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Posttraumatic Stress Following Pediatric Injury:  Update on Diagnosis, Risk Factors, and Intervention FREE

Nancy Kassam-Adams, PhD1,2,3; Meghan L. Marsac, PhD2; Aimee Hildenbrand, BA2; Flaura Winston, MD, PhD2,3
[+] Author Affiliations
1Center for Pediatric Traumatic Stress, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
2Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
3Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Pediatr. 2013;167(12):1158-1165. doi:10.1001/jamapediatrics.2013.2741.
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Published online

After pediatric injury, transient traumatic stress reactions are common, and about 1 in 6 children and their parents develop persistent posttraumatic stress (PTS) symptoms that are linked to poorer physical and functional recovery. Meta-analytic studies identify risk factors for persistent PTS, including preinjury psychological problems, peritrauma fear and perceived life threat, and posttrauma factors such as low social support, maladaptive coping strategies, and parent PTS symptoms. There is growing prospective data indicating that children’s subjective appraisals of the injury and its aftermath influence PTS development. Secondary prevention of injury-related PTS often involves parents and focuses on promoting adaptive child appraisals and coping strategies. Web-based psychoeducation and targeted brief early intervention for injured children and their parents have shown a modest effect, but additional research is needed to refine preventive approaches. There is a strong evidence base for effective psychological treatment of severe and persistent PTS via trauma-focused cognitive behavioral therapy; evidence is lacking for psychopharmacological treatment. Pediatric clinicians play a key role in preventing injury-related PTS by providing “trauma-informed” pediatric care (ie, recognizing preexisting trauma, addressing acute traumatic stress reactions associated with the injury event, minimizing potentially traumatic aspects of treatment, and identifying children who need additional monitoring or referral).

Figures in this Article

In the United States alone, more than 200 000 children are injured by violence annually, and 20 million children are injured unintentionally, resulting in 241 000 inpatient admissions, 8.7 million emergency department visits, and more than 10 000 000 primary care visits.13 Given the high prevalence of child injury, even modest rates of problematic emotional and functional health outcomes can have a major effect not only on the burden of injury but also on the everyday practice of pediatrics.4,5 One type of emotional response, posttraumatic stress (PTS), is common after pediatric injury, both for injured children and for their parents.69 If unrecognized, PTS symptoms can pose a threat to full recovery after injury (eg, worse functional outcomes and poorer health-related quality of life)1012 and increase use of health care services.13 The pediatrician and other members of the pediatric health care team can play important roles in ensuring optimal outcomes and efficient use of medical services by practicing “trauma-informed care.”14

“Trauma-informed” pediatric care involves incorporating an understanding of the effect of traumatic stress into medical treatment for illness or injury.14 The care team recognizes and addresses preexisting trauma, as well as traumatic stress reactions associated with the injury, while minimizing potentially traumatic aspects of injury care. Pediatric providers face significant challenges in identifying and addressing PTS symptoms in injured children.15,16 Increasing providers’ understanding can improve identification and appropriate management of these symptoms in injured children, thereby improving child health outcomes.

We provide a narrative review of PTS following pediatric injury. We present a framework for understanding PTS and summarize evidence regarding (1) the prevalence and effect of injury-related PTS symptoms, (2) risk factors for the development of PTS symptoms, and (3) prevention and treatment approaches. (Note that this review focuses on PTS after injuries not related to child abuse or family violence, as the latter are embedded in an ongoing relationship context with different implications for PTS sequelae.) The goals of this review are to highlight what pediatricians (hospital-based clinicians and primary care providers) need to know about injury and PTS and to provide a basic introduction to secondary prevention approaches applicable for pediatric practice.

Medical events, including injury and its treatment, can lead to traumatic stress reactions, including intrusive thoughts, avoidance of reminders of the event, and increased arousal (eg, exaggerated startle response). The Medical Trauma Working Group of the National Child Traumatic Stress Network defined “pediatric medical traumatic stress” as a “set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences.”17 A general traumatic stress framework is a useful way to understand both normative and problematic child and family responses to injury and related medical treatment. Traumatic stress reactions are conceptualized as understandable, although potentially distressing, responses to very challenging experiences.

