Trauma-Informed Care and Relationship Building in the Pediatric Intensive Care Unit

When the child life specialist enters the situation to introduce services and assess for needs, the patient and family have likely already met many people, heard many new things, and felt an onslaught of emotions and thought processes that are difficult to describe. As a child life specialist in the pediatric intensive care unit, much has happened before the child is transferred to our unit, before I am able to make this first contact with the family. 

Building therapeutic relationships with children and families who are experiencing stress is always a challenging process, though it is the most important aspect of what we do as child life professionals. Trauma-informed care reminds us that any situation can be potentially traumatic, that each and every relationship we build not only has the power to heal, but is also dangerous because it creates or adds to the vulnerability patients and families may already feel. Yet at the same time, it is also primarily through relationships that patients or families experiencing trauma can garner the support they need to maintain or build resiliency even in the face of the most unbelievable conditions. When initiating and building relationships with patients and families experiencing medical or psychological trauma, I find myself incorporating a different level of intentionality to the skills that I would typically employ when introducing services and assessing for needs. First, I consistently prepare myself, the staff that I work with, and even the family members of patients to anticipate, recognize, and normalize a variety of presentations and reactions when it comes to medical or perceived trauma. To communicate this openness to a variety of responses, I tend to stay away from introductory questions such as “how are you?” or, “how is [patient] doing today?” Instead, I start with a validating statement, such as “I can’t imagine the different things you must be feeling and thinking right now,” or “lots of parents here tell me that the question ‘how are you today?’ feels impossible, so what if we just start with ‘what’s something I can do for you right now?” 

When introducing myself, I err on the side of purposeful communication without too many details, definitions, or forced choices. Rather than the traditional explanation of child life services as promoting coping through play and/or education (which makes it seem like these are the only two pertinent dimensions during a very unpredictable and chaotic time), I find myself instead sticking to, “My job is to help families deal with the hard things that bring them into the hospital, and any new or hard things that might happen while you are here.” Occasionally, I get questions and requests best directed to other services, such as FMLA paperwork, insurance information, or a letter for the child’s school. However, being able to communicate these to the appropriate channel on the family’s behalf saves them one additional step, promotes control in what can feel like a helpless situation, and gives me an opportunity to transfer rapport and help the family to perceive the social support system of the multidisciplinary team (thereby promoting resilience). 

At the same time, I have found that broadly introducing my role in this way lends to accommodating and responding to a variety of trauma-induced feelings or needs that may not have otherwise fit within the categories of play and/or education. For instance, it’s hard for a patient or family member to describe their need for a supportive presence in a moment of silence, a hand to hold as they tell the story of watching their child’s accident, or disclosing perceived feelings of guilt or responsibility. Or, a child may not know how to help themselves when every time they close their eyes, they are plagued by intrusive thoughts that throw them back into the moment of the traumatic experience. Then there’s also the teen who literally just wants to Snapchat his friends to prove that he is, indeed, still alive. By adopting a broad introduction of services, I am able to communicate an inclusive orientation that can triage a variety of needs, rather than narrowing my support from the outset into defined realms that may or may not be of concern in that particular moment. The more flexible I feel I can be in my description of my role, the more I feel that this displays a similar flexibility to needs, experiences, and communication styles.

Asking questions used to be one of my primary modes of assessment; however, questions can easily be interpreted as criticisms or judgments when one is in the throes of trauma. Now I find myself relying more on observation, on silence, on slowing down and being present. Silence, much like speech, is a skill that takes time, practice, and dedication to learn; simultaneously, growing comfortable with silence requires an emotion-focused coping orientation, as there are many situations and predicaments that cannot be solved with words. Like the opening vignette, a small action or validating statement seems to open the door for more in-depth assessment information than I could have gotten from asking the tried-and-true, “tell me what brings you to the hospital today.” Sometimes the incident is purely accidental; other times there has been non-accidental trauma, parental oversight, or other tension in the family that somehow connects to the child’s hospitalization. Therefore, explaining the reason for hospitalization may be very complicated, confusing, or palpably tenuous.

Although this makes trauma seem more common, it also reminds us that trauma is a normative developmental experience that, like other challenging experiences such as grief, can be a transformative process with the appropriate relationship-based supports. When we are aware of and intentional about the potential effects of trauma, it is possible to not only build therapeutic relationships with patients and families experiencing trauma, but to lay an important foundation for the skills and resources that will foster resilience in the years to come.

REFERENCES

American Psychological Association. (2008). Children and trauma: Update for mental health professionals.

Bonanno, G. A., & Mancini, A. D. (2008). The human capacity to thrive in the face of potential trauma. Pediatrics, 121(2), 369-375.

National Institute of General Medical Sciences. (2017). Trauma fact sheet.

Sleet, D. A., Dahlberg, L. L., Basavaraju, S. V., Mercy, J. A., McGuire, L. C., & Greenspan, A. (2011).
Injury prevention, violence prevention, and trauma care: Building the scientific base. Morbidity and Mortality World Report Surveillance Summary, 60(suppl):78–85.

Substance Abuse and Mental Health Services Administration. (2012). Report of project activities over the past 18 months.

Substance Abuse and Mental Health Services Administration. (2014). Trauma-informed care in behavioral health services.

World Health Organization. (2004). Guidelines for essential trauma care.