.
Key words
Childhood psychosocial trauma exposure is highly prevalent and associated with risk for poor physical and mental health outcomes extending throughout life. In a study of nearly 54,000 adult Americans (
Gilbert et al., 2015
), 60% reported experiencing at least one adverse childhood experience (ACE). According to the National Survey of Child Health, 48% of American children have suffered at least one ACE (Bethell, Newacheck, Hawkes and Halfon, 2014
). U.S. Department of Health & Human Services 2017
states that more than 650,000 American children experienced child maltreatment in 2016 and up to 10 million children in the United States witness domestic violence each year (National Coalition Against Domestic Violence 2015
).National Coalition Against Domestic Violence. (2015) Domestic violence national statistics. Retrieved from https://ncadv.org/statistics
Trauma exposure is a problem of epidemic proportions. Numerous studies (
Anda et al., 2008
, Brown et al., 2017
, Dong et al., 2004
) have solidified the realization that exposure to trauma early in life affects the developmental and health outcomes of children in a graded, dose-response fashion (Traub and Boynton-Jarrett, 2017
). The greater an individual's trauma exposure, the poorer their potential lifetime developmental and health outcomes unless appropriate interventions occur. It is crucial that pediatric nurse practitioners (PNPs) incorporate trauma-informed care into their practice. This continuing education article will define childhood trauma and trauma-informed care (TIC), discuss incorporation into pediatric health care, describe trauma-informed mental health care, explore the concept of a trauma-informed community, and provide implications for practice.Trauma and Trauma-Informed Care
The
National Child Traumatic Stress Network 2018
defines a traumatic event as a dangerous or distressing experience outside the range of usual human experience that overwhelms an individual's ability to cope and frequently results in intense emotional and physical reactions, leads to feelings of helplessness and terror, and threatens serious injury. These events can occur as a single event or take place repeatedly over many years, also known as complex trauma. Unfortunately, many American children live lives filled with trauma. It is estimated that up to 90% of children experience some form of traumatic experience in their lives (Heinzelmann and Gill, 2013
). Regardless of whether a single event occurred or the child has experienced complex trauma, those who are survivors of a single traumatic event are less likely to develop the sequelae of trauma symptoms commonly seen in survivors of complex trauma. According to Jennings, 2004
, child maltreatment is the most common form of complex trauma; however, prolonged traumatic exposure can also occur in the context of long-term family or community violence or dysfunction (Fratto, 2016
).These experiences have been associated with long-term adverse effects on physical and psychological health, along with substance abuse issues (
Simon and Brooks, 2017
). Early childhood trauma has been linked to negative effects on adolescent self-esteem, the ability to build healthy relationships, school performance, self-regulation, critical thinking, and self-motivation (O'Connell, Boat and Warner, 2009
). The damaging effects that early childhood trauma has on the developing brain have been studied extensively. Brain imaging studies of children with documented cases of child maltreatment and other psychosocial traumas, excluding abusive head trauma, show distinct changes in the brain's structure and functioning (Delima and Vimpani, 2011
). Fratto, 2016
highlights the fact that researchers have found that early exposure to trauma causes an overexpression in brain receptors that regulate anxiety and fear, which is associated later in life with stress response dysregulation to include increased symptoms of hyperarousal and problems with inhibitory control (Kindsvatter and Geroski, 2014
, Ozkol, Zucker and Spinazzola, 2011
, Sanchez, Ladd and Plotsky, 2001
).The landmark ACE study was originally published in 1998 (
Felitti et al., 1998
), but the outcomes of that study are even more significant today (Hornor, 2015
). This study surveyed over 18,000 adult members of the Kaiser Health Plan regarding their childhood exposure to emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, domestic violence, household mental illness, household substance abuse, parental divorce/separation, and a criminal household member (Dong et al., 2004
).Exposure to trauma can result in stress. However, although nearly every child experiences at least one trauma listed in the ACE study, not all traumatic events are equal in the stress resulting from that exposure (
Lancaster, Melka, Rodriguez and Bryant, 2014
). Some stress in life is normal, but the type of stress that results when a child experiences ACEs may become toxic when there is strong, frequent, or prolonged activation of the body's stress response systems in the absence of the buffering protection of a supportive, consistent adult relationship (American Academy of Pediatrics 2014
