Presentation on theme: "Trauma-Informed Pediatric Care: What Health Care Providers Can Do"— Presentation transcript:
1Trauma-Informed Pediatric Care: What Health Care Providers Can Do Center for Pediatric Traumatic StressThe Children’s Hospital of Philadelphia
2Outline Part 2: Opportunities for prevention and intervention Part 1: Understanding pediatric medical traumatic stressDefinitions and impact of medical traumatic stressTraumatic stress symptoms and risk factorsDevelopmental issues and role of beliefsIntervention modelsPart 2: Opportunities for prevention and interventionTrauma-Informed Pediatric CareIntegrating Family-Centered and Trauma-Informed CareResponding to Medical Traumatic StressPMTS ToolkitD-E-F ProtocolKey Intervention Points / Strategies along the continuum of care
3Impact of Medical Traumatic Stress Up to 80% of children and their families experience some traumatic stress reactions following life-threatening illness, injury or painful medical procedures.20-30% of parents and 15-25% of children and siblings experience persistent traumatic stress reactions.When they persist, traumatic stress reactions can:Impair day-to-day functioningAffect adherence to medical treatmentImpede optimal recoveryAffect relationships between providers and patients.
4What is Medical Traumatic Stress? “A set of psychologicaland physiological responsesof children and their familiesto pain, injury, medical procedures,and invasive or frighteningtreatment experiences.”National Child Traumatic Stress Network, 2003
5Defining Medical Traumatic Stress Medical traumatic stress responses:are related to subjective experience of the eventincludes symptoms of arousal, re-experiencing, and avoidancevary in intensitycan become disruptive to functioning
6Responses to Medical Trauma When facing serious illness or injury many pediatric patients and their families are able to cope well, with the basic supportive interventions and with timeSome may develop persistent traumatic stress reactions, such as posttraumatic stress disorder, which impedes both health and psychosocial functioning.As pediatric health care providers, you have an opportunity to make a difference in how children and their families experience serious illness, injury, and the medical care they receive.
7Responding to Traumatic Stress By incorporating an awareness of traumatic stress responses, health care providers can:Minimize potentially traumatic aspects of medical careIdentify children and families at higher risk for persistent distress or posttraumatic stressProvide brief interventions that reduce the emotional impact of trauma and prevent posttraumatic stress disorder
8PMTS ToolkitHealth care providers treating children and families already have the many of the basic interpersonal and psychosocial skills required in addressing traumatic stress responsesThe information and tools contained in the Pediatric Medical Traumatic Stress Toolkit can help you hone or enhance your skillsYou can download a copy of the Toolkit materials at:
10Integrating Family-Centered Care and Trauma-Informed Care “…involves improving patient and family access to information about their condition, building on family strengths and enhancing family skills in caring for the child and increasing the involvement and collaboration of family members in health care decisions.”-Institute of Medicine, US
11Family-Centered CareIncorporates maximum possible involvement of families during all phases of care, and calls for:Clear and continuous communication between family members and the health care teamAttending to the psychological needs of family membersCultural competence of providers
12Trauma-Informed CareIncorporates an understanding of traumatic stress in each clinical encounter with children and their families.Minimizes potentially traumatic aspects of medical careConsiders traumatic aspects of:Child’s experience of illness/injuryTreatment/ ProceduresHospitalization/Separation from parentsLoss/grievingSupports adaptive coping based on child family strengthsScreens for indicators of higher risk
15D-E-F ProtocolHealth care providers are experts in treating illness, restoring functioning, and saving lives.After attending to the basics of children’s physical health (the A-B-C’s), providers can promote their patients’ health and recovery by paying attention to the next steps – “D-E-F”.D-E-F provides a straightforward, reliable method for identifying, preventing and treating traumatic stress responses.Reduce DistressProvide Emotional SupportRemember (and involve) the Family
17How to Assess - Distress Pain: Use hospital’s pediatric pain assessment: Ask Patient:“How is your pain right now?”“What was your worst pain?”Fears and Worries: Ask children about fears:“Sometimes children are scared or upset when something like this happens. Is there anything that has been scary or upsetting to you?”“What worries you most?”Grief /Loss: Acknowledge intense and conflicting feelings. Ask:“Anyone else hurt or ill? Any other recent losses?” (damage to home, loss of pet, loss of family member)“Any personal losses?” (loss of ability, body image, etc.)
