Download Traumatic Stress and Childhood Illness

Traumatic Stress and Childhood
Illness: Providing Trauma Informed
Care
Tiara T. Muhr, RN, MSN
UW PPC Trainee
Madison, WI
Overview
• Prevalence of Chronic Childhood Illness
• Medical Traumatic Stress
• Stress Responses
• Prevalence of Medical Traumatic Stress
• Treatment Implications
• Trauma Informed Care
• Screening Tools
• Post-Traumatic Growth
• Resources for Providers
Epidemiology
Chronic Childhood Illness
• 13 – 20% of U.S. children have chronic health
conditions
▫ 1/3 have moderate to severe health conditions
(Knafl & Santacroce, 2010)
Each Year in the U.S.
• 5 out of 100 children hospitalized for a major
acute or chronic illness, injury, or disability
• 11,000+ children diagnosed with new cancers
▫ 250,000 children who are cancer survivors
• 1,000 + children have organ transplants
▫ several thousand more are awaiting transplants
(National Child Traumatic Stress Network NCTSN)
Pediatric
Medical Traumatic Stress
• Psychological and physiological responses of
children and their families to pain, injury,
serious illness, medical procedures, and invasive
or frightening treatment experiences.
(NCTSN, 2011)
Why do medical events potentially
lead to traumatic stress?
• These events challenge beliefs about the world as a safe
place; they are harsh reminders of one’s own (and
child’s) vulnerability.
• There can be a realistic (or subjective) sense of life
threat.
• High-tech, intense medical treatment may be
frightening, and the child or parent may feel helpless.
• There may be uncertainty about course and outcome.
• Pain or observed pain is often involved.
• Exposure to injury or death of others can occur.
• The family is often required to make important decisions
in times of great distress.
Traumatic Stress Responses
• Arousal
▫ Fearful
▫ Jumpy
▫ Insomnia
• Re-experiencing
▫ Intrusive thoughts
▫ Flashbacks
• Avoidance
▫ Avoidance of
reminders of trauma
• Dissociation
▫ Memory Problems
Children’s vs. Parental Responses
• Children react to
medical procedures
and treatments
• Somatic symptoms
▫ Mimic those of
illness
• Parents,
grandparents, &
siblings undergo
different stressors
• Psychological
▫ Higher rates of
PTSD
Prevalence of Significant Traumatic
Stress Symptoms
• 2006 Meta-analysis found average of
▫ 20% in studies of injured children
▫ 12% in studies of ill children
▫ Similar rates for parents of ill children
(Kahana, et al., 2006)
PTSD and Chronic Health Conditions
• PTSD identified in 22% of parents of children
with chronic health conditions
▫ 19.6% - mothers
▫ 11.5% - fathers
• 85% of siblings of cancer survivors found to have
traumatic stress
(Cabizuca, et al., 2009)
Family Experience of
Traumatic Stress in Cancer Survivors
45%
40%
45%
Moderate to severe PTSD symptoms
35%
35%
30%
29%
25%
24%
20%
15%
10%
5%
0%
Teens
(Kazak, et al., 1997)
Siblings
Mothers
Fathers
Traumatic Stress Responses
Treatment Implications
Dissociation
• Inability to integrate information into memory
• Inability to recall condition, treatment,
prognosis information
• Emotionally unavailable to child
(Santacroce, 2002)
Avoidance & Treatment Adherence
•
•
•
•
Frequent hospitalizations
Increased provider visits
Higher health care costs
Increased burdens of care on families
26% of heart transplant recipient deaths
attributed to non-adherence. PTSD a
contributing factor. (Shaw, 2001)
Stuber & Shemesh Study
• 19 pediatric liver transplant patients
▫ 6 had PTSD symptoms
▫ 3 of 19 non-compliant
 All 3 had PTSD symptoms
 All 3 became compliant when treated for PTSD
(Stuber & Shemesh, 2006)
Hypervigilance
• Overprotect child
▫ Forbid participation in beneficial activities
• Overemphasize illness
• Fail to discipline
▫ Behavioral issues
Trauma Informed Care
Information for Providers
Trauma Informed Care Objectives
• Ensure that children have access to effective
trauma services and interventions
▫ Increase knowledge about trauma within systems
▫ Increase skills for identifying and triaging
traumatized children
▫ Promote strong collaborations across systems and
disciplines
What Providers Can Do
• Every child and family will not
need the same level of support.