). This prolonged activation of the stress response systems can disrupt the development of brain structure and other organ systems, increasing the risk of stress-related disease, both physical and psychological, and cognitive impairment into the adult years (American Academy of Pediatrics 2014
).Child maltreatment and exposure to other forms of trauma pose significant and costly health risks both acutely and long term (
Hanson and Lang, 2016
). Chandler, 2008
states that the effects of trauma have been shown to outlive the trauma itself, with the meaning of trauma interpreted by individuals well after the trauma has ended. Exposure to trauma affects individuals differently. Because of the prevalence of trauma exposure throughout the lifespan, identifying a plan to address its impact should be the responsibility of any organization working with both children and adults. Berliner and Kolko, 2016
noted that the “concept of TIC appears to have emerged out of increasing awareness of the prevalence and implications of childhood trauma in clinical contexts as well as the general population” (p 170). As this awareness continues to grow and is supported by research, there has been a universal recommendation highlighting the importance of service systems being aware, sensitive, and responsive to the potential impact of trauma (Hanson and Lang, 2016
). This, at its core, is the concept of trauma-informed care but is also best practice.Finding a universal definition for TIC across literature is difficult; however,
Olivet, McGraw, Grandin and Bassuk, 2010
defined TIC as “a strengths based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment” (p 233). How TIC is defined and conceptualized in any given system might vary depending on the needs and uniqueness of each organization. Most organizations implementing TIC focus on workforce development (training, awareness, secondary traumatic stress), trauma-focused services (use of standardized screening measures and evidenced based practices), and organizational environment and practices (collaboration, service coordination, safe physical environment, written policies, and defined leadership; Hanson and Lang, 2016
). Hanson and Lang also note that the essential rationale for TIC is that addressing child trauma earlier and more effectively will result in improved outcomes, less need for more extensive and expensive services, and reduced long-term costs.Trauma-Informed Pediatric Health Care
TIC originated in psychiatry, social work, counseling, psychology, and addiction studies and has become the basis for support programs in mental health, child protective services, corrections, and juvenile justice (
Koetting, 2016
). Pediatric health care is beginning to recognize the importance of incorporating TIC concepts into pediatric health care practices. Most children and families recover well after a child's injury or illness; however, about 30% develop posttraumatic stress symptoms (trauma symptoms) after an illness or injury (Price et al., 2015
). This vulnerability is exacerbated in children and families who have been previously exposed to psychosocial traumas (Weiss et al., 2017
).Trauma exposure, with or without an additional illness or injury, can negatively affect a child's experience of medical care (
Johnson and Martin-Herz, 2010
) and result in greater use of health care services (Marsac, Cirilli and Kassam-Adams, 2011
). Health care visits can be re-triggering for trauma victims, because the majority of pediatric visits require the provider to be very close to the child and touch the child's body (Raja et al., 2015
). The anogenital examination can be particularly re-triggering for children or parents who have experienced sexual abuse. TIC care must become a routine part of pediatric health care.TIC aims to decrease the impact of emotional and psychological trauma on all participants within a system of care (
Weiss et al., 2017
). A comprehensive multilevel approach that changes the way organizations and individual practitioners’ view and approach trauma must be initiated (Oral et al., 2016
). TIC consists of four essential elements: realizing the significant impact of trauma; recognizing how trauma may affect children, families, and staff; applying TIC knowledge into practice; and preventing re-traumatization (Substance Abuse and Mental Health Services Administration 2015
). The stimulus for TIC is rooted in the realization that pediatric health care systems and providers are often unaware of trauma experiences that children and families have suffered, which may lead to re-traumatization and failure to link with needed services (Oral et al., 2016
).TIC includes acknowledging and understanding the effects of traumatic events, providing common coping strategies, and promoting effective treatments (
Oral et al., 2016
). The transformation of an organization into a trauma-informed organization involves changes that embrace the development of a culturally sensitive infrastructure that addresses the needs of traumatized individuals (Harris and Fallot, 2001
