kassam adams

Nancy Kassam-Adams, PhDChildren’s Hospital of Philadelphia

nlkaphd@mail.med.upenn.edu

Finding and Helping Stressed Children

In Health Care Settings

Why health care settings? Impact of medical events on children & families Interconnections - trauma & physical health

Finding & helping children with trauma Trauma-informed care Screening for trauma / risk In the hospital / in primary care

Online resources for providers & parents

Overview

See kids & families during / right after certain types of trauma

Scary medical events (asthma attack, injury, sudden serious illness)

Disaster / violence

See children for many reasons Not only at times of illness or difficulty May have ongoing relationship with child / family

Reach children and parents who will not seek MH services

For some, a more acceptable way to seek care Including under-served populations (language, resources)

Health care settings: Opportunities to address child trauma

Trauma & physical health: Interconnections

Physical health:

illness, injury,treatment Traumatic

stress /PTSD symptoms

Emotional impact of medical events

Health impact of trauma exposure

Health impact of traumatic stress

Exposure to trauma

Medical events as potentially traumatic events (PTEs)“I thought I was going to die. I thought I must really be hurt. I was so scared because my mom was not there.”

“It all happened so quickly. I was ‘out of it’ and in pain. I was given the first chemo treatment without being told what was going on – that upset me for a long time after that.”

“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.”

“We went from taking him to our family doctor, thinking that he had some kind of virus or flu, to by the end of the afternoon being in the ICU and having him inundated with needles, and tubes, and… Wow! How did the day end up like this?”

Pediatric intensive care: clinically significant PTS symptoms

Children with significant PTSD s...0%

10%

20%

30%

40%

50%

25%27%

21%

28%

35%

(n-120) Canada

(n=17) UK

(n=19) UK

(n=102) UK

(n=29) Netherlands

45%

32%

28% 29%

20%

0%

10%

20%

30%

40%

50%

Parents with sig PTSD symptoms(UK studies)

3 mo (n=102)4 mo (n=50)8 mo (n=102)12 mo (n=72)21 mo (n=71)

Children Parents

Pediatric injury: clinically significant PTS symptoms

14%

34%

15% 15%

9%

22%

15%17%

0%

10%

20%

30%

40%

50%

significant PTS symptoms

< 1 mo (N=243) US1 mo (N=79) Australia 1.5 mos (N=209) Switzerland2 mos (N=119) UK 5 mos (N=164) US6 mos (N=177) US6 mos (N=69) US6 mos (N=79) Australia

20%

11%

33%

47%

15%

0%

10%

20%

30%

40%

50%

significant PTS symptoms

< 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

Children

Parents

In families facing childhood cancer, rates of PTSD are often higher in parents than in the child with the cancer.

24%

29%

45%

35%

0%

10%

20%

30%

40%

50%

Teens Siblings Mothers Fathers

Moderate tosevere PTSDsymptoms

Symptoms in families of teen cancer survivors one year or more post-treatment

Pediatric cancer:clinically significant PTS symptoms

Kazak, et al. (2004). Posttraumatic stress symptom and posttraumatic stress disorder in families of adolescent cancer survivors. Journal of Pediatric Psychology.

Health status (broadly)

Large Medicaid sample of girls 0-17: PTSD associated with increased risk for circulatory, endocrine, and musculoskeletal conditions. (Seng et al. 2005)

Treatment adherenceAfter organ transplant, PTSD symptoms associated with poorer treatment adherence.

(Shemesh et al 2000; Shemesh 2004)

Functional health outcomes

After injury, PTSD associated with worse functional outcomes:

poorer quality of life for up to 2 years, more missed school days

(Holbrook et al 2005; Zatzick et al. 2008; CHOP data)

PTSD / traumatic stressaffects health outcomes

FRIENDS

SCHOOL

COMMUNITY

CULTURE

FAMILY

CHILD

Impact of potentially traumatic eventInfluenced by: Child prior experiences Child coping capacity Impact on family Family ability to help child

heal Impact on peers / school /

community Availability of social

resources that support child’s healing and recovery

Culture and extended community

HEALTH CARE SYSTEM

CULTURE

FAMILY

CHILD

Impact of potentially traumatic medical eventInfluenced by: Child prior experiences Child coping capacity Impact on family Family ability to help child

heal

Experiences and interactions with health care system / providers

Culture and extended community

“Trauma-informed” health care

With basic knowledge of medical traumatic stress, health care providers can … Minimize potentially traumatic aspects of medical

care child’s experience of illness / injury treatment / procedures provider interactions with child and family

Support adaptive coping

Provide basic information & anticipatory guidance to parents and children

Screen for high distress / high risk.