Injury-related traumatic stress reactions are extremely common. The vast majority of children and parents report at least 1 severe traumatic stress reaction in the first month after injury.8,18 Some aspects of traumatic stress reactions may serve adaptive purposes. After a traumatic experience, naturally occurring processes of psychological recovery often involve repeatedly thinking about the event, balanced with efforts to distract oneself or temporarily avoid distressing reminders. This interplay between reexperiencing and avoiding appears to facilitate recovery by allowing the individual to process and assimilate the new distressing experience while “dosing” his or her exposure so that it is not overwhelming.19 Pediatric providers may find this basic traumatic stress framework useful as a way to help children and parents understand the temporarily distressing emotional reactions that many will experience after an injury.

However, not all traumatic stress reactions are adaptive or helpful. Some acute reactions can be intensely distressing and may interfere with managing essential tasks during recovery. Persistent PTS symptoms can impair day-to-day interpersonal and academic functioning whether or not a child meets full diagnostic criteria for a traumatic stress disorder. Posttraumatic stress disorder (PTSD) or acute stress disorder (ASD) are diagnosed when a specific combination and severity of PTS symptoms creates impairment and warrants clinical attention.20 In 2013, the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) introduced several changes to diagnostic criteria for ASD and PTSD.21,22 The DSM-5 criteria continue to require that the individual has directly or indirectly experienced a potentially traumatic event and has PTS symptoms that cause significant distress or impair functioning. The DSM-5 criteria include symptoms in several categories (Table): intrusion (intrusive distressing memories or dreams, or distress at trauma reminders), avoidance (of thoughts, feelings, people, and activities that are reminders of the trauma), dissociation (altered sense of reality of surroundings or oneself), changes in mood or cognition (persistent exaggerated negative expectations of self, others, or the world; persistent negative emotional state; and feelings of detachment from others), and changes in arousal (hypervigilance, exaggerated startle, sleep disturbance, or concentration difficulties). DSM-5 criteria recognize potential developmental differences in symptom presentations in children (eg, recurrent distressing memories may present as repetitive play with trauma-related themes) and create an early childhood PTSD subtype with lower symptom thresholds for children 6 years of age or younger. Several recent studies indicate that these alterations may not go far enough in adjusting diagnostic criteria for youth and that school-aged children with significant and impairing PTS symptoms are more accurately identified by lower symptom thresholds for PTSD25 and for ASD.26

Table Graphic Jump LocationTable.  Summary of Diagnostic Criteria for Traumatic Stress Diagnoses

After an injury, many children and parents display transient distress, but a significant subset experience persistent PTS symptoms.8,18 A meta-analysis6 of 18 studies found that 19% of injured children developed significant PTS symptoms. Similar rates are reported for parents.79 Posttraumatic stress symptoms have been documented in children and parents after various types of pediatric injury (eg, injuries associated with interpersonal [nonfamily] violence,27 road traffic accidents,8,18,28 burns,7,2931 and animal bites32). Posttraumatic stress symptoms are observed after traumatic brain injury3335 at comparable rates to other injuries. It can be challenging to differentiate dissociative amnesia (a PTS symptom) from organic memory loss after a traumatic brain injury; removing amnesia as a symptom criterion may improve the validity of diagnostic criteria for PTSD after a traumatic brain injury.35 Le Brocque et al36 identified 3 types of PTS symptom trajectories over 2 years after an injury in children 6 to 16 years of age: resilient (consistently low symptoms; 57% of children), recovery (elevated stress with quick recovery; 33% of children), and chronic (consistently elevated symptoms; 10% of children). In a similar study of younger children (1-6 years of age) with burn injuries,31 the vast majority had resilient (72%) or recovery (18%) trajectories, but about 1 in 10 had more problematic trajectories—either chronic (8%) or delayed onset (worsening symptoms; 2% of children).

A growing body of research evidence indicates that various emotional and physical health outcomes of injury are associated with each other. For example, PTS symptoms may co-occur with depression in injured children12,27 and in their parents.37 Posttraumatic stress symptoms are associated with poorer general health outcomes and impaired quality of life. Studies with hospitalized injured children and adolescents,10,12,38 including those with mild to severe traumatic brain injury,34,39 have shown that PTS symptoms are associated with poorer functional recovery a year or more after the injury.

