Medical Traumatic Stress Research Articles

Resilience in children and their parents enduring pediatric medical traumatic stress.

Due to the general lack of familiarity with the concept in the medical field, resilience is rarely considered in pediatric medical traumas. Resilience is an ability that enables recovery after adversities such as traumas, surgeries, serious health problems, or social issues. Stress from medical traumas encompasses both the psychological and physical responses of children and their families. Lack of resilience in children with medical traumatic stress may contribute to poor adjustment, slow recovery, disruptive behaviors, and psychiatric disorders. Furthermore, persistent parental distress increases the child's risk of low resilience. Consequently, these patients and their parents require early identification. This is achievable using a common stress measure such as the Perceived Stress Scale. Moreover, health care providers can screen patients' risks for low resilience, which include few social contacts, poor family functioning, and low cohesion among family members. Findings from the stress scale and screened risks could indicate the need for additional psychosocial support at the time of diagnosis of a serious illness, soon after injuries, and before and after operations. Such interventions can include decreasing distress, counseling children and their parents, and enabling strong connections to health care providers. Health care providers can help parents to minimize distress and adjust to their child's illness, thereby supporting the child's resilience, adjustment, and recovery.

Integrating play in trauma-informed care: Multidisciplinary pediatric healthcare provider perspectives.

Children and their family members may experience potentially traumatic events during medical treatment that can result in pediatric medical traumatic stress reactions. Play is a normative part of childhood that may facilitate engagement in medical care and may be incorporated in trauma-informed care. This qualitative study used semistructured interviews to examine the role of play and its potential use in trauma-informed care. The perspectives of 30 multidisciplinary pediatric healthcare providers representing 5 divisions (Cardiology, Endocrinology, Oncology, Orthopedics, Pulmonology) in 2 children's hospitals were gathered. Constant comparison and directed content analysis were used to analyze the data. Themes and subthemes were derived in 3 areas: (a) aspects of pediatric medical care that are potentially traumatic (specific events; and physical, emotional, and family-level consequences), (b) uses of play in pediatric healthcare settings (general [relieve boredom] and trauma-specific [prevention/alleviation]), and (c) potential barriers to the use of play in trauma-informed care (infection control; lack of provider training). The results document aspects of pediatric medical experiences that providers recognize as potentially traumatic, highlighting the importance of trauma-informed care. They also identify ways to use play to engage with children and families in a trauma-informed way. Additional training and development regarding play may increase the viability of using play in trauma-informed pediatric healthcare. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A pilot randomized controlled trial evaluating a web-based training program on pediatric medical traumatic stress and trauma-informed care for emergency department staff.

This pilot parallel group superiority randomized controlled trial investigated the efficacy and acceptability of a web-based training program on pediatric medical traumatic stress and trauma-informed care (Australian and New Zealand Clinical Trials Registry number: ACTRN12617001148369). Eligibility criteria for this study included being a nurse or physician working in an ED in Australia or New Zealand, being fluent in English and having Internet access. Emergency department (ED) staff (N = 71) were randomly assigned into the training (n = 32) or control group n = 39). We hypothesized that compared to the control group, ED staff in the training group would show a greater improvement in knowledge of pediatric medical traumatic stress 1-week post training and that improvement would be maintained at 1-month post training. At baseline participants completed a brief questionnaire assessing knowledge of pediatric medical traumatic stress. The training group then completed the 15-min online training program. The knowledge questionnaire was readministered to all participants' 1 week and 1 month posttraining, after which the control group gained access to the training. Acceptability was based on a program evaluation measure utilizing quantitative and qualitative items. The training group had significantly greater knowledge following training and at follow-up than the control group (p > .001, f = .42) and reported high rates of satisfaction. The results demonstrated an improvement in ED staff knowledge as a result of the training and provide preliminary support for the efficacy and acceptability of brief online training to improve the knowledge of ED staff interested in pediatric medical traumatic stress and trauma-informed care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Integration of Adlerian Play Therapy in Pediatric Hospitals

The multifaceted challenges faced by children with chronic illnesses illuminate a need for additional supports focusing on this population’s mental health. Although child life (CL) services and specialists support the immediate needs of the children, there is still an absence of resources to serve the long-term mental health needs of children with chronic illnesses. Adlerian play therapy (AdPT), an evidence-based intervention, is a developmentally responsive approach to counseling children and is compatible with hospital settings. This article provides guidelines for integrating AdPT into the existing system through the guidance of the pediatric medical traumatic stress (PMTS) model.

