July 01, 2015

Medical Effects of Trauma: A Guide for Lawyers

Heather Forkey

The views expressed herein have not been approved by the House of Delegates or the Board of Governors of the American Bar Association, and accordingly, should not be construed as representing the policy of the American Bar Association.

A teen client tells you she thinks her school problems are due to how tired she is. No matter what she does, she has trouble falling asleep. When she does fall asleep, she often wakes up and can’t go back to sleep. She has gained weight and is always hungry. Her foster mother reports she is smoking marijuana and that is making her hungry. Your client admits to smoking pot occasionally to help her fall asleep. She doesn’t think it has anything to do with why she is doing poorly in school. 

All of these health issues may actually be related to the client’s history of trauma exposure. Your client’s mother has long battled bipolar disorder and opiate addiction, and your client has had multiple placements in out-of-home care. Issues that have led to placement in the past include neglect, domestic violence exposure (her mother had to be hospitalized due to injury from her boyfriend when your client was eight), and sexual abuse by the mother’s boyfriend when your client was 11. Your client has been truant for most of the school year and was recently placed in foster care again for neglect.

This scenario is common for children in protective custody or juvenile detention and highlights how the adversities children experience can impact their health and well-being in ways that may require your attention and response. Understanding how the body and health can be impacted by trauma will help you recognize when child clients have been medically affected by trauma and how you can best advocate for them. 

Stress and Brain Development

All children are exposed to stressors, traumas that can be considered in a spectrum. Many stressors are positive like final exams or baseball playoffs that help children learn and grow. Other stressors, like the death of a grandparent or house fire are more disruptive to a child, but with support from family and friends, don’t necessarily cause lasting injury. Stressors that are severe, prolonged, and especially those impacting a child’s social-emotional support system, can be the most damaging to children. Parental mental illness or drug abuse, child physical abuse or neglect, or exposure to domestic violence can all lead to significant responses by the child’s body and brain. These are toxic stressors, or traumatic stressors.

Children are impacted by trauma differently than adults because the brain is actively developing. While we are born with the neurons and potential to develop, actual neurological development is shaped by our environment. After birth, nerve cells in the brain move and make connections with other nerve cells. Those connections are reinforced and strengthened and then sheathed with myelin to make the connections smooth and automatic. We are all familiar with how this looks for children living within healthy family relationships:

  • To teach a child to self-regulate, parents respond to a baby’s cry with soothing voices, food, changing diapers, and supportive swaddling. Thus a child learns over time that if they make some noise, their needs will predictably be met, and they can soothe themselves with parent support.

  • To teach a child language, a parent coos back to an infant, assigns words to what a child points to and speaks and explains the world to a child each day, expanding vocabulary over time. 

If a child is living in an unhealthy family environment, the child is exposed to very different stimuli of violence, fear, abuse, or neglect. 

  • In a home with a parent incapacitated by drug addiction, a baby’s cries may go unaddressed, be met with anger, yelling, or abuse, or with food, consoling and care. This child learns that the world is unpredictable and often harsh, and that they can’t reliably impact their environment. Consequently the infant will have difficulty learning to regulate themselves and their own behavior. 

  • In a home where a parent is depressed, cooing may not be met with interaction but with a blank stare, a parent will be unable to provide words for what a child points to, and few words will be spoken in the home, leaving the child with little expectation for interaction with others and a paucity of language skills.

Practice tips:

  • If your client shows physical symptoms consistent with a history of trauma, request a medical screening and assessment to ensure she receives any indicated treatment. This will include a medical exam to check for physical findings consistent with abuse, injury, or in-utero exposure, developmental screening, and mental health screening. Be sure to notify the medical provider of the trauma history.

  • An evaluation by a child mental health professional with expertise in trauma-informed care can assist with identifying and matching children and families who will benefit from specific trauma-informed mental health interventions.

