By Ashley Pagenkopf, MS, CCLS, Child Life Specialist at Cook Children's

I truly cannot believe that the summer is over. The summer months typically provide respite and regrouping for families. That is true for our family, but it is about this time that I start feeling ready to begin the new routine and move through the awkward first weeks of school.  One of my kiddos will have major surgery the second week of school and another kiddo starts middle school this year so my mom heart is extra anxious!

Summer months typically provide some respite at the hospital too. We see less illness and historically a fewer number of patients. I don’t think that any of us would say that this summer felt restful, though. While there is less illness in the summer, the number of traumas tends to increase, and we see a great deal of tragedy over the summer months.  This summer has been no exception. 

What is the well-known saying? We need a vacation from our vacation. I can’t imagine that I’m the only one feeling that at the close of this summer. Just like the beginning of a new year, we can all appreciate the reset that a new school year can bring. But we can’t ignore the intense emotions, anxiety and stress that a new school year inevitably brings to kids and families.

The weeks before and the first few weeks of school, the emergency room experiences an uptick in the number of kids coming in for behavioral health needs. There are so many stressors to starting something new, and post-pandemic we are needing more than ever to be aware of this and address it in every environment a child encounters – home, school and healthcare.

The Association of Child Life Professionals recently began an initiative nationwide addressing emotional safety within the healthcare environment. Emotional safety is defined by the ACLP as “an intentional, interdisciplinary practice to promote resiliency, healing and trust for pediatric patients and their families during medical experiences.”

This means that when a child walks through the doors of the hospital, we are all working together to be trustworthy adults that help a child recover more quickly from difficult experiences and help them work towards emotional, physical, and spiritual healing. While child life specialists promote and advocate for emotional safety, it is the job of the entire multidisciplinary team to provide this high level of care to patients and families.

When I look at this definition of emotional safety, I am reminded as a parent that this is what I want for my kids within my own home. I want my children to be able to recover quickly and withstand the storms of life. I want them to trust themselves, peers that are trustworthy, and adults that are trustworthy. I deeply desire for my girls to experience a balanced, healed life physically, emotionally and spiritually.

I don’t know about you, but as a mom, I am certain that I am not always promoting emotional safety within my home. I always desire it, but I know that I can often get in the way of my children feeling emotionally safe. In my exhaustion and selfishness, I can forget to really take the time to process the difficult emotions and validate my girls’ feelings. I often want them to just get over the hard without ever acknowledging how hard it may be. (And just in case you aren’t aware, things have been HARD over the last couple of years – especially for our kids.)

I have three girls that often cry in response to hard things. Even I cry often in response to hard things, but I can still find myself being annoyed at their tears. When in reality, the expression of our emotions often leads to healing and tears are needed.

I have also found that my kids need me at this time in their life to be their cheerleader and their advocate. My kids count on me to fight for them and to help them feel safe in all situations. Even my oldest, who is learning to advocate for herself, needs me to be there to help her when her school world or friend world is crumbling around her. 

As a child life specialist, emotional safety is extremely important to me in the healthcare environment. It is a right of every human to feel safe in every way while they are receiving healthcare services.

As a parent, it is also my responsibility to provide an emotionally safe home. This provides the framework for my girls to know what emotional safety is. When our children can understand what emotional safety is, they will be able to advocate for it not only in their healthcare experiences but also at school and at their jobs.

As we begin another new school year, I want to challenge you as parents and grandparents to consider this definition of emotional safety. Consider how you can promote resiliency among your kids and grandkids. Take some time to be with your kids in the next few days and weeks.  Allow them to really express their emotions to you (tears and all), validate their emotions and cheer them on towards the next right thing. Our kids need us to model in our homes what an emotionally safe environment should look like so that they can truly expect that level of safety in their all encounters.

Imagine living through a tornado. The wind howling over the sound of sirens. Lightning illuminates your home. Then, you hear it - the roar. You watch the ceiling start to give way. Fear turns to panic. Running on adrenaline, your body prepares for the worst.

