Rob Steele, MD (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy, Kansas City. Before we introduce our guest, I want to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/CMEpodcast and claim the CME with the button that says Claim CME. How convenient it says Claim CME. That's awesome. Today, we are joined by Dr. Allie Gibson to talk about signs of traumatic stress and how primary care providers can support children and families who may be experiencing it.

Dr. Gibson is a Licensed Clinical Psychologist at Children's Mercy Kansas City and a Clinical Assistant Professor of Pediatrics in the UMKC School of Medicine. She has specialized training and expertise in working with families of children with neurodevelopmental disorders, including ADHD and autism, disruptive behavior disorders, and those who have experienced traumatic life events.

A formative part of her clinical training involved working at a community mental health center providing evidence based evaluation and treatment of youth who had experienced traumatic events with a focus on providing trauma focused cognitive behavioral therapy services. Dr. Gibson is passionate about working with families of young, at-risk children with disruptive behaviors to help prevent future maltreatment and limit the development of other mental and behavioral disorders.

Dr. Gibson, thank you so much for, being with us today.

Allie Gibson, PhD: Thanks for having me.

Host: Now, before we get started this is a podcast, so it's only audio, but I've got you on video here and I understand you've got three cats. So I'm going to be on the lookout for those three.

Allie Gibson, PhD: They're locked out.

Host: Oh, they are. Okay.

Allie Gibson, PhD: I have the door shut because they were running wild this morning and I thought, hmm, it might be a little distracting.

Host: Okay. Yeah. Okay. Fair enough. Well, that's disappointing for me. Our listeners aren't going to necessarily going to be able to enjoy that part, but that's fine. I'll go without the cats then. Why don't we jump right into it and let's just start basically on just what child traumatic stress is, you know, what are the kinds, what typically causes it, the patients that you see, what do they typically come in and what are their experiences?

Allie Gibson, PhD: Generally speaking, childhood traumatic stress occurs when a youth goes through something traumatic and their experience overwhelms their ability to cope with those feelings, right? So, there's a lot of different kinds of traumatic events. So, some might include some kind of abuse, physical, sexual, or emotional abuse, neglect, experiencing something like a natural or a technological disaster, experiencing violence in your family or in your community, similar things like public events like mass violence, a school shooting, a terrorist attack. But this can also include a sudden or violent loss of a loved one, experiencing a serious accident or a life threatening illness that might require extensive medical treatment or hospitalization, refugee or war experiences, and even a military family related stressor.

Having a parent deployed, parental loss or injury, those all could cause trauma for a child. And the person doesn't necessarily have to directly experience the event. They might witness it. They might learn about it occurring to a close family member or friend. So there's a lot of different ways that youth can be exposed to trauma and therefore experience traumatic stress.

So, some youth, when they experience early and repeated exposures to overwhelming events, they might experience complex or developmental trauma. So there's a lot of different ways this can happen for kiddos.

Host: I imagine just the age and developmental level of the child, determines not just whether an event is traumatic, but just the level of trauma that they experience?

Allie Gibson, PhD: Absolutely, we do see variation across different kind of age ranges. So a younger child like a preschooler or an early school age child, they might have difficulty describing what's bothering them or really explaining what they're experiencing emotionally. So you may see them incorporate aspects of the event through their imaginary play.

They might have more disruptive behaviors, like tantrums, being more irritable. They may seem more afraid, like those fears of things like the dark, or monsters might come up more often. And the other thing we see for young children, they may have regressions in skills they previously had achieved. So, they might return to things like thumb sucking, changes in their language skills. Difficulties falling asleep and staying asleep is a big one for a lot of my patients. They might have more trouble separating, more bedwetting, and other just difficulties kind of separating from a caregiver.

Whereas an older child, they may be more concerned about their own actions during the event, feeling guilt or shame about what they did or didn't do during the traumatic event they experienced. But typically, we also see them exhibiting sleep changes, more difficulties with concentration and learning at school, they may complain more about physical things like headaches or stomach aches, but they may also have changes in their behavior as well. They might be more disruptive or disrespectful, more reckless or aggressive than before.