18How to Help - DistressProvide the child with as much control as possible over the clinical encounter.The child should understand what is about to happen, and have a say about what is about to happen2. Actively assess and treat pain.Have some control over pain management3. Listen carefully to hear how the child understands what is happening.Have child explain things back to you to ensure understanding
19How to Help - Distress, cont. 4. Clarify any misconceptions.Use words the child can understand5. Provide reassurance and realistic hope.Describe what is being done and who is working to help child get better6. Pay attention to grief and loss.Use hospital’s bereavement services and grief protocolsEncourage parents to listen to children’s concerns and be open to talking about experience
21How to Assess - Emotional Support What does your child need now?Ask parent: “What helps your child cope with upsetting or scary things?Ask child: “What has been the best thing so far that helps you to feel better?”Who is available to help the child?Do the parents understand the treatment plan?Are they able to help calm their child?Are they able to be with their child for procedures?How can existing supports be mobilized?Ask parent: “Who can you or your child usually turn to for help or support? Are they aware of what is happening?”
22How to Help - Emotional Support 1. Encourage parents’ presence:Encourage parents to be with their child as much as possible during hospital stay and to talk to their child about worries, hopes, etc.Parents know their child better than anyone and can help staff understand their child’s needs and coping strengths.2. Empower parents to comfort and help their child:Help parents understand the illness or injury and treatment plan so that they can give age appropriate explanations to their child.Encourage parents to use the ways they soothe and calm their child at home.
23How to Help - Emotional Support 3. Encourage social support & involvement in “normal” activities:Suggest age appropriate positive activities that fit the child’s medical status.Promote the child’s appropriate contact with friends, classmates, teachers, etc.
25How to Assess - Family Assess parents’, siblings’ and others’ distress “Have you or other family members been very upset since this happened?”Gauge family stressors & resources“Are there other stressors for your family right now?”“Have you been able to get some sleep? Eat regularly?”Address other needs (beyond medical)“Are there other worries (money, housing, etc.) that make it especially hard to deal with this right now?”
26How to Help - Family Encourage parents’ basic self care. Encourage parents to get sleep, eat, and take breaks from the hospital.2. Remember family members’ emotional needs.Help them to enlist support systems (friends, family, faith community).If parents or other family members are having a difficult time, use hospital services, consider a referral3. Be sensitive to resource needs of the family.Lack of resources can significantly interfere with the child’s recovery.If problems are identified, utilize psychosocial resources to address them (i.e., housing, finances, insurance, language barriers, immigration status, care of other children).
27Intervention Models - Medical Traumatic Stress Prevention and Treatment ModelStratifies children and families into three levels of intervention, based on early symptomsPhases of Medical Traumatic Stress ModelMatches potential interventions to different stages of traumatic stress development
29Prevention Model: Levels of Symptomotology Universal- Some distress, but most children and families have coping strengths and resourcesTargeted- Acute distress or risk factors present; child / family does not appear to have strong coping resources; other concurrent (non-medical) stressors are presentClinical And Treatment- significant distress, multiple risk factors, few coping strengths, and/or posttraumatic stress symptoms (PTSS)
30Prevention Model: Levels of Intervention Universal: Basic support to the widest population of ill and injured children – understand normal reactions and support their inherent competence, resilience and coping strengths. Universal interventions are helpful for most children / families.Targeted: Early identification of, and intervention with, children and families who have significant risk factors, significant distress, or whose symptoms are interfering with normal functioning and development.Clinical / Treatment: Identifying and referring children and families with severe distress, impaired functioning, or serious pre-existing issues for mental health assessment / treatment.
31Universal (Preventive) Interventions For: children and families are distressed but resilient; who have coping strengths and resourcesHelp restore a sense of safety for the child and / or family. (Remember: a hospital environment doesn’t always feel safe.)2. Consider the traumatic aspects of treatment / procedures and a child’s experience of illness or injury.
32Universal (Preventive) Interventions 3. Reduce unnecessary secondary exposures within the medical environment. (View your environment through a child’s / parent’s eyes.)4. Encourage and support child’s and family’s help-seeking behaviors. Help them access extended support networks including friends, family, school, community, religious, as well as hospital resources.5. Create a supportive environment, remembering that children will have a wide spectrum of reactions and different courses and lengths of emotional recovery.
33Targeted Interventions For: children and families with acute distress, who have additional risk factors, and/or have few coping strengths and resourcesProvide interventions and service specific to symptoms.Monitor distress levelContinue use of DEF protocol and trauma-informed careKnow when a referral is needed
34Knowing When a Referral is Needed Ask your patients (and their parents) about their ongoing reactions and coping strategies.Listen for ongoing or severe traumatic stress symptoms.Consider:Is the child participating in daily activities to the extent possible given their medical condition?Are stress reactions interfering with treatment adherence?Are new fears or worries troubling the child or parent?
