January 2016

Championing Trauma-Informed Care in Pediatrics

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Imagine a trembling child in the Emergency Department (ED), with a parent about to collapse in tears while squeezing a tiny hand. A nurse notices the family’s rising distress and takes a few moments to talk with them about their fears and concerns, and to suggest specific ways to cope with the procedure that’s about to happen. She is practicing trauma-informed care, a skillset that most clinicians realize is pivotal but for which very few providers have had specific training.

Integrating a trauma-informed approach into healthcare settings is a way that medical teams can help to prevent or minimize emotional trauma for children and families facing injury, illness, and hospitalization. As just one example, by integrating these principles into ED care, medical personnel can potentially improve health outcomes for the 8 million children who are treated in EDs each year for unintentional injuries resulting from motor vehicle crashes, falls, and other causes.

About one in six children seen in the ED for an unintentional injury — and one in six of their parents — experienced clinically significant psychological symptoms, including post-traumatic stress and depression, several months after injury, according to a study recently published in Pediatric Emergency Care. The study included 263 child-parent pairs who completed standardized psychological assessment measures five months after receiving ED treatment, with the parents reporting on overall recovery for their children.

“Five out of six go on to do pretty well, so we don’t want the message to be that if you get injured, you’re going to have psychological problems,” said Nancy Kassam-Adams, PhD, associate director of behavioral research at the Center for Injury Research and Prevention (CIRP) at The Children’s Hospital of Philadelphia (CHOP) and director of the Center for Pediatric Traumatic Stress at CHOP, who led the study. “But nearly one-third of families in our study had either a parent or child who was struggling emotionally months later. This result argues for the importance of trauma-informed care, including anticipatory guidance about emotional recovery for the whole family.”

Online Game Serves as Screening Tool for Kids With Coping Difficulties

Clinicians can help parents and children understand common emotional reactions to an injury and also to recognize when they could become problematic. Evidence-based resources that CHOP researchers developed to promote emotional recovery after an injury are available, such as a website for parents of injured children, www.AfterTheInjury.org, along with downloadable assessment and patient education tools at www.HealthCareToolbox.org.

Once children and parents leave the ED, however, it is difficult for clinicians to know who is having trouble coping well in the following weeks. Dr. Kassam-Adams and her team’s ongoing research is looking at how to use an online game platform called Coping Coach as a screening tool after discharge. The game starts with a short symptom assessment each time a child logs on.

“By building this game that kids can play with for a month or two after leaving the hospital, we can keep track of how they’re doing and then send messages to their parents and doctors if it seems that they may benefit from intervention,” Dr. Kassam-Adams said. The project is funded by the National Institutes of Health, and supported by the SPRINT program at CHOP’s Office of Entrepreneurship and Innovation.

Research conducted by the Center for Pediatric Traumatic Stress at CHOP and its collaborators has helped to identify some of the risk factors that can worsen a parent or child’s trajectory for recovery. They include families who have had prior traumatic experiences, children whose pain was not well-controlled during their hospital stay, and children who tended to cope by withdrawing or avoiding anything that triggers memories of the trauma.

According to Dr. Kassam-Adams, trauma-informed healthcare providers can help to address those risk factors early on: “For example, a clinician who learns that a child previously witnessed a neighborhood shooting can be aware of how those stress symptoms may manifest during the child’s ED experience,” she explained. “The care families receive can help them better manage any pain and distress in the short run, and may open the door for additional help after they are back at home.”

Clinicians Want More Training in Trauma-informed Care

Many medical providers agree that they have a key role in supporting children from a psychosocial perspective. An international online survey of 2,600 hospital ED staff showed that more than 90 percent viewed psychosocial care as an important part of their job — yet only 14 percent felt confident about educating children and families about traumatic stress reactions. Nearly all the respondents desired training in this area, according to the study published in The Journal of Pediatrics.

“This is very good news here about healthcare professionals’ strong commitment to the best care for injured children and their interest in learning more to improve psychosocial aspects of this care,” said Dr. Kassam-Adams, one of the investigators involved with the study conducted through PERN, an international collaboration of emergency medicine research networks.

Even better news is that as the idea of trauma-informed care is catching on, CHOP’s Violence Prevention Initiative rolled out a comprehensive model to help a wide spectrum of healthcare providers, including ED staff, receive on-the-job training for trauma-informed care. The framework is based on research from CIRP that appeared in JAMA Pediatrics. Lead author Meghan Marsac, PhD, a pediatric psychologist and behavioral researcher at CIRP, encourages clinicians to remember the three R’s:

  • Realize the impact of trauma
  • Recognize emotional symptoms
  • Respond by putting knowledge into practice.

Since July 2013, CHOP has trained more than 1,000 staff members in trauma-informed care, with plans to train many more departments in the upcoming year. While future research is necessary to determine the effect of network-wide implementation on patient and staff outcomes, CHOP’s commitment to a trauma-informed systems approach already is being incorporated into the policies, practices, and culture of the entire institution.

Online training courses and other resources on providing trauma-informed care are available at HealthCareToolbox.org.

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