  • For children living in adversity, the nerve connections in the brain are appropriate to the environment, protect them from that danger, and allow them to adapt to the setting in which they must survive. Those safety responses are natural and automatic. 

Effect of trauma on body functions

Our bodies were designed to live in the wilderness and thus our body systems are prepared to deal with predators like lions and tigers. If you have a client who has experienced trauma or toxic stress, you may hear they are having physical symptoms that would be appropriate if fleeing or fighting a tiger. Parents or caregivers may complain that a child’s eating, sleeping or toileting are off. These are predictable responses when trying to stay safe from a predator. 

  • Sleep is impacted because the fear hormones tell the brain it is unsafe to fall or stay asleep. 

  • Overeating may occur because the body thinks it is constantly running from a tiger, and has switched off the feeling of fullness (satiety center) so the child can take in enough calories to keep running. 

  • Toileting is impacted when the brain won’t let the body relax the way it needs to for normal bowel health.

Practice tips: 

  • Having your client see the pediatrician may help. If the caregiver can explain to the physician that the child has been exposed to toxic stressors, the physician may be able to recommend relaxation techniques or, if necessary, medications to help the child with sleeping or toileting. Child yoga or mindfulness training can help children deal with these issues as well. 

Effect of trauma on physical health

Toxic stress can also impact physical health. You may find your client’s health seems to worsen as stressors mount. Asthma may flare around court dates, or the child may not feel well or get sick right after you have discussed placement or permanency issues. This too has a biologic basis. 

Inflammation/compromised immune system. Remembering that the body responds to stress hormones as if it is dealing with a predator, it is not surprising that the body turns up the inflammation response with early life stress. Stress hormones tell the body it may soon have to deal with an injury or animal bite. This inflammatory process can also lead to lung inflammation and asthma symptoms. Evidence shows that prolonged stress also inhibits the body’s ability to fight infection. This means some children may be more likely to get the flu or colds when they are otherwise stressed.  

In the long term, these responses can put your client at increased risk for other health disorders. Obesity, type II diabetes, increased cardiovascular and cancer risks all are associated with this prolonged inflammatory response. 

Practice tips:

  • Remind clients with asthma that the stress of court really can make them sicker, and that they should remember to take their prevention and treatment asthma medications around court dates and other stressful times. 

  • Ensure clients follow up with their physician if the symptoms get especially severe. 

  • Advocating for your client should include making sure the child or teen has quality health care to monitor for symptoms associated with inflammatory response: obesity, type II diabetes, cardiovascular and cancer risk.

Somatic symptoms. You may have a client cancel due to headaches or stomach aches each time you try to schedule meetings to discuss their case. That may be due to the client’s stress response. Stress hormones can cause the “sickness syndrome.” At times of stress from a predator, it is safer if a person feels sick and just stays hidden in bed instead of going out to face the predators. Somatic symptoms are a real response to stress, ones which can be protective in the wilderness, but that can make scheduling appointments frustrating. 

Practice tips:

  • Clients with somatic symptoms may benefit from learning relaxation techniques, using guided meditation or identifying distraction tools.

    • Have a child put a stuffed animal on his stomach and watch the toy go up and down as the child controls deep breathing.

    • Have the child close eyes and have the child’s caregiver guide the child to think about each part of their body (starting with toenails and working up to eyeballs and hair) and try to relax each body part in turn.

    • Have the child make a music mix of the songs that relax them most to keep on their handheld device, and play when they start to feel unwell.

    • If you are comfortable teaching the child basic stretches or yoga poses, they can be useful if the child is feeling anxious or upset. 

Drug/Alcohol exposure. The issues families struggle with that are traumatic stressors for children (parental mental health problems, parental substance abuse) may also directly affect the health of your clients. Some parents dealing with mental health concerns may use illicit drugs or alcohol to self-medicate. 

Parental substance use while a child is in utero may alter brain development and impact the child’s development and learning. 

