How Health Providers Support People Affected by Childhood Trauma
Seeing a health care provider can be an overwhelming experience for many. Standard clinical settings with their cracked vinyl seating, fluorescent lights and antiseptic smells don't make the visit any more pleasant. For people who have experienced trauma, especially trauma in childhood, these details can magnify the discomfort.
Trauma experienced in childhood has particularly insidious effects. Without proper treatment, the trauma can be buried, and often symptoms do not appear until the late adolescent years or adulthood. This makes the trauma even more difficult to treat.
Hospitals across the country have made changes in their environments to soothe patients in stressful moments, from planting gardens and installing green spaces to adding natural light and providing views of the outdoors.
Health care providers can create ecosystems where trauma is treated before patients need hospital care by better understanding how trauma, particularly from childhood, manifests in the body and mind.
What Is Trauma?
The Substance Abuse and Mental Health Services Administration (SAMHSA) describes trauma as what happens when someone experiences an event, a sequence of events or a set of circumstances that causes them to feel physically or emotionally unsafe. When traumatic events disturb a child's inner ecosystem of emotions, sense of self and close relationships, they can have an adverse effect on the child's well-being and daily functioning.
Trauma can be acute or complex, depending on the circumstances and the individual's perception of them. Acute trauma can occur after a single event, such as a flood or school shooting. Complex trauma may occur after repeated exposure to multiple traumatic events that are often invasive and interpersonal, such as emotional abuse or neglect, according to the National Child Traumatic Stress Network.
How Trauma Affects a Child's Development
Both acute and complex trauma affect physical and mental health. For developing children, trauma also influences their sense of safety. If the trauma occurs with, because of or in spite of a caregiver, the child's ability to form secure attachments later in life can be affected.
However, these effects may not be immediately obvious in children, explained Janet Schneiderman, PhD, chair of the nursing department and research associate professor at the USC Suzanne Dworak-Peck School of Social Work.
"Physical health symptoms take a long time, often, to come out," she said.
Trauma symptoms may also contradict each other, which can confuse or prevent diagnosis. "They can emerge, disappear, reemerge, be delayed," said Marleen Wong, MSW, PhD, on the USC podcast Listen.Up.People. Wong is the David Lawrence Stein/Violet Goldberg Sachs Professor of Mental Health, senior vice dean of field education, and a clinical professor of social work at USC Suzanne Dworak-Peck School of Social Work.
One more clear way to see trauma expressed in children is in their development, as elaborated in the podcast episode "Child Trauma: Effect Across a Lifetime." Preschool and early elementary-aged children experience regressive symptoms, meaning they act in ways that are developmentally younger than they are.
School-aged children will often struggle to remember what they most recently learned. For example, a child who learned long division prior to the trauma may forget how to do long division afterward; the traumatic symptoms interfere with their brain's ability to synthesize information. A traumatized child's brain no longer allows them to enter the relaxed state that supports learning.
"They're constantly going from one situation to another where they're very stressed, very tense," said Megan Healy, a graduate of USC's Master of Social Work program and emergency response social worker with the Los Angeles County Department of Children and Family Services. "And that does something to the chemicals in their body, and their brain that doesn't allow them to function at the rate of every other student in the room."
—Megan Healy, emergency response social worker and USC alumna
As a result, children with traumatic experiences often struggle to move forward academically — as evidenced by test scores, grades and graduation and drop-out rates.
"You see kids who feel like they're crazy because they can't sleep, they can't eat, they can't think," said Wong. "And they stop going to school."
Eventually the combination of stress and unaddressed trauma leads to damaged health that care providers may not uncover until years later.
Aside from developmental symptoms, many effects of childhood trauma don't appear until children become adults, said Schneiderman.
These long-term effects are well-documented in the CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study, a landmark report connecting early adversity such as sexual assault or emotional neglect to later health outcomes, such as chronic illness.
One example is obesity: "For girls who have suffered sexual abuse, the likelihood of developing obesity in their later teens increases," said Schneiderman. Practitioners don't know exactly why, but these connections may have to do with the accumulation of stress over a person's lifetime.
From nurse practitioners to mental health counselors, care providers can recreate an ecosystem of support and safety by recognizing these effects and responding to them with compassion, resources and specialist attention as needed.
