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Looking for Trouble in all of the Right Places… Pediatric Medical Traumatic Stress
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Ginger Depp Cline, Ph.D., ABPP
Pediatric Health Psychology Program
Assistant Professor
Psychology Service
Baylor College of Medicine – Department of Pediatrics
Texas Children’s Hospital

2. No disclosures to report aside from work affiliation

3. Objectives
Understand the Pediatric Medical Traumatic Stress Model & Pediatric Psychosocial Preventative Health Model including symptoms of posttraumatic stress
Appreciate posttraumatic stress symptoms (PTSS), risk factors, and trajectories within medical conditions (i.e., cancer, diabetes, injuries)
Understand multi-level interventions for PTSS and other implications
Ground rules
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5. Integrative Trajectory Model of Pediatric Medical Traumatic Stress (PMTS)
“Set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences” (National Child Traumatic Stress Network, 2003)
6 Assumptions
Commonalities across traumatic medical events
Range of normative reactions
Range of pre-existing psychological functioning
Developmental lens is essential
Social ecological approach is best for intervention
PMTS impacts health outcomes
Kazak, Kassam-Adams, Schneider, Zelikovsky, Alderfer, & Rourke (2006)
Price, Kassam-Adams, Alderfer, Christofferson, & Kazak (2016)
Medical illness included as possible trigger for PTSD in DSM-IV and DSM-IV-TR (leads to “intense fear, helplessness or horror” (American Psychiatric Association, 2000, p. 463))
But…continuum of symptoms versus purely psychiatric focus (posttraumatic stress symptoms)
Commonalities across traumatic medical events
Life threat
Range of normative reactions
May be adaptive initially (re-experiencing, avoidance)
Posttraumatic stress and posttraumatic growth are correlated with each other
Range of pre-existing psychological functioning
Developmental lens is essential
Social ecological approach is best for intervention
Need increased focus on cultural/ethnic differences
Diathesis-stress model of PTSD
A person’s developmental history, coping skills, available role models, social support, genetics, structural/chemical neurological differences, and aspects of the unique aspects of the trauma itself are all examples of factors that could differentially explain development of PTSD symptoms (McKeever & Huff, 2003)
Health outcomes – increased risk of reinjury, poor QoL, and poor school/social functioning
Phase 1: Peri-Trauma
Phase 2: Acute Medical Care
Phase 3: Ongoing care or discharge from care

6. Pediatric Psychosocial Preventative Health Model (PPPHM) (Kazak, 2006)
Medical Traumatic Stress Working Group
of the National Child Traumatic
Stress Network (NCTSN)
Most families are resilient; however subgroups are at-risk for negative outcomes
If could target families who may be at-risk, can focus intervention on them
Universal = understandably distressed but resilient
Targeted = experience acute distress and some risk factors
Clinical = multiple risk factors and persistent distress

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DSM-5 – PTSD –
Exposure to actual/threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Directly witnessing the traumatic event(s)
Witnessing, in person, the event(s) as it occurred to others (especially primary caregivers)
Learning that the traumatic event(s) occurred to a close family member or close friend. (occurred to a parent or caregiving figure)
Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (i.e., first responders collecting human remains, police officers repeatedly exposed to details of child abuse) – does not apply to exposure through media unless exposure is work related
Emotional reactions no longer included in Criterion A – A2 (must experience intense fear, helplessness, or horror)
4 clusters versus 3
Green = children < 6 years (more in line with Scheeringa’s alt. algorithm – higher rates of PTSD found in studies using these 2 guidelines versus DSM-IV TR – more sensitive (Gigengack, van Meijel, Alisic, & Lindauer, 2015)
Partial symptomology of PTSD, defined as meeting criteria A and B though with fewer than needed criteria C and D symptoms (Breslau, 2001b), has led to more problems in work, social, and family relationships than no symptoms, and these reported levels of difficulties were equivalent to those suffering from a full diagnosis (Breslau, 2001b).
Community lifetime prevalence = 1-14%
Increased risk for comorbid conditions (depression, anxiety, substance abuse)

8. Intrusion Symptoms
Presence of one (or more) of the following intrusion symptoms associated with the trauma that began after the trauma occurred
Recurrent, involuntary, and intrusive distressing memories of the traumatic event (in children < 6 years, repetitive play with themes of the trauma and may not appear distressing)
Recurrent distressing dreams with content/affect related to trauma (in children, may be frightening dreams without recognizable content)
Dissociative reactions (i.e, flashbacks) in which the individual feels/acts as if the event is recurring (in children, reenactment may occur in play)
Intense or prolonged psychological distress at exposure to internal/external cues that symbolize/represent an aspect of the trauma
Marked physiological reactions to internal/external cue that symbolize/represent an aspect of the trauma

9. Avoidance Symptoms
Persistent avoidance of stimuli associated with the trauma, beginning after the event, as evidenced by one or both of the following: (for children < 6 years, one or more of these symptoms)
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the trauma
Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the trauma
For children < 6 years, could also include the following:
Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion)
Markedly diminished interest or participation in significant activities, including constriction of play
Socially withdrawn behavior
Persistent reduction in expression of positive emotions

10. Negative Alterations in Cognitions/Mood
Negative alterations in cognitions and mood associated with the trauma beginning or worsening after the trauma, as evidenced by two (or more ) of the following:
Inability to remember important aspect of trauma (typically due to dissociative amnesia and not to other factors such as TBI, alcohol, or drugs)
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad, “No one can be trusted,” “the world is completely dangerous,” “my whole nervous system is ruined”)
Persistent, distorted cognitions about the cause/consequences of the trauma that lead the individual to blame himself/herself or others
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame)
Markedly diminished interest or participation in significant activities
Feelings of detachment or estrangement from others
Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings)
For children < 6 years (two or more of the following):
Irritable behavior and angry outbursts, Hypervigilance, Exaggerated startle response, Problems with concentration, and/or Sleep disturbance

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Arousal/Reactivity
Marked alterations in arousal/reactivity associated with the trauma, beginning or worsening after the trauma, as evidenced by two (or more) of the following: (not included for children < 6 years)
Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
Reckless or self-destructive behavior
Hypervigilance
Exaggerated startle response
Problems with concentration
Sleep disturbance (e.g., difficulty falling asleep, staying asleep, or restless sleep)
Duration of disturbance is more than one month (same for children < 6 years)
Disturbance causes clinically significant distress/impairment in social, occupational, or other important areas of functioning (same for children < 6 years)
Disturbance is not attributable to the physiological effects of a substance or a medical condition (same for children < 6 years)

12. Specify whether: (for children < 6 years of age also)
With dissociative symptoms:
Depersonalization
Persistent or recurrent experiences of feeling detached from, as if one were an outside observer of, one’s mental processes or body (e.g., feeling as if in dream, feeling a sense of unreality or of time moving slowly)
Derealization
Persistent or recurrent experiences of unreality of surroundings (e.g., world is experienced as unreal, dreamlike, distant, or distorted)
With delayed expression:
Full criteria not met until 6 months post trauma

13. DSM-V – The “Other” ASD - 308.3
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DSM-V – The “Other” ASD
Exposure to actual/threatened death, serious injury, or sexual violence in one (or more) of the following ways:
Directly witnessing the traumatic event(s)
Witnessing, in person, the event(s) as it occurred to others (especially primary caregivers)
Learning that the traumatic event(s) occurred to a close family member or close friend (especially if occurred to a parent or caregiving figure)
Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (i.e., first responders collecting human remains, police officers repeatedly exposed to details of child abuse) – does not apply to exposure through media unless exposure is work related
ASD added to DSM-IV in 1994 to describe early traumatic responses and possible predictors for posttraumatic stress disorder (PTSD)
Theoretical/not empirical
Difficult to assess emergently