). Pediatric health care organizations, to truly become trauma informed, need to consider the trauma exposures of not only the child but also their parents or other adult caregivers because of the dependent nature of the child/caregiver relationship.TIC involves the incorporation of six broad principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues (
Substance Abuse and Mental Health Services Administration 2015
). Safety is paramount. Patients and families who have experienced trauma may have feelings of danger and insecurity. They may be in a constant state of hyperarousal, feeling insecure or unsafe. A conscious effort must be made to ensure that all patients, families, and staff are physically and emotionally safe. The second principle of TIC is that of trustworthiness and transparency, both of which are fundamentally embedded in PNP practice. Organizations and individual practitioners must approach decisions with transparency, which engages the trust of patients and families. PNPs should be open honest with patients and families throughout every health care encounter. Peer support is important for patients and families who have encountered traumatic events. It is vital that they understand they are not alone in experiencing trauma and that there are others with similar lived experiences. Peer support is also crucial for health care providers working with victims of trauma, because they are at risk for experiencing vicarious trauma (Raunick, Lindell, Morris and Backman, 2015
). The fourth fundamental concept involves collaboration and mutuality. All levels of an organization, including the pediatric health care provider, can contribute equally to helping traumatized children and families heal. Empowerment, voice, and choice, the fifth principle of TIC, must be incorporated into every pediatric health care encounter. Developing plans of care for victims of trauma require patient-centered approaches that empower children and their families (Oral et al., 2016
). Finally, TIC embraces cultural, historical, and gender issues. Every effort must be made to ensure that all pediatric care is culturally sensitive and free of bias and stereotypes. Integrating these principles into pediatric health care requires support at all levels of an organization, the buy-in of individual practitioners and staff, and implementing policies and protocols to ensure that trauma-informed practices are carried out by all staff (National Research Council 2003
).Trauma-informed pediatric care uses a tiered approach that includes universal, targeted, and specialty levels (see Table). At the delivery level, TIC is universal; recognizing the widespread prevalence of trauma exposure. All staff are prepared to respond to patient and family behaviors, interactions, and needs using a trauma-informed approach (
Sperlich et al., 2017
). Targeted interventions are implemented based on a known history of trauma exposure. A referral to trauma-focused mental health services for a child who has been exposed to trauma or linking a parent who is endorsing drug or alcohol concerns with appropriate treatment are examples of targeted interventions. For some patients and families, targeted interventions will not meet their needs, and they will require a more intense, trauma-specific plan, such as a parent endorsing drug or alcohol concerns who does not follow through with treatment, resulting in safety and medical neglect of his/her children. A referral to Child Protective Services is indicated for this family to ensure the safety of the children.TABLEPediatric trauma-informed model of care
| Type of care | Usual care | Trauma-informed care | Examples |
|---|---|---|---|
| Universal | Medical and surgical history | Screening for trauma exposure | Psychosocial history Safe Environment for Every Kid Adverse Childhood Experiences |
| Targeted | Referral to counseling for behavioral concerns | Referral to trauma-focused mental health therapy | Trauma-focused cognitive behavioral therapy Eye movement desensitization and reprocessing |
| Specialized | Counseling and medications | Targeted intervention plus specific familial interventions to address trauma noted in screening (parental drug/alcohol, domestic violence) | Case management services to ensure follow-through with recommendations Referral to Child Protective services when concern for child maltreatment arises |
Source:
Sperlich et al., 2017
.Trauma-Informed Mental Health
To prevent the damaging and lasting effects trauma can have on a young person's life, it is imperative that survivors be referred to trauma-focused mental health treatment to prevent trauma symptoms from developing or worsening or to help young people learn how to cope with those symptoms that have already developed. PNPs should have a basic understanding of the most common mental health interventions available to youth who have experienced a traumatic event(s). There are many mental health interventions geared toward youth with trauma histories. For the purposes of this article, only the most commonly used and well-studied interventions will be discussed. These specialized interventions require specific training and certification. PNPs should be aware of local resources available for referral for these specialized trauma-focused mental health services.
