does Trauma Look Like?
How does brain develop?
How does trauma impact that brain’s development?
Why are children’s responses variable?
Impacts on mental health.
Impacts on development.
Impact on health for lifespan.
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5. History and Review of Systems
Trauma’s influence on brain results impacts bodily functions.
Response to Trauma: Bodily Functions
Function Central Cause Symptom
1. Difficulty falling asleep.
Stimulation of reticular
Sleep 2. Difficulty staying asleep.
activating system.
3. Nightmares.
1. Rapid Eating.
Inhibition of satiety center,
Eating 2. Difficulty staying asleep.
anxiety.
3. Food hoarding.
1. Constipation.
Increased sympathetic tone,
Toileting 2. Lack of satiety.
increased catecholamines.
3. Enuresis.
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6. History and Review of Systems
Response to Trauma: Behaviors
Category More Common With Response Misidentified As
- Females
- Detachment - Depression
- Young Children
Dissociation - Numbing - Inattentive ADD
- Ongoing trauma/
(Dopaminergic) - Compliance - Developmental
pain
- Fantasy Delay
- Inescapable/Helpless
- ADHD
- Hyper vigilance
- Males - ODD
- Aggression
Arousal - Older Children - Conduct Disorder
- Anxiety
(Adrenergic) - Observer - Bipolar Disorder
- Exaggerated
- Able to act - Anger Management
Response
difficulties
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7. History and Review of Systems
Exposure to trauma impacts development and school functioning.
Response to Trauma: Development and Learning
Impact on Working Impact on Inhibitory Impact on Cognitive
Age
Memory Control Flexibility
Frequent severe
Difficulty acquiring tantrums.
Infant /
developmental Easily frustrated.
Toddler
milestones. Aggressive with other
children.
Difficulty with school
skill acquisition. Frequently in trouble Organizational Difficulties.
School Aged Losing details can lead at school and with
Child to confabulation, peers for fighting and Can look like learning
problems or ADHD.
viewed by others as disrupting.
lying.
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8. Identifying Trauma
Medical Analogy: Tuberculosis
Tuberculosis Trauma
Not every child develops disease. Not every child exposed develops symptoms.
Some exposed will be unaffected, some will develop Some exposed will be unaffected, some will develop
latent disease, some will become acutely ill. latent disease, some will become acutely ill.
All children exposed should have a PPD. All children exposed should have screening.
If trauma screening positive, should have full trauma
If PPD positive, should have CXR.
assessment.
Specific treatments are available and effective. Specific treatments are available and effective.
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9. Case: 38-month-old Child (JG)
Foster mother is concerned about JG’s behavior.
Severe tantrums.
Hurts other children and damages furniture.
Very short attention span, does not follow directions.
BMI > 95%
Wants to eat all the time.
Obese.
Limited vocabulary.
Not toilet trained.
Insomnia.
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10. Case: 16-year-old Youth (EM)
Male who recently had a fight with his stepfather.
Ended in police involvement.
Diagnosed with ADHD 3 years ago.
Increased aggression 18 months ago.
Diagnosed with bipolar disorder 1 year ago.
Trouble with insomnia.
Frequent headaches- some are severe
and associate with nausea and photophobia.
Medications: Concerta, Tenex, Clonidine
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11. Discussion of Cases
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12. Next

13. How To Screen
Physician can probe for information about toxic stressors in a non-
threatening, but trauma informed manner.
Open Ended Questions to Ask
In the case that the physician may need to be more direct, use what
they know about how the body responds to lay out concerns.
More Direct Questions to Ask
Formal Trauma Screening Tools

