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Traumatic stress from injury: Research into practice

Flaura Koplin Winston, MD PhDNancy Kassam-Adams, PhD

Angela Marks, MSEd

Center for Injury Research and Prevention(http://traumalink.chop.edu)

EMSC, 2006

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Injury & traumatic stress

Life threat (self or others)

Fear, helplessness, horror

Symptoms• Avoidance• Intrusive thoughts• Hyperarousal

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Goals

Provide an overview of our EMSC-funded research base for traumatic stress in children and their parents after injury

Illustrate interventions for traumatic stress

Discuss practical application

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Stress vs. Traumatic Stress

Many aspects of illness and injury are stressful.• Painful / difficult to deal with• Strain individual’s & family’s coping resources

Some aspects are potentially traumatic.• Extremely frightening or horrifying• Life-threatening• Sudden, painful, or overwhelming

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Medical events associated with intense emotional distress

• Serious / life-threatening illness (cancer, HIV, transplantation)

• Injury (fractures, burns) Intentional (e.g., assault) Unintentional (e.g., car crash)

• Painful or scary procedures

• Medical emergencies

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Experiences

“I thought I was going to die. Thought I must really be hurt. I was so scared because my mom was not there.”

“I saw my son lying in the street. Bleeding, crying, the ambulance, everybody around him. It was a horrible scene. I thought I was dreaming.”

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Traumatic stress symptoms

Re-experiencingThoughts & feelings pop into

one’s mind.Re-living what happened - feels

like it’s happening again.Get upset at reminders.

AvoidanceTry to block it out & not think

about it.Try to stay away from

reminders.Feel numb or no emotions.

Increased arousalAlways afraid something bad

will happen.More easily startled / jumpy.Trouble with sleep or

concentration.

DissociationThings feel unreal -- like a

dream.Trouble remembering parts of

what happened.

Traumatic stress symptoms Posttraumatic Stress Disorder

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Impact of traumatic stress on health & functioning

PTSD associated with:

wide range of adverse health outcomes in children preschool thru adolescence

(Graham-Bermann & Seng 2005; Seng et al 2005)

poorer treatment adherence post-transplant

(Shemesh et al 2000; Shemesh 2004)

lower health-related quality of life & functional outcomes (e.g., more missed school days) after injury

(Holbrook et al 2004; CHOP data)

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Data on medical PTSS has been reported but largely without a conceptual model.

We have proposed a model with the goal of guiding intervention.

The model has three phases

• Phase I. Peri-trauma

• Phase II. Early, ongoing and evolving responses

• Phase III. Longer-term PTSS

Traumatic stress model

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The CHOP Traumatic Stress Model

Potentially Traumatic Event (PTE) - 0bjective

Perception of the PTE - Subjective

Early (Acute)/ Ongoing and Evolving Responses

Long term PTSS

I . Peri-Trauma I I . Early, Ongoing, Evolving Reponses I I I . Long-term

Kazak, A., Kassam-Adams, N., Schneider, S., Alderfer, M., Zelikovsky, N., & Rourke, M. (in press). An integrative model of pediatric medical traumatic stress. J ournal of Pediatric Psychology.

Alter subjective experience of

PTE

Address immediate needsReduce distressPrevent PTSS

Reduce PTSS

Three stages of response…..

… with different implications for intervention.

Trajectory of response to traumadis

tress

time

PTE

Phase I

Phase II Phase III

Treatment of response to traumadis

tress

time

PTE

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Acute traumatic stress reactions are common, but…

88% of injured children 83% of their parents

report at least one acute PTS symptom in the first month after child injury

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Significant minority has persistent symptoms

16% of injured children 15% of their parents

have persistent PTS symptoms & impairment 4 to 8 months after child injury

Can we identify those at risk?Can we identify those at risk?Can we prevent persistent symptoms?Can we prevent persistent symptoms?