The treatment model with the highest degree of empirical support for the treatment of traumatized children is trauma-focused cognitive behavioral therapy (TF-CBT). This is a treatment model that can be used with any child who is experiencing emotional or behavioral difficulties in the wake of a traumatic event(s), including complex trauma (
National Child Traumatic Stress Network 2018
). The methods used in TF-CBT focus on tolerable amounts of exposure to the trauma to achieve mastery over the trauma reminders (Rodenburg et al., 2009
). TF-CBT has been shown to improve functioning and decrease symptoms related to anxiety, depression, posttraumatic stress disorder (PTSD), behavioral problems, and other trauma-related symptoms. The key components of TF-CBT include psychoeducation, relaxation skills, affective modulation skills, cognitive coping, trauma narrative and processing of the traumatic event, in vivo mastery of coping skills, parenting sessions, conjoint youth/parent sessions, and safety planning sessions. TF-CBT has been shown to be effective across cultures, and the length of treatment generally lasts between 12 and 25 sessions (National Child Traumatic Stress Network 2018
).Emotional dysregulation is another trauma symptom that is common to traumatized youth. Adolescents who struggle with emotional dysregulation often present with histories of self-injurious behavior, suicidal ideation/attempts, and poor relationships with others. Elements of mindfulness are incorporated into dialectical behavior therapy (DBT) to treat emotional dysregulation. DBT is a form of cognitive behavioral therapy. Originally developed to be used with adults, DBT has been modified for use with adolescents. The four major treatment components of DBT include mindfulness, distress tolerance, emotion regulation, and social/interpersonal effectiveness. This intervention has shown significant improvements related to feelings of suicidality, self-harm, emotional dysregulation, and depressive symptoms (
Perry-Parrish, Copeland-Linder, Webb and Sibinga, 2016
).Eye movement desensitization and reprocessing (EMDR) was initially developed to be used with adults diagnosed with PTSD. However, this intervention is now commonly used with children as well, after appropriate modifications to the treatment protocol were developed. EMDR facilitates desensitization to the traumatic memory through short, imaginal exposure to the memory and then subsequent offering of bilateral stimuli. Initially, the stimuli that were regarded as a key element of this therapy were saccadic eye movements; however, external bilateral stimuli such as taps from the hands of the therapist are also used. A meta-analysis has shown that EMDR is effective in treating PTSD symptoms in children, especially when used in conjunction with other evidence-based treatments such as CBT (
Rodenburg et al., 2009
).Implications for Practice
Understanding the widespread prevalence of childhood trauma exposure is crucial for every PNP. Trauma exposure rarely occurs in isolation. Children who have experienced one form of psychosocial trauma are at increased risk to experience multiple traumas. For instance, sexual abuse victims frequently experience multiple traumatic events such as exposure to domestic violence, parental drug and alcohol abuse, parental mental health concerns, physical abuse, emotional abuse, and/or neglect (
Hornor and Fisher, 2016
). PNPs will encounter children and families who have experienced trauma—trauma exposure that may or may have not been previously identified. Screening for trauma exposure should be a routine part of pediatric health care, both inpatient and outpatient (National Center for Trauma-Informed Care 2014
). However, studies indicate that few pediatricians (Kerker et al., 2016) and PNPs (Hornor et al., 2017
) routinely screen for all psychosocial traumas identified as ACEs. Trauma exposure screening is especially essential in practice settings such as primary care and many pediatric sub-specialties where there is ongoing contact between the health care provider and patient/family. Screening should occur at minimum at all initial encounters, both inpatient and outpatient, and at least annually at subsequent visits, and whenever a concern for child maltreatment or other psychosocial traumas arise. When screening for trauma, pediatric health care practitioners must ensure that they have the resources to address positive results or have the knowledge to refer the patient/family to appropriate community resources (Raja et al., 2015
). It is important for the PNP to then follow up with families to encourage and ensure linkage with recommended resources. If screening or subsequent failure to link with recommended resources indicate a concern for child maltreatment, a referral to child protective services is indicated.Screening can be completed in a variety of ways. Any screening method should be prefaced with a brief explanation that these are questions that we ask all families because these problems are very common in our society, they can negatively affect your child, and we would like to offer assistance. The PNP can gather a psychosocial history (see Box 1) by asking questions to parents/caregivers. There are validated self-report screening tools available (see Box 2). The parent/caregiver can complete a written or online screening and then discuss positive results with the PNP. Another important reason to screen for psychosocial risk factors is that caregivers want their child's health care provider to screen for and assist with unmet social needs (
Beck and Klein, 2016
). Colvin et al., 2016
, in a cross-sectional study of caregivers of hospitalized children, found that greater than 70% of caregivers believed their child's health care provider should ask about concerns such as income, housing, food insecurity, educational needs, insurance, domestic violence, immigration, and guardianship. PNPs must feel comfortable asking sensitive questions across inpatient and outpatient care settings.BOX 1