• Majority will benefit from
psychoeducation, comfort, and
basic assistance.
• A smaller number with acute
distress will need
interventions that promote
medical adjustment or
adherence.
• Only a few families with severe
distress will need mental
health treatment.
UNIVERSAL trauma-informed care
• Minimize potentially traumatic aspects of medical
care and procedures
• Provide child and family with basic support and
information
• Address distress (pain, fear, loss)
• Identify family strengths and resources (help
parents and family help the child)
• Screen to determine which children and families
might need more support, and make appropriate
referrals
• Provide anticipatory guidance about adaptive ways
of coping
Health Professionals Can…
• Provide information and basic coping assistance for
all children & families facing potentially traumatic
medical experiences (illness, injury, painful
procedures).
• Promote early identification and preventive
interventions with children & families who may be
more vulnerable to posttraumatic stress.
• Refer high-risk families and those with persistent
traumatic stress symptoms for mental health
assessment and intervention.
• Further educate yourself through continuing
education, reading professional literature, and
consultation with knowledgeable colleagues.
D-E-F Protocol for Trauma Informed Care
Screening Tools
•
•
•
•
•
D-E-F Nursing Assessment Form
Hospital Emotional Support Form
PCL-C for DSM-IV
Psychosocial Assessment Tool (PAT)
Screening Tool for Early Predictors of PTSD
(STEPP)
Post Traumatic Growth
• Transformation resulting in positive growth as
result of experiencing trauma
▫
▫
▫
▫
▫
Personal strength
Belief in new possibilities
Enhanced abilities in relating to others
Deeper appreciation of life
Spiritual changes
(Kilmer & Gil-Rivas, 2010)
Provider Resources
• National Child Traumatic Stress Network
▫ http://www.nctsn.org/
• Health Care Tool Box – Trauma Informed Care
▫ http://www.healthcaretoolbox.org
• Center for Pediatric Traumatic Stress
The Children’s Hospital of Philadelphia
▫ Phone: 267-426-5205
▫ E-Mail: [email protected]
Handouts
• D-E-F Nursing Assessment Form
• Hospital Emotional Support Form
• 309.811 DSM-IV Criteria for PTSD
Sources
Cabizuca, M., Marques-Portella, C., Mendlowicz, M.V., Coutinho, E. S. F., Figueira, I. (2009).
Posttraumatic stress disorder in parents of children with chronic illnesses: A meta-analysis.
Health Psychology, 28(3).
Kazak, Alderfer, Rourke, et al. (1997). Posttraumatic stress symptom and posttraumatic stress
disorder in families of adolescent cancer survivors. Journal of Pediatric Psychology.
Kahana, S.Y., Feeny, N.C., Youngstrom, E.A., & Drotar, D. (2006). Posttraumatic Stress in Youth
Experiencing Illnesses and Injuries: An Exploratory Meta-Analysis. Traumatology 12; 148.
Kilmer, R.P. & Gil-Rivas, V. (2010). Exploring posttraumatic growth in children impacted by
hurricane Katrina: Correlates of the phenomenon and developmental considerations. Child
Development, 81(4), p. 1211-1227.
Knafl, K.A. & Santacroce, S.J. (2010). Chronic conditions and the family in P.J. Allen,
J.A.
Vessey, & N.A. Shapiro (Eds.) Primary Care of the Child with a Chronic Condition. St Louis,
MO: Mosby Elsevier.
National Child Traumatic Stress Network (2010). Medical stress in children and families (pdf).
http://www.nctsnet.org/nctsn_assets/pdfs/edu_materials/MedicalTraumaticStress.pdf
Santacroce, S.J. (2002). Uncertainty, anxiety, and symptoms of posttraumatic stress in
parents
of children recently diagnosed with cancer. Journal of Pediatric Oncology, 19, p. 104-111.
Shaw, R.J. (2001) Treatment adherence in adolescents: Development and psychopathology.
Clinical Child Psychology and Psychiatry, 6(137).
Stuber , M.L. & Shemesh, E. (2006). Post-traumatic stress response to life-threatening illnesses in
children and their parents. Child and Adolescent Psychiatric Clinic of North America.