Traumatic Stress among School-Aged Pediatric Surgery Patients and Their Parents.

Since hospitalization can be a traumatic event for children, many of them may suffer from a cluster of chronic psychological and emotional difficulties called Pediatric Medical Traumatic Stress (PMTS). Although PMTS causes considerable functional impairment and psychological distress and may decrease the children's compliance with post-surgical care, awareness of this condition is low and thus not enough effort is made to prevent it. The objective of this study is to assess prospectively the prevalence and characteristics of PMTS in school-age children following hospitalization in a general pediatric surgery ward and in their parents, which has not been documented before. We recruited parents of 88 children aged 6 to 13 years old, hospitalized in a pediatric surgery ward and which form a representative sample of the children of this age in the ward. Three to five months after discharge from the hospital, the parents completed questionnaires measuring symptoms of psychological distress. About 26.4% of children displayed symptoms of PMTS, and 11.6% of parents suffered from posttraumatic stress disorder following their child's hospitalization. Moreover, we found a medium high positive correlation between the parents' level of distress and that of their child. In view of the prevalence of PMTS among school-aged children following surgical intervention, it is necessary to promote increased awareness, preventive interventions, and early identification and treatment of this condition.

Knowledge and training in paediatric medical traumatic stress and trauma-informed care among emergency medical professionals in low- and middle-income countries

ABSTRACTBackground: Provision of psychosocial care, in particular trauma-informed care, in the immediate aftermath of paediatric injury is a recommended strategy to minimize the risk of paediatric medical traumatic stress.Objective: To examine the knowledge of paediatric medical traumatic stress and perspectives on providing trauma-informed care among emergency staff working in low- and middle-income countries (LMICs).Method: Training status, knowledge of paediatric medical traumatic stress, attitudes towards incorporating psychosocial care and barriers experienced were assessed using an online self-report questionnaire. Respondents included 320 emergency staff from 58 LMICs. Data analyses included descriptive statistics, t-tests and multiple regression.Results: Participating emergency staff working in LMICs had a low level of knowledge of paediatric medical traumatic stress. Ninety-one percent of respondents had not received any training or education in paediatric medical traumatic stress, or trauma-informed care for injured children, while 94% of respondents indicated they wanted training in this area.Conclusions: There appears to be a need for training and education of emergency staff in LMICs regarding paediatric medical traumatic stress and trauma-informed care, in particular among staff working in comparatively lower income countries.

Surgical procedures and pediatric medical traumatic stress (PMTS) syndrome: Assessment and future directions

IntroductionSurgical procedures involve traumatic stress. Children may develop chronic psychological distress and dysfunction after surgery, with consequent reluctance to comply with medical follow-up care. A literature review of this topic shows that it has been understudied. Our study aims to assess the frequency and characteristics of symptoms of persistent psychological distress in children following surgery, which have not been documented before, in order to promote its awareness and its early identification. MethodsParents of 79 children (aged 1–6) that were hospitalized in a pediatric surgical ward, comprising a representative sample, completed three validated questionnaires assessing their children's psychological symptoms 3–5months after the hospitalization. ResultsA significant portion of children suffer from psychological distress 3–5months after hospitalization. Moreover, 10.39% of the children exhibited symptoms of PTSD, and 28.6% of parents reported that the child's distress causes dysfunction. Additionally, our findings emphasize the parents' concerns regarding the child's behavior, function, and health following hospitalization. ConclusionSince a significant prevalence of hospitalization-related traumatic stress is documented, the awareness to it has to be improved, in order to reduce its frequency and increase adherence to medical follow-up care. Type of studyPrognosis study. Level of evidence1.

3.0 Medical Traumatic Stress: Risk, Resilience, and Response

3.0 Medical Traumatic Stress: Risk, Resilience, and Response

What Do Clinicians Caring for Children Need to Know about Pediatric Medical Traumatic Stress and the Ethics of Trauma-Informed Approaches?