And for teens, we often see them withdrawing more. They may be concerned over being labeled as different than their peers. They may also have feelings of shame or guilt. But we might see more like angry or resentful behaviors, use of things like drug and alcohol or tobacco, and more maybe destructive behaviors or things just showing they're upset and they're experiencing this stress in kind of a different way.

Host: I imagine that's sometimes difficult, you know, some of the signs and symptoms that you just described are relatively nonspecific. It's only that you may have identified a traumatic event, but they're still nonspecific. And so I imagine it's sometimes difficult to tease out what might be directly related to the traumatic event versus just other things within that child's life. Is that a fair assessment?

Allie Gibson, PhD: Absolutely. It can be. And so a really important part of assessment is just identifying, has there been some sort of traumatic event that has happened? Because that's key for any kind of diagnostic purposes, but it also helps us kind of contextualize the situation. Did the child go through something stressful or scary that could explain these symptoms?

And I do a lot of ADHD evaluations and this comes up sometimes, right? I'm like, actually I don't think this is ADHD. I think the child's more disruptive or they're having more trouble with concentration and focus at school because of this other event they experienced or are continuing to experience in their lives.

Host: And so, with regard to those signs and symptoms, typically how fast do you see those manifest in those behaviors? And, do you have a sense of how long they typically last?

Allie Gibson, PhD: It's quite variable. So, I would expect some of these symptoms to occur within the first couple of days after a traumatic event. We kind of consider that normal. They went through something scary and they're experiencing these different symptoms. So for the first one to four weeks, you might be noticing some of these symptoms. And we might call this acute stress. This is just sort of saying, yep, you went through something stressful and scary, and your body is kind of reacting, and you're getting readjusted.

But if those symptoms last for more than a month, and they continue to cause the child significant impairment, whether it's having trouble in school, having trouble getting along with their family. For older teens, maybe it's their job functioning, or any other element of their life where they're experiencing significant impairment; that would be concerning to me, especially after a month where these things are still persisting and really getting in the way.

And I would generally say that symptoms are noticeable within about three months. But they, in some cases, may have a delayed kind of expression or onset.

Host: So, with regard to the consequences of children and adolescents that are facing this trauma, could you comment one, on just the ones that actually get help, which is probably less than half, I imagine. When you look at other mental, and behavioral challenges with our adolescents, we know that majority of those patients may never find the help that they really need.

But for those that actually are getting help, what are the consequences that you see even despite intervention?

Allie Gibson, PhD: I think the consequences of trauma can be wide ranging. We do know that it can worsen pre-existing health concerns. It can lead to changes in the child's cognitive functioning, their emotional regulation, their interpersonal relationships with others. We also know that it can be related to suicidal thoughts, attempts, and death by suicide.

But the other thing to think about is how it might generate secondary adversities. So, a family separation, a financial hardship, social stigma, legal procedures. So these can have kind of rippling effects for the family, regardless of if that child received treatment or not. Sometimes we see challenges with the child's ability to form positive relationships and just cope with that negative experience.

Host: As you're evaluating these patients, I know that one of the challenges that I had in practicing with adolescents that have gone through this, is the coordination between therapy and whether medication is ever necessary. So, talk to us for the primary care physicians that are listening to this podcast; what is a good approach, with regard to how you coordinate that care and how do you make the decision, hey, medication might actually be helpful in this situation because of perhaps overwhelming anxiety or other symptoms?