This is what trauma can feel like. While a severe weather event can be traumatic, there are many reasons a person may experience trauma. It is defined as anything that overwhelms a person’s ability to cope. But trauma isn’t always easy to spot, even though its effects can last a lifetime.

“There are three different kinds of trauma. The first is acute, or a one-time event like a dog bite or car wreck,” said Denise Coover, LCSW, a trauma informed care specialist at Cook Children’s Medical Center. “Then there’s chronic trauma, where you may have several things happening at once, like domestic violence at home and bullying at school. Complex trauma happens when traumatic experiences occur within the context of a close relationship, such as sexual abuse committed by a family member, or someone who should keep you safe.”

During a traumatic event, the body releases two major stress hormones: norepinephrine and cortisol. Similar to adrenaline, norepinephrine boosts the heart rate and controls the fight-or-flight response. Cortisol is your body’s main stress hormone and slows non-essential functions, like digestion, when a threat is perceived.

“If your body experiences this stress response on a regular basis, it can cause long-term health problems,” said Kia Carter, M.D., co-medical director of Psychiatry at Cook Children’s. “A lot of people don’t realize that chronic exposure to stress hormones can cause high blood pressure, obesity, diabetes, issues with sleep and fatigue, as well as feelings of depression and hopelessness.” 

These hormones can also increase your memory of the event, leading to flashbacks, nightmares and PTSD. But when it comes to memory overall, people who’ve experienced significant trauma may find it hard to remember in general. This is due to the part of the brain that stores memory, the hippocampus, being overexerted.

The amygdala is another part of the brain affected by the stress response. This region controls emotions and can cause someone to react differently to something as simple as a door slamming. You can think of the amygdala as the brain’s ‘watchdog.’

“If someone has experienced something like domestic violence or a shooting, they may be sensitive to loud noises,” said Dr. Carter. “That’s because their amygdala is working overtime to keep them safe. We call this hypervigilance.”

For children, hypervigilance can make it hard for them to concentrate at school and follow directions. Instead of focusing on the classroom, their brain may be trying to anticipate what bad thing is going to happen next.

The prefrontal cortex is connected to the amygdala and is responsible for rational thinking. Chronic stress in childhood can damage the prefrontal cortex, which is still developing, and lead to a survival response being triggered even when there is no danger.

Understanding Trauma

According to the National Council for Behavioral Health, 70% of adults in the U.S. have experienced some type of traumatic event at least once in their lives. That's 223.4 million people. 

“Sometimes, when people experience trauma, they will compare themselves to others. For example, they may say, ‘I’m not a Syrian refugee so I haven’t experienced real trauma,’” said Coover. “But it doesn’t matter, if something overwhelmed your ability to cope, that makes it traumatic for you.”

At Cook Children’s, 94% of hospitalized psychiatry patients in 2020 reported experiencing at least one form of trauma. Untreated trauma in children can cause a number of problems including behavioral issues, mood swings, depression, anxiety, self-injury, hopelessness and thoughts of suicide. Kids may feel isolated because of how the traumatic event has affected them. Coover says it’s important for parents and teachers to be aware of the signs of trauma because they’re not always obvious.

“A child who’s falling asleep at school may seem like a problem student, but when you start digging into their history you may realize that they don’t feel safe at home and they’re in survival mode. But when they’re in the classroom, they feel safe so all of the sudden they can sleep,” she explained.

Another sign of trauma in both children and adults is physical pain without a known reason, called somatic symptoms. This is often seen in the form of migraines, stomach aches, and rouge pain the body that is not associated with injury. This phenomenon has been documented by experts such as psychiatrist Bessel van der Kolk in his book ‘The Body Keeps the Score.’ Kolk claims that stress and trauma becomes stored in the body if not addressed, and can eventually lead to illnesses such as autoimmune disorders and cancer.

“Whether you remember the trauma or not, your body always does,” said Coover. “I’ve had parents tell me this or that happened but their child was too young for it to affect them and I have to tell them, “No, that’s not the case.’”