14. Presence of nine (or more) of the following symptoms from any of the five categories of intrusion, negative mood, dissociation, avoidance, and arousal, beginning or worsening after the trauma
Intrusion symptoms
Recurrent, involuntary, and intrusive distressing memories of the traumatic event (in children < 6 years, repetitive play with themes of the trauma and may not appear distressing)
Recurrent distressing dreams with content/affect related to trauma (in children, may be frightening dreams without recognizable content)
Dissociative reactions (i.e, flashbacks) in which the individual feels/acts as if the event is recurring (in children, reenactment may occur in play)
Intense or prolonged psychological distress at exposure to internal/external cues that symbolize/represent an aspect of the trauma

15. Negative mood
Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings)
Dissociative symptoms
Altered sense of reality of one’s surroundings or oneself (e.g., seeing oneself from another’s perspective, being in a daze, time slowing)
Inability to remember important aspect of trauma (typically due to dissociative amnesia and not to other factors such as TBI, alcohol, or drugs)
Avoidance symptoms
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the trauma
Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the trauma

16. Arousal symptoms
Sleep disturbance (e.g., difficulty falling asleep, staying asleep, or restless sleep)
Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
Hypervigilance
Problems with concentration
Exaggerated startle response
Duration of disturbance is 3 days to 1 month after trauma (typically begin immediately after trauma but persistence for at least three days and up to a month)
Disturbance causes clinically significant distress/impairment in social, occupational, or other important areas of functioning
Disturbance is not attributable to the physiological effects of a substance or a medical condition and is not better explained by a brief psychotic disorder.

17. Other Specified Trauma- and Stress-Related Disorder (309.89) Examples:
Adjustment-like disorders with delayed onset (more than 3 months post stressor)
Adjustment-like disorders with prolonged duration (more than 6 months) without prolonged duration of stressor
“Ataque de nervios”
Other cultural syndromes
Persistent complex bereavement disorder
Unspecified Trauma- and Stressor-Related Disorder (309.9)
When significant symptoms and impairment but do not meet formal criteria (i.e., in emergency room settings)
 bound to certain cultures and distinct from other psychological disorders. Included among the syndromes are ataques de nervios (ADN), which are reported to be bound to the Hispanic culture and closely resemble panic attacks. Ataques de nervios: culturally bound and distinct from panic attacks?
In ataque de nervios, anxiety and fear are considered normal and healthy responses to the occurrence of the syndrome.

18. Post-traumatic Stress Symptoms & Disorder (PTSS/D)
Younger children
Differential symptom presentation
Medical populations
Intrusion symptoms in medical patients may be future oriented
Hyperarousal = preoccupation and alertness to physical symptoms
Mintzer, Stuber, Seacord, Castaneda, Mesrkhani, & Glover (2005)
Shemesh et al. (2000)
Shemesh et al. (2005)
Daviss , Coon, Whitehead, Ryan, Burkley, & McMahon (1995)
Gold, Kant, & Kim (2008)
(e.g., relapse, treatment) (i.e., return of illness?)
May experience more avoidance symptoms and intrusions than re-experiencing and arousal
Repetitive play
Difficulty concentrating, increased arousal (difficulty sleeping), irritability, enuresis
Disorganized/agitated behavior
Recurrent/distressing thoughts
Nightmares
Sleep disturbance
Difficulty concentrating
Particular patterns in families with illness
diminished interest in activities, feeling of detachment, and shortened future versus amnesia
Few reports of startle response or physiological reactivity, but many report hypervigilance, sleep disturbance, and concentration difficulties

19. Assessment of Traumatic Stress
Important to assess parent and child symptoms of ASD/PTSD separately
Poor agreement (especially for adolescents)
Difficulty assessing symptoms in younger children
May not report symptoms due to avoidance
Comorbidities
Landolt, Vollrath, Ribi, Gnehm, & Sennhauser (2003)
Kassam-Adams, Garcia-España, Miller, & Winston (2006)
Meiser-Stedman, Smith, Glucksman, Yule, & Dalgleish (2007)
Gerson & Rappaport (2013)
McGarvey, Canterbury, & Cohen (1998)
Hiller, Halligan, Ariyanayagam, Dalgleish, Smith, Yule, et al. (2016)
-own symptoms may influence rating of other person’s symptoms; more internal symptoms (hard to observe); may underrate due to guilt, avoidance, etc.
relational PTSD (Scheeringa & Zeanah, 2001) – symptoms of child/parent mutually influence each other
Children’s symptoms have been found to correlate significantly with “best estimate” procedure (clinician and records review) (Q)
Kassam-Adams, Garcia-Espana, Miller, & Winston (2006)
Parents who rated more symptoms in themselves also rated more symptoms in their child and vice versa
Comordibities (Depression, substance abuse – 59%) – self-medication
Parental symptoms – child’s dev. Of PTSD but also relation to parenting differences (more environmental influences)

20. American Academy of Pediatrics – “The reduction of toxic stress in young children out to be a high priority for medicine as a whole and for pediatrics in particular.” (Garner, Shonkoff, Siegel et al, 2012) What are possible effects of posttraumatic stress symptoms (PTSS)?
Why do we care?
American Academy of Pediatrics – “The reduction of toxic stress in young children out to be a high priority for medicine as a whole and for pediatrics in particular.” (Garner, Shonkoff, Siegel et al, 2012)
C & J
Behavioral/motivation
Avoidance/denial
Neurochemical effects
Nonadherence as major cause of organ failure/loss (TRANSPLANT)
Possibility of treating PTSD symptoms to improve adherence
More phone calls and visits for reassurances (arousal)

21. Effects of Posttraumatic Stress Symptoms (PTSS)
Decreased adherence
Increased use of medical resources
Decreased quality of life
Trauma Recovery Project in Adolescents
(Holbrook, Hoyt, Coimbra, Potenza, Sise, & Anderson (2005)
Behavioral problems associated with PTSD symptoms (e.g., alcohol/drugs, difficulty staying in school, social relationship problems, thoughts of suicide, depression, and loss of interest)
Significantly lower Q of L in adolescents with long-term PTSD
Stuber et al. (2003)
Kean, Kelsay, Wamboldt, Wamboldt (2006)
American Academy of Pediatrics – “The reduction of toxic stress in young children out to be a high priority for medicine as a whole and for pediatrics in particular.” (Garner, Shonkoff, Siegel et al, 2012)
C & J
Behavioral/motivation
Avoidance/denial
Neurochemical effects
Nonadherence as major cause of organ failure/loss (TRANSPLANT)
Possibility of treating PTSD symptoms to improve adherence
More phone calls and visits for reassurances (arousal)

22. What are possible risk factors for PTSS? Think - Pair - Share

23. What’s Associated With PTSS?
Worse severity of illness & subjective appraisal of life threat
Abruptness of onset
Decreased social support
More premorbid stressors/traumas
Acute stress response
Emotional distress and/or dissociation
Initial physiological responses/symptoms
C & O
Life threat may depend on child’s age/developmental level
Indirect relationship between child’s pain and parents’ acute stress response (T)
Heart rate (during transport and first 20 minutes of hospitalization) (PTSD 6 weeks later)
Parents’ role in cueing danger to child and in supporting coping
If more anxious, may cue more danger and be less “able” to decrease child’s distress
Little research attention on age, gender, ethnicity, or cognitive functioning related to risk for ASD/PTSD in illness/injured population (X) (toolkit)
Impact of parental symptoms on children
Overprotection and/or hypervigilance of health; avoidance (I)
May see more correspondence between young children and parent’s symptoms (rely more on adults to interpret events in environment)
Pain – early (1st 7 days) opiate management reduces later PTSS (burn population) – lasts up to 4 years
Attention to hypervigilance and threat seeking
Stuber et al. (2003), Gold et al. (2008), Silver, Westbrook, & Stein (1998), Sheridan, Stoddard, Kazis, Lee, Li, Kagan, et al. (2014) Hildenbrand, Marsac, Daly, Chute, and Kassam-Adams (2016)

