Building Your Trauma Responsive Tool Box: Screening for Trauma
Over the last few weeks I’ve been talking about reflective practice which is essential to early childhood and trauma work. Now I want to get back to the roots of this blog and dive deeper into trauma-responsive or trauma-informed care. Specifically, what can trauma-responsive care look like for OTs.
If you missed my AOTA recap post, check it out here. It’s about my reflections on the presentation I gave with two amazing colleagues about our ethical responsibility to provide trauma-responsive and neurodiversity affirming care when working with children.
One of the ideas that came to me as I’ve thought about that talk since a few weeks ago is that children in every practice setting we work in have experienced trauma. Although some settings may have higher client populations who have experienced trauma, unfortunately for us in the US, trauma is everywhere.
Where are Occupational Therapists Working?
Occupational therapists work in a tremendously wide variety of settings with people of all ages, backgrounds and ability statuses. Common settings you might find OTs working include
Schools
Hospitals & Rehabilitation Centers
Outpatient Rehab Clinics
Pediatric Development & Early Intervention Programs
Psychiatric Care Facilities
Human Resources Departments
In addition to these common settings, you can also find occupational therapists working in community mental health, neonatal intensive care units, juvenile justice centers, and countless other places.
How Much Trauma is Really Happening in the US?
One of the ways that information has been collected about large groups of the population is through the Adverse Childhood Experiences study. In 2023, the CDC conducted a study using the ACE Questionnaire, which asks about the following 10 circumstances:
Feeling that you did not have enough to eat, had to wear dirty clothes, or had no one to protect and care for you
Lost a parent through divorce, abandonment, death or another reason
Lived with someone who was depressed, mentally ill, or attempted suicide
Lived with anyone who had a problem with drinking or using drugs, including prescription drugs
Parents or adults in your home ever hit, punched, beat, or threatened to harm each other.
Anyone you lived with going to jail or prison
Parent or adult in your home ever swearing at you, insulting you, or putting you down
Parent or adult ever hit, beat, kicked, or physically hurt you in any way
Feeling that no one in your family loved you or thought you were special
Experienced unwanted sexual contact
*Source: Adverse Childhood Experience Questionnaire for Adults, ACES Aware, California Surgeon General’s Clinical Advisory Committee, See below for link (3)
They found that more than 60% of adults reported experiencing one adverse childhood experience (ACE) and almost 20% reported experiencing 4 or more ACEs (1).
In 2024, the CDC conducted the first self-report study of high school students and found that ACEs were common among young people. Over 75% of respondents reported experiencing at least one ACE and over 18% reported experiencing at least 4 ACEs. Most commonly, the teens reported emotional abuse (61.5%), physical abuse (31.8%) and poor mental health in their household (28.4%) (2).
Statistics like this make it clear that, in fact, most people experienced at least one stressful or traumatic event or situation during their childhood. They are clients, patients and consumers in every place that occupational therapists work. The need for trauma-responsive care exists everywhere, whether the purpose of someone’s services is to address trauma or not.
Building Your Trauma-Screening Tool Chest
Building your skills for trauma screening is difficult and a long process for many of us! When I was starting out, I never asked about trauma and had no idea how to respond when a client or caregiver told me about trauma. Typically they heard some version of “wow, I’m really sorry that happened to you.” Not a terrible response but not enough…
Of course this blog is a blog- not medical or supervision advice, please remember that. I think that not asking about trauma is completely appropriate if you have no training, feel too dysregulated by the topic, or won’t have the necessary skills to respond appropriately with your conversation, resources, referrals, or clinical treatment planning for the client. At the same time, I hope I am encouraging you to maybe move toward the edge of your comfort zone by engaging in your own learning to support you in integrating a trauma-responsive stance into your work.
