Traumatic stress from injury: Research into practice

1. 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 (http://traumalink.chop.edu) EMSC, 2006

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

3. 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

4. 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

5. 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

6. “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.” Experiences

7. 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 Traumatic stress symptoms Posttraumatic Stress Disorder

8. 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)

9. Traumatic stress model • 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

11. Trajectory of response to trauma Phase III Phase II distress Phase I PTE time

12. Treatment of response to trauma distress PTE time

13. 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

14. 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 prevent persistent symptoms?

15. Early, ongoing and evolving responsesFocus of EMSC-funded work Opportunities to address current distress and prevent development of persistent distress: • Information • Anticipatory guidance • Screening

16. INJURY: Tip sheets for parents and kids

17. 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.

18. 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

22. Pediatric Medical Traumatic Stress Toolkit for Health Care Providers

23. Pocket cards

24. Pocket cards

25. Pocket cards

26. 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

27. Traumatic Stress: ED Clinician RolesExample: 16 yr old mva

28. Traumatic Stress: ED Clinician RolesExample: 16 yr old mva

29. 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

30. 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

31. 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

32. 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

33. Web links for resources • Injury Tip Sheets & Primary Care materials www.chop.edu/traumalink/carit • Tipsheets and resources re: medical traumatic stress www.chop.edu/cpts • Pediatric Medical Traumatic Stress Toolkit www.nctsn.org/medtoolkit