Nancy Kassam-Adams

Creating trauma-informed systems: Child welfare, education, first responders, health care, juvenile justice.

Children and adolescents who are exposed to traumatic events are helped by numerous child-serving agencies, including health, mental health, education, child welfare, first responder, and criminal justice systems to assist them in their recovery. Service providers need to incorporate a trauma-inform

Traumatic stress in parents of children admitted to the pediatric intensive care unit.

Objective: To measure the prevalence of parental acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) and to examine the relationship between ASD symptoms and PTSD symptoms in parents of infants and children admitted to the pediatric intensive care unit (PICU). To examine the correlation between parental perceptions of illness severity and objective measures. To assess the association among demographic, situational, and illness factors and the severity of ASD and PTSD. Design: Prospective cohort study. Setting: Thirty-eight bed PICU at an urban children’s hospital. Patients: The parents of 272 children admitted to the PICU for >48 hrs. Interventions: ASD symptoms were assessed using the Acute Stress Disorder Scale during the child’s admission. PTSD symptoms were assessed using the PTSD Checklist at least 2 months after discharge. The severity of illness was measured using the Pediatric Risk of Mortality (PRISM III) score. Measurements and Main Results: Of the 272 parents completing the initial assessment, 87 (32%) met symptom criteria for ASD. Of the 161 parents completing follow-up, 33 (21%) met symptom criteria for PTSD. PTSD symptoms at follow-up were associated with ASD symptoms assessed in the PICU, unexpected admission, parent’s degree of worry that the child might die, and the occurrence of another hospital admission or other traumatic event subsequent to the index admission. Neither ASD nor PTSD responses were associated with objective measures of a child’s severity of illness (PRISM III score). Conclusion: Traumatic stress symptoms are common among parents in the PICU and may persist long after discharge. There is strong support from these data for continued attention to supporting parents both during and after a child’s PICU admission.

Predicting Child Ptsd: The Relationship between Acute Stress Disorder and PTSD in Injured Children.

OBJECTIVE To examine the prevalence of acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) in injured children and to evaluate the utility of ASD as a predictor of PTSD. METHOD Children hospitalized for injuries sustained in a traffic crash were enrolled in a prospective study. ASD was assessed in 243 children within 1 month after injury, and PTSD was assessed in 177 of these children 3 or more months after injury. The relationship between ASD and PTSD was examined via correlations between symptom severity scores and calculation of sensitivity, specificity, and positive and negative predictive values for categorical prediction of PTSD from ASD or subsets of ASD symptoms. RESULTS Eight percent of children met the symptom criteria for ASD and another 14% had subsyndromal ASD; 6% met the symptom criteria for PTSD and another 11% had subsyndromal PTSD. ASD and PTSD symptom severity were associated. Sensitivity was low for prediction of child PTSD from child ASD. Subsyndromal ASD was a more effective predictor of PTSD. CONCLUSIONS A substantial minority of injured children are affected by traumatic stress disorders. ASD in children may not be an optimal categorical predictor of PTSD. With increasing attention to early posttrauma services for children, empirically valid assessment/triage models deserve further study.

Ethical issues in trauma-related research: a review.

Ethical decision-making about trauma-related studies requires a flexible approach that counters assumptions and biases about victims, assures a favorable ethical cost-benefit ratio, and promotes advancement of knowledge that can benefit survivors of traumatic stress. This paper reviews several ethical issues in the field of traumatic stress: Benefit and risks in trauma-related research, whether trauma-related research poses unique risks and if so what those might be, informed consent and mandatory reporting, and supervision of trauma-related research. For each topic, we review potential ethical issues, summarize the research conducted thus far to inform ethical practice, and recommend future practice, research questions and policies to advance the field so that research on trauma can continue to be a win-win situation for all stakeholders in the research enterprise.