Getting Started- Work to Establish Safety
Establishing safety is critical when working with any child and family and your assessment or evaluation is the place that begins! Several things should be clear to families as you begin your work
The information they share is confidential except in certain circumstances (name them)
They can bring their full selves once they feel safe doing so
Your role is to engender trust by treating them with non-judgement, respect, and dignity and you anticipate that they won’t feel comfortable sharing every detail about life with you right from the start
Tailoring Your Caregiver Interview
One way to get at a child’s trauma history is by including questions about their life and development in your assessment (you’re most likely already doing this!)
Some questions I ask are:
How did you choose this child’s name?
Ask only if the caregiver you’re working with named the child! I often get lots of epigenetic information from this question
Tell me about what the pregnancy with this child was like? What was going on for bio parents during that time?
What was it like to bring this child into your home? How was life for you during that time?
Tell me about when they started eating. What was the experience like for you and for them.
Tell me more about when the learned to walk and talk? How was it for you to have them reaching these milestones?
As you can see, I stay away from questions with specific answers at first, eventually I may followup with something like “do you remember how old they were when that happened?” but at first, I want the story. When I engage with families this way, I often get lots of the information I’m looking for, including information about difficulties, because I’m asking what a period of time was like instead of asking closed-ended or yes/no questions.
With questioning like this, you are in control of how much detail you ask and how you followup on the caregiver’s responses. If you’re new to trauma screening, maybe you don’t dig much deeper. If you’re a seasoned pro, maybe you dig deeper with the family as they allow.
Tip: be ready for this style of assessment/interview to take a little more time. This will go far in building your relationship with the family and is well worth it in my experience!
Structured Screeners like the ACE Questionnaire
The ACE screener can be used as a great conversation point, when you have the necessary skills and regulation to follow it up thoughtfully. I use the ACE screener when meeting with a child that I have no history about but I do not use the ACE screener for children for whom I know there is a trauma history. For example, a private client who reached out after seeing my website is a good candidate for an ACE screener because I don’t know anything about their history. A child I bring onto my caseload after knowing them or their siblings through work in their classroom may need more than an ACE screener.
When using the ACE or other screeners, keep in mind that it doesn’t tell us anything about how those experiences impacted the child we are working with, only whether or not an event happened. Further, it doesn’t tell us anything about the supports, buffers, and relationships that someone had. One client may have had 2 ACES (seem’s low) but no supportive family, neighbors, teachers, or friends to help them through. They are more likely to be negatively impacted than someone who had 3 or 4 ACES but who had a robust network of trusted support people to nurture them through their difficult experiences. If you use something like the ACE screener, make sure you ask questions about the support and resources that were available to the client.
Here are 4 questions you can ask to bolster your trauma-screening for young children:
Who does the child go to for support? How accessible to the child is that person/those people?
What is the caregiver’s support network like? How available and accessible is that network?
How often does the child have access to developmentally appropriate activities throughout the week? They could be at home, at school or in the community.
What is the child’s sleep routine like? What kind of support is available to the child at bedtime and throughout the night, should they wake up?
Screening for trauma and getting started with trauma work can be daunting but you can do it! Hopefully this was a helpful introduction into the assessment process. Are you already doing these things in your practice? Would you like to?
References & Resources
Swedo EA, Aslam MV, Dahlberg LL, et al. Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011–2020. MMWR Morb Mortal Wkly Rep 2023;72:707–715. DOI: http://dx.doi.org/10.15585/mmwr.mm7226a2
Swedo EA, Pampati S, Anderson KN, et al. Adverse Childhood Experiences and Health Conditions and Risk Behaviors Among High School Students — Youth Risk Behavior Survey, United States, 2023. MMWR Suppl 2024;73(Suppl-4):39–49. DOI: http://dx.doi.org/10.15585/mmwr.su7304a5
Disclaimer
The information provided on this blog is for informational purposes only. It is not intended to assess, diagnose, treat, or prevent any medical or mental health conditions. The content shared on this site should not be considered a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician, mental health professional, or other qualified healthcare provider with any questions you may have regarding a medical or psychological condition. Never disregard professional advice or delay seeking it because of something you have read on this blog.
