Hope Lives Here Traumatic stress from injury: Research into practice Flaura Koplin Winston, MD PhD Nancy Kassam-Adams, PhD Angela Marks, MSEd Center for Injury Research and Prevention ( EMSC, 2006

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

Hope Lives Here 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

Hope Lives Here 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

Hope Lives Here 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

Hope Lives Here 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.”

Hope Lives Here Traumatic stress symptoms Re-experiencing Thoughts & feelings pop into one’s mind. Re-living what happened - feels like it’s happening again. Get upset at reminders. Avoidance Try to block it out & not think about it. Try to stay away from reminders. Feel numb or no emotions. Increased arousal Always afraid something bad will happen. More easily startled / jumpy. Trouble with sleep or concentration. Dissociation Things feel unreal -- like a dream. Trouble remembering parts of what happened. Traumatic stress symptoms  Posttraumatic Stress Disorder

Hope Lives Here 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)

Hope Lives Here  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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Trajectory of response to trauma distress time PTE Phase I Phase II Phase III

Treatment of response to trauma distress time PTE

Hope Lives Here 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

Hope Lives Here 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?

Hope Lives Here Opportunities to address current distress and prevent development of persistent distress:  Information  Anticipatory guidance  Screening Early, ongoing and evolving responses Focus 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 Sensitivity88%96% Specificity48%53% PPV25%27% NPV95%99% Winston, Kassam-Adams, et al. (2003). Screening for risk of persistent posttraumatic stress in injured children and their parents. JAMA, 290 (5):

Dr. John Surgeon Department 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

Hope Lives Here Pocket cards

Hope Lives Here Traumatic Stress: ED Clinician Roles Example: 7 yr old new Dx leukemia D istress 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 E motional 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 F amily 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

Hope Lives Here Traumatic Stress: ED Clinician Roles Example: 16 yr old mva

Hope Lives Here Traumatic Stress: ED Clinician Roles Example: 16 yr old mva

Hope Lives Here Traumatic Stress: ED Clinician Roles Example: 16 yr old mva D istress 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 E motional 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 F amily: Manage fear, anger and mistrust again Larger support system: Include friends Barriers:  Simultaneous, emergent medical treatment  Preconceived notions by medical staff

Hope Lives Here 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

Hope Lives Here 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

Hope Lives Here 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

Hope Lives Here Web links for resources  Injury Tip Sheets & Primary Care materials  Tipsheets and resources re: medical traumatic stress  Pediatric Medical Traumatic Stress Toolkit