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Kassam adams

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  • 1. Finding and Helping Stressed Children In Health Care Settings Nancy Kassam-Adams, PhD Children’s Hospital of Philadelphia nlkaphd@mail.med.upenn.edu
  • 2. Overview Why health care settings?  Impact of medical events on children & families  Interconnections - trauma & physical health Finding & helping children with trauma  Trauma-informed care  Screening for trauma / risk  In the hospital / in primary care Online resources for providers & parents
  • 3. Health care settings:Opportunities to address child traumaSee kids & families during / right after certain types of trauma  Scary medical events (asthma attack, injury, sudden serious illness)  Disaster / violenceSee children for many reasons  Not only at times of illness or difficulty  May have ongoing relationship with child / familyReach children and parents who will not seek MH services  For some, a more acceptable way to seek care  Including under-served populations (language, resources)
  • 4. Trauma & physical health:Interconnections Health impact of Exposure trauma exposure to trauma Physical health: illness, injury, Emotional impact treatment of medical events Traumatic stress / PTSD symptoms Health impact of traumatic stress
  • 5. Medical events aspotentially traumatic events (PTEs) “I thought I was “It all happened so going to die. I quickly. I was „out of it‟ thought I must and in pain. I was given really be hurt. I was the first chemo treatment so scared because without being told what my mom was not was going on – that upset there.” me for a long time after that.” “We went from taking him“I saw my son lying in to our family doctor,the street. Bleeding, thinking that he had somecrying, the ambulance, kind of virus or flu, to byeverybody around him. the end of the afternoonIt was a horrible scene. being in the ICU andI thought I was having him inundated withdreaming.” needles, and tubes, and… Wow! How did the day end up like this?”
  • 6. Pediatric intensive care:clinically significant PTS symptoms 3 mo (n=102) (n-120) Canada 50%50% 4 mo (n=50) 8 mo (n=102) (n=17) UK 45% 12 mo (n=72)40% 40% 21 mo (n=71) (n=19) UK30% 35% 30% 32% (n=102) UK 28% 29% 27% 28% 25% 20%20% (n=29) Netherlands 20% 21%10% 10%0% 0% Children with significant PTSD Parents with sig PTSD symptoms symptoms 3 - 8 mos post-discharge (UK studies) Children Parents
  • 7. Pediatric injury: clinically significant PTS symptoms50% < 1 mo (N=243) US 1 mo (N=79) Australia 1.5 mos (N=209) Switzerland40% 2 mos (N=119) UK 5 mos (N=164) US 6 mos (N=177) US30% 34% 6 mos (N=69) US 6 mos (N=79) Australia20% 22% 50% < 1 mo (N=243) US 1.5 mos (N=180 mothers) Switzerland 17%10% 14% 15% 15% 15% 47% 1.5 mos (N=175 fathers) Switzerland 40% 3 mos (N=62) US - burn injury 9% 6 mos (N=177) US0% significant PTS symptoms 30% 33% 20% Children 20% 15% 10% 11% 0% significant PTS symptoms Parents
  • 8. Pediatric cancer:clinically significant PTS symptoms In families facing childhood cancer, rates of PTSD are often higher in parents than in the child with the cancer. 50% 45% 40% Symptoms in families of teen 35% cancer survivors 30% one year or more 29% Moderate to severe PTSD post-treatment 24% 20% symptoms 10% 0% Teens Siblings Mothers FathersKazak, et al. (2004). Posttraumatic stress symptom and posttraumatic stress disorder infamilies of adolescent cancer survivors. Journal of Pediatric Psychology.
  • 9. PTSD / traumatic stressaffects health outcomes Health status (broadly) Large Medicaid sample of girls 0-17: PTSD associated with increased risk for circulatory, endocrine, and musculoskeletal conditions. (Seng et al. 2005) Treatment adherence After organ transplant, PTSD symptoms associated with poorer treatment adherence. (Shemesh et al 2000; Shemesh 2004) Functional health outcomes After injury, PTSD associated with worse functional outcomes: poorer quality of life for up to 2 years, more missed school days (Holbrook et al 2005; Zatzick et al. 2008; CHOP data)
  • 10. Impact ofpotentially traumatic eventInfluenced by: CULTURE Child prior experiences COMMUNITY Child coping capacity SCHOOL Impact on family FRIENDS Family ability to help child heal FAMILY Impact on peers / school / community CHILD Availability of social resources that support child’s healing and recovery Culture and extended community
  • 11. Impact ofpotentially traumatic medical eventInfluenced by: CULTURE Child prior experiences Child coping capacity HEALTH CARE SYSTEM Impact on family Family ability to help child heal FAMILY Experiences and CHILD interactions with health care system / providers Culture and extended community
  • 12. “Trauma-informed” health care With basic knowledge of medical traumatic stress, health care providers can …  Minimize potentially traumatic aspects of medical care  child’s experience of illness / injury  treatment / procedures  provider interactions with child and family  Support adaptive coping Provide basic information & anticipatory guidance to parents and children  Screen for high distress / high risk. Screen  refer / get consultation
