Table 3.

Case study 2: Susan and Charlie - historical trauma.

Assessment	Charlie is a 32-week gestational age Choctaw male, born to a mother with obesity, gestational diabetes and a history of alcoholism.
Additional History	Social determinants of health screening enable the NICU staff to learn that:
	•Susan and her husband work to provide housing, and food to over 15 family members. Susan is caregiver to many family and community members but neglects her own health.
	•Living on the reservation of a federally recognized tribe, Susan has access to health care through the Indian Health Service (IHS) but rarely utilizes the IHS due to a previous negative experiences. Her last experience with the IHS was spending three months at a Youth Regional Treatment Center for substance abuse as a teenager. She has been sober for the past 11 years.
	•Both Susan's grandmother and great-grandmother were separated from their families and sent to Indian Boarding schools as young children, and both later developed alcoholism as teenagers.
NICU Course & Discharge	•After delivery, Charlie is moved to the NICU. Susan is reminded of stories of child separation told by the women in her family. Even after she is discharged, Susan visits Charlie every day, sometimes multiple times a day to make sure he hasn't been moved.
	•After 6 weeks in the NICU, Charlie is discharged. When Susan brings him home, she shares with her family that she constantly worried that the medical staff would take Charlie away from her against her wishes. In the weeks that follow, she becomes more despondent. Unbeknownst to her family, Susan resumes substance use after 11 years of sobriety.
Follow-up	At the 2-month well visit, Susan is relieved when a Community Health Worker (CHW) greets her in Choctaw and offers to take Charlie's car seat.
	•When asked how things are going at home, Susan shares that being a parent to Charlie as well as a caregiver to other family members has been very difficult. Susan quietly shares with the CHW that after she puts Charlie to bed, she sometimes pours herself a drink. She is afraid to tell anyone because she fears Charlie will be taken away, much like her grandmothers were taken. Susan becomes tearful when the CHW praises her for taking such good care of Charlie and bringing him to his medical appointments.
	•Susan learns that CHWs work with the medical staff to care for families and identify resources. She also learns that there are childcare and home-based programs available. Susan is surprised to hear that the CHW has a similar story of trauma, recovery and relapse but chose to serve the community to help other women like her. She accompanies Susan and Charlie when the nurse calls them back.
Actionable Steps	1) Screen for ACEs and SDOH
	2) Utilize Trauma-Informed Care in communities with historical trauma
	3) Understand historical experiences and their intergenerational trauma effects and those potential effects on epigenetic changes
	4) Provide culturally and linguistically appropriate care

IHS=Indian Health Service.