Annual EMSC Grantee Meeting

Screening and Secondary Prevention for Psychological Sequelae of Pediatric Injury:

A Completed Targeted Issue Grant Summary

June 20-22 2006

FLAURA WINSTON: Good morning. My talk is actually in your binder; hence I’m going to reduce the length of the talk just to make sure that you get your break at 10:00. Okay? So if I don’t go through every one of--that’s okay. If I don’t go through every slide, that’s fine.

So I want to thank the Emergency Medical Services for Children Program for giving us this support for so many years in--starting from even identifying that injuries cause traumatic stress in children to, now the exciting part of translating that into tools that can improve the outcome of kids. And I want to thank Dan for his mentorship and his role all along. But I also want to thank--we can get the first slide up there--I’d like to acknowledge Angela Marks, who’s here, she is then the coordinator for this work and feel free to talk with her. And I’m sorry to say that Nancy Kassam-Adams who has been my frick and frack for this whole project isn’t here. She’s actually presenting this work in Buenos Aires right now. I get Washington. But that’s fine with me.

For those of you who are out there day and night in the field, knowing, seeing injury, you know this. But to be honest with you, a lot of people don’t. That when a child is injured, there is an experience in many children of fear, helplessness, and horror and self-threat, life-threat and that children can develop symptoms that are associated with traumatic stress.

And one of the stories that just really got us to be thinking about this was a child who was seen in our emergency medical department ultimately diagnosed with an ankle sprain, but she was dragged by a trolley. And so, that really got us to be thinking that it’s not the life threat that is related to traumatic stress. Although it is important, it’s actually the experience that the children go through.

And so, what I want to give you a sense of is what our EMSC funded research base has looked like and that has helped us to, now develop interventions. I’m going to illustrate some of those, and to talk about a practical application for all of this. So first I think I need to talk about--I started to, the difference between stress and traumatic stress. We all feel stressed. How many people in this room feel stressed right now? Okay. All of us do. I mean, we’re doing too much, we’re feeling badly about things and we may have actually just had something happen in our lives that’s upsetting.

But the difference with traumatic stress is that there are symptoms that occur, it goes on for too long, and it starts to impair the life of the child. And so, we want to be focusing in our work, on of course, reducing stress but particularly reducing traumatic stress. And there’re things that really make something traumatic. Is it life threatening? Is it scary? Is it sudden, painful, overwhelming? How much of this is emergency medicine? I mean, much of it. So when you hear me talk about injury, I want you to just think about what you do in your everyday life, in pre-hospital, in the field, all the way through trauma care.

And besides injury, you can have a new diagnosis of cancer, new diagnosis of HIV. There are intentional injuries and unintentional injuries. And Joel Fine is here, I’m sure, he can raise his hand. He’s doing a lot of work related to unintentional injuries and thinking about that as well with traumatic stress, painful or scary procedures, and medical emergencies. So just to give you some quotes from our research like to bring this home. First, there was a child said to us, “I thought I was going to die, I thought I must be really hurt, I was so scared because my mom wasn’t there.” This is extremely common when kids are injured and you scoop them off of the playground, or in the middle of the street and bring them into the emergency department.

On the other hand, we can’t forget our very first study, very first interview about traumatic stress when we’re talking to parents, the parents said to us, “You can’t forget the parents. My child’s doing okay but what about me? I saw my son lying in the street bleeding, crying. The ambulance, everybody around him, it was a horrible scene. I thought I was dreaming.” That dreaming is dissociation. Okay? It’s really clinically known what that is.

So the four symptoms, if you don’t know about it, and I’m not going to go into this in detail, well, because of time. Re-experiencing, just keeps going on and on in your mind. Avoidance, you’re pushing it away. You’re aroused and then dissociation, you sort of think of it as a dream. And the easy way I like to think about traumatic stress is that, it’s in your mind, it keeps coming in whether you want it or not, it’s a nightmare, it’s everywhere and you keep pushing it away to try to deal with it. Well, that’s not healthy. What ends up happening is you push it away but you’re also pushing other things away.

But it still comes, and then you push more things away, and then more comes in and you push it away. To the point where it can become an impairment because you actually have restricted your life because you don’t want those reminders, and the reminders cause things like hyper arousal which causes your heart to beat too quickly and then you might think you’re going to die. You can see how it just is a spiral. So the traumatic stress symptoms a lot of people experience, but as I said they’re not post-traumatic stress disorder unless, it goes on for a long time and impairs life.

So, why do we care about this? We care about it because there’ve been multiple studies now that were recognizing more about traumatic stress in children and others that show that there are wide range of health outcomes, poor health outcomes associated with traumatic stress. There is poor treatment adherence and kids who, let’s say, have transplants and there is a lower quality of life and functional outcomes. More missed school days and that type of thing after school--after injury, for kids who have traumatic stress.

So we have created a model, Joel Fine, Nancy Kassam-Adams and Ann Kasac (ph) and like a (inaudible), that thinks about traumatic stress is the peri-traumatic event, the early ongoing evolving response and then more long term. So we think about this, the peri-traumatic event, as I was saying, is potentially traumatic. You know, if the perception is that it’s traumatic in the child’s mind or the parents mind. But then you go into a period that lasts at least around a month, the early acute ongoing evolving response, and then you see whether or not it’s going to develop into long-term traumatic stress symptoms.

So, as a cartoon model of this--there--so you have your traumatic event, it goes on and very quickly for almost everybody has symptoms right away and then, ultimately a lot of people get better. Most people get better. Unfortunately, there are those people who have their event, get their symptoms and they don’t get better. Or maybe they even get worse.

And what our goal in our research is--well, if you think about it there’s the phase one, the phase two, and the phase three. In our research, what we hope to do is to take those folks who are going to go on to develop ongoing symptoms and actually bring them back to baseline again. So to identify the people who are at risk and then to bring them back to baseline. And what we found is that 88 percent of children, 83 percent of their parents, have traumatic stress symptoms in the early event. Ongoing though, about 16 percent of children, 15 percent of their parents have persistent symptoms. They might say, “That’s terrific, we’ve solved the problem.” But the reality is it’s 15 percent of a really large number. We know how many kids are injured in this country. And we know that this is a population that we need to address and we need to think about.

And so we’ve looked at--with our EMSC work is how can we identify those at risk and what we can we do to help them prevent their symptoms. I don’t know why that’s happening. So the three areas we’ve thought about, and this is all in keeping with the National Institute of Mental Health, is we need to provide psycho-education. We have to give information to families and education. Anticipate what’s going to happen with them, and then guide them through that, and then screen for those who will likely have problems ongoing.

What I’m going to present today is our finished work. I was informed by Ken that that’s what I should do. We do have work ongoing that Angela and I would be glad to talk about, about what to do once you have a child who has screened positive.

So here are some examples of tip sheets. We had a longitudinal study that was funded by Maternal and Child Health that looked at 360 parents and their injured children for six to nine months, and what we found were what were some of the risk factors? What were some of the things that could predict long term whether or not the children did poorly? And we incorporated these in downloadable, easy to use information handouts that, I think our emergency department is now starting to use and others. Feel free to use them any way you want.

We’ve created one that was for parents. After the injury, “What can I do to help my child cope?” or “Helping my child cope”. And then, we have one that’s actually for children as well.

And one of the most exciting things was looking at children in the hospital who’ve been treated for injuries after motor vehicle crash. We developed a screener that was published in JAMA a couple of years ago. And this is a screener, it has high sensitivity so it’s not going to miss very many kids. It rules out those kids who don’t have symptoms, but it doesn’t have the specificity. The specificity has to come with diagnosis. So by asking four questions of the child, four questions of the parents, and four questions from the chart, we can have a negative predictive value of in the high 90s where if you rule out based on this, you are not going to go onto traumatic stress.

And they’re simple questions like, for the parents, “Did you see the crash?” You know the fact is that when parents see it, it increases their traumatic stress responses if they’re there. It’s great for the kids, bad for the parents. “Were you in the ambulance with your child?” Again, helpful for the kids, bad for the parents.

And then, “Before the injury, did your child have behavior problems?” And then it goes on with questions for the child, but also, “Did the child have a fracture?” This is something very painful and we found this is associated with traumatic stress.

I don’t know what I’m doing wrong but--there. Okay. When we went on to then say, okay, now we’ve got a screener, we have information handouts, how do we get this information to the people who matter? Well, who are the people who truly matter when it comes to traumatic stress? All of you matter in trying to make it the least stressful it can be early on but the people who matter about dealing with traumatic stress are the primary care physicians. So we have, again, for anybody to use, a template letter that any trauma surgeon can send that says, “This is what you need to do for the wound, but beyond the physical injury there are other things you might want to look at. And so let me tell you something about traumatic stress.” And we created information for pediatricians about the questions they should ask and the things that they could do. Again, available for anybody that might want to use any of those materials.

And then the most high-tech thing we did--and, how many of you actually have electronic medical records in your primary care settings? It’s growing. It’s still quite new but it’s growing. If you’re part of a hospital-based network with electronic medical records, there’s a way to be able to let your primary care providers know automatically whether or not there was an injured child that’s about to be seen by them. And so what we did is we took advantage of that and created trauma alerts so that whenever a child came in, whether it was for an ear infection or primary care--so this is an example of an ear re-check--an alert came up that said, “This patient has recently been seen in the emergency department for an injury. Consider using the best practice Smart Set to assess for post-traumatic stress disorder.

And the things that were in there is there’s injury follow-up, and HPI and then, actually, even suggested wording for questions. This is where we’re all headed at electronic medical records and, I’m sure, this is a lot about what that wonderful PECARN network is going to be using in terms of making sure that we’re ready for disasters and other types of things as to get information out quickly. So here’s an example, ask the parents, “Since this happened, have you noticed any changes on your child’s feelings or behavior?” And then it gives you possibilities of how people would respond. We can show you more about this. We also have suggested plans of action based on what you find. Then finally, in terms of tool kits, with our EMSC funding we actually leveraged it by working with the National Pediatric Traumatic Stress Network--National Child Traumatic Stress Network out of SAMSA to create a tool kit for health care providers. Nancy Kassam-Adams really spearheaded this and so I take no credit whatsoever. Angela worked quite hard on it as well and so you can ask them some more, but I want to introduce you to the fact that this exists.

So we all think about ABC, right? Airway, breathing, circulation. Some people do the D for dextrose but we have a new D. There are three other things to think about: the distress, emotional support and the family. So, for the distress, assess the managed pain, ask about fears and worries and consider grief and loss. The emotional support is, ”Where are the parents right now?” And, “What are the barriers to getting the support?” And then in terms of the family, “How is everybody else doing?” And guide--gauge the family’s stressors and address their other needs. So I’m not going to go into for time, I’m going to skip these, they’re in your binder to look at and you can actually get examples of this and I’m going to go right to an example of--I think the next one. Sorry. Why is this not? Can you advance to the next slide please? Yeah.

Sixteen-year-old who’s been in a motor vehicle crash. So what’s that child feeling like? The ambulance comes and it goes all over the place and then you end up with people staring down at you. This is the view from the child that you can’t ever forget. And so, what do we think about with distress? Fear about death, but they can’t show it because he’s 16. He might not trust the people around him because these are adults, he doesn’t know who they are, their procedures, he might have a lot of anger at the driver, he’s alone, his parents aren’t there but he can’t really say it because he’s 16. The emotional support, make sure you have eye contact with him, allow any decisions for him to make that are possible, provide non-judgmental space for him to talk because maybe it was his fault, going out and getting hit by the car. And then try to understand the meaning of the event, where it goes.

This is true for injuries or violence or anything else. And then for the family, manage their fears, anger and mistrust. And their larger support system, bring them in, include friends and others. And the barrier is how busy you are. So if you have somebody who has the time to do this, it’s really terrific but you’re going to have to deal with the pre-conceived notions of the staff about, “Oh, my gosh, 16-year-old, he was just running out in the middle of the street, big deal.” Or “he’s got an ankle sprain; I don’t need to worry about traumatic stress”. We had that experience a lot when working in the ER.