24. What’s Associated With PTSS? Cont…
Pain
Stimulates release of hormones that enhance fear conditioning/overconsolidation of memories
Opiate use and reduced PTSS (lessens adrenergic activation)
Mutual maintenance theory (Sharp and Harvey, 2001)
Pain and PTSD perpetuate each other through anxiety sensitivity, avoidance, and attentional biases
Parental distress/symptoms
Functional limitations
Stuber et al. (2003), Gold et al. (2008), Silver, Westbrook, & Stein (1998), Sheridan, Stoddard, Kazis, Lee, Li, Kagan, et al. (2014) Hildenbrand, Marsac, Daly, Chute, and Kassam-Adams (2016)

25. Course of Symptoms
Almost all experience anxiety, insomnia, numbing, dissociation, detachment, re-experiencing, and avoidance in first 4 weeks (Gerson & Rappaport, 2013)
Some evidence for linkage to later PTSD severity, as with adults
But need more studies
Dissociation did not add to prediction in this study!
Chronic trajectory = high levels of initial symptoms, preinjury behavioral problems, and serious injuries (burns, multiple internal injuries)
Price et al. (2016)

26. Specific Medical Conditions/ Experiences
Video clip? A Lion in the House
Ambiguous – general psychological distress – sets stage for PTSS
Some interventions focus on reducing parent’s illness uncertainty (managing ambiguity) (Tackett et al., 2016)
Also some studies for burns, asthma, awareness under anesthesia, PICU, NICU, etc.
Weak research related to ethnicity/culture; most studies have predominance of Caucasian participants!!

27. Cancer Multiple stressors
Distress peaks in first few months following diagnosis; stabilizes by 1 year
Patiño-Fernández, Pai, Alderfer, Hwang, Reilly, & Kazak (2008)
51% of mothers met criteria for ASD during first 2 weeks following diagnosis
40% of fathers met criteria during first 2 weeks following diagnosis
Kazak, Alderfer, Rourke, Simms, Streisand, & Grossman (2004)
150 cancer survivors (11-19 years old) & parents who were 1-10 years post-treatment
13.7% of mothers & 9.6% of fathers qualified for PTSD (SCID)
4.7% currently for survivors (SCID)
Higher rates of traumatic stress in parents of children with cancer (44%) than in adult patients (5-10%) I
Diagnosis, Death of other children, ICU admissions, Treatment, Relapse threat
Parents as “witnesses” and “perpetrators” (p. 196)
Parents often play active role in treatment (holding, making decisions, etc.)
Increased care burden for mothers?
Symptoms may not appear until adolescence or young adulthood Stuber et al. (2003)
Developmental differences in understanding parent’s role
Older patients
Life-threat most stressful experience
Younger patients
Procedures
Symptoms less appreciated due to limited communication abilities
Autobiographical memory from 18 months forward (higher risk) Graf, Bergstraesser, & Landolt (2012)
Kazak et al. (2003)
Landolt et al. (2003)
Kangas, Henry, & Bryant (2007)
Kangas, Henry, & Bryant (2005a)
Kazak, Alderfer, Barakat, Streisand, Simms, Rourke, et al. (2004)

28. Graf, Bergstraesser, & Landolt (2012)
Peak incidence in cancer in first 4 years of life, but limited research on PTSS within this age group
Of 48 children (8-48 months of age),
9 (18.8%) met full criteria based on alternative algorithm (0% met original criteria)
41.7% met partial criteria
Related to age, treatment impact on functioning, maternal PTSD severity, shorter time since diagnosis/treatment, and more medical complications
Symptoms less appreciated due to limited communication abilities
Autobiographical memory from 18 months forward (higher risk)

29. Stuber, Nader, Houskamp, & Pynoos (1996)
Interviewed 30 youth during first week of BMT treatment
3-18 years old; UCLA Medical Center
Most being treated for leukemia
Results:
27% reported mild PTSS
Older patients
Life-threat most stressful experience
Younger patients
Procedures
Taskiran, G., Adanir, A.S., & Ozatalay, E. (2016)
1.2 +/– 1 year later - More symptoms of trauma for BMT patients and mothers than controls
48% had mild symptoms; 18.5% Clinically significant
57.6% of mothers met full or partial criteria
Few met criterion C (avoidance)
Acute Stress really
Life threat severity positively correlated with age

30. What about Siblings?
Changing family roles/responsibilities; caregiver?
Patient, sibling, and parents’ distress
Witnessing treatments
More separation from family & support
113 siblings of patients with cancer
Results:
56.8% believed treatment was scary
27% believed their sibling would die during treatment; 16% still believed it would happen
49.3% had mild PTSS; 32.0% had moderate-severe PTSS as measured by PTSD-RI
Alderfer, Labay, & Kazak (2003) W
88% White
Female and older siblings endorsed more symptoms on the IES-R
More symptoms than patients due to less access to social support?

31. Screening Psychosocial Assessment Tool (PAT2.0) Kazak (2006)
132 female and 72 male caregivers for children with newly diagnosed cancer
55% fell in universal group
32% in targeted group
13% in clinical group
ASDS scores significantly lower for mothers in universal versus targeted and clinical groups
Those in targeted group scored significantly lower than in clinical group
Strong psychometrics reported
Pai et al. (2008) )
PASS AROUND….
Takes 10 minutes; self-report; Score of 1 = family may need increased psychosocial services
78% caucasian
Reliability = .81
Maternal total score of 1 or higher & ASDS
Sensitivity = .75
Specificity = .74
Maternal total score of 1 or higher & BASC-2
Sensitivity = 1.0 (above “at-risk” cut-off)
Specificity = .60 (below “at-risk” cut-off)

32. Cancer - Summary Acute stress symptoms common following diagnosis
Parents experience more symptoms than adult and child patients
Siblings affected by PTSS
Initial distress, anxiety, perceived social support, and perceived threat significant predictor
Screening program has been successful in identifying who may be at-risk

33. Diabetes

34. Diabetes
Type 1 Diabetes (T1DM) as one of the most common chronic illnesses in children
Life style changes at diagnosis
Similarity with other medical conditions with PTSD outcomes
Process of many stressors
Immediacy and life threat
Hospitalization, ill
Associated morbidity
Parents have to observe and then actively participate in painful treatment
Stress may be related to metabolic control
Decreases organization and subsequent adherence
Increased stress increased stress hormones increased blood sugar values
Lowes, Gregory, & Lyne (2005)
Horsch, McManus, Kennedy, & Edge (2007)
Insulin injections, BS monitoring, diet changes, & exercise
HbA1C as measure of metabolic control
May have temporary good control due to residual insulin production after diagnosis
Recommended cut-off = 8%
Most studies focus on parents

35. Landolt, Ribi, Laimbacher, Vollrath, Gnehm, & Sennhauser (2002)
38 youth with T1DM; Switzerland
6 weeks after diagnosis, 24% of mothers and 22% of fathers met PTSD criteria (Posttraumatic Diagnostic Scale)
51.4% of mothers and 41.7% of fathers met subclinical PTSD
Not associated with:
Age/gender of child, SES, Family structure, or Length of hospital stay
Similar to parents of children with cancer and burns
No difference between moms and dads (parental role overshadowing gender effects?)