Screen refer / get consultation

Health careproviders

Screen (in healthcare setting) for current distress or risk of persistent distress

All children and families with recent acute trauma

UNIVERSAL

TARGETEDDistress / risk factors

Severe orpersistent distress

MH treatment

INDICATED

Minimize potentially traumatic aspects of medical care Strengthen existing supports & coping Screen for risk factors or severe acute distress

Provide anticipatory guidance Follow-up several wks later Refer if distress persists

Mental health professionals

DEF protocol: Medical Trauma Working Group, National Child Traumatic Stress Network

DEF: pocket cards

At the hospital

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 “D-E-F”:

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

Nurse identified a concern about:

D: DISTRESS

26%

Pain 15%

Fears / Worries 17%

Grief / Loss 2%

E:EMOTIONALSUPPORT

10%

Coping needs / strategies 5%

Parent availability (to provide support) 6%

Mobilizing existing support system 4%

F: FAMILY

21%

Distress in parent / sibling 12%

Family stressors 13%

Other family needs impacting current care 6%

At least one concern identified: 45%

Stepped Preventive Care: Hospitalized injured children & teens

Child (age 8 - 17) admitted to hospital for acute injury

Universal brief screen in hospital (about 1 in 4 screen positive) risk of ongoing PTS symptoms (STEPP), current PTS or depression symptoms

Targeted preventive intervention for those who screen positive Stepped care model

deliver ‘just enough’ care delivered by RN’s and MSW’s tailor to child’s need / re-assess

Indicated mental health services (<10%) provided as needed MH professionals

Psychosocial Assessment Tool (PAT)Development / validation: Children with cancer (Kazak et al. 2011)

Adaptations / validation underway for other areas (e.g. sickle cell)

Purpose / Use: Practical , systematic screening ID level of psychosocial need & resources for patient & family Guide nursing & psychosocial care plan

Implementation: Currently in use in 21 hospitals in the US and 18 international

Kazak, et al. (2011). Association of psychosocial risk screening in pediatric cancer with psychosocial services provided. Psychooncology. 20: 715–723.

Form to communicate screening results

Primary care

Primary care:Screening for trauma / traumatic stress

Lipschitz (2000) -- urban teen girls at routine primary care visit• 92% endorsed at least one trauma exposure

• 86% witnessed community violence• 68% heard about a homicide• 49% victim of violence• 38% witness domestic violence

• 14% PTSD Sabin et al (2006) -- injured teens returning to primary care

• 30% had >4 previous traumatic events (before injury)• 4 to 6 mos after injury:

• 30% posttraumatic stress symptoms• 11% depressive symptoms• 17% high alcohol use

• No problems detected by their primary care providers post-injury

Suggested screening question for each primary care visit with a child:

“Since the last time I saw your child, has anything really scary or upsetting happened to your child or anyone in your family?”

Cohen, Kelleher, & Mannarino (2008)

Primary care: Identify & respond

Automate support for continuity of care: Via electronic health record

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

Pediatric Management of Early Childhood Traumatic Stress Inquire about stressors in the child’s life.

Key questions: What do you notice about changes in your child’s behavior? When did this start? What was happening at the time?

Provide developmental guidance about trauma response

Provide education/guidance about: behavior management, routines and daily living activities to

promote recovery and sense of safety

Refer for mental health intervention, if needed

Provide close follow-up and ongoing monitoring

Online resources for providers & parents

WEBSITE FOR PROVIDERS: www.HealthCareToolbox.org

WEBSITE FOR PROVIDERS: www.HealthCareToolbox.org

Website for parents: www.aftertheinjury.org

Special thanks to the children and families who have generously participated in our studies and programs.

This work funded by:National Institute of Mental Health (NIMH)National Cancer Institute (NCI)Emergency Medical Services for Children (EMSC) Maternal and Child Health Bureau (MCHB)Substance Abuse / Mental Health Services Administration (SAMHSA)Centers for Disease Control (CDC)Verizon FoundationWomen’s Committee, Children’s Hospital of PhiladelphiaSt. Baldrick’s Foundation

Thanks