In considering risk factors, it is important to distinguish between markers associated with PTS outcomes and etiological variables that play a role in PTS symptom development.40 Markers can help screen for PTS risk and thus assist in targeting limited resources to children and families who need more support (eg, social work services) or monitoring (eg, follow-up calls or return visits). On the other hand, etiological factors that are malleable in the peritrauma and posttrauma periods may provide avenues for actions by the care team to secondarily prevent or limit the exacerbation of PTS symptoms.41 (In the following discussion, we refer to both types of variables as risk factors and note where these factors may play a role in etiology.)

The strongest evidence regarding risk factors for injury-related PTS comes from meta-analyses that examined predictors of PTS in injured children6,42 or in children exposed to a range of acute traumatic events including injury.43,44 (These meta-analyses calculated effect sizes either as a standardized mean difference, d, where d ≥ 0.5 denotes a medium to large effect, or as a weighted average correlation coefficient, r, where r ≥ 0.3 denotes a medium to large effect.) Risk factors with medium to large effect sizes identified in these meta-analyses included peritrauma subjective life threat (d = 0.82, r = 0.38)6,42 (eg, whether the child believes he or she could have died, whether or not the injury was objectively life-threatening); peritrauma fear (r = 0.36)44; early postinjury psychological reactions of PTS, depression, or anxiety (d = 0.94-1.96, r = 0.44-0.64)6,43,44; parents’ early PTS symptoms (r = 0.34-0.41)42,43; low posttrauma social support (ie, from parents, teachers, and friends) (r = 0.33)44; posttrauma poor family functioning (r = 0.46)44; and specific posttrauma coping strategies (ie, social withdrawal, distraction, or thought suppression) (r = 0.38-0.70).44 Notably, objective injury severity is not in and of itself a risk factor for PTS symptoms.43,44

Some acute physiological and psychological responses are associated with risk for later PTS symptoms. Heart rate at triage or within the first 24 hours of hospital admission for injury predicts the presence or severity of PTSD at 6 weeks,45 3 months,46 and 6 months after injury.45 In medical settings, heart rate is a readily available marker that may enhance screening for PTSD risk.47,48 The potential mechanisms through which elevated acute heart rate is associated with later PTSD remain unclear, although early subjective appraisals of stress and life threat may be associated with stronger physiological responses.49

Greater acute PTS symptoms have consistently been associated with persistent PTS symptoms.18,50,51 Le Brocque et al9 found that the risk of a chronic PTS symptom trajectory was increased when a child had preinjury behavior problems and a more serious injury, combined with more severe acute PTS symptoms. However, a diagnosis of ASD (per DSM-IV criteria) for injured children is not a sensitive predictor of later PTSD diagnosis.18,50,51 In other words, many injured children who go on to have PTSD would not have received a diagnosis of ASD within the first month of their injury.

Coping Strategies and Appraisal Processes

Children’s postinjury psychological recovery is influenced by several potentially malleable processes that occur at the individual level, at the interpersonal level, and in the child’s larger social environment. At the individual level, coping and appraisals together account for a large proportion of the variance in children’s long-term PTS symptoms.52 A key aspect of the child’s postinjury recovery environment is the nature and availability of social support. However, children are not simply passive recipients of social support, and they vary in the extent to which they seek support in the aftermath of injury. The coping strategy of seeking social support has been linked to reduced PTS symptoms in children after injuries or after other acute traumatic events,44,53 and, conversely, social withdrawal as a coping strategy is associated with greater risk of PTSD.44 Persistent PTS symptoms have been associated with children’s use of avoidance coping, distraction, blaming others, and maladaptive cognitive strategies such as thought suppression.5254 On the other hand, use of religious coping may reduce persistent PTSD symptoms.54

A growing body of research has examined the role of posttrauma cognitive appraisals in children’s emotional recovery. (“Appraisals” refer to subjective interpretations [eg, the meaning that an individual attaches to an experience].) Maladaptive appraisals of a traumatic event and of one’s reactions to it include negative (unrealistic) appraisals of one’s vulnerability to future harm or negative interpretations of intrusive memories. These maladaptive appraisals predict the development and maintenance of PTS symptoms in injured children.55 (Note that it is important to distinguish between realistic and unrealistic appraisals of vulnerability to harm because the former can provide an opening for important injury prevention interventions in pediatric care.) History taking during follow-up care after an injury should include probing for coping mechanisms, as well as the child’s interpretations and appraisals (of the injury and its aftermath), in order to identify those mechanisms that may get in the way of recovery and that may require attention.