36. Landolt, Vollrath, Laimbacher, Gnehm, & Sennhauser (2005)
Horsch et al. (2007)
64 mothers of children < 16 years with T1DM for at least 1 month (up to 5 years)
Results:
PTSD
10% met full criteria + 15% with partial symptoms
65% rated receiving diagnosis as most stressful
2nd most stressful event = ongoing threat of hypoglycemic event
Landolt, Vollrath, Laimbacher, Gnehm, & Sennhauser (2005)
Poor glycemic control at 6 & 12 months associated with parental PTSD
33% had psychological problems in the past (31.7% received treatment)
16.7% clinically significant depressive symptoms
43.3% clinically significant anxiety symptoms
73.3% experienced stressful event prior to diagnosis
In another study, every mother who experienced hypoglycemic event met criteria (at 6 weeks) -Landolt, Vollrath, Laimbacher, Gnehm, & Sennhauser (2005)

37. Şişmanlar, Ş. G. , Demirbaş-Ḉakir, E. , Karakaya, I. , Ḉizmeciouğlu, F
Şişmanlar, Ş.G., Demirbaş-Ḉakir, E., Karakaya, I., Ḉizmeciouğlu, F., Hatun, S., & Ağaoğlu, B. (2012)
One of first studies looking at PTSS in youth with diabetes (as opposed to parents)
54 youth with diabetes (8-18 years); multiple regression with 42 of these
18.5% reported severe or very severe PTSS; 51.9% at moderate level
Only related to # of hypoglycemic events in the past month
Not related to age, gender, SES, traumatic life events, family status, family history of chronic illness, severity of attack/DKA

38. Diabetes - Summary
Traumatic stress has been found in families with newly diagnosed T1DM
Distress does not decrease over time as much as with cancer; similar rates at 1 year post-diagnosis
Parental symptoms have been associated with poor metabolic control
Boman, Viksten, Kogner, & Samuelsson (2004)

39. Injury
“Pediatric unintentional physical injuries continue to be the leading cause of morbidity and mortality in children aged > 1 year in the United States” (Gold, Kant, & Kim, 2008, p. 81)
As many as one fourth of all children experience serious injuries (Caffo & Belaise, 2003)
Relation with less family supervision (less cohesion and more stress)?

40. Special Features of Acute Injury
Often a high threat of actual injury/death and increased uncertainty and disorganization (Lewandowski & Baranoski, 1994)
Sudden shift in control
There may also be a lack of familiarity with the health care workers and procedures with emergent care (Lizasoain & Polaino, 1995; Axelrod, 1976)
PTSD rates among injured children range from 13-45%
Treatment as possible trauma (ambulance, unfamiliar caregivers)

41. Landolt, Ystrom, Sennhauser, Gnehm, & Vollrath (2011)
12 years of age and older
New diagnosis of cancer/Type I diabetes or unintentional injury (excluding TBI)
T1 = 5-6 weeks later; T2 = one year post admission
Results:
At T1,11.1% and T2 10.2% with scores in clinical range
Children with injuries and cancer had significantly more PTSS than children with T1DM
Children with injuries had highest rate at both times
Nonsignificant change in rate for children over time; parents’ rates decreased significantly (mothers & fathers)
Risk for chronic concern

42. Post-Traumatic Stress Disorder (PTSD) in Children Following Moderate-Severe Injuries
32/55 children ages seven to thirteen years of age and a parent following a moderate- severe, unintentional injury requiring emergency medical care/hospitalization:
injury severity score (ISS) of eight or higher,
spoke/understood English,
did not have a history of mental retardation,
had a Glasgow Coma Score (GCS) of greater than nine if head injury,
and had a mailing address and phone contact availability
Assessment during hospitalization
Screening Tool for Early Predictors of PTSD (STEPP)
Pain (child)
ASC-Kids (child)
Kidcope (child)
Brief Symptom Inventory -18 (parents)
Follow-up assessment at least 4 weeks later via telephone
Child CPTSD-I over the telephone (child)
Cline, Wilson, & Prout (2011). Journal of
Trauma Nursing, 18,
(58% response rate of those able to contact)
The GCS ranges from a score of three to fifteen, with three being the worst. It is based on the patient’s best eye, verbal, and motor response to stimuli. Typically, a coma score of eight or less signals a severe brain injury (Centers for Disease Control and Prevention, n.d.).
Nonparticipation rate (possible there were more that I didn’t receive)
23 Not interested (Child said no, in too much pain (jaw break), parent said child fine, parent too tired, want child to forget what happened, parental death, leaving, think child would be too upset to talk, too much going on (upcoming surgery), another child to deal with (too much) (42% of those able to contact)
Didn’t qualify (MR, Spanish speaking)
2 Already discharged
Couldn’t recruit within 5 days of injury
Maternity leave
Gender
Males = 23 participants
Females = 9 participants
Ethnicity
White = 29 participants
Nonwhite = 2 participants
No answer = 1 participant
Income
$0-20,999 = 6 participants
$21,000-39,999 = 11 participants
$40,000 – 59,999 = 5 participants
$60,000 – 79,999 = 5 participants
$80,000 – 99,999 = 2 participants
$100,000 + = 2 participants
Procedures = x-rays, CT scans, blood work, IV, ultrasound, surgery, foley, MRI, traction, C-collar/backboard, NG tube, chest tube, etc.

43. Modes of Injury Penetrating injuries (3) Falls (9) Sports (1)
Horse (1)
Skateboards (2)
Bikes & wagon (2)
Motorized bikes/ATV (11)
MVA (3)

44. PTSD Outcomes Among Study Participants
10 with full PTSD (31.3%)
4 with partial PTSD (12.5%) Partial =
2 no follow-up (6.3%)
16 no sig. PTSD (50%)
Partial symptomology = criteria A and B though with fewer than needed criteria C and D symptoms (Breslau, 2001b),
51.6% not enough symptoms to qualify for partial or full PTSD (11 w/ 7 or fewer symptoms; 5 with 5 or fewer symptoms; least number reported = 2 (1 person with 2 and 1 person with 3 symptoms reported)

45. Table 1 Participant Descriptives (Means, Standard deviations)
Variables
PTSD (N=10)
No PTSD (N=20)
Age
9.00 (SD = 1.70)
11.37 (SD = 1.46)
Pain
2.90 (SD = 1.52)
1.90 (SD = 1.33)
Initial Parental Distress
22.90 (SD = 14.39)
14.50 (SD =10.94)
# of injuries
2.20 (SD = 1.69)
2.21 (SD = 1.08)
Days admitted
5.10 (SD = 6.06)
4.00 (SD = 1.56)
ISS
9.40 (SD = 1.26)
9.84 (SD = 2.57)

46. Significant correlations:
Age at the time of injury (-.52***)
Female gender (.37*)
Meeting criteria for acute stress disorder (with or without dissociation) (.38*)
Trends:
Prior medical experience (-.31****)
Immediate parental distress (.32****)
Child’s initial pain rating (.33****)
*p<.05, **p<.01, ***p<.003, ****p<.10 (trend)

47. So, consider screening with inclusion of:
All variables with at least a trend towards significance (i.e., initial pain rating, initial parental distress, and prior medical experience, age, gender, and acute stress disorder)
χ² (6, N=30) = 22.08, p=.001, Nagelkerke R² = .72
Sensitivity (.80), specificity (.90), and overall accuracy of 87%
So, consider screening with inclusion of:
Age
Gender
Acute stress symptoms
Initial pain rating
Initial parental distress (BSI-18)

48. TBI and PTSD – Iselin, Le Brocque, Kenardy, Anderson, & McKinlay (2010)
Overlap of symptoms
Sleep disturbance, irritability, difficulty concentrating, memory loss
Recommend to use PTSD-AA method for assessing PTSD if TBI is present (Schreeringa et al. 2006)
Excludes the dissociative criteria (C3); subthreshold symptoms
Better at predicting psychosocial functioning

49. Screening
7% of physicians in ED believed children were at-risk for PTSS
86% believed severity of injury was strongly associated with risk
Only 18% provide any verbal information about PTSS and only 3% provide written information
Only 14% felt confident educating about PTSS
16.3% for what behaviors would indicate the need for mental health follow-up
20.8% for how to access MH care
Trauma informed care is not routinely included in medical training
Only 20% of Level I Trauma centers screen for PTSS
Ziegler, Greenwald, DeGuzman, & Simon (2005), Alisic et al (2016), Kassam-Adams, Rzucidlo, Campbell, Good, Bonifacio, Slouf, Schneider, et al. (2015), & Marsac, Kassam-Adams, Hildenbrand, Nicholls, Winston, Leff, & Fein (2016)

