HOW CHILDREN AND FAMILIES COPE WITH PEDIATRIC MEDICAL TRAUMA AND STRESS

Lindsay Amper, PhD

La Rabida Childrens Hospital Chicago Child Trauma Center

Posttraumatic Stress Disorder

Defining Psychological Trauma DSM-IV PTSD Criterion A Exposure to traumatic event in which both of the following were present Experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others The persons response involved intense fear, helplessness, or horror
NCTSN

Traumatic Stress Symptoms

Re-experiencing Thoughts & feelings pop into ones mind. Re-living what happened - feels like its happening again. Get upset at reminders. Avoidance Try to block it out & not think about it. Try to stay away from reminders. Feel numb or no emotions.
NCTSN

Traumatic Stress Symptoms

Increased arousal Always afraid something bad will happen. More easily startled / jumpy. Trouble with sleep or concentration. Dissociation Things feel unreal -- like a dream. Trouble remembering parts of what happened.
NCTSN

Acute Stress Disorder

Avoidance of Internal/External Reminders Hyper-arousal (Anxious, Irritable, Insomnia, Poor Concentration, Hyper-vigilant, Reactive) Significant psychosocial and health impairment

NCTSN

Acute Stress Disorder

3+ of 5 dissociative symptoms (Detached, Dazed, Derealization, Depersonalization, Amnesia) Recurrent unwanted memories Awake/Asleep Distress related to internal and external reminders Duration 2-30 days, occurs within 4 weeks of traumatic event

NCTSN

Stress vs. Traumatic Stress

Many aspects of illness and injury are stressful. Painful / difficult to deal with Strain individuals & familys coping resources Some aspects are potentially traumatic. Extremely frightening or horrifying Life-threatening Sudden, painful, or overwhelming

Individual and Family PERCEPTION of the experience

http://copingclub.com/hayley-copes-with-burn-wounds/

NCTSN

Pediatric Medical Trauma

The childs and familys experience of scary, painful, and/or highly distressing medical events and their responses to them.

NCTSN

Risk Factors
Child
Subjective perception of life threat and/or traumatic experience Developmental level Pain Separation from parents/caregivers History of trauma Prior behavioral/emotional problems Lack of peer support Acute stress reactions NCTSN

Caregiver

Subjective perception of life threat and/or traumatic experience Parental trauma history Prior emotional/mental health issues Concurrent losses, stressors Lack of social support

Sources of Resiliency
Child
Social support Strong family support/strong relationship Strong coping resources/able to learn and use coping skills Positive outlook on medical issue Supportive medical providers Medical care that works to reduce traumatic impact of procedures Having developmentally appropriate understanding of their illness/care plan

Caregiver

Social support/ open to support Strong coping resources/ able to learn and use coping skills Positive outlook on medical issue Resourceful Medical providers who are attuned to caregivers stress/strain

Kelly- patient #1
6-year-old African American female, 25% burns, lives with mother, older sister and brother Spends significant amount of time with maternal grandfather (grandmother passed away last year) Mother works and attends school part-time Close relationship with sister (until the burn) Kelly initially blames sister for the accident

Assessment:
During hospitalization: dissociative symptoms, hypervigilance, exaggerated startle, reexperiencing (emotional dysregulation),separation anxiety Post discharge: reexperiencing symptoms, hypervigilance, exaggerated startle, and mild separation anxiety

Kellys Narrative

I was sitting on the couch watching High School Musical 2. This was in the front room. The water was sitting on my lap. And then, the hot, boiling water spilled on me. It was sitting on my lap. It turned over. I was scared. [My brother] told me to shut up. It

Kellys Narrative

When the water fell on me, I was crying. I was just looking and screaming. I was rocking back and forth. I was crying when I got into the ambulance.

Kellys account of the ambulance ride

I was lying like this but not with my feet up. The water was hot and it made me hot. I was feeling sad that I got burned. I was very, very, very, very sad.

Kellys and Moms Narrative

I was at [Dominion Hospital]. Then I was up in the air in a plane. I threw up on my bear, the green bear, Arius. I was asleep in the plane. Moms perspective: I met her at the [other hospital]. I had to drop off my other kids. I was feeling scared and sad because Kelly was hurt.

Kellys visual representation of being in the ICU

Kellys Narrative

One time I was at the other hospital they took me to a bath. My mom wasnt in the room. I was feeling sad when my mom wasnt there. I was very, very, very, very, very, very, very, very, very, very sad! They took me in a wheelchair. It was a long ride. They were fast, they said hold on and it was crazy! It was fun! They picked me up and put me in the bathtub. They told me to sit down and I didnt because I was too scared. I was scared of the bath. They washed me. They gave me soap and a towel. When I got out of the bathtub they had to cut skin from my thigh and put it on my hand.

Kellys Sisters Perspective

My story begins off with July 10th, my godmothers birthday. This was when [my sister] was burnt. We were bored and we had on clothes (t-shirt). I asked my mom if we could make something to eat. She said we could make some soup. [My sister] was watching HS Musical 2 and having fun and was on the couch. She had the soup between her legs. I heard somebody crying and [she] was crying and screaming. I saw her, the soup dropped on her. And I was depressed because I thought it was my fault. I was in the waiting room and I was scared and depressed and nervous. Then I went over my aunts house.

Kellys Sisters Perspective

I was excited and happy when I realized that it was not really my fault. I had an idea I was going to get her a get well gift, a teddy bear that said get well. Then I worried she wouldnt like it. She liked it great. Both of us were happy. I still think about it now at bedtime. I keep thinking it was my fault and when I see the pictures of her not burnt, I remember that we are going to work it out.

Anthony Burn patient

Anthony is an African American, 6-year-old child (at time of first visit) 80% total body surface area burn Many surgeries during ICU admission (primarily skin debridement and allografting), intubated, tracheostomy Mother and 3-year-old sister were staying together nearby throughout entire hospitalization. Mother at hospital during the day but is often unable to respond to Anthonys pleas for support. Father is minimally involved

Anthony Burn patient

Assessment for PTSD during his hospitalization :

Three reexperiencing symptoms (intrusive recollections, nightmares, and psychological reactivity). Three avoidance symptoms (avoiding thoughts/feelings associated with the fire, diminished interest in being with peers, and difficulty feeling happiness or love). Two increased arousal symptoms (sleep problems and irritability/anger).

Anthony Burn patient

1 week post-discharge- 1st outpatient appointment for reassessment Anthony wakes frequently during the night with nightmares and enuresis. Anthony is having frequent, intense and sometimes unpredictable temper tantrums. Anthony is avoiding contact with his friends and prefers to be by himself (was once a very social child). Concern about compliance related to wearing burn garments ( All of the previous symptoms of PTSD remain.

He has to wear his garments so his skin gets better

I was in the fire for too long. I dont like it when kids ask me all the time about my burns. It makes me feel bad.

This is his itchy medicine, blood pressure medicine, and his

What do you think?

What puts members of these families at risk for ongoing traumatic stress reactions? Consider the parent-child relationships and the impact that this has on physical and emotional healing. What strengths/resilience factors do you see? What developmental or cultural factors may play a role here?