1. Finding and Helping Stressed Children
In Health Care Settings
Nancy Kassam-Adams, PhD
Children’s Hospital of Philadelphia
nlkaphd@mail.med.upenn.edu

2. Overview
 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

3. Health care settings:
Opportunities to address child trauma
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)

4. Trauma & physical health:
Interconnections
Health impact of Exposure
trauma exposure to trauma
Physical
health:
illness,
injury, Emotional impact
treatment of medical events Traumatic
stress /
PTSD
symptoms
Health impact of
traumatic stress

5. Medical events as
potentially traumatic events (PTEs)
“I thought I was “It all happened so
going to die. I quickly. I was „out of it‟
thought I must and in pain. I was given
really be hurt. I was the first chemo treatment
so scared because without being told what
my mom was not was going on – that upset
there.” me for a long time after
that.”
“We went from taking him
“I saw my son lying in to our family doctor,
the street. Bleeding, thinking that he had some
crying, the ambulance, kind of virus or flu, to by
everybody around him. the end of the afternoon
It was a horrible scene. being in the ICU and
I thought I was having him inundated with
dreaming.” needles, and tubes, and…
Wow! How did the day end
up like this?”

6. Pediatric intensive care:
clinically significant PTS symptoms
3 mo (n=102)
(n-120) Canada 50%
50% 4 mo (n=50)
8 mo (n=102)
(n=17) UK 45% 12 mo (n=72)
40% 40%
21 mo (n=71)
(n=19) UK
30% 35% 30% 32%
(n=102) UK 28% 29%
27% 28%
25% 20%
20% (n=29) Netherlands 20%
21%
10% 10%
0% 0%
Children with significant PTSD Parents with sig PTSD symptoms
symptoms 3 - 8 mos post-discharge (UK studies)
Children Parents

7. Pediatric injury:
clinically significant PTS symptoms
50% < 1 mo (N=243) US
1 mo (N=79) Australia
1.5 mos (N=209) Switzerland
40% 2 mos (N=119) UK
5 mos (N=164) US
6 mos (N=177) US
30% 34% 6 mos (N=69) US
6 mos (N=79) Australia
20%
22% 50%
< 1 mo (N=243) US
1.5 mos (N=180 mothers) Switzerland
17%
10% 14% 15% 15% 15% 47% 1.5 mos (N=175 fathers) Switzerland
40% 3 mos (N=62) US - burn injury
9% 6 mos (N=177) US
0%
significant PTS symptoms
30% 33%
20%
Children
20%
15%
10%
11%
0%
significant PTS symptoms
Parents

8. Pediatric cancer:
clinically significant PTS symptoms
In families facing childhood cancer, rates of PTSD are often higher
in parents than in the child with the cancer.
50%
45%
40%
Symptoms in
families of teen 35%
cancer survivors 30%
one year or more
29%
Moderate to
severe PTSD
post-treatment
24%
20% symptoms
10%
0%
Teens Siblings Mothers Fathers
Kazak, et al. (2004). Posttraumatic stress symptom and posttraumatic stress disorder in
families of adolescent cancer survivors. Journal of Pediatric Psychology.

9. PTSD / traumatic stress
affects health outcomes
 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 adherence
After 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)

10. Impact of
potentially traumatic event
Influenced by: CULTURE
 Child prior experiences COMMUNITY
 Child coping capacity SCHOOL
 Impact on family FRIENDS
 Family ability to help child heal FAMILY
 Impact on peers / school /
community
CHILD
 Availability of social resources
that support child’s healing and
recovery
 Culture and extended
community

11. Impact of
potentially traumatic medical event
Influenced by: CULTURE
 Child prior experiences
 Child coping capacity
HEALTH CARE SYSTEM
 Impact on family
 Family ability to help child heal FAMILY
 Experiences and CHILD
interactions with health
care system / providers
 Culture and extended
community

12. “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

13. Mental health
INDICATED Health care
professionals Severe or providers
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 & coping
 Screen for risk factors or severe acute distress
 Screen (in healthcare setting) for current distress
or risk of persistent distress

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

15. DEF: pocket cards

17. At the hospital

18. 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

19. Putting DEF into practice:
Trauma-informed hospital care
At least one concern identified: 45%
Nurse identified a concern about:
D: Pain 15%
DISTRESS Fears / Worries 17%
26% Grief / Loss 2%
E: Coping needs / strategies 5%
EMOTIONAL
SUPPORT Parent availability (to provide support) 6%
10% Mobilizing existing support system 4%
F:
Distress in parent / sibling 12%
FAMILY Family stressors 13%
21% Other family needs impacting current care 6%

20. 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

21. 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.

22. Form to communicate screening results

23. Primary care

24. 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

25. Primary care: Identify & respond
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)

26. Automate support for continuity of care: Via electronic health record

29. 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

30. 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

31. Online resources for
providers & parents

32. WEBSITE FOR PROVIDERS: www.HealthCareToolbox.org

33. WEBSITE FOR PROVIDERS: www.HealthCareToolbox.org

34. Website for parents: www.aftertheinjury.org

35. Thanks
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 Foundation
Women’s Committee, Children’s Hospital of Philadelphia
St. Baldrick’s Foundation