50. Winston, Kassam-Adams, Garcia-Espana, Ittenbach, & Cnaan (2003)
Screening
Winston, Kassam-Adams, Garcia-Espana, Ittenbach, & Cnaan (2003)
Patients 8-17 years admitted after traffic injury at large, urban Pediatric Trauma I center
The Screening Tool for Early Predictors of PTSD (STEPP)
12 item screener; children 8-17; originally developed for injured children
(Nancy Kassam-Adams, Ph.D.)
Results:
16% (n=25) of children and 15% (n=25) of parents classified as positive for persistent traumatic stress on Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA)
Sensitivity = .88 for children and .96 for parents D
Need more tools to identify children/adolescents and families who may be at-risk
Empirically supported triage
Only in English for this study; recent work on translating STEPP into Spanish and piloting
High sensitivity

51. Positive Child Screen ≥ 4 Positive Parent Screen ≥ 3
Screening Tool for Early Predictors of PTSD (STEPP)
Ask Parent:
Yes No
Did you see the incident (accident) in which your child got hurt? 1
Were you with your child in an ambulance or helicopter on the way to the hospital?
When your child was hurt (or when you first heard it had happened), did you feel really helpless, like you wanted to make it stop happening, but you couldn’t?
Does your child have any behavior problems or problems paying attention?
Ask Child:
Was anyone else hurt or killed (when you got hurt)?
Was there a time when you didn’t know where your parents were?
When you got hurt, or right afterwards, did you feel really afraid?
When you got hurt, or right afterwards, did you think you might die?
Record From Medical Record (Do Not Ask child or Parent):
Suspected extremity fracture?
Was pulse rate at emergency department triage >104/min if child is under 12years or >97/min if child is 12 years or older?
Is child 12 years or older?
Is this a girl?
Add Total for Each Column:
Winston et al. (2003)
The Children’s Hospital of Philadelphia
Positive Child Screen ≥ 4
Positive Parent Screen ≥ 3

52. Injuries - Summary
ASD and PTSD/PTSS reported in children/adolescents and parents following injuries
Worse severity scores for children/adolescents versus parents
The STEPP has been useful for patients with MVAs
Requires further investigation
Additional factors may be useful in screening measures
age, acute stress symptoms, and pain
Recent research has also demonstrated presence of PTSS in parents of children in PICU and general hospital floor (Franck, Wray, Gay, Dearmun, Lee, & Cooper, 2014)
related to single parent status
related to parental symptoms (need more information and engagement with planning tx)

53. But….Posttraumatic Growth What is this? -1 minute paper-
Posttraumatic Growth Inventory
Kids’ schemas less stable – easier to change?
Less growth with more resiliency
Growth only occurs if trauma evaluated to be very upsetting and driving meaning making
Associated with female, younger age, and married status
Associated with severity of event, amount of distress caused, and enduring time since event

54. But….Posttraumatic Growth
Tedeschi & Calhoun (1995, 2004)
“positive psychological change experienced as a result of struggle with highly challenging life circumstances” (Wang, Wang, Wang, Wu, & Liu, 2013)
5 domains for benefit after trauma:
Greater appreciation for life
Improved relationships
Increased personal strength
Awareness of new life possibilities
Spiritual growth
Growth versus resiliency (less likely to perceive threat to self or world views)
Picoraro, Womer, Kazak, & Feudtner (2014)
Levine, Laufer, Stein, Hamama-Raz, & Solomon (2009)
Traumas often destabilize world view…can rebuild schemas
Sense making & benefit finding
Posttraumatic Growth Inventory
Kids’ schemas less stable – easier to change?
Less growth with more resiliency
Growth only occurs if trauma evaluated to be very upsetting and driving meaning making
Associated with female, younger age, and married status
Associated with severity of event, amount of distress caused, and enduring time since event

55. Intervention Medical professionals
Educate medical teams and primary care physicians about traumatic stress responses & optimal methods for communicating with families
Preparing families for procedures and course of illness
Self-care
Families
At diagnosis
During procedures/treatment
At discharge
Upon symptom recurrence

56. Prevention Model Indicated/Treatment
Who? Families with multiple risk factors, severe distress,
and/or long-lasting distress
Referral for psychosocial support
More complete assessment of concerns/needs
Focused intervention
Selective/Targeted
Who? Families with identified risk factors or those
in distress
Increased anticipatory guidance
Monitor distress
Selected/Targeted
People in same family can respond differently
Remain sensitive to child’s needs & maintain normalcy (friends, activities)
Follow child’s lead & be available
Monitor parents’ own reactions
Universal
Who? All families
Psychoeducation regarding common reactions
Provide literature/resources for families
to review
Enact trauma-informed care

57. A Resource: Pediatric Medical Traumatic Stress Toolkit For after the “A-B-Cs” – The “D-E-F” Protocol
Reduce Distress
Promote Emotional support
Remember the Family
Risk factors in peri-trauma period for iatrogenic trauma
Airway, breathing, circulation
Role of pediatric psychologists – provide education and consultation support for trauma informed medical practice
To raise awareness and to increase “trauma-informed” practice in clinics/hospitals
May help providers reduce possible iatrogenic trauma
Increase identification of families in need
Lead to psychoeducation for parents regarding traumatic stress
Medical Traumatic Stress Working Group
of the National Child Traumatic Stress Network (NCTSN)

58. Distress Assess and treat pain
Give information about treatment and procedures
Listen for child’s/family’s understanding
Clarify misconceptions
Normalize and ask about fears
Provide reassurance and offer hope
Consider grief/loss
Medical Traumatic Stress Working Group
of the National Child Traumatic
Stress Network (NCTSN)
Child life
Children receiving higher doses of morphine had most reduction of PTSD symptoms at 6 months
May alleviate physiological arousal
Ratcliff et al. (2006)
25% decrease in ASD diagnoses at Shriners Hospitals for Children after implementation of pain protocol in 1992
Make environment more familiar
Simplify language; repeat
Sometimes kids get nervous when they get a new diagnosis. Is there anything that is worrying you?
Behavioral observation key for young children (agitation, uncontrolled crying, withdrawn, oppositional/aggressive behavior, marked startle response, changes in dev. milestones)
Was anyone else hurt/sick? Other recent losses?
Remember developmental differences in understanding illness/injury/treatments/permanence of death (punishment, Drs as mean) - consult

59. Emotional Support Encourage parents to stay and to talk with child
What helps your child cope?
What has been the thing that helped you the most so far?
Help parents “help” child
Understanding the illness/injury & treatment
How to comfort/support child
Rely on external supports (“who do you usually rely on for help?”)
Encourage typical routines and age typical activities (incorporating peers)
Medical Traumatic Stress Working Group of the National
Child Traumatic Stress Network (NCTSN)
Marsac, Donlon, Hildenbrand, Winston, & Kassam-Adams (2014)
Give handouts
Parents as experts on their child
Importance of parents being with younger children especially (coping resource) – even during invasive procedures
Hospital Emotional Support Form (Glenn Saxe, Ph.D.)
Emphasis on peer support as well (as protective) - return to routines and distraction (and emotional processing) Marsac, Donlon, Hildenbrand, Winston, & Kassam-Adams (2014)