Psychosocial assessment
Individuals living in the home with the child
Parental mental health concerns
Parental drug or alcohol concerns
Exposure to domestic violence
Exposure to someone known or suspected to have sexually abused a child
Previous familial involvement with Child Protective Services
Previous familial involvement with law enforcement
Parental history of child maltreatment as a child
Parental support systems
Food insecurity
Housing concerns
BOX 2
Psychosocial trauma screens
Safe Environment for Every Kid
Adverse Childhood Experiences
Child & Adolescent Trauma Screen https://depts.washington.edu/hcsats/CBT/Assessment/Child%20and%20Adolescent%20Trauma%20Screen%20(CATS)%20Youth-Self%20Report%20(7-17%20years).pdf
Domestic Violence Screening
Many of these traumatic events involve violation of a person's bodily integrity and can influence their attitudes toward medical care (
Raja et al., 2015
). Depending on the nature of their trauma, health care visits may be re-triggering to the patient because of the close proximity to the health care provider and the need for the provider to touch the patient's body. Traumatized children understand the world and interact differently than children who are not trauma exposed (Fratto, 2016
).The PNP must be able to recognize trauma symptoms. PTSD is the most common mental health disorder to result from trauma exposure. The diagnostic criteria for PTSD in children are as follows: a tendency to persistently re-experience the traumatic event through intrusive thoughts, feelings, dreams, and flashbacks; avoidance of stimuli that remind the child of the traumatic event; negative alterations in mood and cognitions (negative beliefs about self and the world); persistent feelings of fear, horror, anger, guilt, shame, or detachment; and alterations in arousal and reactivity (hypervigilance, irritability, anger outbursts, reckless behavior, decreased attention, poor concentration, and sleep disturbance;
American Psychiatric Association 2013
). Other mental health disorders that often coexist with PTSD include depression, anxiety, disruptive behavioral disorders (oppositional defiant disorder and conduct disorders), substance abuse, and suicidal behaviors (Sege et al., 2017
). The concept of trauma-informed pediatric care involves incorporating an understanding of posttraumatic stress symptoms (trauma symptoms) and a realization that what appears to be a behavioral or mental health disorder in a child could be the result of trauma exposure (Kassam-Adams et al., 2014
).Children exposed to trauma can manifest many of the disruptive behaviors, impulsivity, and executive function characteristics of attention deficit hyperactivity disorder (ADHD;
Schilpzand et al., 2018
). Traumatized children are far more likely to be identified as problem children and have difficulty in the classroom and with peers. When assessing a child for ADHD or any other behavioral/mental health concern, the PNP must consider trauma exposure in the differential diagnosis. - Schilpzand E.
- Sciberras E.
- Alisic E.
- Efron D.
- Hazell P.
- Jongeling B.
- Anderson V.
- Nicholson J.
Trauma exposure in children with and without ADHD: Prevalence and functional impairment in a community-based study of 6-8-year-old Australian children.
European Child & Adolescent Psychiatry. 2018; 27: 811-819
Oh et al., 2018
state that trauma exposure should also be included in the differential diagnosis for developmental delay, asthma, recurrent infections requiring hospitalization, somatic complaints (headaches, stomachaches, nausea), and sleep disruption. Kerker et al., 2015
found that a higher number of psychosocial traumas before age 5 years was associated with a greater likelihood of mental health and chronic health problems in childhood.Many of the serious long-term behavioral impairments associated with trauma exposure may become apparent in adolescence as risk behaviors: suicide attempts, sexually transmitted diseases, drug use, and risky sexual behavior (
Sege et al., 2017
). Adolescents may experience cognitive and emotional dysregulation with feelings of rage and shame. The PNP must also consider trauma exposure as the source of adolescent behavioral concerns. Trauma can be at the heart of a multitude of behavioral and somatic complaints. It is crucial for the PNP to screen children and adolescents for trauma exposure, especially those exhibiting the behavioral and somatic complaints described, and if identified, to link them with appropriate trauma-informed mental health care.PNPs can help parents and caregivers better understand that the behaviors a child is exhibiting may be a reaction to stress caused by trauma exposure and that these behaviors can persist long after the trauma exposure has ended. Explain that even though the child is physically safe and no longer experiencing trauma exposure, the child may not feel psychologically safe. It is not enough for the PNP to link trauma-exposed children with counseling; the trauma-exposed child needs to be linked with trauma-informed mental health care. It is important for the PNP to monitor follow-through with needed trauma-informed mental health services. Parents must also understand that a child cannot really begin to heal from trauma exposure if he/she remains exposed to trauma. Elimination of trauma exposure is the criterion standard of care. However, there are some circumstances that prevent the elimination of all trauma from a child's life. In those circumstances, trauma-informed mental health services can be a source of support to the child. Some trauma-exposed children with severe persistent trauma symptoms may need linkage with a trauma-informed psychiatric mental health nurse practitioner or psychiatrist for medication management to augment trauma-informed therapy.