Child Stress Disorders Checklist: A Measure of ASD and PTSD in Children

OBJECTIVE To assess the psychometric properties of the Child Stress Disorders Checklist (CSDC), a 36-item observer-report instrument that measures acute stress and posttraumatic symptoms in children. METHOD The CSDC was administered to parents of 43 children with acute burns and 41 children who had experienced a traffic crash. This instrument was also administered to the burned childrens primary nurse to estimate interrater reliability. The CSDC was completed again by parents of burned children, 2 days and 3 months later. Convergent validity was determined by correlating scores on the CSDC with scores on instruments of known validity for assessing posttraumatic stress disorder (PTSD) in children. Concurrent validity was determined through an examination of the relationship between CSDC scores and an index of trauma severity (percentage of body surface area burned). Discriminant validity was assessed by administering the Child Behavior Checklist (CBCL): it was hypothesized that PTSD symptoms would be more closely related to the PTSD scale of the CBCL than the Thought Problems scale of the CBCL. RESULTS The CSDC has reliable and valid psychometric properties. CONCLUSIONS The CSDC, an observer-report instrument of ASD and PTSD in children, has important utility in clinical and research settings.

Acute stress disorder and posttraumatic stress disorder in parents of injured children.

Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) were examined in 334 parents of children with traffic-related injuries. In the first month after their childs injury, 12% of parents had ASD and another 25% had partial ASD. Among 251 parents assessed again approximately 6 months postinjury, 8% had PTSD and another 7% had partial PTSD. The ASD and PTSD severity were associated (r = .54), but ASD status was not a sensitive predictor of later PTSD. Independent predictors of ASD severity included prior trauma exposure, peritrauma exposure and perceptions of the childs pain and life threat, and child ASD severity. Independent predictors of PTSD severity included prior trauma exposure, parent ASD severity, and parent-rated child physical health at follow-up.

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

OBJECTIVE 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. METHODS 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. RESULTS 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 models five assumptions, and suggest a sixth assumption related to health outcomes and PMTS. CONCLUSIONS 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.

Posttraumatic Stress Disorder Symptom Structure in Injured Children: Functional Impairment and Depression Symptoms in a Confirmatory Factor Analysis

OBJECTIVE To examine the factor structure of posttraumatic stress disorder (PTSD) symptoms in children and adolescents who have experienced an acute single-incident trauma, associations between PTSD symptom clusters and functional impairment, and the specificity of PTSD symptoms in relation to depression and general distress. METHOD Examined PTSD symptom structure in two samples of children (8 to 17 years of age) assessed an average of 6 months after unintentional injury: (1) a combined dataset of 479 children assessed with a PTSD symptom checklist, and (2) a sample of 204 children assessed via a standardized clinical interview. We evaluated the fit of six alternative models for the factor structure of PTSD symptoms, and the association of PTS symptom clusters with indicators of functional impairment. We then evaluated three models for the structure of PTSD and depression symptoms jointly, to examine specificity of PTSD versus general distress or mood symptoms. RESULTS In both samples, the DSM-IV 3-factor model fit the data reasonably well. Two alternative four-factor models fit the data very well: one that separates effortful avoidance from emotional numbing, and one that separates PTSD-specific symptoms from general emotional distress. Effortful avoidance and dysphoria symptoms were most consistently associated with impairment. The best-fitting model for PTSD and depression symptom clusters had three factors: PTSD-specific, depression-specific, and general dysphoria symptoms. CONCLUSIONS The DSM-IV model for PTSD symptom categories was a reasonable fit for these child data, but several alternative models fit equally well or better, and suggest potential improvements to the current diagnostic criteria for PTSD in children.

A pilot randomized controlled trial assessing secondary prevention of traumatic stress integrated into pediatric trauma care

Medical settings provide opportunities for secondary prevention of traumatic stress and other sequelae of pediatric injury. This pilot randomized trial evaluated the delivery and effectiveness of a targeted preventive intervention based on best practice recommendations and integrated within acute medical care. Hospitalized injured children were screened for risk of developing posttraumatic stress disorder (PTSD). Those at risk (N = 85) were randomized to the intervention (n = 46) or usual care (n = 39). The preventive intervention did not reduce PTSD or depression severity or increase health-related quality of life, compared to usual care. Both groups improved over time, but 6 months postinjury approximately 10% of each group still met criteria for PTSD, suggesting room for improvement in comprehensive pediatric injury care.

The medical traumatic stress toolkit.

Children and their parents who are exposed to medical life-threat due to illness or injury are at risk for developing symptoms of posttraumatic stress. However, the prevention, detection, and treatment needed are often not available in the acute care settings of the hospital. The National Child Traumatic Stress Network and the Substance Abuse and Mental Health Services Administration have created a set of materials for use by hospital health providers and families that is available for download free from the National Child Traumatic Stress Network website, www.nctsn.org.