14. Open Ended Questions
These questions may prompt the family to remember
stressors they might not have thought to tell the
physician.
“Do you know of any really scary or upsetting things that have
happened to you (your child) before he/she came to live with you?”
“Since the last time I saw you (your child) has anything really scary or
upsetting happened to you (your child) or anyone in your family?”
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15. Direct Questions
When trying to identify domestic violence, substance
abuse, bullying or child abuse, one may have to be
more direct.
“You have told me that your child is having difficult with aggression, attention and sleep. Just as
fever is an indication the body is dealing with an infection, when these behavioral symptoms are
present, they indicate that the brain and body are responding to a stress or threat. Do you have
any concerns that your child is being exposed to threat?”
“The behaviors you describe and the trouble she is having with school and learning are often
warning signs that the brain is trying to manage stress or threat. Sometimes children respond
this way if they are being harmed, or if they are witnessing other they care about being harmed.
Do you know of violence exposure at school, with friends, or at home?”
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16. Formal Screening Tools
Very useful for most objective data.
Trauma Screening Tools
Number of
Admin and Cultural Cost and
Tool Description Items and Age Group
Scoring Time Considerations Developer
Format
Assesses Child and 20-30 min to
UCLA PTSD-RI: 20-22 items Available to Intl.
exposure to Parent: 7-12 administer English
Post Traumatic depending on Soc. for
trauma and years
Stress Disorder child, parent, or Traumatic Stress
impact of 5-10 min to Spanish
Reaction Index youth version. members.
events. Youth 13+ score
Available to Intl.
Elicits trauma 9 items for child 8-16 years English
Abbreviated Soc. for
related 2-5 minutes
UCLA PTSD RI Traumatic Stress
symptoms. 6 items for adult 3-12 years Spanish
members.
TSC-C: 54 items
TSC-C Trauma
Elicits trauma TSC-YC: 90 8-16 years English
Symptom Proprietary
related items, caregiver 15-20 minutes
Checklist for ($168 per kit)
symptoms. report for young 3-12 years Spanish
Children
children
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17. How to Respond
Scripts
Anticipatory Guidance
Referrals: Trauma Specialists

18. Scripts
Step One: Describe Pathophysiology of Trauma Response
Our bodies are designed to help us
survive in the wilderness where the
ability to respond to threat, such as a
hungry tiger, is required to protect our
bodies.
Our bodies and brains are designed
so that at times of threat the brain is
intent on fighting, running, or hiding.
NOT on learning or remembering the
facts about the event.
These responses are supposed to be
strong, but short lived, and following
the threat the body is designed to
Part Two

19. Scripts
Step Two: Help Caretaker Recognize Feeling of Trauma
Parents and older children should be prompted to recall a time when
they felt threat (car accident, fight, victim of crime) and remember how
their bodies felt. The heart raced and their muscles were ready to go.
While they may remember acutely the minutes before the accident or
threat, they may have little recollection of the actual frightening event.
Part Three

20. Scripts
Step Three: Help Caretaker Extrapolate Own
Experience to Situation of Toxic Stress
Parents are guided to imagine the experience of living in a situation
where “the tiger” is in the house. This causes the fight, flee, or hide
response, but instead of having the chance to return to baseline
following a short lived threat, the feeling stays.
Part Four

21. Scripts
Step Four: Brain Response
When trying to learn piano, one plays
the same piece over and over.
Eventually the brain connections are
so strong, fingers practically play the
piece by themselves, no need to think.
Response to trauma is the same.
Once the connections are made and
reinforced, little stimulation causes
strong response.
Parts of the brain dedicated to
responding to trauma hypertrophy and
grow connections. Parts of the brain
used in learning and logic are pruned
away and get smaller. States become
traits.
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22. Anticipatory Guidance
Lower tone and intensity of voice.
Come down to child’s level.
Help child avoid a stress response.
Help child interpret your facial or vocal tones.
Relaxation, breathing exercises, and yoga will promote calm behavior.
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23. Anticipatory Guidance
Part One
What you will see:
Traumatized children will respond to anything perceived
as threat more quickly and more forcefully than other
children.
Why does this occur??
Answer

24. Areas of the brain responsible for recognizing and
responding to threat are turned on, hypertrophied.
How do you Respond??
Answer

25. Do not take these behaviors personally.
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26. Anticipatory Guidance
Part Two
What you will see:
Traumatized children are more likely to misread facial
and non-verbal cues and perceive threat where none is
intended.
Why does this occur??
Answer

27. Brain does not recognize that this new situation does not
contain the same threats.
How do you Respond??
Answer

28. Helping the child interpret your face or voice tone will
help avoid the child escalating in situations that otherwise
seem innocuous.
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29. Anticipatory Guidance
Part Three
What you will see:
Traumatized children need to be redirected or behavior
starts to escalate.
Why does this occur??
Answer

30. - Responding with aggression trigger which will put the
child’s brain back into threat mode.
- Logic centers shut down, fight, flight or hide response
takes over.
How do you Respond??
Answer

31. - Avoid yelling and
demonstrating aggression.
- Lower the tone and
intensity of voice.
- Come down to the child’s
level.
- Keep directions devoid of
strong emotion.
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32. Anticipatory Guidance
Part Four
What you will see:
Traumatized children do not have skill set for self-
regulation or for calming down once upset.
Why does this occur??
Answer

33. Relaxation, breathing techniques, and yoga all stimulate
parts of the brain which help it to reorganize synapses
and cells and promote calm and centered behavior.
How do you Respond??
Answer