Medical experiences can be frightening and traumatic for children. Ill and injured children can experience pediatric medical traumatic stress-psychological and physiological distress responses related to their medical event and subsequent medical treatment experiences-which can lead to symptoms of posttraumatic stress disorder (PTSD) and suboptimal health outcomes. Trauma-informed care provides a framework for acknowledging, addressing, and mitigating the risks of psychological trauma associated with medical treatment experiences and is congruent with the ethical principles of respect for autonomy, beneficence, nonmaleficence, and justice. Health care systems and professionals are encouraged to apply the principles of trauma-informed care to address the effects of pediatric medical traumatic stress.

Factors that Support the Use of Child–Parent Psychotherapy as an Intervention for Child–Parent Dyads Exposed to Pediatric Medical Traumatic Stress

Clinical interventions for young children who experience medical traumatic stress are needed however the effectiveness of treatments remains unclear. This paper explores the current conceptual literature for clinical interventions with young children who have experienced medical traumatic stress. Concepts from trauma and attachment theories are examined and applied to a case composite. In addition, empirical literature related to interventions with young children who have experienced medical traumatic stress will be reviewed. Child–parent psychotherapy (CPP)—is identified as a promising intervention that addresses the needs of children who experience medical traumatic stress. This approach is also grounded in the theory models already noted. Based on this conceptual analysis, it is recommended that additional case applications are studied to provide more information about the potential of CPP with the population of parent–child dyads who have experienced pediatric medical traumatic stress.

Systematic Review: A Reevaluation and Update of the Integrative (Trajectory) Model of Pediatric Medical Traumatic Stress.

The objective of this systematic review is to reevaluate and update the Integrative Model of Pediatric Medical Traumatic Stress (PMTS; Kazak et al., 2006), which provides a conceptual framework for traumatic stress responses across pediatric illnesses and injuries. Using established systematic review guidelines, we searched PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and PubMed (producing 216 PMTS papers published since 2005), extracted findings for review, and organized and interpreted findings within the Integrative Model framework. Recent PMTS research has included additional pediatric populations, used advanced longitudinal modeling techniques, clarified relations between parent and child PMTS, and considered effects of PMTS on health outcomes. Results support and extend the model's five assumptions, and suggest a sixth assumption related to health outcomes and PMTS. Based on new evidence, the renamed Integrative Trajectory Model includes phases corresponding with medical events, adds family-centered trajectories, reaffirms a competency-based framework, and suggests updated assessment and intervention implications.

Child-Parent Psychotherapy in the Context of the Developmental Disability and Medical Service Systems

Child-Parent Psychotherapy (CPP), an evidence-based dyadic treatment for young children who have experienced trauma, shows promise in intervening with children with developmental disabilities, as illustrated in the cases we described of 14-month-old "James" and 6-year-2-month-old "Juan" (Harley, Williams, Zamora, & Lakatos, 2014). In their thoughtful commentary on these cases, Ghosh Ippen, Noroña, & Lieberman (2014) discuss additional clinical considerations important to the use of CPP with this population. In this response, we explore further implementation of CPP in the context of the developmental disability and medical service systems. In particular, we highlight the importance of resilience in parents’ responses to their child’s developmental disability, contributions from pediatric psychology to understanding pediatric medical traumatic stress, infusing relationship-based approaches in collaboration with other service systems, and addressing barriers to service access in ethnic minority families. Finally, we provide recommendations for training and fidelity monitoring when applying CPP to children with developmental disabilities and their families.

Research of pediatric medical traumatic stress in abroad

Pediatric medical traumatic stress is a new research which is based on posttraumatic stress,which is attracting more and more nursing workers' attention.The paper gives a brief introduction of pediatric medical traumatic stress and its related symptom,summarizes the achievement abroad,learns the experience of pediatric medical traumatic stress abroad,provides a reference for nursing workers to have a better understanding of pediatric medical traumatic stress in order to let the sick children receive better treatment. Key words: Children; Posttraumatic stress; Pediatric medical traumatic stress; Nursing

Maternal Report of Infant Emotional Well‐Being Following Their Infant's Hospitalization for Neonatal Cardiac Surgery

