Psychological Reactions to Injury

In addition to the medical and biomechanical aspects of pediatric injury, researchers at the Center for Injury Research and Prevention also address its psychosocial consequences. The aftermath of a traumatic injury is a challenging time for most injured children and their families. Through a number of related studies, the Child and Adolescent Reactions to Injury and Trauma (CARIT) research program is examining the range of responses that children (and their parents) experience after pediatric injury. Our studies have found that psychological distress, such as Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder (PTSD), occurs in significant numbers of:

  • Children with unintentional injuries such as traffic-related injuries
  • Youth injured by interpersonal violence
  • Parents of injured children

Studies now underway are expanding upon these findings and are adding to our understanding of how traumatic stress symptoms may develop in children and parents. Through the CARIT research program, Injury Center researchers are also developing screening tools and intervention methods to promote emotional recovery — and are creating models for integrating them into medical care after pediatric injury.

Areas of Concentration

For children, youth and parents facing pediatric injuries from a variety of causes (including traffic crashes, interpersonal violence and others), Injury Center researchers are working to:

CARIT Research Summaries

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 were 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, researchers will develop 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. Our 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 Angela Marks if interested.

Collaborations and Related Projects

The Injury Center’s behavioral researchers are involved in a number of related projects with colleagues at The Children's Hospital of Philadelphia and the University of Pennsylvania.

  • The Center for Pediatric Traumatic Stress

    The Center for Pediatric Traumatic Stress (CPTS) at The Children's Hospital of Philadelphia develops and evaluates empirically-based interventions for children who have experienced traumatic stress due to medical illness or injury, and their families.

    This includes developing manualized "best practice" protocols for preventing and treating traumatic stress, and establishing service delivery models to integrate prevention and treatment into healthcare and school-based systems. Current areas of intervention development focus on traumatic stress related to life-threatening illness, acute injury and critical care.

    The Injury Center worked with CPTS on projects aimed at improving communication about traumatic stress post-injury between acute and follow-up care settings. Download informational materials for parents and healthcare providers developed by CPTS and the Injury Center.

  • Evaluating acute stress and PTSD in violently injured youth

    Emergency medical settings can play a crucial role in assessing violently injured youth and responding in ways that help to promote positive recovery and to reduce the risk of later PTSD.

    In collaboration with colleagues in the Divisions of Emergency Medicine at The Children's Hospital of Philadelphia and the Hospital of the University of Pennsylvania, we are investigating acute stress in children, adolescents and young adults who are injured by interpersonal violence.

    These studies have shown that it is feasible to assess immediate responses in the Emergency Department, that acute stress is common in these youth, with about 30 percent experiencing multiple types of acute stress symptoms, and that the degree of acute stress is associated with the degree of PTSD symptoms assessed several months later.

  • Acute and long-term stress responses of parents in the pediatric intensive care unit (PICU)

    Parents may be at risk for post traumatic stress symptoms when their severely ill or injured child is admitted to the intensive care unit. In collaboration with colleagues in the Division of Critical Care Medicine and the Department of Psychology, a prospective study was conducted to exame parents' responses during and after their child's intensive care admission.

    This study explored potential risk factors, and assessed the post traumatic stress symptom constellation as a potentially useful way to understand parents' responses to this difficult experience. Results from the study show that one-third of parents met criteria for a diagnosis of ASD while their child was in the PICU, and a fifth met criteria for PTSD several months later. ASD symptoms were quite common among parents of children in the PICU, and many parents continued to report their symptoms months after their child was discharged.

    Parental posttraumatic stress responses did not correlate with objective measures of severity of illness, but were related to parent perceptions of life threat for their child and to parent acute stress reactions in the PICU.

    A recent study conducted in the PICU aimed to develop a practical screening measure for the children admitted to the PICU and their parents.Identifying individuals at risk for traumatic stress with an empirically-validated screening measure may help in the development and provision of effective treatment or preventive interventions that would ameliorate the affects of trauma on children and their parents.

Our Research

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  • Recovery tools for parents and children
    Through the CARIT project, Center researchers have developed parent and child tip sheets to provide basic information on positive recovery, self-care, and common reactions to injury.