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respond to social interactions in a developmentally appropriate way (Sadock & Sadock 2003). Their interactions can vary between being excessively inhibited or diffuse. Those who are inhibited in their interactions are hypervigilant or ambivalent or demonstrate contradictory responses— which are often very frustrating to the parents, who rightly feel as though their efforts to establish a reciprocally affectionate relationship are continuously thwarted or actively sabotaged. Children whose attachments are diffuse fail to establish appropriately selective attachments, thus behaving in an excessively familiar way with strangers. Child and adolescent psychiatry trainees must be able to appreciate both the disturbance in attachment in children who have experienced abuse or neglect throughout infancy or early childhood and the impact of these attachment difficulties on caregivers. They must be cognizant of the feelings of inadequacy that attachment disorders engender in caregivers with respect to their parenting skills, as well as the resulting sense of anger, frustration, and helplessness they feel toward their children (George & Solomon, 2011). In older children, trauma may manifest as dysregulated mood or behavior, attention difficulties, cognitive delays, and disturbances in interactions with peers and caregivers (Ford et al., 2012). These interactions might include defiance toward authority figures or severe disturbances in conduct. Taken in a developmental context, when trauma is the etiology of these symptoms, a child will begin to fail at school and not meet academic, social, or emotional milestones . A child psychiatry trainee must be aware of the various ways in which trauma can present and the reciprocal relationship with development. On the one hand, trauma influences development by distorting, slowing, or inhibiting it. On the other hand, how the child is affected by trauma depends on the developmental stage at which it GENERAL CONSIDERATIONS The goals of training child psychiatrists include familiarizing them with the manifestations of trauma, developing their understanding of the impact of trauma on children at various developmental stages, and making them aware of treatment approaches, as outlined in other chapters of this book. This task can be divided into three components: building a foundation of knowledge, developing skills, and fostering appropriate attitudes toward providing traumainformed care. KNOWLEDGE The first requirement for building a trauma-informed knowledge base is to understand the impact of abuse on child development and to appreciate the range of traumarelated symptoms at various ages. Child psychiatry training should offer the trainee ample settings in which to identify trauma and in which trauma symptoms are likely to present. The trainee may encounter trauma in infants during wellchild visits or when in the emergency room. In infants, trauma may manifest overtly when the child is brought to medical attention after being shaken or with broken limbs. In less overt cases, the child might present with emotional withdrawal or failure to thrive—though the child psychiatry trainee must be aware that abuse is the etiology for failure to thrive in a minority of cases (Egan, Chantoor, & Rosen, 1980). Trauma in very young children manifests differently from trauma in older children or teenagers. Young children who have been victims of abuse or neglect might present with disorders of attachment (Iwaniec, 1997), commonly referred to as reactive attachment disorder of infancy or early childhood. These children are unable to initiate or Training Child Psychiatry Fellows to Provide Trauma-Informed Care SIGALIT HOFFMAN, M.D. JOHN SARGENT, M.D. 31 304 Education, Training, Dissemination, and Implementation Emergency Room The emergency room (ER) is a setting in which child psychiatrists commonly find themselves. In the ER, it is the child psychiatrist’s primary responsibility to ensure the physical safety of the child. The goal of training in this setting is to be able to provide a timely and relatively comprehensive evaluation of the child in a condensed timeframe. Despite the eagerness of many trainees to glean every piece of information possible due to the acuity with which the patient often presents, and because of their relative inexperience in the emergency setting, they should be encouraged to perform a focused assessment that centers on safety and to provide a placement recommendation that offers the least restrictive environment needed to ensure the child’s safety (Tasman et al., 2011). In terms of trauma, the child psychiatrist must be aware that any self-destructive behavior or suicidal statements might be related to a traumatic experience that is either discrete or ongoing (Briere, 1992). The child psychiatrist must also be conversant with the legal resources available to ensure the child’s safety. As a mandated reporter, a child psychiatrist cannot hospitalize a...

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