CARIT Research Projects
- PTSD in children and parents up to one year after a crash
- Prospective study of children's and parents' reactions to traffic crashes
- Research on screening and secondary preventive interventions for injured children and their parents
- Development of a measure of acute stress disorder for children
PTSD in children and parents up to one year after a traffic crash
In 1998, the Injury Center research team conducted a prospective assessment of PTSD symptoms in 102 children after traffic crashes. Telephone follow-up interviews with parents, seven months to a year after the injuries occurred, revealed significant psychological distress in children and parents: 25 percent of the children and 15 percent of the parents met symptom diagnostic criteria for Post Traumatic Stress Disorder (PTSD). Many of these families had not sought help from mental health professionals for their psychological distress, nor had they talked with friends and family about their distress. The physical severity of the injury did not predict the severity of the distress that parents or children experienced. Children with minor injuries were also at risk for PTSD symptoms — 21 percent of children with no injury or minor injuries developed PTSD by the time of the follow-up assessment.
Prospective study of children's and parents' reactions to traffic crashes
With funding from the Maternal and Child Health Bureau, researchers at the Injury Center initiated a prospective study in 1999 to follow 360 children hospitalized after being injured in a traffic crash (as a passenger, a pedestrian or a bicyclist). Children and their parents were assessed within a few weeks of the injury and again four to eight months later.
Results of this study provided strong evidence that injured children and their parents may be affected by traumatic stress disorders and that early screening for PTSD risk is possible. The study also identified key factors in the etiology of PTSD that helped to inform our subsequent development of preventive interventions.
Many children and parents who participated in this study experienced at least a few Acute Stress Disorder (ASD) symptoms within the first month post-injury, suggesting that it is normative to experience at least transient traumatic stress after a child is hospitalized for traffic crash-related injuries. However, about 1 in 4 children and 1 in 3 parents experienced more severe and distressing ASD symptoms during the first month after a traumatic injury, and at the time of follow-up assessments (conducted an average of six months post-injury), about 1 in 6 children and parents still had clinically significant symptoms.
Predictors of PTSD outcomes for children included pre-existing factors (prior PTSD, behavioral/emotional concerns, family stress), factors associated with the event and its aftermath (exposure to frightening sights and sounds, acute pain), acute responses (elevated heart rate, child's and parent's acute stress symptoms), and factors occurring in the recovery period (degree of child's physical recovery, family stress, social support).
A 12-item screening measure named the Screening Tool for Early Predictors of PTSD-(STEPP), was developed to aid in the delivery of improved services through triaging. The STEPP demonstrated excellent screening tool properties including very high sensitivity and reasonable specificity for prediction of later PTSD outcome in injured children admitted to the hospital and their parents. (See press release 
)
Research on screening and secondary preventive interventions for injured children and their parents
Building on prior research findings, the Injury Center team is developing models for screening and prevention of post-traumatic stress after pediatric injury. In a project funded in 2002 by the Emergency Medical Services for Children (EMSC) Program, they examined the feasibility of screening for PTSD risk in a busy emergency room setting, by having Emergency Department (ED) nurses administer the STEPP during the course of their normal clinical encounters.
Nurses reported that the STEPP was easy to use, its length was appropriate for the ED setting, that parents and children seemed comfortable being asked such questions in the ED setting, and they also felt comfortable asking the questions. The majority of nurses indicated a willingness to use the STEPP in the future, but only a small percentage indicated strong support for this idea.
In addition to testing the feasibility, the STEPP’s predictive utility was examined when administered in the ED by following-up with parents and children who were screened by the nurses three months later to assess PTSD symptoms. The results indicate that the STEPP, as it stands, is not an effective screening tool to use with a general ED population.
However, the STEPP continued to be an accurate predictor for PTSD outcomes for those children in this ED population who went on to get admitted. Item-level analysis of the STEPP and our previous samples from other studies was performed, and revisions were made to the STEPP screener that might more accurately predict risk in a general ED population.
As part of the same overall project funded by EMSC, the Injury Center also developed and piloted several types of brief preventive interventions for recently injured children and their parents.
The focus of the first two interventions was on improving systems of communication about traumatic stress in injured children between acute medical care settings (emergency and inpatient trauma service) and the primary care providers (PCPs) that follow them; this involved piloting two modes of communication – one was paper-based and the second utilized an electronic medical record system.
In the first study, trauma surgeon discharge letters to PCPs included information for PCPs on traumatic stress, practical tips for providing anticipatory guidance to injured children and their families, and evidence-based handouts for parents.
The second study created an automated alert in the primary care electronic health record when a child was treated in the emergency department for an unintentional injury. At the child’s next visit, the PCP was automatically prompted to access a series of questions assessing risk factors and PTS reactions, and was provided with suggestions for anticipatory guidance and parent informational materials.
In both studies, feedback was obtained from PCPs regarding the acceptability and utility of the information and the feasibility of addressing traumatic stress in primary care visits. Results suggested that information was well-received and useful, but also identified practical challenges for integrating such tools in office practice.
The second series of interventions involved a stepped approach to secondary prevention of traumatic stress after pediatric traumatic injury, by matching type of intervention to level of risk.
Injured children and their parents were assessed in the Emergency Department or during inpatient admission, using the revised STEPP screening measure. All families received an informational handout on child and family reactions to trauma and ways for parents to promote optimal recovery.
Those at higher risk for persistent distress (based on screener results) also received brief psycho-education on these topics and a follow-up mailing and phone call two weeks later. Children and parents with persistent distress at follow-up were invited to take part in a two-session intervention focused on helping parents help their child deal with acute stress reactions.
PTSD symptoms were assessed three months post-injury for all children screened in the ED or inpatient unit. Results of this pilot study support the feasibility of screening and the utility of targeting interventions for those at higher risk.
In March of 2005, the CARIT program was awarded three more years of funding from EMSC to further the development of preventive interventions. With this grant, they are developing practical evidence-based tools aimed at helping parents help their children. These tools are being created in print, video, and in interactive Web-site formats.
Development of a measure of acute stress disorder for children
Acute Stress Disorder (ASD) is a constellation of early post traumatic stress symptoms occurring in the first month after a traumatic event. Currently, there are no established and well-validated child self-report measures of ASD.
In a project funded in 2001 by the National Institutes of Mental Health (NIMH) the Injury Center team developed a self-report checklist of ASD, the Acute Stress Checklist for Children, also known as the ASC-Kids. This 29-item checklist was developed through a careful process that included review of content validity by an expert panel and feedback from children about item wording.
In a validation sample of 150 children and teenagers with recent traumatic injuries, the ASC-Kids showed excellent reliability and demonstrated strong predictive validity for post traumatic stress symptoms assessed several months later.
The ASC-Kids has recently been translated to Spanish, Reacciones Agudas Postraumáticas en Menores, or RAP-M. The next steps are to perform a validation study of the RAP-M and compare it with the English-language measure. Copies of the English and Spanish versions of the ASC-KIDS are available upon request. Please e-mail Kristen Kohser if interested.