ABSTRACTLittle is known about the immediate impact of neonatal cardiac surgery on emotional and behavioral functioning in infancy. This exploratory, qualitative study investigated if infants who underwent cardiac surgery in the first 3 months of life exhibited emotional and behavioral dysregulation or traumatic stress responses. Ninety‐one infants and their mothers were recruited while inpatients. Mothers were interviewed about their perceptionof the impact of illness, surgery, and the hospitalizationon on their infant 4 weeks after discharge. Responses were analyzed by two coders using thematic analysis. Eighty‐three of the mothers interviewed described impacts on the infant, which emcompassed five themes: infant behavior (n = 44, 48%), emotions (n = 43, 47%), physical health (n = 31, 34%), relationship and social interaction (n = 27, 30%), and development (n = 18, 20%). Our expectation that there would be impacts in the period soon after neonatal cardiac surgery consistent with a pediatric medical traumatic stress response model was supported. Maternal report of infant well‐being following neonatal cardiac surgery delineated three groups of infants: those who appear unscathed; those who appear generally happy, but demonstrate specific alarm and avoidance responses in the presence of medical trauma; and those with significant problems in emotional regulation, behavioral regulation, or both.

Beyond the Physical Injuries

Experiencing a traumatic event and then the required care for the physical injuries can elicit stress symptoms in the injured child and parents. Stress-related symptoms affect a significant number of injured children and can have an impact on emotional and physical health outcomes after injury. Yet the majority of children who suffer from posttraumatic stress disorder postinjury go undiagnosed and untreated. Medical traumatic stress symptoms that occur often as adaptive responses initially can persist. Acute stress disorder is diagnosed when the stress symptoms persist less than 1 month postinjury and affect normal functioning. Inclusion of screening for acute stress and the development of models and guidelines are needed to systematically incorporate the care for the emotional trauma as an integral part of pediatric trauma care. Pediatric trauma nurses with knowledge and resources are in a position to minimize potentially traumatic aspects of the care they deliver, recognize traumatic stress symptoms, and help parents to support their child's coping and promote appropriate help seeking.

Assessment and management of psychosocial challenges in pediatric liver transplantation

Assessment and management of psychosocial challenges in pediatric liver transplantation

PMTS and stress response sequences in parents of children with spina bifida

Objective To test the presence and progress of Pediatric Medical Traumatic Stress (PMTS) symptoms in parents of children with spina bifida (SB). Methods Parents of 23 newborns with SB were interviewed prospectively and parents of 58 school-aged children with SB were interviewed retrospectively. PMTS symptoms were assessed with 17 DSM-IV criteria for the clusters Intrusion, Avoidance, and Increased Arousal. Results Within 3 months after the SB diagnosis, 75% of the parents met diagnostic criteria for symptoms of Intrusion and Increased Arousal, but not of Avoidance. In parents of school-aged children with SB, PMTS symptoms had declined in the first 4 years of the child's life and stabilized during the school years. Approximately 30% of the mothers and 20% of the fathers still met diagnostic criteria for Intrusion, Avoidance and Increased Arousal. In mothers of children with open SB, symptoms of Intrusion and Increased Arousal had decreased more slowly than in mothers of children with closed SB. Conclusions An SB diagnosis initially provokes traumatic stress symptoms in three-quarters of the parents; however, in most of them, these symptoms diminish during the first 4 years of the child's life. In a minority of the parents, severe stress symptoms persist beyond middle childhood. Professional psychological help may need to be offered to this selective group of parents whose levels of stress do not decline after the child's preschool years. Longitudinal research is needed to further investigate and confirm the trends that were found in parents’ psychological adjustment to SB.

Commentary: Life Threat, Risk, and Resilience in Pediatric Medical Traumatic Stress

