Trauma-informed Care for Child Injury Flaura Koplin Winston, MD PhD and Nancy Kassam-Adams, PhD University of Pennsylvania
CIRP http://injury.research.chop.edu/
Children s Hospital of Philadelphia Bench to Bedside Ranked top children s hospital 1 st children s hospital in US 1 st pediatric trauma center in PA Leading pediatric research institution Pediatrics department for U of PA
University of Pennsylvania One campus: interdisciplinary Among top 5 US universities 12 grad/prof schools, 165 research centers 3,800 faculty; 20,000 students; 1000 post-docs Research budget: $814 million
CENTER FOR INJURYRESEARCH AND PREVENTION THE CHILDREN S HOSPITAL OF PHILADELPHIA RESEARCH INSTITUTE Dedicated to advancing the safety of children, youth and young adults through research & action. (injury.research.chop.edu) Comprehensive From Before the Injury prevention To After the Injury healing Interdisciplinary Clinical medicine, public health, epidemiology, behavioral science and engineering Engaged Large network of partnerships with universities, government, industry Translational Tangible tools & recommendations grounded in science, designed for impact
Overview Understanding medical traumatic stress How common? Risk / protective factors Impact on children and families Trauma-informed pediatric care Secondary prevention model Examples from practice
Understanding medical traumatic stress
Traumatic stress symptoms Re-experiencing It pops into my mind. Feels like it s happening again. I get upset when something reminds me of it. Increased arousal I am always afraid something bad will happen. I jump at any loud noise. I can t concentrate, can t sleep. Avoidance I block it out, try not to think about it. I try to stay away from things that remind me of it. Dissociation It felt unreal -- like I was dreaming. I can t even remember parts of it. Common in children and parents after difficult medical events.
Traumatic stress disorders (DSM-IV) Acute stress disorder Posttraumatic stress disorder Event with fear, helplessness, horror Event with fear, helplessness, horror Dissociation Re-experiencing Avoidance Anxiety & arousal --- Re-experiencing Avoidance Increased arousal 2 days - 4 weeks At least 1 month Symptoms cause impairment Symptoms cause impairment A minority of ill / injured children and family members develop ASD or PTSD (diagnosis).
Injury and acute medical events I thought I was going to die. I 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.
Pediatric injury: clinically significant PTS symptoms 50% 40% 30% 34% < 1 mo (N=243) US 1 mo (N=79) Australia 1.5 mos (N=209) Switzerland 2 mos (N=119) UK 5 mos (N=164) US 6 mos (N=177) US 6 mos (N=69) US 6 mos (N=79) Australia 20% 10% 22% 14% 15% 17% 15% 15% 9% 50% 40% 47% < 1 mo (N=243) US 1.5 mos (N=180 mothers) Switzerland 1.5 mos (N=175 fathers) Switzerland 3 mos (N=62) US - burn injury 6 mos (N=177) US 0% significant PTS symptoms 30% 33% Children 20% 10% 20% 11% 15% 0% significant PTS symptoms Parents
Risk factors for PTSD after Injury Pre-existing Prior traumatic experiences Prior posttraumatic stress Prior behavioral problems Peri-trauma Fear / Subjective life threat Separated from parents Pain Heart rate in ED Early/ongoing responses Cognitive appraisals Child acute stress reactions Parent acute stress reactions Maladaptive coping e.g. social withdrawal
Trauma-informed pediatric care
Trauma-informed services Applicable to broad range of service systems where children are seen schools, health care, law enforcement, juvenile justice. Trauma-informed services = integrate basic knowledge about psychological trauma into the way that professionals interact with children or deliver services minimize potential to newly traumatize child or family integrate formal or informal screening to determine when more assistance may be needed
Trauma-informed pediatric care Increasing awareness about the impact of trauma among health care practitioners and administrators is essential since many children are regularly seen by their pediatrician or health care provider. - NCTSN Service Systems Brief No.1, 2008 Trauma-Informed Pediatric Care means incorporating an understanding of traumatic stress in each patient encounter, in order to: Reduce the impact of difficult or frightening medical events. Help children and families cope with emotional reactions to illness and injury.
