kassam adams
TRANSCRIPT
Nancy Kassam-Adams, PhDChildren’s Hospital of Philadelphia
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: [email protected]
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