Since the initial descriptive studies in the 1980s, the medical traumatic stress field has grown substantially, with an estimated 8-fold increase in papers about children and their families from 2000 to 2007 compared to the 1990s (Kazak, Schneider & Kassam-Adams, in press). Pediatric conditions can be traumatic experiences across family members and a traumatic stress framework can help explain short- and long-term responses to illnesses and injuries. Traumatic stress is compelling, in part, because it maps on to a competency based framework for understanding the trajectory of adjustment, from acute stress through potential long-term effects. The two reports in this issue related to cancer (Jurbergs, Long, Ticono, & Phipps, 2007) and burns (Landolt, Buehlmann, Maag, & Schiestl, 2007) are largely consistent with the existing literature and help to advance our understanding of posttraumatic stress symptoms (PTSS) in pediatrics. In this commentary, we link these papers to three concepts key to PTSS—life threat, risk, and resiliency. Both papers highlight the importance of considering what circumstances place children and families at risk for developing PTSS (e.g., history of traumatic experiences and recurrent) or are associated with resiliency (e.g., maternal presence when the injury is occurring) and potentially growth enhancing aspects of traumatic events. Although Jurbergs et al. (2007) present some data that is somewhat discrepant from others (including some from our laboratory), we offer comments in terms of how we may understand variability across studies. In both investigations, the perception of life threat appears to be a key element that contributes to PTSS across developmental stage and type of medical condition. That is, for young children with burns, maternal presence at the time of the trauma may minimize the potential for children to perceive their burn as life-threatening (they may feel safer with their parents). This is consistent with evidence that separation anxiety may help explain traumatic stress responses for young children with burns (Stoddard et al., 2006). For parents of children with cancer, relapse could introduce or reintroduce child life-threat. Although relapse has not been studied as a discrete event, their finding is consistent with other evidence that parental perceptions of life-threat are related to PTSS (Kazak et al., 2001). Thus, a child’s severe burn or cancer diagnosis may be examples of actual or threatened harm to self or others, but yet not necessarily include the subjective experience of lifethreat that is important for not only the diagnosis of posttraumatic stress disorder (PTSD), but the development of PTSS. It is important to understand circumstances that may place children and parents at greater risk for developing PTSS after potentially traumatic events (PTE; Kazak et al., 2006) that occur as part of pediatric illness and injury. Jurbergs and colleagues (2007) highlight that increased exposure to traumatic events may result in greater PTSS. In parents of children who had relapsed, this traumatization was associated with substantively more PTSS, compared to parents of children with cancer who had not relapsed. The framing of relapse as a ‘‘second hit’’ for parents after the initial ‘‘first hit’’ of child cancer diagnosis seems useful. Indeed, parents may have more extensive trauma histories; cancer could realistically be the third, fourth, or fifth ‘‘hit.’’ Alternatively, if parents believe that their child’s chances of cure were high during initial treatment, relapse could mark the first time they perceive their child’s life as truly threatened. Both articles highlight resiliency in families of children. Acute short-term stress responses are ‘‘normal’’ and understandable in the face of potentially traumatic events. Landolt and colleagues (2007) show that interpersonal circumstances at the time can be associated with PTSS for

Evidence-based Assessment, Intervention and Psychosocial Care in Pediatric Oncology: A Blueprint for Comprehensive Services Across Treatment

This paper describes the translation of psychological research into clinical services in pediatric oncology, based on two decades of research and clinical services in the Division of Oncology at The Children's Hospital of Philadelphia (CHOP). Two models helpful in conceptualizing clinical care underlying intervention work at CHOP are summarized: The Pediatric Psychosocial Preventative Health Model (PPPHM; Kazak, 2006) and the Medical Traumatic Stress Model, specific to pediatric illness and injury (Kazak, Kassam-Adams et al., 2006). Integration of these two models offers a "blueprint" for development and evaluation of services to children with cancer and their families relevant for all families across the complete spectrum of disease and treatment. The dissemination of evidence-based psychosocial practice in pediatric oncology remains a large and challenging goal. The proposed blueprint may facilitate collaborative work to help assure that children with cancer and their families have access to evidence-based care.

Pediatric medical traumatic stress in pediatric oncology: family systems interventions

Traumatic stress offers a helpful framework by which the ongoing reactions of children with cancer and their families can be understood. Family systems interventions in pediatric oncology are reviewed, with a focus on reducing pediatric medical traumatic stress (PMTS) across members of the family. A recently developed model of PMTS is presented and applied to the pediatric cancer population. Two family interventions to decrease traumatic stress systems are reviewed. Reductions in traumatic stress symptoms were observed at postintervention follow-ups for family members in both studies. The pediatric medical traumatic stress model provides a useful heuristic for understanding the psychological consequences of pediatric cancer on the child and their family over the course of treatment and beyond. Two family systems interventions show promise in improving outcomes for childhood cancer survivors and their parents. Although interventions are promising, future development of these interventions to modify them for dissemination is needed.