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Opportunities to address current distress and prevent development of persistent distress:

Information

Anticipatory guidance

Screening

Early, ongoing and evolving responsesFocus of EMSC-funded work

INJURY: Tip sheets for parents and kids

Screening Tool for Early Predictors of PTSD (STEPP)

Predicting PTSD 6 months later

ChildParent

Sensitivity 88% 96%Specificity 48% 53%

PPV 25% 27%NPV 95% 99%

Winston, Kassam-Adams, et al. (2003). Screening for risk of persistent posttraumatic stress in injured children and their parents. JAMA, 290 (5): 643-649.

STEPP ©

QUESTIONS FOR PARENTS No Yes

Did you see the incident (accident) in which your child got hurt? 0 1

Were you with your child in an ambulance / helicopter coming to the hospital? 0 1

When your child was hurt (or when you first heard about it), did you feel really helpless? 0 1

Before this injury, had your child ever had behavior or attention problems for a while? 0 1

QUESTIONS FOR KIDS

Was anyone else hurt or killed (when you got hurt)? 0 1

Was there a time when you didn’t know where your parents were? 0 1

When you got hurt, or right afterwards, did you feel really afraid? 0 1

When you got hurt, or right afterwards, did you think you might die? 0 1

INFORMATION FROM MEDICAL RECORD

ED triage heart rate over 104 (child under 12) over 97 (child 12 and older) 0 1

Extremity fracture? 0 1

Child is a girl 0 1

Child is 12 or older 0 1

Dr. John SurgeonDepartment of Surgery – Children’s Hospital

… Lastly, an important but often overlooked consequence of an injury is post-traumatic stress (PTSD), which can develop in a child or the parent of an injured child regardless of injury severity or treatment duration. With this letter, I have enclosed a brochure and pocket guide on pediatric injury and traumatic stress. These highlight signs and symptoms to look for to identify patients and families at greater risk for PTSD, and give suggestions for anticipatory guidance. A parent handout is also enclosed.

Trauma surgeon’s

discharge letter

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Pediatric Medical Traumatic Stress Toolkit for Health Care Providers

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Pocket cards

Pocket cards

Pocket cards

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Traumatic Stress: ED Clinician RolesExample: 7 yr old new Dx leukemia

Distress• Child worries about needles: Topical anesthetic for IV• Child thinks hospitals are where people die: Clarified• Talked with child about all of the people he will meet

Emotional Support• Family: assured that mom or dad can always be with him• Asked how family thinks child wants to get information• Social work present during disclosure

Family• Family worries about death, disability (grief/loss)• Assess role and involvement of other family members

Barriers: Don’t have all the answers for reassurance Time is short

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Traumatic Stress: ED Clinician RolesExample: 16 yr old mva

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Traumatic Stress: ED Clinician RolesExample: 16 yr old mva

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Traumatic Stress: ED Clinician RolesExample: 16 yr old mva

Distress• Fears death, can’t show it: Reassure, be subtle• Mistrust: Explain every person, procedure and reason• Angry at driver• Alone – family not there yet – assign one staff to be with him

through entire ED visit

Emotional Support• +Eye contact; allowed decision making if possible = respect• Provide non-judgmental space for narrative• Try to understand meaning of the events: family, authority,

safety, medical experiences

Family:• Manage fear, anger and mistrust again• Larger support system: Include friends

Barriers: Simultaneous, emergent medical treatment Preconceived notions by medical staff

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Traumatic stress after injury: Critical issues

Universal interventions may be harmful

Injury severity does not reflect PTSD risk

Time constraints

Need practical, effective ways to assess

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Summary

Traumatic stress is a helpful way of understanding reactions of patients and families to injury AND other medical events

Intervention can begin at medical triage with trauma informed care and screening by all providers

Treatment may need to continue over time

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Current / future work

Develop other modes of delivering information and intervention • interactive web-based• in-hospital video (DVD)

Consider other ways of engaging providers in secondary prevention

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Web links for resources

Injury Tip Sheets & Primary Care materialswww.chop.edu/traumalink/carit

Tipsheets and resourcesre: medical traumatic stress

www.chop.edu/cpts

Pediatric Medical Traumatic Stress Toolkitwww.nctsn.org/medtoolkit