Role of Parents in the Recovery of a Child

At the interpersonal level, parents play a key role in children’s emotional recovery after injury. However, parents themselves can experience PTS symptoms after a child’s injury, regardless of whether they witnessed the event, were themselves injured, or were not present.7,8 Our current understanding of the interplay of child and parent responses after injury relies heavily on cross-sectional studies, but recent studies have examined potential mutual influences between parent and child PTS symptoms over time. Le Brocque et al9 found a strong association between parent and child PTS symptom trajectories after injury (ie, children of resilient parents were most likely to be resilient). For children with an injury or some other medical event, mothers’ and fathers’ PTS symptoms predicted child symptoms over 1 year, but child symptoms did not predict later parent symptoms.56

There are a number of mechanisms through which a parent’s PTS symptoms might affect the child’s emotional recovery after injury. Parents’ own emotional responses can affect how accurately they appraise their child’s emotional needs, which is essential for effective coping assistance. For example, even when parent-child agreement was strong regarding a child’s postinjury pain, it was poor for a child’s PTS symptoms.57 Parents’ ratings of their child’s PTS showed a systematic bias toward the parent’s own symptoms (ie, parents with more symptoms also rated their child as having more symptoms).57 Interviewing the injured child directly when taking a history may yield the most accurate assessment of the child’s PTS symptoms.

Several recent qualitative studies gathered parents’ own views on providing assistance for their child after injury58 or after another acute traumatic event.59 Parents do not recognize all the ways in which their children cope following injury, so they may have difficultly supporting these strategies.58 The majority of parents attempt to recognize what their child needs59 and to help their child cope after an injury, but many have a limited range of coping assistance strategies58 or find this process challenging.59 As part of a child’s injury care plan, parents may need specific suggestions on how to provide adaptive coping assistance.

Although an extensive body of literature exists regarding effective treatments of pediatric PTSD60,61 (when symptoms persist for ≥1 month and impair function), more recent efforts focus on secondary prevention of persistent symptoms through early intervention. Taking into account the time course and trajectory of children’s psychological responses to injury,62 secondary prevention efforts are delivered early in the trauma trajectory (ie, <6 weeks after an injury), and their intensity and focus are matched to the individual’s risk status and level of need, escalating from universal to targeted to indicated levels of intervention.63Universal preventive interventions are appropriate for all exposed individuals, targeted preventive interventions are appropriate for those with known increased risk, and indicated interventions are for those with more severe distress and may include treatment of acute PTS symptoms. Stepped care models systematically combine preventive interventions across these 3 levels, with treatment as warranted. Many universal and targeted preventive interventions can be delivered directly by pediatric health care providers; most indicated interventions, as well as treatment for persistent PTSD, must be delivered by mental health professionals. Careful empirical evaluation of prevention efforts is needed, given evidence that well-intentioned early “debriefing” interventions, applied universally to trauma-exposed individuals, are ineffective in reducing psychological sequelae,64

Universal Preventive Interventions

Universal secondary preventive interventions for injured children begin with trauma-informed pediatric care.14 The Medical Trauma Working Group of the National Child Traumatic Stress Network created the “D-E-F” protocol to distill key evidence-based guidelines for trauma-informed health care of ill or injured children.65 The organizing idea for the D-E-F protocol is that after pediatric providers have attended to the ABC’s (airway, breathing, and circulation) and addressed physical health needs, the next step is to address “D” (distress), “E” (emotional support), and “F” (the family). For example, addressing distress includes optimizing pain management, minimizing potentially traumatic aspects of treatment and procedures, asking about fears and worries, and providing reassurance and realistic hope. Our Figure presents examples from the D-E-F pocket card set designed to help health care teams remember these core ideas and integrate them into medical care.

