Screening & Secondary Prevention of Traumatic Stress after Injury Flaura Winston, MD, PhD Nancy Kassam-Adams, PhD Angela Marks, MSEd TraumaLink, Children’s Hospital of Philadelphia Funded by: Maternal & Child Health Bureau (MCHB) Emergency Medical Services for Children Program (EMSC)

Injury & traumatic stress  Life threat (self or others)  Fear, helplessness, horror  Symptoms Avoidance Intrusive thoughts Hyperarousal

Acute traumatic stress reactions are common, but… 88% of injured children83% of their parents report at least one acute PTS symptom in the first month after child injury

Significant minority has persistent symptoms 16% of injured children15% of their parents have persistent PTS symptoms & impairment 4 to 8 months after child injury Can we identify those at risk? Can we prevent persistent symptoms?

STEPP screener  Development sample Traffic injured Hospitalized  12 items: child, parent, chart Child Parent Sens88%96% Spec48%53% PPV25%27% NPV95%99% Winston, FK, Kassam-Adams, N, et al JAMA, 290 (5): , 2003.

Targeted Issue Study 1.Develop screening protocol ED-based screening protocol 2.Develop systematic follow-up protocols a)Trauma d/c letters b)Prompted screening via EMD in Primary Care 3.Develop 2 o prevention interventions a)Universal b)Selective for those with identified risk factors

1. ED-based screening protocol Feasibility:  250 STEPP screeners by 70 nurses Easy-to-use (89%), Length OK (97%) Discomfort with asking perceived life threat (33%) Validity:  In ED, general injury population? No Lessons learned:  In-patient screening doesn’t translate to ED  Format OK  Review wording

2. Systematic follow-up  Transition to primary care when emergency / acute care is complete Mail info with discharge letter Automated electronic alerts as part of EMD  Goals for child’s next primary care encounter Ask: How are you doing now? Provide info and anticipatory guidance Monitor or refer as appropriate

Primary MD training

2a. Trauma d/c letter Trauma surgeon as educator  Included with trauma d/c letter Paragraph “I would like to highlight the importance of addressing traumatic stress in all injured patients…” Brochure & patient handout Lessons learned:  Well-received by MDs

2b. Prompted screening via EMR Products developed:  Primary Care MD alert to recent injury  Template with prompts, dx, & handout Lessons learned:  Alerts not noticed (generic problem with EMR)  Too long (time pressure), Unease (limited referrals)  Shorten length, limit role of MD, clear action plan

Generally well-functioning child and family UNIVERSAL SELECTIVE Some risk factors present Persistent distress MH intervention INDICATED Minimize potentially traumatic aspects of medical care Provide general support & information Promote child / family positive coping Screen (in healthcare setting) for indicators of higher risk Follow-up several wks post-injury Anticipatory guidance Referral if distress / risk persists 3. Secondary prevention interventions

3a. Universal psycho-education  Products developed: Print handout  Key messages  Low literacy  Catchy graphics PDF - downloadable  Lessons learned: Well-received  Healthcare & families Randomized trial planned

3b. Selective intervention  Products developed for those with identified risk: Workbook & Manualized Protocol  Accurate assessment of symptoms  Child’s symptoms as distinct from parent’s  Creation of a coping plan  Anxiety sensitivity training  Avoidance training  Lessons learned: Well-received by parents & children Requires referral protocol Randomized trial planned

TraumaLink approach In-Depth Study Publish Research Surveillance Identify Issues Intervention Impact ResearchtoActiontoImpact