Some examples of childhood trauma include:

• Physical, sexual and emotional abuse
• Neglect
• Domestic violence
• Homelessness
• Parents with untreated mental illness and/or substance abuse
• Divorce
• Bullying
• Losing a parent
• Incarceration of a parent

“Domestic violence is one that seems to surprise people, because they think if the child isn’t being hit it doesn’t affect them,” Coover said. “But it absolutely does, even if they just hear it. Sometimes what they’re imagining is even worse, or maybe it’s spot on. And kids tend to blame themselves for their parents fighting. They take on that guilt even though it’s not theirs to carry.”

Experts like Coover and Dr. Carter also warn that isolation triggered by the COVID-19 pandemic has led to even more traumatic experiences for many kids, especially those growing up in unhealthy environments. With so many students being forced into virtual school last year, their ability to escape and connect with people outside of their home was taken away.

“We are starting to see more kids talk about the effect the pandemic has had on them,” said Dr. Carter. “I had a patient tell me recently they’d been home alone for many months and hadn’t been able to see their friends or other people. They said they were tired of living that way, this patient became hopeless about life changing, which resulted in this patient attempting suicide.” 

The Power of Sharing

Dawn Hood-Patterson, Ph.D., thinks about trauma in the context of her own life. At 17, she was living in Colombia with her family when her trauma story began.

“I lived in Colombia during the time when Pablo Escobar had a grip on many regions in the country—there were car bombs, protests and the sound of gunshots. During that period of unrest, my dad was murdered outside our home,” she said. “So when I think about my trauma story, I think about what fostered my capacity for dealing with that.”

Dr. Hood-Patterson attributes her resilience in part to her parents who gave her a loving and supportive home. She also credits the school counselors who recognized that her frequent stomach aches were not just random pain, but the result of the stress that comes with living in a country experiencing civil unrest.

“It was all the adults who recognized the trauma was bearing impact on my life, and who said, ‘This trauma is real and we see Dawn in the midst of it,’” she said. “These same people gave me tools that helped me make meaning out of the chaos. And they said, ‘Here are some friends around you that have experienced similar things so you don’t feel so alone.’”

As program manager of Community Health and Adverse Childhood Experiences at the Center for Children’s Health, led by Cook Children’s, Dr. Hood-Patterson is using her experience to help people in North Texas. She’s part of the team behind The ACEs Task Force.

Adverse Childhood Experiences (ACEs) is a term based on a study conducted between 1995 and 1997 by Kaiser Permanente and the Centers for Disease Control and Prevention (CDC). The study, which involves 10 questions about what a person experienced before the age of 18, shows ACEs are associated with high-risk behaviors, chronic disease and reduced quality of life in adulthood. In 2019, The ACEs Task Force unveiled their “Blueprint for Safe, Healthy and School-Ready Children”. The plan includes 25 ways pregnant women, families, children and caregivers need to be supported in order to counteract adversity. Access to health care, healthy food, quality, affordable and safe housing are among the top concerns. Transportation, mental health services, substance use disorder treatment and high quality, affordable child care are also priorities for the task force.

Currently, Dr. Hood-Patterson and team are working on a project that would create support groups for parents and caregivers living with adversity. The so-called ‘Caregivers Alliance’ is part of the Build-a-Bridge program, led by Cook Children’s, and is in the early planning phases. It would focus on giving people a chance to share their stories of trauma and connect.

“This was born out of conversations that we had with community partners where we learned that a lot of people who are struggling with adversity often feel like they have a laundry list of things to do,” she said. “For families who receive things like housing assistance or SNAP benefits, every conversation they have is about updating paperwork and not missing deadlines. We envision this alliance to be a space where people can be seen and heard, and support one another.”

The Caregivers Alliance would also include access to education from the Center for Children’s Health for topics like car seat safety, water safety, safe sleep practices and more.

“I’m a believer that something powerful happens when we share out stories with each other,” said Dr. Hood-Patterson. “When we have the opportunity to share our stories, whether they’re of triumph or trauma, it hones our ability to make meaning out of the seemingly meaningless chaos of suffering.”