Trauma-Informed Community
The growing awareness of trauma is associated not just with mental health care but with a wide variety of systems and society at large. Not only can individuals experience traumatic events, but whole communities can be shaped by experiencing trauma. Consider the Texas flooding in 2017 resulting from Hurricane Harvey or the bombing at the Boston Marathon in 2013. Entire communities rallied despite experiencing adversity and became stronger. To “bounce back” or return to functioning after a trauma, communities must demonstrate awareness of the preponderance of trauma histories that are already present within their citizens.
Chandler, 2008
suggests that this “awareness is key to creating a safe environment for healing” (p 366). Not everyone experiences trauma in the same way. For many individuals, experiencing a trauma is not an isolated event. The question is how do you empower an entire community to be trauma informed? Systems are still struggling to identify what it means exactly to be trauma-informed and what the best way to implement trauma-informed practices are; however, it starts with identification. Understanding that the need exists is the first step.Cultivating a safe environment is the best way to integrate trauma-informed practices in the community. Empowering the individual through collaboration, strength-based services, and implementing culturally sensitive practices minimizes the likelihood for re-victimization (
Chandler, 2008
). Not only do we need to address the trauma itself but we need to encourage mindfulness, self-care, and being goal oriented. By connecting with others as cohorts in care, we promote resilience. Resilience is what allows individuals and communities at large to return to baseline or “normal.” Encouraging the identification and linkage of children and families with resources to address the potential impact of trauma is the next step. To be successful, resources need to be accessible and abundant enough to address growing needs. People have to know where they can turn in light of a traumatic event and that when needed, these services will be available.It is crucial for PNPs to understand TIC and incorporate TIC into their practice behaviors. Potential barriers to the implementation of TIC into pediatric health care include time constraints, worry about further upsetting or re-traumatizing children and families, lack of training, and confusing information of trauma-informed practices (
Kassam-Adams et al., 2014
). These barriers must be acknowledged and overcome. Universal screening of all pediatric patients and families for trauma exposure is a vital aspect of TIC. Traumas must be identified and addressed. Fostering resilience is at the heart of TIC. Resilience building is important for all children but is crucial for the trauma-exposed child. At-risk children should be linked with resilience-building programs such as home visitation, Nurse Family Partnership, Help Me Grow, or Head Start for young children or community mentorship programs for older children and teens such as Big Brothers/Big Sisters. Incorporation of TIC into pediatric health care practice is crucial to the health and well-being of American children, not only for the children of today but also for the children of future generations. PNPs should be advocates within their practice organizations, communities, states, and nation for the development of policies and legislation that support TIC. Together we can build a trauma-informed America—one child, one family, and one community at a time.References
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Biography
Gail Hornor, Pediatric Nurse Practitioner, Nationwide Children's Hospital, Center for Family Safety and Healing, Columbus, OH.
Cathy Davis, Forensic Interviewer/Mental Health Advocate, Nationwide Children's Hospital, Center for Family Safety and Healing, Columbus, OH.
Jennifer Sherfield, Forensic Interviewer/Mental Health Advocate, Nationwide Children's Hospital, Center for Family Safety and Healing, Columbus, OH.
Kerri Wilkinson, Forensic Interviewer, Nationwide Children's Hospital, Center for Family Safety and Healing, Columbus, OH.
Article info
Footnotes
Conflicts of interest: None to report.
Identification
Copyright
Copyright © 2018 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