Place holder to copy figure label and caption
Figure.
D-E-F Pocket Cards (Revised 2011) From the Pediatric Medical Traumatic Stress Toolkit for Health Care Providers17
Graphic Jump Location

Many universal preventive interventions provide children and parents with information and psychoeducation about traumatic stress reactions and adaptive coping strategies. Randomized controlled trials (RCTs) of single-session universal preventive interventions for injured children do not indicate an effect on PTS symptoms,66,67 but in one trial,67 behavioral sequelae were reduced in younger injured children. Web-based universal prevention resources have been a more recent focus of development because of their potentially wide reach.68 An RCT comparing usual care with a combination of print information for parents and a basic informational website (http://kidsaccident.psy.uq.edu.au) for injured youth showed reduced anxiety in the intervention group (while the control group’s anxiety increased) and reduced PTS symptoms among children with greater PTS at baseline who received the intervention.69 Evaluation of a publicly available website designed to teach parents how to assess their children’s reactions and promote emotional recovery of injured children (www.AfterTheInjury.org) indicated that, after using the site, parents had more specific knowledge about monitoring their child’s PTS symptoms and were able to generate new, positive strategies to help their child recover.70

Targeted and Indicated Preventive Interventions

In this context, we define targeted preventive interventions as those delivered to injured children who have some known additional risk for PTS symptoms, with the aim of interrupting or modifying processes that could lead to persistent PTS. In a recent meta-analysis of early psychological interventions for children after an injury or after another single traumatic event, Kramer et al71 found modest effect sizes for the prevention of PTS symptoms, with targeted interventions somewhat better than universal interventions. Effective interventions included psychoeducation, promotion of coping strategies, and safe exposure to trauma-related triggers.71 For example, the Child and Family Traumatic Stress Intervention is a 4-session intervention targeted to children with at least 1 severe early PTS symptom. This intervention helps parents and children gain a common understanding of the child’s traumatic stress reactions and provides tailored help for specific symptoms.72 In a recent RCT of the Child and Family Traumatic Stress Intervention for children exposed to violence, sexual abuse, accident, or injury, PTSD rates were reduced at 3 months.72 These results suggest that parent-child processes are a promising focus for targeted secondary prevention efforts and point to the importance of including parents in trauma-informed pediatric care.

There is limited research evidence regarding indicated preventive interventions (ie, treating severe acute PTS symptoms in children with the goal of preventing persistent PTSD). Building on the success of trauma-focused cognitive-behavioral therapy (TF-CBT) for treatment of persistent PTSD, a multisite 3-armed RCT is now under way comparing TF-CBT, family-focused TF-CBT, and a wait-list control as an indicated intervention for children with early PTSD diagnosed 6 weeks after hospital admission for injury.73,74

Recent trials of psychopharmacology for secondary prevention of PTSD have yielded mixed results. For example, one small RCT75 of children with burn injuries found sertraline hydrochloride to be effective based on parent reports but not child reports of PTSD symptoms; another RCT76 found that a 10-day course of propranolol hydrochloride initiated within 12 hours after an injury decreased PTSD symptom severity in boys but increased PTSD symptom severity in girls.

Treatment of PTSD

An extensive body of research literature supports the effectiveness of psychotherapy, in particular TF-CBT, for children with persistent PTSD.60,61 Trauma-focused cognitive-behavioral therapy involves several components: psychoeducation about trauma reactions, skill building for anxiety management, helping the child process and “reframe” maladaptive trauma-related appraisals, and encouraging safe exposure to trauma-related triggers. Parents are often involved in treatment to support the child’s evolving coping strategies.60 The current evidence does not support psychopharmacology as a first-line treatment for either acute or persistent PTSD in children; additional studies are needed to examine the utility of medication for severe or comorbid PTS symptoms that do not respond to psychotherapy.77

Stepped Care Models

Stepped care integrates universal, targeted, and indicated interventions in a systematic model of care that encompasses trauma-informed pediatric care, universal screening of injured children for PTS risk, targeted services to those at risk, and provision of indicated trauma-focused mental health interventions when PTS symptoms persist. Brief screening tools have been developed and continue to be refined for this purpose.47,48,78 For injured adults, stepped care models have been shown to effectively address the development of PTS symptoms.79 A pilot RCT80 of a stepped care model for hospitalized injured children (inpatient screening for risk factors or elevated PTS symptoms, followed by targeted follow-up and clinical intervention when indicated) demonstrated the feasibility of implementation but did not reduce 6-month PTS symptoms. A multisite RCT73 now under way is testing a stepped care model with a 2-stage screening process (at 2 weeks and 6 weeks after injury), offering mental health intervention only if significant PTS symptoms are present at 6 weeks.