  • Alcohol is one of the most common exposures in utero, and the minimum amount that causes toxicity is unknown. Exposure to alcohol very early in the child’s gestation can impact development of facial features, leading to “fetal alcohol syndrome.” With binge drinking, a child can be exposed to significant amounts of alcohol after facial features are formed. This can still result in neurologic and developmental effects, but these may be harder to attribute to alcohol without careful evaluation by a genetics or developmental specialist familiar with fetal alcohol spectrum disorders. 

  • Opiate exposure (heroin, methadone, OxyContin, etc.) leads to predictable symptoms in a newborn, but less well-documented impacts on development and learning as children grow. 

  • Drug effects. Similarly, cocaine, nicotine, antidepressant medication, anti-seizure medication, and sedatives all can have long-term impacts on childhood development and learning. 

Practice tips:

  • If you suspect or if health records show your client has had in utero exposure to drugs or alcohol, have a medical provider with experience in child development evaluate the client. The result may show the child is eligible for educational supports and/or more extensive benefits. 

Infections/environmental exposures. The child’s exposures in utero may include exposure to infections, including Hepatitis C, HIV, and syphilis. Environmental exposures, including unsafe housing, lead paint, unsecured drugs, and secondhand smoke, can cause further injury. 

Practice tips: 

  • If you suspect or health records show that a client may have been exposed in utero due to a parent using IV drugs or having multiple sexual partners; or after birth, exposed to sexual abuse, neglect, or parental drug use, seek specialized medical care for the client. 

  • A general pediatrician or physician who specializes in the care of abused children can help test the child for infections or exposures.

Compromised health care. When a family has been stressed by violence, mental illness, or substance abuse, even routine child health care can be compromised. Hearing and vision issues that would routinely be identified for children receiving regular health care can go unidentified and lead to language and reading delay and school failure. Incomplete immunizations can make a child more vulnerable. 

Practice tips:

  • Refer children for medical care when they have missed routine health care appointments.

  • Make sure the pediatrician knows why a child has missed appointments (parental issues, having moved for foster care, care provided elsewhere).

  • If you have access to information from the school nurse, other medical providers such as emergency department or interim doctors used while a child was in foster placement, make sure the child’s regular pediatrician gets this information.

  • If the child does not have a regular pediatrician, reinforce with the family how important it is for continuity of care with a pediatrician to be established.

  • Notify the pediatrician of exposures you know the child has had in the home and specific health concerns.

Effect of trauma on behavior and learning

It may be that the concerns you notice have more to do with a client’s attention or learning. Exposure to toxic stress affects children’s brains and bodies. Again, it is worth considering that the body under stress is preparing to deal with predator attack. Many children who have been exposed to the ongoing traumas of neglect, domestic violence, or abuse respond appropriately to these threatening home situations with increased aggression, hypervigilance, and exaggerated responses to small stimuli. In a setting where the child or their loved ones are in danger or their needs are not being met by a caregiver, the ability to remain alert to threat and respond quickly and aggressively does, in fact, protect the body. 

Unfortunately, because the stress response in these children is chronically stimulated, the body loses the ability to distinguish threatening situations from nonthreatening ones.  Because the child’s brain is just developing and making connections, how the body responds to trauma becomes an ingrained response. Dr. Bruce Perry has coined the phrase, “states become traits.” When these behaviors are noted outside the context of the trauma, they may appear maladaptive, yet they would be considered an appropriate response in the context of the trauma itself. Thus, when these children show their hypervigilance and aggression in school or foster placements in response to minor stimuli, they can be misidentified as having Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder, or conduct disorder.

Practice tips:

  • Ensure the child is screened and assessed for trauma exposure and receives any indicated mental health treatment.

  • Be sure the pediatrician or mental health provider doing screenings or testing for behavioral health knows the child has a trauma history that may be impacting behavior.

  • Make sure any child prescribed medication for a mental health issue has routine follow up with a pediatrician and/or mental health provider familiar with trauma and how it presents.

  • Make sure the medical and/or mental health provider has information from day care and school about the child’s functioning and performance. 