60. Helping Parents “Help”
Be honest
Focus child’s attention away from procedure
Encourage parents to distract the whole time in procedure room (before and after procedure too)
Requires active attention/participation
Avoid non-distracting behaviors (reassurances, apologizing)
Encourage positive self-talk (mantra)
“I can handle this”
“It will be over soon”
“I’m strong”
Praise child after procedure
Blowing bubbles/pinwheel, breathing, electronic handheld game, pop-up book, interactive book (I Spy), imagery and story-telling, physical touch (blanket, stuffed animal, parent)
Multisensory and age appropriate (allow child choice); Point, ask questions, give directions (Exaggerate)
Parents taught to coach child & child received sticker after procedure
If reassuring, directing child’s attention to shot
Bauchner, Vinci, Bak, Pearson, & Corwin (1996)
Trend towards increased satisfaction if present and given instructions for how to help
Parents who were not present were more anxious (p=.025)
Zelikovsky, Rodrigue, Gidycz, & Davis (2000)
Breathing exercises and relaxation were taught to child and family; tape with prompts played throughout procedure
Intervention group evidenced less distress and more coping behaviors than control group
Spirito & Kazak (2006)
Dahlquist (1999)

61. Family Evaluate distress at family level/resource needs
Encourage self-care
Identify family strengths and coping resources
Encourage parents to use successful coping strategies and hospital/clinic resources
Chaplain, child life, psychology, etc.
Include family in information sharing and planning as much as possible
Medical Traumatic Stress Working Group
of the National Child Traumatic
Stress Network (NCTSN)
Franck, Wray, Gay, Dearmun, Lee, & Cooper (2014)
Who is having an especially hard time?
Are there other family stressors currently?
What has worked for you in the past?
Reduces parental uncertainty (risk factor)

62. Medical Professionals – Self-Care
Secondary Traumatic Stress (STS): The stress resulting from helping or wanting to help a traumatized or suffering person
The presence of (PTSD) symptoms in caregivers, which are presumably related to experiences of the patients rather than those of the caregivers
Cognitive shifts and relational disturbances may occur
Occurs quickly and unexpectedly
“Self-care is an ethical imperative. We have an obligation to our clients - as well as to ourselves, our colleagues, and our loved ones - not to be damaged by the work we do.”
Compassion Fatigue
Not included in current DSM-IV-TR; has been proposed to be considered for DMS-V (Kanno 2010)
Exposure to their trauma
Elwood, Mott, Lohr, & Galovski (2011)
Saakvitne and Pearlman (1996)

63. Assessment of Secondary Traumatic Stress
Professional Quality of Life Scale/Compassion Fatigue Self Test for Helpers (CFST)
Compassion Satisfaction
Burnout
Trauma/Compassion Fatigue Scale

65. STS Interventions: Personal
Engage in appropriate self-care practices
Self-reflection and self-monitoring:
How do you feel after exposure to a traumatic event?
Follow basic health principles
Rest, activity, nutrition, routines, relationships
Identify “healing” activities
Strike an appropriate work-life balance

66. STS Interventions: Personal
Develop self-awareness skills
Identify personal “triggers”
Identify and make sense of “disrupted schemas”
Example: “Nothing I do matters anyway.” Belief in a just and safe world for good people.
Engage in personal psychological intervention where needed

67. STS Interventions: Professional
Undertake regular professional supervision or consultation
Maintain professional networks
Have a realistic tolerance for failure
Be aware of work and personal goals
Including the ways that they may differ from and/or influence one another

68. STS Interventions: Organizational
Develop a workplace environment that recognizes the potential for stress related to caring for sick/injured/maltreated children
Ensure a culture of support and respect
Attend to the concept of secondary traumatic stress in training activities
Note: There is not consistent evidence to support the use of debriefing to reduce later trauma symptoms among staff (or victims).
Those with highest stress were less aware of risk for STS (Meadors & Lawson, 2008)
TANDEM
Debriefing not having any benefit over control

70. Formal Psychological Intervention for Families
Limited research for effectiveness of psychopharm interventions – no evidence to be first-line intervention (only used cautiously and only if TF-CBT wouldn’t be a fit) (pediatrics)
(Morina, Koerssen, & Pollet, 2016)
Need for screenings to identify those patients most in need of intervention
Handout!!! (Stages of Illness/Injury & Recommendations)

71. Medical Crisis Counseling Model (Pollin, 1994,1995)
Normalize emotional distress
Help identify concrete actions to help with coping; identify coping strengths
Target trauma interpretations, reduce avoidance, and increase social support
Also addresses:
Loss of control, self-image, dependency, stigma, abandonment, fear of expressing anger, isolation, and fears of death
Williams & Koocher (1999)
Koocher & Pollin (1994)
Kassam-Adams (2014)
Originally focused on chronic illness
Not psychopathology; expected response to extreme stress
Traumatic injuries, painful medical procedures, new diagnosis, withdrawal of life support, disagreements about tx, unrealistic parental expectations
Significant time normalizing emotions and listening to concerns
Teach positive self-talk and relaxation skills

72. TCH & Injury Psychosocial Follow-up Clinic
Collaboration among the Trauma Service (i.e., administration, physicians, nurses), the Pediatric Health Psychology Program within the Psychology Service, and Social Work
Consultation with Trauma Service professionals/staff regarding injury and psychosocial risks
Team meetings & training/education for nurses conducting screenings
Written information regarding typical reactions, how to help child, and warning signs given during hospitalization (include info. about Injury Follow-up Clinic)
Screening for risk for traumatic stress
Referral to Psychology Service (medical team or self/family)
Assessment for traumatic stress and other mental health concerns (coping)
Referral for services - Trauma-focused CBT modified for children with injuries

73. Portions from the Screening Tool for Early Predictors of PTSD (STEPP)
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Portions from the Screening Tool for Early Predictors of PTSD (STEPP)
Winston et al. (2003). Screening for risk of persistent posttraumatic stress in injured children and their parents. JAMA, 290 (5): 643:649.
Ask parent:
YES NO
Does your child have any behavior problems or problems paying attention? 1
Ask child:
Was anyone else hurt or killed (when you got hurt)?
Was there a time when you didn’t know where your parents were?
When you got hurt, or right afterwards, did you feel really afraid?
When you got hurt, or right afterwards, did you think you might die?
Record from medical record (DO NOT ASK CHILD OR PARENT)
Suspected extremity fracture?
Was pulse rate at ED triage:
>104 if child is under 12?
>97 if child is 12 or older?
Is this a girl?
ADD TOTAL
Positive screen = ≥ 4
Screen is: POSITIVE NEGATIVE
(Please page social work)
*If positive, please page social work
©Children’s Hospital of Philadelphia, 2002

74. Flow Chart If screen positive, consultation with Social Work
Normalization & psychoeducation
Anticipatory guidance
Provide pamphlet about Psychosocial Injury Follow-up possibilities (Trauma Focused Cognitive-Behavioral Therapy)
Refer to Psychology if immediate coping support needs (diagnostic interview, etc.)
If screen negative, given pamphlet about PHPP outpatient program if problems arise in the future
Rule-outs:
Substance abuse
Suicidality
Intentional violence
Abuse
Forensic question
Refer to community mental health and/or psychiatry (suicidality)

75. Signs posted in patient rooms (English and Spanish)
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Signs posted in patient rooms (English and Spanish)

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14 year old, Latina female
Intentional gunshot wounds; Spinal cord injury
Family deaths
Support for family in talking about what happened with her
Coping support (multiple visits per week for several weeks)

78. 16 year old, Latina female MVA accident with multiple deaths
Significant orthopedic and internal injuries
Pain
Coping/pain management strategies
Fear of ambulances/tractor trailers
Coping skills
Trauma narrative
Exposure work
Communication about deaths/grief support
Multiple visits per week
Pain – deep breathing, passive relaxation, distraction, and guided imagery
With trainee

79. 13 year old, Latino male Dog attack Concerns with adjustment
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13 year old, Latino male
Dog attack
Concerns with adjustment
Followed triage formula
Screened positive
Seen by social work for support
Inpatient Psychology support not necessary