Eight Ways to Create an Environment That Supports Childhood Trauma Recovery
One practical way health care providers can support patients or clients who have experienced trauma is through creating calm spaces — beginning with the first point of contact. Staff members who greet visitors should have a peaceful demeanor.
"These things are very difficult because we're in an environment where health care is timed," Schneiderman said. But setting a tone of welcoming reassurance can help settle a patient's nerves and make the entire process run smoothly.
Roselyn Schwichtenberg, an alumna of USC's Master of Health Administration program and interior designer certified by the American Academy of Healthcare Interior Designers, offers further guidance for designing clinics and offices that soothe and promote healing.
Provide seating where provider and client can be on the same level, which can be less intimidating for the client and encourage conversation. For example, have two armchairs of similar size angled toward each other. In the exam room, invite the patient to sit on the chair rather than the exam table when possible. "We can decrease the power imbalance between the patient and the provider by getting on their level," Schneiderman added. Another option is designating a separate space for consultations that can be warmer or more homelike than the rooms for exams.
2. Wall Paint
Steer clear of strong colors or the absence of color, which can make the space less inviting. Choose a neutral color that is neither too cold nor too warm, such as a warm gray. Schwichtenberg says that patients tend to report whites as feeling too sterile. If using colors, pick muted tones. Instead of bright green or vivid blue, try sky blue or olive green. Keep in mind that too many colors can be hard to maintain.
Carpet and rugs can add warmth and color to a room and soften the acoustics — great for consultations. In exam rooms, however, hard surfaces are easier to keep clean.
If possible, choose bulbs that are dimmable. Bright light is important for exams, but the glare can be intense and triggering for some. Dimmer settings could be used for more personal conversations, particularly around trauma.
Choose fabrics that are both comfortable and low maintenance. Vinyl, which is durable and easy to clean, is a common choice for clinicians' offices. Look for options that are soft to the touch, almost like suede or leather, says Schwichtenberg. This can contribute to a restful atmosphere and put clients at ease.
6. Natural Elements
Elements of nature can be relaxing to patients and providers alike. "It allows them to feel a little bit less stressed because they're able to know there's something out there," said Schwichtenberg. Ideas include bringing in plants (depending on the office's policy, as plants can carry germs); displaying art or graphics that emulate nature; and using wood materials where possible, such as the cabinets.
7. Areas of Respite for Staff
Working with people who have experienced trauma can be exhausting for clinicians. Set aside a nook where staff members can take 5- to 10-minute breaks. "If [possible], we have a place outdoors that they can get away," said Schwichtenberg. "We try to make it an intimate space, so they can get a reset if they need it."
8. Low-Cost Ideas
Not all clinics have the resources to invest in trauma-informed design. Schwichtenberg believes even small, subtle touches can help change a patient or client's demeanor. Start small, she advised.
- Bring in a couple of plants.
- Paint a wall, or even just a stripe on the wall.
- Apply a wall decal with a supportive quote.
For children with trauma, consider the following:
- Create a writable surface on the wall that they can write and color on with dry-erase markers.
- Hang magnetic dry-erase panels and provide magnets.
Readings on Childhood Trauma and Recovery
For more information on trauma-informed care and clinical practice, visit:
- The Link Between Childhood Trauma and Obesity: USC Suzanne Dworak-Peck School of Social Work
- Abstract Healing: Art Therapy for Patients With Chronic Conditions: Nursing@USC
- 20 Songs That Helped People Get Through the Aftermath of Trauma: The Mighty
- Becoming a Trauma-Informed Practice: American Academy of Pediatrics
- Design Strategies for Pediatric Spaces: HDR
- Directory of Certified Healthcare Interior Designers: American Academy of Healthcare Interior Designers
- How to Report Suspected Child Maltreatment: Child Welfare Information Gateway
- The Power of Music: Creating Playlists to Heal Grief and Trauma: Real World Therapy
- Resource Page on Trauma in Clinical Practice: SAMHSA-HRSA Center for Integrated Health Solutions
- Trauma-Informed Care: The National Child Traumatic Stress Network
- Why Indoor Plants Make You Feel Better: NBC News
Citation for this content: Nursing@USC, the online FNP program from the University of Southern California