Trauma Awareness for the Infant/Toddler Population

I recently attended our state conference and there was a standout session by Marcella Jacobs of the Kennedy Krieger Institute on OT and Trauma Training for Infants and Toddlers. It was very informative and thought provoking, so I've decided to share some of the things that I learned from that session. Warning, there are some sad references in this post, because of the types of trauma that infants and toddlers incur.

First off, she brought up a point that maybe some will find as common knowledge but I think is important to reiterate. If you move into a specialized OT role (though we all interact with children of trauma, knowingly or not), or a position that is not traditionally filled by an OT, you are going to have to look outside the OT CE box to learn new and relevant things. So to become a trauma-aware OT practitioner, she looked to courses offered mainly to psychologists and other groups that would apply to her OT life. Something to think about when planning your professional development.

As someone who has spent so much time in the phys-dys hospital world, "trauma" usually means multiple orthopedic injuries with potential (possibly undiagnosed) neuro injuries. Obviously, this isn't the same in pediatrics. Trauma to an infant or toddler can be any experience(s) that cause continued autonomic nervous system activation which changes the chemistry and constructs of the developing brain. So while that can be physical, such as shaken baby syndrome, it can also be chemical, such as prenatal drug use, or emotional, in the case of abuse. Other potential causes of trauma include neglect, hospitalization, or disaster. Being placed in foster care and having a continual rotation of caregivers and "siblings" can also be traumatic.

Brain scans show that compared to a person who did not have a traumatic experience, a person s/p trauma may have less activity in the fronto-temporal regions. This includes a less active parietal lobe which can lead to decreased speech. Occipital lobe activity is increased, which is sometimes seen in a child's hypervigilance.

Children with disabilities are at an increased rate for abuse and neglect, so it is likely that OTs will encounter children who have gone through or are going through a traumatic situation. I remember an upper-elem student that I worked with who was very verbal about the effect that his disability had on his family life- his deep sadness at not having his parents around was continually heartbreaking to me. And truthfully, if you are worried that your parent might not come back for their next scheduled visit or whether a complication of a condition you barely understand will land you in the hospital tomorrow, how can you really be ready to learn and grow?

I had not heard of the term "PURPLE crying" before, let alone knew that it was a normal baby phase. But when this was discussed it was clear that this would be a time when abuse would increase. Personally, this was incredibly intimidating and terrifying to me as a person who does not have children yet, but by having the information, new parents are more prepared for this time period. The aftereffects of shaken baby syndrome are just horrendous... I may never forget the faces of the toddlers and older school children I saw who had survived, and the EI team was absolutely inconsolable after a child died from this.
PURPLE Acronym

I had also not heard of the ACE study, which looks at the effect of 'adverse childhood experiences.' The ACE score is from 0-10 and measures exposure to traumatic experiences in the first 18 years of a person's life. There are multiple studies that have shown an increased risk for adverse health behaviors (smoking, drugs, alcohol use), heart disease, suicide attempts, development of depression, cognitive impairment, and early death. Again, these questions make me think of the kids I saw in the school system some of whom had such varied awful life experiences.
The ACE Study Pyramid illustrates how childhood adversity leads to early death.

There are numerous signs/symptoms of trauma in infants and toddlers. Withdrawal can be common, and OTs may also notice decreased purposeful play, sensory processing differences, and uneven development/splinter skills. There are many invisible symptoms as well which have major effects in a child's life. This includes decreased growth hormone, decreased development of mirror neurons, decreased brain size and development, and decreased serotonin.

OK, this has been intensely depressing so far to write up. And it may have been that way for you to read. If you've made it this far, you deserve a reward, and if it's been making you sad you may need to inflate those endorphins through exercise or finding a way to think happy thoughts. (chocolate? cat videos?) Not trying to make light of the situation, but having ways to deal with the stress you're exposed to as an OT is imperative to prevent burnout. I think that this was one of the reasons that I couldn't tolerate ICU rotations well.

Finally, the good stuff! Some treatment ideas! These are more directly from the presentation but I am going to share them because I think that it is a difficult resource to get. The CDC states that the most effective treatment model for infants and toddlers is to promote parent/child attachment. This is directly in line with the early intervention model of empowering parents to improve their child's development. Research shows that music followed by tactile input is the most effective treatment. Ms Jacobs recommended using both a sensory integrative and trauma informed treatment approach. Helpful tips included making sure to decrease the stress response before doing anything else; being mindful of your own nonverbal cues including eye contact and touching; avoiding teasing and sarcasm; and being consistent and kind.

Parents, definitely consult with your therapist before trying any treatments, anything listed here is considered to be tried at your own risk. I have listed some suggestions that were offered by Ms Jacobs.
Gentle tactile stimulation through grooming and play
Calming music (Vibrational healing sounds were suggested) and performing typical preschool songs with motions
Swaddling and infant massage (if you are trained)
Cooperative games between child and parent- ball games, rapper snappers
Consider deep pressure activities such as weighted blanket or body glove with both parent and child (again, only with therapist supervision! Don't put weights on your kid!)

It's horrible that any child is exposed to trauma, but with proper training and intervention, there is a way for OT to make a difference to these families.

This was a terrific presentation and I'm happy to be able to share some of Ms Jacobs' awesome insights with you.

Further Resources:
National Child Traumatic Stress Network: tons of great resources especially for those in schools
CDC resources on Child Maltreatment
Child Trauma Academy: has free online trainings
You can also email the presenter Marcella Jacobs if you have direct questions


Christopher Alterio said...

Great post, Cheryl - I hope lots of folks read it.

Cheryl said...

Thank you so much Chris! It's easy to be a blogger when there's great source material, this was an awesome presentation!