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or previous adverse interactions with clinicians,9 suggesting the experience
of presenting for health care itself may actually be traumatizing. Experiencing health care seeking as hostile may lead to long-term adversarial psychological responses when subsequent care needs arise and may cause hesitancy or distrust that ultimately leads to a decrease in care when warranted.15 Survivors have
a uniquely high burden of medical
and mental health care needs and have and psychological trauma related to their 9
BEST PRACTICES FOR MEDICAL AND MENTAL HEALTH CARE
The high likelihood of interacting with HT survivors who have experienced psychological trauma related to their exploitation, and who may then doubly experience the health care setting
itself as traumatizing, suggests that
best practices for care require urgent establishment. First, clinicians of all training backgrounds and levels, in all settings (the emergency department, outpatient clinic, inpatient hospital unit, and rural and urban communities) with children and adolescents should feel comfortable assessing possible indicators of HT exploitation during any medical
or mental health care encounter. How best to assess for HT remains elusive,
as no single standardized screening
tool has been uniformly adopted across pediatric health care settings, and
efforts to enhance survivor detection are variable. For example, The Vera Institute of Justice developed a screening tool to be used in conjunction with an overall are seen as identifying those at high risk 16 Similarly, at the
individual jurisdictional level, the state
of Delaware devised a screening tool as
and the Child Protection Accountability Commission (CPAC) for statewide implementation across pediatric health pre-assessment checklist intended to
a comprehensive follow-up when appropriate.17 (Table 1)
Because HT survivors likely have experienced what is considered an extremely severe form of abuse9 and may experience health care delivery itself as traumatic, approaching care from a trauma-informed care (TIC) standpoint is paramount. Broadly, delivering TIC means building trust, assuming a non-judgmental attitude, conveying respect, ensuring a sense of safety, and empowering the individual seeking care to participate in and direct care decisions.10 For example, for a survivor presenting with an acute sexual assault concern, TIC delivery involves providing the survivor autonomy to decline forensic evidence collection but such as testing for STIs, prophylaxis,
or outpatient follow-up. While this may sound like the ideal practice of medicine and gold standard care irrespective
of chief complaint, TIC uniquely and and anticipation by the clinician that prior traumatic experiences will affect how children or adolescents view themselves and others as well as their attitudes, manner, words, and interactions, including with the clinician.11 Many clinicians endorse the importance of TIC delivery to prevent re-traumatization during routine, bedside care.18 When applied to HT victims, TIC is the critical realization that a child or adolescent survivor’s responses to the external environment, including interactions
with the clinician during the health care encounter, may be manifestations of stress or represent maladaptive behaviors developed to survive in a hostile, repressive environment10 in which they were routinely exploited. A TIC approach often requires more time during the health care encounter and proper training and education of the clinician.10 Ensuring that proper support and resources are available enhances the ability to provide TIC to survivors of traumatic experiences18 and prevents secondary, vicarious trauma among health care providers managing challenging situations.
In 2014, The Trauma Center at Justice Resource Institute19 developed a TIC services delivery program for HT survivors, the recommendations and components of which were adapted
and are included here in table form (Table 2). Using this TIC approach, clinicians should address the immediate needs of the HT survivor, including treatment of physical injuries, STIs or other infections, acute illnesses, and issues of reproductive health.9
A TIC approach should also be applied when addressing non-medical needs
of the HT survivor; besides multiple
and complex medical issues, potential health consequences of HT include psychological/emotional issues. Prolonged exposure to toxic stress, prolonged activation of the physiological stress response system, adverse cognitive development, and impaired behavior functioning affect the ability to form future stable relationships.15 Therefore, delivery of TIC care to HT survivors by clinicians should also include attention to long-term psychological/emotional needs, including referrals to mental health/ counseling services.15
Assessment is key before initiating mental health treatment, especially with
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Del Med J | January/February 2021 | Vol. 93 | No. 1