Prevention model: Levels of intervention INDICATED Severe or persistent distress MH treatment TARGETED Distress / risk factors Provide anticipatory guidance Follow-up several wks later Refer if distress persists UNIVERSAL All children and families with recent acute trauma Minimize potentially traumatic aspects of medical care Strengthen existing supports / promote adaptive coping Screen for risk factors or severe acute distress Screen (in healthcare setting) for current distress or risk of persistent distress
Mental health professionals INDICATED Severe or persistent distress MH treatment TARGETED Distress / risk factors Provide anticipatory guidance Follow-up several wks later Refer if distress persists Health care providers UNIVERSAL All children and families with recent acute trauma Minimize potentially traumatic aspects of medical care Strengthen existing supports / promote adaptive coping Screen for risk factors or severe acute distress Screen (in healthcare setting) for current distress or risk of persistent distress
DEF protocol: Medical Trauma Working Group, National Child Traumatic Stress Network
Putting DEF into practice: Trauma-informed hospital care Hospital in small city in northeast US, serves huge rural region Pediatric ICU and general pediatric floor Project led / initiated by MDs and Nursing leaders Implementing DEF : Is it feasible for nurses to assess in the course of regular care? How would this change nursing care? UNIVERSAL: Nurses attempted to use DEF to assess all patients results used to inform nursing care plan Jan July 2009: 503 patients/families assessed by nurses Primarily acute illness; also surgery/procedure; injury
Putting DEF into practice: Trauma-informed hospital care Inpatient Nursing Assessment
Putting DEF into practice: Trauma-informed hospital care At least one concern identified: 45% Nurse identified a concern about: D: DISTRESS 26% E: EMOTIONAL SUPPORT 10% F: FAMILY 21% Pain 15% Fears / Worries 17% Grief / Loss 2% Coping needs / strategies 5% Parent availability (to provide support) 6% Mobilizing existing support system 4% Distress in parent / sibling 12% Family stressors 13% Other family needs impacting current care 6%
UNIVERSAL screening with TARGETED follow-up INDICATED Severe or persistent distress MH treatment TARGETED Distress / risk factors Provide specific intervention Follow up / monitor Refer if distress persists UNIVERSAL All children / families with acute medical event Medical care: Minimize potentially traumatic aspects Strengthen existing supports / promote adaptive coping for risk factors or severe acute distress Screen (in healthcare setting) for current distress or risk of persistent distress
Doron Injury (1) 2 days after injury In hospital Doron Ben-Ari is 14 years old and was admitted to the hospital 2 days ago, after being struck by a car while skateboarding in the street with his friends. Tibia fracture. Had surgery to reduce fracture. Casted. Doron arrived at the Emergency Department unaccompanied, his father arrived about an hour later. Mr Ben-Ari has been at hospital with Doron throughout. Ms Ben-Ari came to hospital today for the first time. Screened at hospital 2 days post-injury: Positive screen for PTSD risk factors. On symptom checklist endorses re-experiencing and arousal symptoms.
Doron Injury (2) 2 days after injury In hospital What you learn from talking with Doron and his father: Doron was very afraid in ambulance and ED (A&E). Worst pain since this happened = 10 (in ED); Current pain = 7 Has not been sleeping well - had nightmare that he died in surgery. Mr Ben-Ari is unsure about plan for discharge and about follow-up care. Does not understand what the doctors are planning to do next or when Doron will be able to go home. Family history: Mr Ben-Ari works in manufacturing - often works evenings / nights Ms Ben-Ari has history of depression. She was involved in an accident 8 years ago and unable to work since then. Both parents have history of alcoholism both sober 20 years.
What would you do next? 1 - Consider: Risk / protective factors for this child & family? Developmental / cultural factors to keep in mind? 2 - Assess: D - E F 3 - Plan: What can / should health care team do? Role for mental health professionals? Follow-up needed? (when? how? by whom?)
Resources
Website for parents: www.aftertheinjury.org
WEBSITE FOR PROVIDERS: www.healthcaretoolbox.org
WEBSITE FOR PROVIDERS: www.healthcaretoolbox.org
Web-based training resources Trauma-focused CBT tfcbt.musc.edu Child traumatic grief ctg.musc.edu NCTSN Learning Center for Child and Adolescent Trauma learn.nctsn.org
If You Don't Ask, They Won't Tell: Identifying and Managing Early Childhood Trauma in Pediatric Settings Video-based training resource for pediatric health providers Video and PowerPoint Interviews between physician and parent Demonstrate skills and techniques How to identify and discuss a pre-school age child's traumatic experience with a parent. For more information: Betsy McAlister Groves, LICSW Division of Developmental and Behavioral Pediatrics, Boston Medical Center e-mail: betsy.groves@bmc.org
Thanks Special thanks to the children and families who have generously participated in our studies and programs. This work funded by: US National Institute of Mental Health (NIMH) US Emergency Medical Services for Children (EMSC) US Maternal and Child Health Bureau (MCHB) US Substance Abuse / Mental Health Services Administration (SAMHSA) US Centers for Disease Control (CDC) Verizon Foundation Women s Committee, Children s Hospital of Philadelphia
Resources www.aftertheinjury.org Website for parents For professionals section: materials to download and use in patient care www.healthcaretoolbox.org For health care professionals Lots of resources Download patient education materials www.nctsn.org National Child Traumatic Stress Network