Allie Gibson, PhD: You know, I'm definitely always going to emphasize some sort of psychosocial or mental health treatment, whether that be trauma focused cognitive behavioral therapy, parent child interaction therapy. All these different kinds of treatments are very important, but you're right, I do see some families who the child is experiencing kind of intense physical symptoms. They're experiencing flashbacks, their heart is racing, sweating, startled easily, seeming very sad or depressed. And I think in those situations, sometimes a medicine is really helpful. Since I'm not a medical doctor, I can't speak to specific medicines, but I do view this as an opportunity to work in collaboration with mental health providers, whether that be a provider the child is seeing in the family therapy services here at Children's Mercy or in the community. But I do find that that coordination of care is key and it's hard sometimes. I have some patients right now who are being seen in the community mental health center for crisis support because they're able to see them urgently to get them stabilized with the goal of kind of getting them back to their primary care doctor eventually. But I do think and recognize that that is a challenge, of just having good communication, having the opportunity to kind of track those symptoms over time and see if they are changing as we would expect, or kind of persisting on that trajectory, leading more towards something like a PTSD diagnosis.

Host: Yeah, that is always a challenge trying to coordinate that. Within the family unit, often, and maybe it's the most of the time, I don't know, those traumatic events aren't isolated to the child themselves, the family is involved. So how do you approach that? Because, obviously you've got a patient in front of you; but yet they're in an environment, a family environment, in which there's a lot of dynamics. So how do you approach that from the family unit?

Allie Gibson, PhD: One thing that we really emphasize at the beginning of therapy is safety for the child, ensuring that they are physically safe, that we are giving them opportunities to talk about this experience in an open way. I'm also always recommending limiting media, social media about the stressful or scary event for everyone. We don't need to be kind of reliving this event on television. l'm always emphasizing practicing healthy habits, trying to get back to your normal routine, spending time together as a family, doing your favorite activities, and the other thing I like to highlight is that almost all of the treatments for trauma incorporate the family unit.

It's really important to have that parental support when we're processing something traumatic and we are helping that child through that event with the parent. That is so important to have them incorporated in treatment as strongly as we can.

Host: And then, how about for those that are school aged children? Is there a role within the schools ideally, that can play in helping that child get through not just the event, but also to make them as healthy as possible going forward?

Allie Gibson, PhD: I think a lot of it is just giving the child some grace and understanding. They may be exhibiting regressive behaviors like we talked about earlier, more disruptive behaviors. Really coming at that with a sense of curiosity, why is this happening? One of my supervisors always said, don't be furious, get curious, because some of these behaviors can be really challenging. They can really push the limit for caregivers and teachers, but just understanding that this is coming from a place that the child doesn't want to feel like this, and giving them extra supports; helping them practice their healthy habits, helping them connect with someone that they feel safe to talk to, perhaps a counselor or another teacher the child has a good relationship with. But I think just giving the family a lot of grace is really important because there's so much of this that's out of control.

Host: Well, shout out to your supervisor because, don't get furious, get curious that's a really good pearl of wisdom. Well, Dr. Gibson, I appreciate your time, and your expertise, this has been fantastic talking with you. And I think you've given our listeners some good tools to move forward for those children that have experienced traumatic events. I am disappointed that Petunia, Ozzy and Winston did not show up on camera here, but that's okay. I have a question then for you, probably one of the most important questions.

So, one of the things that I came across is that there is a cat in a small town in Mexico that ran for mayor, Morris the Cat there. Yes, it's true. And so my question is Petunia, Ozzy, and Winston, do any of them have the intellect to be able to run a city?

Allie Gibson, PhD: I would say Ozzy has the energy. He's a people person. He'd be out there shaking hands and getting head scratches, but the joke is that he's an orange cat and all orange cats only share one brain cell and they take turns, so I don't think he's set up for it. Petunia really likes to nap, and she's not a people person, but Winston, he's our outside cat turned inside boy and I think he has the street smarts and a sweet personality and I think he might be able to run the roost.

Host: Okay, very good. Well, then maybe they could just be the cabinet then, you know, and the three of them could run the city themselves. Well, Dr. Gibson, thank you again for your time and all the pearls of wisdom that you've given to us. As a reminder, claim your CME credit for listening to our show today. Visit cmkc.link/CMEpodcast and claim your CME with the little button that says claim CME. This has been another episode of Pediatrics in Practice, a CME podcast. See you next time.