80. Inclusion of Discharge Directions
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Inclusion of Discharge Directions
EXAMPLE 1: Standard paragraph for any patient treated for injury
 Emotional or psychological consequences of injury are important but often overlooked. You may want to check in with this family at your next visit to see how they are doing. Parents can visit for additional information and resources. In addition, the family may seek an evaluation through the Pediatric Health Psychology Program at Texas Children’s Hospital to determine if goal-directed therapy may be warranted (Trauma-Focused Cognitive-Behavioral Therapy; ).
EXAMPLE 2: Child is thought to be at some additional risk for traumatic stress
 Emotional or psychological consequences of injury are important but often overlooked. Based on a brief screening assessment during this admission, our team provided extra psychosocial support for this child and family. You may want to check in with this family at your next visit to see how they are doing, and encourage the parents to visit for additional information and resources. In addition, the family may seek an evaluation through the Pediatric Health Psychology Program at Texas Children’s Hospital to determine if goal-directed therapy may be warranted (Trauma-Focused Cognitive-Behavioral Therapy; ).
Alter for other medical conditions as appropriate

81. Outpatient Screening Measures:
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Outpatient Screening
Measures:
CHILD TRAUMA SCREENING QUESTIONNAIRE (CTSQ)
YOUNG CHILD PTSD SCREEN (YCPS)
ed by Trauma Service 4 weeks post-discharge (Redcap program)
If positive, referred to Pediatric Health Psychology Program for evaluation
Option for later clinical research (links between risk factor screening, symptoms, and potentially diagnosis if complete evaluation).
See handout
English and Spanish
2 providers and trainees (one bilingual – ages 3-6)

82. Child Trauma Screening Questionnaire (CTSQ)
*Please indicate whether any of these things have happened to you since the accident.
Positive screen ≥ 5
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1. Do you have lots of thoughts or memories about the accident that you don’t want to have?
Yes No
2. Do you have bad dreams about the accident?
3. Do you feel or act as if the accident is about to happen again?
4. Do you have bodily reactions (such as a fast-beating heart, stomach churning, sweating and feeling dizzy) when reminded of the accident?
5. Do you have trouble falling or staying asleep?
6. Do you feel grumpy or lose your temper?
7. Do you feel upset by reminders of the accident?
8. Do you have a hard time paying attention?
9. Are you on the “look-out” for possible dangerous things that might happen to yourself or others?
10. When things happen by surprise or all of a sudden, does it make you “jump?”
Spanish version
Positive screen ≥ 5
Screen is: POSITIVE NEGATIVE
(Please page social work)
©2006 This work is copyright and not for reproduction in any format. Please obtain permission to reproduce this from Justin Kenardy
©2006 This work is copyright and not for reproduction in any format. Please obtain permission to reproduce this from Justin Kenardy

83. YOUNG CHILD PTSD SCREEN (YCPS)
Parent:
Below is a list of symptoms that children can have after life‐threatening events, such as injuries. Circle the number (0‐1) that best describes how often the symptom has bothered your child in the LAST 2 WEEKS.
0             1               2
No       A little        A lot
Positive screen ≥ 2
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1. Does your child have intrusive memories of the accident? Does s/he bring it up on his/her own?
0    1    2      
2. Is your child having more nightmares since the accident occurred?  
3. Does s/he get upset when exposed to reminders of the accident?  
For example, a child who was in a car crash might be nervous while riding in a car now.
Or, a child who was in a hurricane might be nervous when it is raining.
4. Has s/he had a hard time falling asleep or staying asleep since the accident?
5. Has your child become more irritable, or had outbursts of anger, or developed extreme temper tantrums since the accident?
6. Does your child startle more easily than before the accident? For example, if there’s a loud noise or someone sneaks up behind him/her, does s/he jump or seem startled?
Spanish version
Positive screen >=2
© Michael Scheeringa, MD, MPH, 2010, Tulane University, New Orleans, LA.
This form may be reproduced and used for free, but not sold, without further permission from the author.

84. Pediatric Injury Psychosocial Follow-up Clinic -Outpatient-
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Pediatric Injury Psychosocial Follow-up Clinic -Outpatient-
Pediatric Health Psychology Program in the Psychology Service (TCH/BCM)
Diagnostic interview and assessment of symptoms of traumatic stress
Outcomes:
Community referrals (rule-outs, etc.)
Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)
12-20 sessions of intervention with empirical support
Ages 2-3 to 18 years

85. Trauma Focused-CBT Morina, Koersssen, & Pollet (2016)
Has demonstrated effectiveness as early intervention with children with sexual abuse and has been shown to be effective with other trauma forms as well
Web-based course:
Morina, Koersssen, & Pollet (2016)
Meta-analysis
TF-CBT reduces PTSD as compared to waitlist; less efficacy for reducing depression
Most researched intervention with large effect size (compared to waitlist)
May be underutilized
Cohen (2003)
Limited research for effectiveness of psychopharm interventions – no evidence to be first-line intervention (only used cautiously and only if TF-CBT wouldn’t be a fit) (pediatrics)
Meta-analysis
Intervention reduces PTSD as compared to waitlist; less efficacy for reducing depression
TF-CBT is most researched with large effect size (compared to waitlist)
May be underutilized
1-6 months
Progressive logical thinking video as example (first minute or so)

86. TF-CBT Most evaluated treatment for traumatized children
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TF-CBT
Most evaluated treatment for traumatized children
8 randomized controlled trials
Compared to supportive treatment, youth improvement for:
PTSD, depression, anxiety, shame, and behavior
Compared to supportive treatment, parent improvement for:
Distress, support, and depression
Positive results for diverse backgrounds (Cohen et al., 2001 (maltreatment))
Preschool Version (Scheeringa, Amaya-Jackson, & Cohen)
85-90% of children improved markedly (and in only 8 sessions typically; for more complex trauma)
Evaluated with Caucasian and African-American children; adapted for Latino and hearing impaired/deaf; being adapted for Native American children and for children in other countries
Evaluated with natural disasters (Jaycox et al., 2010)
Need cognitive skills of at least 3-4 year old

87. TF-CBT Manualized but flexibility is required
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TF-CBT
Manualized but flexibility is required
Purpose of 1st visit = get family to come back!
Normalize
Typical reactions
Everything will be okay
Symptom tracking can be helpful
PRACTICE
Must be fun! (always end session on good note)
Have seen lots of kids like yours; of course you feel this way
Treatment is effective
CPSS and sample graph

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PRACTICE…
“The time to learn to tread water is not when you are in the middle of the ocean”
Psychoed – fight or flight response
Thought stopping (change the channel – can control), imagery, problem-solving, self-talk, reclaiming life/behavioral activation

89. Psychoeducation Frequency of trauma
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Psychoeducation
Frequency of trauma
Common emotional/behavioral responses
Information about symptoms and diagnosis
What is involved with treatment; prediction of difficulties; hope for recovery
Assessment
Symptoms? Which are worst? When? How often? Trigger?
UCLA, Child PTSD Symptom Scale (CPSS), Child-Post-traumatic Cognitions Inventory (CPTCI), ASC-Kids, DIPA
How coping?
What has trauma stopped you from doing?
What would you like to be different? (goals)
Empirical support for TF-CBT
3 minutes, 3 seconds
Address immediate concerns (sleep, etc.)
Continues throughout therapy

90. R= relaxation
A= affective modulation
C= cognitive coping & processing

91. Trauma Narrative Why important? Took out video - 4 minutes, 54 seconds
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Trauma Narrative
Why important?
Took out video - 4 minutes, 54 seconds
Gradual exposure
Desensitizes child to reminders, decreases avoidance/hyperarousal, and integrates trauma into life
Can ignore and get an infection
Can wash with initial pain but then heal
Would have put behind them if he/she could
Read it each week as well
Part you thought you’d never tell anyone
Praise and enjoyable activity at end of each session
SUDS ratings
How have I have gotten stronger? What I learned? How changed?