  • 13. Mental health INDICATED Health careprofessionals Severe or providers persistent distress  MH treatment TARGETED Distress / risk factors  Provide anticipatory guidance  Follow-up several wks later  Refer if distress persists UNIVERSAL All children and families with recent acute trauma  Minimize potentially traumatic aspects of medical care  Strengthen existing supports & coping  Screen for risk factors or severe acute distress  Screen (in healthcare setting) for current distress or risk of persistent distress
  • 14. DEF protocol:Medical Trauma Working Group, National Child Traumatic Stress Network
  • 15. DEF: pocket cards
  • 16. At the hospital
  • 17. Putting DEF into practice:Trauma-informed hospital care Hospital in small city in northeast US, serves huge rural region Pediatric ICU and general pediatric floor Project led / initiated by MDs and Nursing leaders Implementing “D-E-F”:  Is it feasible for nurses to assess in the course of regular care?  How would this change nursing care? UNIVERSAL: Nurses attempted to use DEF to assess all patients – results used to inform nursing care plan Jan – July 2009: 503 patients/families assessed by nurses  Primarily acute illness; also surgery/procedure; injury
  • 18. Putting DEF into practice:Trauma-informed hospital care At least one concern identified: 45% Nurse identified a concern about:D: Pain 15%DISTRESS Fears / Worries 17% 26% Grief / Loss 2%E: Coping needs / strategies 5%EMOTIONALSUPPORT Parent availability (to provide support) 6% 10% Mobilizing existing support system 4%F: Distress in parent / sibling 12%FAMILY Family stressors 13% 21% Other family needs impacting current care 6%
  • 19. Stepped Preventive Care:Hospitalized injured children & teensChild (age 8 - 17) admitted to hospital for acute injury Universal brief screen in hospital (about 1 in 4 screen positive)  risk of ongoing PTS symptoms (STEPP),  current PTS or depression symptoms Targeted preventive intervention for those who screen positive  Stepped care model  deliver ‘just enough’ care  delivered by RN’s and MSW’s  tailor to child’s need / re-assess Indicated mental health services (<10%)  provided as needed  MH professionals
  • 20. Psychosocial Assessment Tool (PAT)Development / validation: Children with cancer (Kazak et al. 2011) Adaptations / validation underway for other areas (e.g. sickle cell)Purpose / Use: Practical , systematic screening ID level of psychosocial need & resources for patient & family Guide nursing & psychosocial care planImplementation: Currently in use in 21 hospitals in the US and 18 international Kazak, et al. (2011). Association of psychosocial risk screening in pediatric cancer with psychosocial services provided. Psychooncology. 20: 715–723.
  • 21. Form to communicate screening results
  • 22. Primary care
  • 23. Primary care:Screening for trauma / traumatic stress Lipschitz (2000) -- urban teen girls at routine primary care visit • 92% endorsed at least one trauma exposure • 86% witnessed community violence • 68% heard about a homicide • 49% victim of violence • 38% witness domestic violence • 14% PTSD Sabin et al (2006) -- injured teens returning to primary care • 30% had >4 previous traumatic events (before injury) • 4 to 6 mos after injury: • 30% posttraumatic stress symptoms • 11% depressive symptoms • 17% high alcohol use • No problems detected by their primary care providers post-injury
  • 24. Primary care: Identify & respondSuggested screening question for each primary care visit with a child: “Since the last time I saw your child, has anything really scary or upsetting happened to your child or anyone in your family?” Cohen, Kelleher, & Mannarino (2008)
  • 25. Automate support for continuity of care: Via electronic health record
  • 26. If You Dont Ask, They Wont Tell: Identifying andManaging Early Childhood Trauma in Pediatric SettingsVideo-based training resource for pediatric health providers Video and PowerPoint Interviews between physician and parent Demonstrate skills and techniques How to identify and discuss a pre-school age childs traumatic experience with a parent.For more information: Betsy McAlister Groves, LICSW Division of Developmental and Behavioral Pediatrics, Boston Medical Center e-mail: betsy.groves@bmc.org
  • 27. Pediatric Management ofEarly Childhood Traumatic Stress Inquire about stressors in the child’s life. Key questions:  What do you notice about changes in your child’s behavior?  When did this start?  What was happening at the time? Provide developmental guidance about trauma response Provide education/guidance about:  behavior management, routines and daily living activities to promote recovery and sense of safety Refer for mental health intervention, if needed Provide close follow-up and ongoing monitoring
  • 28. Online resources forproviders & parents
  • 29. WEBSITE FOR PROVIDERS: www.HealthCareToolbox.org
  • 30. WEBSITE FOR PROVIDERS: www.HealthCareToolbox.org
  • 31. Website for parents: www.aftertheinjury.org
  • 32. ThanksSpecial thanks to the children and families who havegenerously participated in our studies and programs.This work funded by:National Institute of Mental Health (NIMH)National Cancer Institute (NCI)Emergency Medical Services for Children (EMSC)Maternal and Child Health Bureau (MCHB)Substance Abuse / Mental Health Services Administration (SAMHSA)Centers for Disease Control (CDC)Verizon FoundationWomen’s Committee, Children’s Hospital of PhiladelphiaSt. Baldrick’s Foundation

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