Trauma Informed Care

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

ACLP Bulletin | Summer 2017 | VOL. 35 NO. 3

Jessika C. Boles, PhD, CCLS

“Oh, he’s not a trauma case,” the nurse leans in to tell me as I approach the glass-walled ICU unit with a fleece blanket and a toiletry bag in hand. I can understand her confusion; these items are, after all, my staple techniques for normalizing the hospital environment as I introduce child life services to newly admitted trauma patients and families. 

“You’re right,” I reply to the nurse. “Medically, he isn’t a trauma – he’s got the flu, right?” She nods as I continue. “I just saw mom’s face when I walked by and I recognized the look in her eyes. He may not ‘be’ a trauma, but I think she is experiencing this as a trauma right now.” Throughout this exchange outside the door, I notice that mom has not moved or broken eye contact with her son’s sedated, intubated face this entire time. In fact, this is the same position I have seen her in each time I have walked by the door this morning. She is still wearing the clothes she arrived in at the emergency department, when they came seeking care for what seemed like a routine fever and infection. Two hours later, her son was unresponsive and intubated. Two hours later, he was transitioned to the oscillator as he continued to decline. Two more hours later, and he was on the maximum ECMO (extra-corporeal mechanical oxygenation) settings that a child his size, a five year-old, could tolerate. I quietly walk in the room, draping the blue and green blanket in my arms across his bed, gently tucking in the sides to keep him warm. Mom continues to watch his face. I then grab another blanket and drape it around mom’s shoulders. She still does not shift her gaze. I leave the toiletries at the bedside, and kneel down next to her so that I can also see her son’s face. Then the loud sobs come bursting out, and mom’s proclamation that “this is all my fault,” as she reaches into her pocket to show me a Tamiflu prescription bottle with her name on it. This is the part where it is tempting to share staggering statistics about the number of medical traumas that occur in our country each year, and the unsurprising truth that half of the population has or will experience a traumatic (or potentially traumatic) event during childhood (American Psychological Association, 2008). It is alluring to follow with a reminder that unintentional injuries remain the leading cause of death and disability for individuals under the age of 44 (Sleet et al., 2011). Next, to put it all into perspective, perhaps we can reflect on the fact that “injury accounts for 16% of the global burden of disease” (World Health Organization, 2004, p. v). Ironic that many articles about trauma can leave their readers quite traumatized after the first few sentences!

Trauma, as we understand it as psychosocial care providers, isn’t always the victim of the ATV accident, the toddler battered and bruised by abusive caregivers, or the preteen sibling that was the first to find her sister’s body hanging in the closet. Though sometimes it can be seen in the mother that gave her child rescue breaths in the middle of traffic, or the school teacher that rescued a student from a chemical explosion, there are many other times where trauma is less obvious, less dramatic, less predictable. Instead it can be the shock of a sudden and rapidly progressing illness, an unexpected diagnosis, or even a planned intensive care unit admission that prompts intrusive memories of previous distress.

Medically, traumas are defined as “serious injuries to the body” that can involve contact, blunt force, or penetration, through either an unpredictable and unforeseen force, or a controlled mechanism, such as in the case of surgical injury (National Institute of General Medical Sciences, 2017). Psychologically, however, this definition feels inadequate as we know that trauma is not so much about the set of circumstances in which a person finds themselves, but rather the cognitive appraisals and emotional reactions that are elicited – whether these are immediate, delayed, or even vicarious.

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

In the words of the Substance Abuse and Mental Health Services Administration (SAMHSA): Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being. (SAMHSA, 2012, p. 2)

Trauma, therefore, is not only an illness, injury, or affliction; rather, it is an experience, an interpretation, and a process. Historically, the academic and public perception of trauma has been one of symptomatology and pathology – a mental health issue to be recognized, treated, and cured. Recently, however, the trauma-informed care philosophy and movement has challenged care providers and larger communities to reconsider trauma as a universal experience that manifests in individualized ways. Trauma-informed care thereby requires recognition of a patient or client’s subjective experiences, validation and normalization of the effects of trauma, and the importance of individualized support and/or treatment (Bonanno & Mancini, 2008). 

Research since the September 11th, 2001 terrorist attack in New York has shown that only 5-10% of individuals exposed to trauma will develop post-traumatic stress disorder (PTSD), and that only around 10% of bereaved individuals will experience chronically elevated grief reactions akin to PTSD (Bonanno & Mancini, 2008). In addition, “genuine resilience to potentially traumatic events is not rare but common and not a sign of exceptional strength or psychopathology but rather a fundamental feature of normal coping skills” (p. 371).

A key point is that even resilient individuals may experience at least some form of transient stress reaction; however, these reactions are usually mild to moderate in degree, are relatively short-term, and do not significantly interfere with their ability to continue functioning. (Bonanno & Mancini, 2008, p. 371) Difficult events will elicit difficult responses, and patients and families enter into traumatic experiences with different developmental histories, coping strengths, and external resources. 

Much like with any other stressor, children and adolescents need:

  • Age-appropriate education about events and coping skills
    Choice and control when possible
  • Opportunities to express their feelings (often through play)
  • Emotional support and validation
  • Attention to basic needs
  • Normalization of environments and routines, and
  • Close connection to their parents, families, support networks, and community. 
There will be times when additional treatment is warranted and beyond the scope of what can be provided by a child life professional; therefore, it is important to make appropriate referrals should the child demonstrate self-destructive behaviors or violence towards others, severe distress or severe absence of emotion, psychological impairment, or if changes in behavior, mood, and function last more than four weeks (SAMSHA, 2014). 

Trauma-informed care begins with the first contact a person has with an agency (SAMSHA, 2014); for many children and families, this may be the voice of an emergency medical dispatcher, or the arrival of a first response team.

Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.(SAMHSA, 2012, p. 2)

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.

Finally, I find myself using every chance I can to point out the child and family’s strengths and opportunities to build resilience. Even though a parent may feel utterly helpless in their current situation, I praise and validate their abilities to be present for their child, to reach out for help in their community, to accept support from hospital staff. Even though a child may feel similarly helpless, I intentionally recognize and praise their abilities to indicate their needs, to make choices (even when they choose not to engage with me), or to find the strength and desire to play. 

Most of all, I seek out occasions to reinforce the child and family’s support of one another, and their instinct to pursue support from one another. Though there are situations when this approach may not be appropriate, it can help to model 1) healthy and supportive relationships, 2) social connection as a source of resilience, and 3) open communication within the family unit.

Twenty years ago, trauma was viewed as a life-shattering event with deep and enduring psychological consequences that could only, if at all, be resolved through intensive cognitive behavioral therapy. Today’s trauma-informed care approach acknowledges that any and every situation can result in trauma, depending on an individual’s cognitive and emotional appraisals of the event and the coping resources they believe to be available. 

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. 

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.


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.