Working with abused children: A crash course

Children who are abused or neglected are much more likely to suffer from an array of health and behavioral issues, not just as adolescents but throughout their adult lives. Physicians need to fully understand the effects of childhood trauma to effectively treat marginalized youth, said pediatrician Kenneth R. Ginsburg, MD, during his OMED presentation Monday morning.

Abused or neglected children, he said, are much more likely as adults to use drugs, become obese, contract viral hepatitis, have heart disease, and develop certain autoimmune disorders and cancers. But the impact of abuse on the brain is especially profound.

“If I never know when I’m going to be in danger—if I’m always feeling that people might come and attack me—then I have to remain hypervigilant,” Dr. Ginsburg said. “What is the hormone of hypervigilance? Cortisol.”

Too much cortisol in childhood adversely affects the amygdala, located in the brain’s temporal lobes. The amygdala plays a major role in decision-making, the processing of memories and emotional reactions.

Childhood trauma also damages the cerebral cortex, which is responsible for executive function—the ability to plan and organize, to set and reach goals. In addition, child abuse harms the hippocampus, which establishes long-term memories.

These effects on the brain are manifested in specific behaviors commonly seen in abuse victims, said Dr. Ginsburg, the author of Building Resilience in Children and Teens: Giving Kids Roots and Wings.

First, traumatized, hypervigilant kids don’t have a clear sense of trust, and they are reactive. “If there is a movie theater and a guy trips over a chair and spills his popcorn, most of us would say to ourselves, ‘A guy spilled his popcorn’ and look back at the movie,” Dr. Ginsburg said. “But not someone who has been traumatized. Someone who has been traumatized can’t refocus because they’ve been triggered and the amygdala is on fire.”

Second, traumatized children are more likely to tell lies.

“Why?” Dr. Ginsburg asked. “Because if your daddy comes home and he opens up the refrigerator and he sees that the last hot dog is gone and he says, ‘Who took the last hot dog?’ And you say, ‘I did, Daddy,’ and he throws you against the wall, you learn.”

Third, abused children are apt to cope by confabulating: They dream up stories about their lives that are not rooted in reality and then confuse these events with actual memories. Dr. Ginsburg described a 19-year-old woman who wanted to be a pediatrician but wondered if she could become one because she couldn’t remember much of her childhood.

“I remember being thrown down the steps, and I remember looking at my daddy’s casket,” she told Dr. Ginsburg. “But I don’t remember my little red shoes. I don’t remember any of the hugs from my mom. And I don’t remember any of my trips to Disneyland.”

Why didn’t she remember these events? “Those were the confabulations she came up with to survive the reality of childhood,” said Dr. Ginsburg.

Trauma-informed care

One knowledgeable, caring person can make a huge difference in an abused child’s life, Dr. Ginsburg stressed. Physicians can fulfill that role, he said, by observing the following protocol for what he calls trauma-informed care.

• Know what is about you and what’s not about you. This means not taking a patient’s behavior personally and understanding one’s own emotional baggage. Offering himself as an example, Dr. Ginsburg noted that he was considered small and cute in high school, which fueled in him a desire to be regarded as sexy and cool. To effectively work with teenagers, he has to recognize and control these tendencies in himself.
• Change your lens. Don’t look at troubled teenagers through the lens of “What is wrong with you?” urged Dr. Ginsburg. Instead, look at them through the lens of “What happened to you?” When using this lens, you are more likely to reach these teens, he said.
• Be able to hold someone’s pain without owning their pain. “What does it mean to hold someone’s pain?” asked Dr. Ginsburg. “It means to be there, to be empathetic. When you own someone’s pain, you are going to burn out very quickly.”

The main goal of trauma-informed care, said Dr. Ginsburg, is to give children back their sense of control. To do so, doctors need to acknowledge children’s strengths.

“Kids live up or down to our expectations,” he observed.

Philadelphia pediatrician Praveena Mallya, DO, said she gleaned useful information from Dr. Ginsburg’s presentation. For instance, he advised physicians not to ask a lot of questions when adolescents share stories of personal trauma, such as being kicked out of the house.

“He said, ‘Just let them talk instead of interrupting them,’ ” noted Dr. Mallya. “That’s the main lesson I took away.”