35Knowing When a Referral is Needed Consider a referral for a more thorough evaluation with a mental health professional if traumatic stress reactions:are severe or prolonged (more than a month)interfere with treatment adherence / recoveryinterfere with returning to normal activitiesinhibit the parent’s ability to care for child or care for self
36Clinical (Treatment) Interventions For: children and families with significant or worsening distress, posttraumatic stress symptoms, multiple risk factors, and few/no coping strengths or resourcesConsult behavioral health specialist for assessmentRefer for further mental health treatmentEffective treatments include:Trauma-Focused Cognitive-Behavioral TherapyShort-term Parent-Child Therapy; Family Therapy
38Phases Model, cont. Phase I: Peri-Trauma Initial events, or events that are still unfolding:in the midst of emergency careduring injury eventduring diagnosis of a serious illnessFocus on reducing the traumatic aspects of this experience for children - both objective and subjectiveProvide anticipatory guidance about what to expect, what’s “normal” and helpful ways of coping
39Phases Model, cont. Phase II: Early, ongoing, evolving responses The days and weeks that follow the traumatic eventFocus on promoting adaptive coping, addressing immediate distressScreen for acute distress and risk factors to determine which children and families might need more supportPractice “watchful waiting” with those less distressedHelp strengthen coping skillsReframe unhelpful beliefsProvide referrals as needed for those significantly distressed
40Phases Model, cont.Phase III: Longer Term Posttraumatic Stress Symptoms (PTSS)Months or years after a traumatic event, illness or injuryFocus on supporting adaptive coping, detecting persistent stress reactions, and referring for further mental health treatment.Identify coping needs and promote family and community / religious support
41Key Intervention Points / Strategies along the Continuum of Care Some children and families experience traumatic stress at the time of illness or injuryOthers experience traumatic stress later during treatment, procedures, rehabilitation, or after hospital dischargeKey intervention points and intervention strategies along the continuum of care include:Pre-hospital / Emergency CareHospital Admission / Inpatient StayPain and Painful Medical ProceduresPlanning for Hospital Discharge
42Key Intervention Strategies: Pre-hospital / Emergency Care Provide simple explanations to children about what is happening, and especially about what will happen next.Minimize additional exposure to traumatic elements at the scene or during transport. When possible, try to provide simple explanations or interpretations for these exposures.Encourage parent presence (if possible), support parents in comforting their child. If parents are not available, you may need to be the support person for the child.
43Key Intervention Strategies: Pre-hospital / Emergency Care Normalize reactions and explain that when you have to come to the ER, reactions such as worry, fear, being mad, sad, or numb are common and expected.Ask about fears and worries and provide simple explanations for medical procedures.Talk with the child at his / her eye level and level of comprehension / understanding.
44Key Intervention Strategies: Hospital Admission / Inpatient Stay Orient children and families - especially to the sights, sounds, and smells of the hospital, and connect them to supportive resources in the hospital.Help children and families establish daily routines and behavioral expectations.Allow child to participate as much as possible in his / her daily care and decision-making.Recognize parents as experts on their child.
45Key Intervention Strategies: Hospital Admission / Inpatient Stay Gauge family distress and other stressors.Discuss anticipated strain on relationships within the family.Help families seek out support from extended family members, friends, community, religious organizations.Identify child and family strengths and help them build on their coping resources.
46Key Intervention Strategies: Pain / Painful Medical Procedures Acknowledge and tolerate common emotional reactions to pain - including anger.Understand acting out / isolation behavior as an effort to numb responses.Don’t trivialize or dismiss fears or worries about painful treatment.Combine pharmacologic and behavioral interventions (e.g. relaxation, distraction) for pain management.
47Key Intervention Strategies: Pain / Painful Medical Procedures Help parents accurately estimate their child’s distress.Discuss with parents ahead of time ways of managing their child’s distress during proceduresRemember that it is often most helpful for parents to provide DISTRACTION, rather than repeated statements of emotional reassurance, during a child’s painful procedure.
48Key Intervention Strategies: Planning for Hospital Discharge Support transition to home or other medical care environment by connecting family to supportive resources outside the hospital.Acknowledge common emotional reactions (fears, worries, sadness, anger) to transitions and new challenges.Anticipate challenges in returning to the home environment, including family role adjustment.
49Key Intervention Strategies: Planning for Hospital Discharge Prepare parents / families for ongoing reactions and feelings, even after treatment ends.Help families identify coping strategies and resources they will use upon returning home.Ask parents about what knowledge or skills they need to support caring for their child medically at home.
50For More Information Center for Pediatric Traumatic Stress The Children’s Hospital of PhiladelphiaGeneral website:Training website:National Child Traumatic Stress Network:Website:Pediatric Medical Traumatic Stress Toolkit (online)Website: