The D-E-F Framework for Trauma-Informed Pediatric Care

The D-E-F protocol is a practical framework to guide trauma-informed pediatric care. Health care professionals are experts in treating illness and injury, restoring functioning, and saving lives. But they may be less comfortable addressing the emotional and psychological impact of illness, injury, and medical treatment, or feel out of their depth when considering the impact of prior traumatic experiences on a child’s current medical care.

"A-B-C" orients us to the crucial first steps to save a life (Airway, Breathing, Circulation). After attending to the basics of physical health (the A-B-C's), use "D-E-F" as a reminder to address Distress, Emotional support, and Family needs as key elements of trauma-informed pediatric care.

DEF Protocol for Trauma-Informed Pediatric Care

D-E-F: Distress, Emotional Support, and Family Needs

The D-E-F framework helps health care professionals identify what they can do, within their own scope of practice, to address and prevent traumatic stress responses in their pediatric patients.

Find practical tools for implementing the D-E-F framework in your setting.

Explore how-to tips and case examples for:

Distress

Emotional support

Family needs

D-E-F and Trauma Informed Care: Learn More

Trauma-informed care is everyone's responsibility. Each and every healthcare professional a child and family comes in contact with has the opportunity to prevent, assess, and intervene in ways that can promote emotional recovery and resilience.

While referral to social work or child life services may be a part of the picture, there is much that frontline health care professionals are uniquely positioned to do.

To build specific skills to implement the D-E-F framework at the bedside with your pediatric patients, take the free online continuing education courses available on this site.

Trauma Informed Care: Addressing Distress

Addressing Distress includes optimizing pain management, as well as helping children cope with any fears and worries.

How do I do this?

Do what you can to reduce unnecessary exposure to traumatic - possibly distressing - elements within the hospital environment. Some things cannot be changed, but look for ways to minimize children’s exposure to scary sights and sounds, separation from parents, etc.
Actively assess and treat pain, using your hospital’s protocol. Optimal pain management reduces the risk of traumatic stress reactions and PTSD.
Provide the child with age-appropriate information about what is happening. To ensure they understand, ask the child to explain what is happening in their own words, and then clarify any misconceptions.
Provide the child with choices when possible - i.e. about positioning during a procedure
Ask directly about fears and worries, and listen carefully to understand and address these. Remember that a child’s perspective may be quite different from our own.
Provide reassurance and realistic hope. Describe to both the child and parent what is being done to help them feel better. Make sure not to promise things which can’t be guaranteed.

Case example: Meet Anthony

After a recent illness, 8-year-old Anthony’s parents noticed an increase in his shortness of breath, coughing, and wheezing. His symptoms did not seem to relieve completely with nebulized albuterol treatments.

A few days ago, when his mother noticed him having trouble breathing, she brought Anthony to the Emergency Department at your hospital. He was admitted for IV steroids and O2 therapy.

Over the first day of his admission, you notice that Anthony is often whiny and fearful when the health care team interacts with him to provide care. Now, while you are in the room, Anthony’s parents remind him that he really needs to cooperate with the nurse so that he can get better. Anthony reacts with anger to this, saying “You can’t tell me what to do!”

What would you do next?

To address Distress, you might:

Assess Anthony’s current pain level to be sure that this is not a reason for his irritability.
Strike up a conversation with Anthony and his parents about how it’s been going since he got to the hospital. Ask “Anything especially worrying you?”

This is a great opportunity to assess Anthony’s distress and help both you and his parents learn about anything that's worrying him. There will often be multiple opportunities in the course of your regular patient care interactions when you can be alert to a patient’s concerns and follow up with a simple question or two.

Want to learn more about addressing distress with your patients? Take an interactive online course “D is for Distress” - with free CE credits for nurses.

Trauma Informed Care: Addressing Emotional Support

Addressing Emotional Support includes assessing the child’s need for emotional support during this episode of care, and then helping both the health care team and the child’s family provide that support in an effective way.

Addressing Emotional Supportwith Pediatric Patients

How do I do this?

