Trauma-informed paediatric care — formative SAQs

SAQ 1 (10 marks)

A four-year-old presents to the ED after a fall. During the assessment, the child becomes mute and physically still when the nurse reaches for the blood pressure cuff. The mother mentions they have recently fled domestic violence. [10] [11]

1. Name and define the SAMHSA four Rs of trauma-informed care. (4) [9] [10]
2. Describe how you would modify your immediate assessment approach for this child. (3) [10] [11]
3. Identify the single most powerful protective factor for this child and describe how you would strengthen it. (3) [13] [2]

Model answer

The four Rs are: Realise that trauma is widespread and affects health; Recognise the signs and symptoms in patients, families and staff; Respond by integrating trauma knowledge into policy, practice and settings; Resist active re-traumatisation of the children and families served. [9] [10]

Modify the assessment by pausing when the child freezes — recognising this as a stress response, not defiance. Lower the sensory load, bring the parent close, explain each step before acting, offer choice (for example, which arm to measure), and avoid forcing non-urgent procedures. Apply universal trauma precautions from the outset. [10] [11]

The most powerful protective factor is the presence of a safe, stable, nurturing adult relationship — here, the mother. Strengthen it by supporting her, keeping her present, acknowledging her protective action in leaving the violence, and connecting the family to social work and community supports. [13] [2]

SAQ 2 (10 marks)

Your department plans to introduce universal ACE screening at well-child visits. Staff have not yet established a referral pathway. [7]

1. Describe the biological mechanism by which cumulative adverse childhood experiences lead to lifelong disease, naming the key physiological system involved. (4) [1] [2]
2. Outline the stepwise trauma-informed care algorithm you would apply at the bedside. (3) [9] [10]
3. Advise on the proposed screening programme, explaining the key risk and the correct sequence of implementation. (3) [7] [10]

Model answer

Chronic adversity without the buffering of a stable caring adult produces toxic stress — sustained activation of the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system. Persistent cortisol and inflammatory mediator exposure disrupts developing brain architecture, alters immune and metabolic regulation, and produces lasting epigenetic change and neuroinflammation. This dose-response mechanism links cumulative ACEs to cardiovascular disease, mental illness and early mortality decades later. [1] [2]

The stepwise algorithm is: universal precautions (assume trauma, create calm); recognise and screen (observe cues, ask when safe and indicated); respond (explain, offer choice, collaborate, empower); resist re-traumatisation (prepare for procedures, control pain, avoid unnecessary restraint); connect and refer (warm handover to supports); build resilience and follow up (strengthen the buffering relationship, schedule review). [9] [10]

Do not begin universal ACE screening until follow-up and support capacity is established. The key risk is causing distress without any support pathway — asking about adversity without being able to act is harm, not screening. Build the response system first, then expand the ask. [7] [10]