The American Academy of Pediatrics (AAP) recently issued a clarion call for a multipronged initiative to reduce the impact of “toxic stress” on young children.1 As part of this call to action, pediatricians were urged to advocate for the development and implementation of new evidence-based interventions to reduce sources of toxic stress and lessen their adverse effects on young children. To this end, Osofksy’s book, which surveys evidence-based interventions with families of children exposed to trauma and violence, is an excellent guide for pediatric care providers wishing to become familiar with the field of early childhood trauma.
Introductory chapters describe conceptual and measurement challenges in the field. Notably, traumatic stress responses lie along a continuum from an isolated traumatic event to patterns of chronic maltreatment or violence exposure, and assessment of trauma in young children requires careful attention to behavior change. The range of triggers for a trauma response in young children is broad and can include grief and loss of a caregiver, medical procedures, natural disasters, terrorism/refugee experiences, community violence, child maltreatment, and exposure to domestic violence. Given such a broad range of childhood adversity, it is no surprise that some clinical topics are given extensive coverage (e.g., innovative court-based programs, traumatic stressors in military families), whereas other areas are covered in passing (e.g., pediatric injury and health-procedure stressors).
Part 1 anchors the volume with a readable summary of the current understanding of the impact of trauma on the developing social brain and echoes the AAP technical report (2012) on lifelong effects of early childhood adversity and toxic stress. This is followed by a discussion of diversity issues that can underlie difficulties with engaging families in need of clinical interventions. This case-based discussion of parent-provider-supervisor relationships has wider applicability than interventions specific to trauma exposure and should be a required reading for all pediatric health care providers in training.
Part 2 includes descriptions by experts in the field of relational treatments for infants and young children exposed to maltreatment or domestic violence: child-parent psychotherapy, attachment-based interventions (e.g. Attachment and Biobehavioral Catch-up program), and components of a relationship-based evaluation of traumatized young children.
Part 3, “Young children from military families exposed to trauma, including the stress of deployment” is likely to serve an awareness-raising function for readers. Three chapters describe the hidden traumas that may underlie behavioral and relational difficulties in young children in military families. The high incidence of combat injury (physical, posttraumatic stress disorder and traumatic brain injury) from the past decade of military engagement in the Middle East makes the Cozza and Feerick chapter of particular salience.
The 3 chapters in Part 4 “Working in juvenile court with abused and neglected young children of substance-abusing parents” seemed the least relevant to practicing health care providers. However, I feel that their inclusion highlights the importance of an early childhood systems of care perspective to providing trauma-informed care. To adequately address the cross-generational needs of families with substance abuse—a high proportion of cases of maltreatment and neglect—cross-agency and cross-system collaborative models are sorely needed. I was struck by the resemblance of the 3 court models, which seek to provide coordinated, family-focused services to the pediatric medical home model in health care.
My favorite section of the book is Part 5, which includes a review of research and promising interventions for children who live through natural disasters, a discussion of how pediatric practitioners can identify and respond to exposure to trauma in pediatric clinics, and a description of Vicarious Traumatization and the need for self-care in providers. Groves and Augustyn’s chapter on identification of traumatic stressors provides practical guidelines about steps outpatient pediatric care providers can take to address child trauma: assess the child’s and parent’s response to the trauma, assess child and family safety, provide developmental guidance and education about common responses to stress, and refer (when indicated) for specialized behavioral health services. They make the important point that not all cases of child trauma necessitate a referral to behavioral health, rather timely and developmentally appropriate management of child and family concerns by the pediatric health provider can serve as an effective early intervention.
Readers who are interested in reading further about early childhood trauma and the movement for trauma-informed care in all early childhood services are encouraged to visit websites sponsored by National Child Traumatic Stress Network (www.nctsn.org) and The Center on the Developing Child (www.developingchild.harvard.edu). Of note, the website of National Child Traumatic Stress Network has a section devoted to medical trauma.
Disclosure: The author declares no conflict of interest.
1. Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption and Dependent Care, and Section on Developmental and Behavioral Pediatrics. American Academy of Pediatrics. Policy Statement. Early childhood adversity, toxic shock, and the role of the pediatrician: Translating developmental science into lifelong health. Pediatrics. 2012;129:e224–e231.