Help children apply their existing coping strategies in this new situation.
Encourage parent presence, and learn from parents as the experts on helping their child.
Give parents specific pointers to help their child in this new situation.
Incorporate evidence-based ways to engage and support children during medical encounters.
When a child must tolerate an uncomfortable or potentially distressing procedure - engage the child in ACTIVE distraction before the procedure begins and throughout the entire procedure. You can serve as the child's "distraction coach" or whenever possible, help parents fill that role.
Help children who must remain in the hospital for a while maintain their connection to family and friends.
Identify any barriers to mobilizing the child’s existing emotional support. For example, parents may feel unsure how to calm and soothe their child in this new situation.

Case Example: Meet Melanie

Melanie, an 11 year old, is sick for 24 hours with fever, nausea, and vomiting. She complains of belly pain, and stays home from school, under her grandmother’s care. Throughout the day, Melanie continues to vomit and becomes more lethargic. Her grandmother takes Melanie to the hospital when her belly pain seems to become much more severe. In the Emergency Department, Melanie has an IV placed and labs are drawn. She is diagnosed with appendicitis and admitted for surgery.

You meet Melanie and her grandmother, Mrs. Davis, when she is admitted to your unit. When you enter Melanie’s room, it is very busy. Several staff are talking with Mrs. Davis and Melanie, asking about her medical history and getting consent for surgery. Melanie and her grandmother both appear anxious and you see that Melanie is tearful. You need to get Melanie ready to go to the OR.

What would you do next?

To promote effective Emotional support, you might:

Tell Melanie that lots of kids feel a little nervous before an operation, and ask if she has any questions about what’s going to happen next.
Answer Melanie’s questions, and briefly describe what she can expect: who will take her to the OR, where she will be when she wakes up, and when she will see her grandmother again.
Suggest that her grandmother help keep Melanie focused on other things - like playing a game on grandmother’s phone - while they wait to go to the OR.

Want to learn more about addressing emotional support with your patients? Take an interactive online course “E is for Emotional Support” - with free CE credits for nurses.

Trauma Informed Care: Addressing Family Needs

Addressing Family needs includes assessing family stressors and resources, and recognizing that a child’s injury or illness impacts the entire family - parents, siblings, and other family members may also be distressed and may have traumatic stress reactions.

How do I do this?

Remember that family members can have a wide range of reactions to a child’s illness, injury, or hospital stay.
Check in with parents. Give them the opportunity to voice their fears, worries, and concerns.
When a parent is angry, irritable, or seems absent / withdrawn, listen for what may be “underneath”.
Support parents in taking a break and getting some rest and self-care, but recognize that parents may be reluctant to leave their child unless they feel confident that their child is OK while they are away.
As you talk with parents about their child’s condition and treatment plan, keep in mind that parents who are worried, exhausted, and juggling many demands at work and home may need to hear the same information more than once.
Ask how siblings are doing, and look for ways for the child and his/her siblings to stay in touch via visits (if appropriate) or via phone, text, video call.

Helping parents cope with their own responses and participate effectively in their child’s care can have long range benefits for your pediatric patients.

Case Example: Meet James (and his family)

James, age 16, was admitted to the oncology unit a week ago. His mother has been present most days, and both parents have taken turns staying overnight. James’ mother has seemed calm, but she mentioned to you yesterday that she is exhausted and feeling the strain. You’ve heard from colleagues that James’ dad has been impatient with staff, even rude at times. When you enter James’ room for the first time this morning, both parents are present. James’ dad says, “Finally someone’s here. The nurses here never come when we need them.”

What would you do next?

To address Family needs, you might:

Listen to James’ dad’s concerns and frustrations and address what you can. After he has had a chance to voice his frustrations, say that often a new diagnosis can be almost as hard on the family as on the patient and ask what concerns him most right now.
Remember to check in with James’ mom about how she is doing in this challenging situation. Even when a parent seems calm and ‘together’, checking in with them is important.
If James has siblings, ask how they are dealing with James being in the hospital, and talk about visits and staying in touch.

Want to learn more about addressing family needs in order to support your patients’ care? Take an interactive online course “F is for Family” - with free CE credits for nurses.

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