34. - Develop breathing techniques, relaxation skills, or
exercises which the child can employ when getting upset.
- Guide the child at first then just use the skills when
distress starts to appear.
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35. Anticipatory Guidance
Part Five
What you will see:
Traumatized children will challenge caretaker, often in
ways that threaten placement.
Why does this occur??
Answer

36. - Children come with negative
beliefs and expectations about
themselves and about caregivers.
- Reenactment or recreating old
relationships with new people to
evoke same reactions in caretakers
that children experienced with other
adults, and lead to familiar reactions.
- These patterns helped children
survive in the past, prove negative
beliefs, help child vent frustration
and give child some sense of
mastery.
How do you Respond??
Answer

37. - Provide disconfirming messages that say child is safe,
wanted, capable and worthwhile and that caretaker is
available, reliable and responsive.
- Praise even neutral behavior.
- Be aware of own emotional responses to child’s
behavior.
- Correct when necessary in calm, unemotional tone.
- Repeat, repeat, repeat.
- Do not take these behaviors personally.
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38. Referrals
Referrals should be to trauma specific therapies if they are available.
For young children: Know More
PCIT: Parent Child Interactive Therapy
CPP: Child Parent Psychotherapy
For older children: Know More
TF-CBT: Trauma Focused Cognitive Behavioral Therapy
CBITS: Cognitive Behavioral Intervention for Trauma in Schools
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39. Young Children 0-5 Years Old
GOALS:
Work with caregivers and
children to address child
behaviors observed during play.
Teach caregivers to understand
the impact of trauma and how
best to respond.
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40. Older Children 5+ Years Old
GOALS:
Trains children and families in:
Relaxation techniques.
Skills and language to access emotion.
Psychoeducation.
Child is guided to create a trauma
narrative.
Child develops a story about what
happened to them.
Final goal: Child is able to tell or read
story.
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41. Coding
Office Visit Codes:
(can use in combination with well-child visit code if criteria for BOTH a well-
child and problem oriented visit are met)
99201-99205 (initial)
99211-99215 (follow-up)
Consult Visit Codes:
99241-99245 (initial)
Screening Codes (must document results in chart)
96110: Developmental Screening (including parent/caregiver completed forms/
rating scales
When using office visit code and screening code at same encounter, add -59
modifier to visit/consult code and -25 modifier to screening code
Health and Behavior Assessment/Intervention
96150: initial face to face assessment including health focused clinical interview,
behavioral observations, health oriented questionnaire, psycho-physiolgoical
monitoring. Billed in 15 minute increments
96151: reassessment
96152 health and behavior intervention; each 15 minutes face to face.
Case Management (non-facetoface)
99339: physician supervision of patient in home/domiciliary requiring complex
and multidicsciplinary care, development and/or revision of care plans, review of
patient status/reports, studies, communication/calls for purpose of assessment or
care decisions with health care providers, family/surrogate. 15-29 minutes per
calendar month
99340: 30 minutes or more
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42. Coding
Diagnosis Codes (ICD-9)
Physical Symptoms
564.00 Constipation Development and Cognitive Function
787.6 Encopresis NOS 781.99 Abnormalities of the nervous, muscle or nervous system
788.30 Enuresis-NOS 799.54 Frontal lobe/executive function deficit
783.41 Failure to thrive 783.40 Lack of normal physiologic development (developmental delay)
783.3 Feeding difficulty 319 MR-severity unspecified
760.71 FAS/FAE 799.59 Other signs/symptoms with cognition
263.1 Malnutrition- mild
263.2 Malnutrition -moderate
263.3 Malnutrition- severe
742.1 Microcephaly
765.10 Prematurity
760.70 Prenatal exposure-unspecified
780.50 Sleep disturbance NOS
Emotional/Behavioral Symptoms
995.52 Abuse/neglect
309.9 Adjustment disorder NOS
300.00 Anxiety NOS
314.01 ADHD combined type (can add inattentive vs impulsive/hyperactive)
313.89 Attachment disorder
799.51 Attention problem - not ADHD
312.81 Conduct disorder
312.9 Conduct disturbance/disruptive behavior- unspecified
311 Depression
799.25 Demoralization/apathy
799.24 Emotional lability
314.9 Hyperkinetic -unspecified
799.23 Impulsiveness
799.22 Irritability
799.21 Nervousness
300.3 OCD
313.81 ODD
799.29 Other signs/symptoms of emotional state
309.81 PTSD