Limited executive function. Children may also look like they have ADHD or another behavioral diagnosis because exposure to trauma limits developing executive function. Executive function, which is made up of working memory, inhibitory control, and cognitive flexibility, is required to learn, function in social settings, and stay focused. These skills develop through practices and are strengthened by experiences. They largely develop in the prefrontal cortex and hippocampus areas of the brain, the areas inhibited by the stress hormones released when children experience trauma. 

In toddlers this impacts the ability to develop language skills, motor skills, social skills, and impulse control. In older children, inhibited executive function presents as learning problems, behavioral difficulties in the school setting, and organizational deficits. In fact, many children can wind up with a diagnosis of ADHD when, in fact, the impulsivity and poor attention that lead to the ADHD diagnosis actually reflect inhibition of the executive function (see chart). 

Practice tip:

  • If you are aware that your client who has ADHD or another mental health diagnosis has had a history of trauma, bring this overlap in symptoms to the attention of caregivers, educators, and mental health professionals who also care for the client, as allowed by ethics considerations. 

Conclusion

Children’s lawyers are well positioned to help guide children and families dealing with trauma. Vigilance on your part, including childhood adversity and toxic stress when considering health and behavior issues, and understanding the different ways trauma presents will help you recognize harmful experiences and their impact. The danger of failing to recognize adversity and the physiologic response as a possible cause of health and behavior concerns is missing or misattributing symptoms to other causes. By recognizing the impact of negative family experiences on child health and development, you can engage community health providers to address these needs effectively. Your guidance can help children understand that, while bad things may have happened to them, their responses are expected and manageable. In this context, the child and family can work toward health, wellness, and achieving the child’s potential.

Heather Forkey, MD, is chief of the Child Protection Program and clinical director for the Foster Children Evaluation Program at the University of Massachusetts Children’s Medical Center and associate professor at the UMass School of Medicine. In addition to her clinical work with children exposed to abuse and neglect, foster care, and trauma, Dr. Forkey has received local and federal grants to address issues involving children in foster care and translate promising practices to address physical and mental health needs of traumatized children. Dr. Forkey participates in local, regional, and national efforts to translate the science of trauma into clinical care improvements. 

This article was produced under grant number 2012-VF-GX-K012 from the Office for Vic¬tims of Crime, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this article those of the contributors and do not necessarily represent the official position or policies of the U.S. Department of Justice or ABA.

References

American Academy of Pediatrics. “Trauma Toolbox for Primary Care.” 

Dantzer, R., J. C. O’Connor, G. G. Freund, R. W. Johnson and K. W. Kelley. “From Inflammation to Sickness and Depression: When the Immune System Subjugates the Brain.” Nature Reviews: Neuroscience 9(1), 2008, 46-56.

Forkey, H. and M. Szilagyi. “Foster Care and Healing from Complex Childhood Trauma.” Pediatric Clinics of North America 61(5), 2014, 1059-72.

Garner, A. S. and J. P. Shonkoff. “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health.” Pediatrics 129(1), 2012,  e224-31.

Johnson, S. B., A. W. Riley, D. A. Granger and J. Riis. “The Science of Early Life Toxic Stress for Pediatric Practice and Advocacy.” Pediatrics 131(2), 2013, 319-27.

American Academy of, Pediatrics. “Fetal Alcohol Spectrum Disorders Toolkit.” (accessed April 15, 2015).

American Academy of Pediatrics. Helping Foster and Adoptive Families Cope with Trauma, 2013.

Perry, Bruce D. et. al. “Childhood Trauma, the Neurobiology of Adaptation, and “Use-Dependent” Development of the Brain: How “States” Become “Traits.” Infant Mental Health Journal 16(4), 1995, 271-291.

Shonkoff, J. P. and A. S. Garner. “The Lifelong Effects of Early Childhood Adversity and Toxic Stress.” Pediatrics 129(1 ), 2012, e232-46.