92. Trauma Narrative Why important: To gain mastery over reminders
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Trauma Narrative
Why important:
To gain mastery over reminders
To decrease avoidance
To correct distorted thoughts
To model adaptive coping
To put the experience in its place in one’s life
Took out video - 4 minutes, 54 seconds
Bike accident and cut example /cabinet example
Unpairing thoughts/reminders from overwhelming emotions
May be shared with parent; preparation for patient and parent
Gradual exposure
Desensitizes child to reminders, decreases avoidance/hyperarousal, and integrates trauma into life
Can ignore and get an infection
Can wash with initial pain but then heal
Would have put behind them if he/she could
Read it each week as well
Part you thought you’d never tell anyone
Praise and enjoyable activity at end of each session
SUDS ratings
How have I have gotten stronger? What I learned? How changed?

93. Trauma Narrative Cont…
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Trauma Narrative Cont…
Where to begin?
Begin with nonthreatening material
Add thoughts/feelings in 2nd pass
Any imagined scenes they can’t remember?
Worst memory/part? Something you haven’t told anyone yet?
Advice for others with similar experience?
How are you different because of this injury/treatment?
What have you learned? How have I grown stronger?
Read sample

94. Trauma Narrative Cont…
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Identify cognitive errors
Guilt (responsibility pie)
Magical thinking (thinking about money example)
Shame
Danger (reality testing)
Rumination (change why? questions to how?)
Re-read and role play (perspective taking) (best friend activity; now & then)
Integrate what they know now? What actually happened?
Incorporate relaxation as needed (SUDS scale assessment); praise efforts
Fun activity at end of each session
Sharing with parent
-demonstrates can talk with parent; not “forbidden”
Responsibility vs. regret
Progressive logical questioning (evidence that is counter to belief)
Examine the evidence and generate alternative thoughts
Best friend role play (talk me out of distortion)
Responsibility pie

95. Outpatient Clinic - 12 year old, Latino male
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Outpatient Clinic year old, Latino male
ATV injury
TBI and orthopedic injuries
Diagnosis of PTSD & Anxiety Disorder
Significant social difficulties as well (secondary to TBI)
Outpatient TF-CBT (twin brother witnessed injury and also received treatment for partial PTSD)
Read narrative
Injury several years ago
Partial PTSD= adjustment

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Working with Triggers
Experiencing exposure to triggers without negative consequences decreases anxiety
Identify triggers and expose gradually
Examples…street crossing, tree/location of injury, seeing news stories with similar themes, hearing sirens

97. Parenting skills Need for normalization of routines and expectations
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Parenting skills
Need for normalization of routines and expectations
How to support child and encourage communication
Behavior management
Praise (specific, immediate, consistent, purely positive, same intensity as criticism, & catch them being good)
Selective attention (extinction bursts)
Effective commands/contingency reinforcement plans (“If..then…”)
Time out
Overprotectiveness
Prep for joint session
Parent as child’s strongest source of healing (even for teens)
Focus on one behavior at a time; collaboratively choose rewards
Explain beforehand; “time out for….” (broken record)
Until calm & released by parent
Release without grudge; look for opportunity to praise
*Sleep as one of most common difficulties; address directly with behavioral plan (sleep hygiene, etc.)

98. Joint Session Share trauma narrative & growth
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Joint Session
Share trauma narrative & growth
Celebration of bravery & progress
3 minutes, 32 seconds
Celebration; relapse prevention (what did you learn)

99. Trauma-Focused   Cognitive Behavioral Therapy for Injuries in Preschoolers
Adapted from:
Michael Sheeringa, MD, MPH; Lisa Amaya-Jackson, MD, MPH; Judith Cohen, MD. Preschool PTSD Treatment, Version 1.7
In collaboration with:
Ginger Depp Cline, Ph.D., Assistant Professor,
Psychology Service, Pediatric Health Psychology Program
Jill Brown Fryar, M.Ed., M.S.W.
Instructor, Psychology Service, Department of Pediatrics
Baylor College of Medicine
Sheeringa – PTSD sexual abuse - Tulane Infant Study - website and the manuals, rating scales, etc all there
General principal is to desensitize the young child to trauma reminders
All evidenced based interventions for preschool age children – internalizing and externalizing – parents are integral part and crucial to the intervention
Parent watching closed circuit TV – my adaptation parent in the room – therapist modeling and guiding in the moment- parent providing feedback and interpretation as needed, given instructions for homework and provides weekly evaluation of behavior changes and ongoing reluctance monitoring
Parents who will complete the structured form to diagnose
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100. Surviving Cancer Competently Intervention Program – Newly Diagnosed (SCCIP-ND) (Kazak et al. 2004)
To prevent PTSS in families with cancer diagnosis; first large, randomized clinical trial
Baseline Assessment:
45% of mothers reported moderate-severe PTSS
35% of fathers
24% of adolescent survivors; 29% of adolescent siblings
Results:
Greater decrease in PTSS after SCCIP than control group
Adolescents had significantly less arousal after SCCIP (IES-R)
Fathers had significantly fewer intrusive symptoms after SCCIP (IES-intrusions)
No significant changes for mothers
Psychotherapy as first line of intervention; little empirical support for psychopharmacological intervention (Gerson & Rappaport, 2013)
I Also Surviving Cancer Competently Intervention Program – Newly Diagnosed (SCCIP-ND)
4 session, Manualized, 1 day intervention (5 direct hours of contact; 2 informal contact during breaks)
85% White

101. Surviving Cancer Competently Intervention Program – Newly Diagnosed (SCCIP-ND) Kazak et al. 2004
Session 1
Help caregivers talk about beliefs about cancer and how these influence feelings, behaviors, and family relationships
Session 2
Understand how adverse beliefs can impact family functioning
Benefits of reframing beliefs to help feelings, behaviors, and family relationships
Session 3
Guided discussion about role of cancer in the family (Family Survival Roadmap)
Beliefs about the future and how to share these beliefs with each other
Key parts: Joining, Interpersonal focus, Normalizing family’s experience, Focus on family strengths/growth
Based on research identifying PTSS symptoms in youth and parents
Manualized
CBT and family systems (focus on family)
Can have follow-up contacts

102. BrightIDEAS Problem-Solving Skills Training
Evidence-based CBT approach to build positive coping skills for parents of children with newly diagnosed cancer (8 sessions)
Bright = sense of optimism (positive orientation) about solving problems
I = Identify the problem
D = Determine the options
E = Evaluate options and choose the best
A = Act
S = See if it worked
D’Zurilla and Nezu (1999) and reinterpreted by the Sahler group (2002)
In the National Registry of Evidence-based Programs and Practices
Decreased distress more than treatment as usual or supportive therapy
Especially helpful for young, single, low SES, and/or minority caregivers
Latina immigrants
Mother chooses problem to focus on

103. Future Implications:
Increased screening for ASD/PTSD in pediatric populations
Development and refinement of psychometrically supported measures
Development of hospital/clinic/practice protocols
Increased focus on evidence-based intervention for traumatized populations
Implementation of hospital/medical provider protocol (“D-E-F”)
Expansion of current intervention programs/trials into other medical populations
Increased attention to secondary traumatic stress in providers
Focus on resiliency factors and/or posttraumatic growth
Stepped care models of intervention
Documentation of pediatric medical traumatic stress in various populations (medical, cultural, ethnic)
Need brief, nonstigmatizing interventions, as many families will do just fine!
TANDEM program at TCH; EAP; self-care

104. Thank you to collaborators…
BCM/TCH
Jill Fryar, M.Ed., M.S.W.
Patty Duran, Ph.D.
Interns/Fellows
Brian Whitaker, PA
Kelly Radcliff, NP
Bindi Naik-Mathuria, MD
Lori Frey, LCSW
Christy Hernandez, BSN, RN
Patients & Families
Texas Children's Hospital Outcomes & Impact Service (TCHOIS)

105. Questions/Comments…
Thank you!