So what are the critical issues? Number one, the Cochran collaboration has said, “The universal interventions where you force people to go through a debriefing or things like that can actually be harmful.” So you want to be very careful how you deal with traumatic stress that it’s on the person’s timeline, that you’re really open to talking but you’re not forcing them to talk. Injury severity does not predict post-traumatic stress risk. You have time constraints and you need to be practical.

So in summary, traumatic stress is a helpful way of understanding the reactions of families and the patients to injury and other medical events. The intervention begins with you guys. It begins in the fields, at medical triage, with trauma informed care and screening by all providers. And the treatment may need to continue over time so their needs to be this continuity of information that then gets to the primary care provider.

So our current work is we have just finished a randomized control trial looking at a workbook for parents and children after an injury to see if that can help them. We’re going to be then translating it into the web-based materials that are going to be available to all of you, as well as DVD’s that potentially could be used in the hospital, and then we‘re also thinking about other ways of engaging extremely busy providers. We have tried it with nurses, with primary care doctors, with trauma surgeons, with ED physicians and it is a challenge. It’s yet one more thing we have to think about and so, suggestions you may have would be helpful.

So there are lots of web links that are all in your handout. I won’t necessarily go through these but you can download just about any of the things that I was talking about today or feel free to contact Angela Marks or me. And I’m open for questions.

Yes, thank you. In the back.

UNKNOWN SPEAKER: My question is in your examination of the 16 percent of injured children and 15 percent of the families that went on to post-traumatic stress symptoms and also among the other group, have you looked at the prevalence of long-term disability in either of those groups and whether that makes a difference?

FLAURA WINSTON: We have begun to look at that. It’s interesting. The challenge is that if somebody does have long-term disability, they do have more potential for problems but they also are more involved in the system. They do--like for example physical therapists are terrific with helping kids deal with challenges they might experience.

It is known that long-term stress can cause problems in the family’s structure. That’s really where it gets into, and it can be related to depression. So, I guess we think about the fact that long-term disability can cause long-term stress symptoms, whether they’re traumatic stress symptoms, is not clear. Threat to life, that kind of thing. And we’ve actually looked at cases where you would expect the child--we see it in four ways. There are children who don’t have long-term disability who don’t go on to traumatic stress--that makes sense. There are children who have long-term disabilities that go on to traumatic stress--that kind of makes sense. But there’re also the ones in between. They are the kids who don’t have long-term disability but still go on, and often we find that in that situation, it’s a chaotic family, there’s a lot of pre-existing trauma in the family as well as stress in the child, pre-existing behavioral problems or just not getting the support that that child needs.

And then, there are those who are just wonderful. They are the kids who have long-term disability but they go on to do fine. And we’ve learned a lot from them as well. And so, what I’m trying to get at here is we need to think about those kids who we forget. And those kids are the ones who don’t get the social work consult. They’re the ones who you know when you get in there that that family is really scared, really upset, there isn’t the social support that that child has. The child has a fracture and is in a lot of pain, these are the kinds of children that I’m hoping you’ll begin to start to pay a little more attention to and think about what you can give that family in terms of support.

Does that answer your question? Thank you. Any other questions? Yes.

UNKNOWN SPEAKER: This question relates to that slide, that kind of template of the letter from surgeon (inaudible).

FLAURA WINSTON: Yes. Do you want me to go back to it? I think it’s almost here. Sorry, guys. Anyway ask your--here it is.

UNKNOWN SPEAKER: The language of that template is at a very high literacy rate. So I’m wondering whether you made a special effort to make the other materials very simple written.

FLAURA WINSTON: Great question. The letter is for the primary care pediatrician or a family practice doctor. That’s who the letter goes to and so the materials, all of our materials, are on a very low literacy rate. The things that actually go to families have been usability tested, have been readability tested, things we’re going to have on the web are—we have so many materials--there’s so many people that need to hear about traumatic stress that don’t know about it. From the pediatrician, and we’ve created materials for them that are learning materials as well as this kind of letter, through to the family and then to the children it’s completely different literacy level for them.

Great question. Thank you. Any other questions? Well, thank you very much for your time. And thanks for all the great work you’re doing.