Many thanks to Dr. Susan Milam Miller, who gave an excellent Grand Rounds this week titled "Caring for our Children, our Family, and Ourselves during COVID-19". Dr. Milam Miller covered a range of topics about our mental health in this pandemic-- from March 2020 as Alexander and the Terrible, Horrible, No Good Very Bad Day, to community and complex trauma, ambiguous loss, and unresolved grief, to trauma-informed care, and even a bit about the magic of a window into children's lives via video visits.

HERE is the recording of Dr. Milam Miller's presentation. 

Here are my notes:

Dr. Milam Miller reminded us that no child exists as as single entity-- children exist within their natural environment, including their families and their community. Listening between the lines to children and their attached adults is important. Knowing what their natural environment looks like is also key.

Clearly, here in Sonoma County, many children (and adults) have lived the trauma of several fire seasons and evacuations, compounded for the last year and a half by the COVID-19 Pandemic. These traumas have caused a tremendous amount of stress for many of us-- children are no exception. As such, we can expect to see signs of traumatic stress in our children.

Traumatic Stress manifests in a range of responses in adults and children:

• Emotional: emotional dysregulation (sadness, fear), numbness, detachment
• Physical: somatization (headaches, stomach aches insomnia), changes in brain function, hyperarousal
• Cognitive: how we think about ourselves and others, triggers, re-experiencing, nightmares/daymares, dissociation, dampening of connection via thoughts and emotions
• Behavioral: the way the mind directs the body: self harm, substances, avoidance (behaviors that are NOT adaptive over time, even if they help at first)
• Interpersonal: pulling away from loved ones, difficulty trusting and forming trusting relationships

Identifying these "adaptive" behaviors that may not serve us over time is key to helping our patients and ourselves survive the trauma. 

Community Trauma  is a strong and powerful shaper of relationships and health

How does a community emerge from trauma? How do we recover and repair? How do healthcare providers care for their community in times of trauma but also for themselves? How do we model for our children and families what healthy coping with community trauma entails?

Complex Trauma describes both children's exposure to multiple traumatic events—often of an invasive, interpersonal nature—and the wide-ranging, long-term effects of this exposure. ... They usually occur early in life and can disrupt many aspects of the child's development and the formation of a sense of self. In COVID times, the list of multiple traumatic events may be long

• what about medical trauma of repeated COVID testing?
• what about shutting down schools?
• what about losing church and extracurricular activities?

Ambiguous loss is a loss that occurs without closure or clear understanding. This kind of loss leaves a person searching for answers, and thus complicates and delays the process of grieving, and often results in unresolved grief. I personally found myself intrigued for the rest of the day by this notion of ambiguous loss-- classically a dear one who disappears on a hiking trip, never to be found again. What about these years of pandemic create ambiguous loss?

• what does it mean to have never finished fourth grade because schools shut down in March 2020?
• what does it mean not to have a graduation ceremony from high school?
• what does it mean to go through puberty during pandemic times without community support?

Trauma Treatment classically has 3 stages:

• Stage 1: Stabilization and establishment of safety (this may include psychotropic medications, DBT to help managing distress, relationship building)
• Stage 2: Addressing and processing of trauma memories or related beliefs and/or grieving the losses inherent in trauma (this is somewhat controversial but has been standard of trauma treatment)
• Stage 3: Restoring or creating connection between survivors and their communities by increased engagement in meaningful and positive activities and relationships

Unsurprisingly, in trauma healing, relationship building is key.

Trauma informed care

“Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing. 

• Safety
• Trustworthiness and transparency
• Peer support
• Collaboration and mutuality
• Empowerment, voice and choice
• Culturally, historic and gender appropriate

Relationship and relational care is everything. Dr. Milam Miller says at some point, we expend WAY too much energy on individual treatments and interventions, really we need to consider community interventions, group treatments, and shared treatments. I love 

Closing questions to ponder from Dr. Milam Miller

1) Who is your buddy? (i.e. the person you call, lean on, ask for help)

2) What does healthy coping look like in these times?

3) Can you recognize the ambiguous loss of this COVID pandemic for the families you care for? Once recognized, how do we process our grief?