Posttraumatic stress related to pediatric injury is common and can pose a threat to a child’s full recovery. A substantial research base has established the occurrence and effect of PTS symptoms following injury, and the interrelationship of these psychological sequelae with physical and functional recovery. Within the past several years, meta-analytic studies6,4244 have identified risk factors with large effect sizes, including preinjury psychopathology, peritrauma subjective experience (fear and life threat), early postinjury psychological reactions, and parents’ early PTS symptoms. Maladaptive trauma-related appraisals appear to influence the development and persistence of PTS symptoms.55 Posttrauma social support and adaptive posttrauma coping strategies serve as protective factors.44

Designed with an understanding of these risk and protective processes, the interventions aimed at preventing or treating persistent PTS symptoms often target coping strategies, appraisals, and parents’ role in child recovery. Universal preventive interventions including information and psychoeducation have shown modest effects,69,70 and web-based delivery promises a wide reach.68 There is promising evidence for targeted preventive interventions.71 However, additional well-designed studies of early posttrauma interventions for injured children are needed before we can confidently draw conclusions about the relative role of universal and targeted intervention efforts. For treatment of PTSD in injured children, TF-CBT has the strongest evidence base60; more research is needed to establish its effectiveness as an indicated intervention to treat severe acute PTS symptoms.61

Role of Pediatric Clinicians

Only a small proportion of recently injured children will come into contact with psychosocial or mental health services. Universal and targeted prevention efforts for injury-related PTS symptoms will likely best be accomplished in pediatric health care settings. Pediatric clinicians see injured children and can offer support and information related to trauma reactions and recovery, minimize frightening or painful aspects of injury care, and screen for PTS risk and symptoms. The recognition and treatment of PTS symptoms in young injured children are critical. Primary care providers are uniquely situated to support a stepped care approach by initiating screening for injured children, routinely tracking symptoms to determine whether children require greater intensity of services, and maximizing continuity of care by ensuring that all those involved in a child’s treatment are aware of relevant traumatic stress reactions.81

Research has identified several challenges for pediatric clinicians’ implementation of this role. Providers may not be aware of PTS symptoms as a common and problematic sequela of injury,82 or they may not recognize PTS symptoms in injured children.15,16 A significant proportion of physicians report minimal training in pediatric PTS, and many do not rate themselves as knowledgeable or skilled regarding discussing PTSD with patients.15 Increasing awareness of the need to respond to child psychological trauma from disasters and mass violence83 may provide opportunities to increase the capacity of pediatric medical settings to respond to “everyday” traumas such as injury. In turn, pediatric medical settings that regularly practice trauma-informed care will be better prepared to respond effectively when community-wide events affect the children and families they serve.

Online Resources

Information and tools for trauma-informed pediatric care, including downloadable patient education materials in English and Spanish, are available online at www.HealthCareToolbox.org. The National Child Traumatic Stress Network offers a wide array of resources for parents and professionals at www.NCTSN.org, including an extensive library of free online training regarding child PTS at http://learn.nctsn.org.

Corresponding Author: Nancy Kassam-Adams, PhD, Center for Pediatric Traumatic Stress, Children's Hospital of Philadelphia, 3535 Market St, Ste 1150, Philadelphia, PA 19104 (nlkaphd@mail.med.upenn.edu).

Accepted for Publication: April 18, 2013.

Published Online: October 7, 2013. doi:10.1001/jamapediatrics.2013.2741.

Author Contributions: Kassam-Adams had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kassam-Adams, Marsac, Winston.

Acquisition of data: Kassam-Adams, Winston.

Analysis and interpretation of data: Kassam-Adams, Hildenbrand, Winston.

Drafting of the manuscript: Kassam-Adams, Marsac, Hildenbrand.

Critical revision of the manuscript for important intellectual content: All authors.

Obtained funding: Kassam-Adams, Winston.

Administrative, technical, or material support: Kassam-Adams, Hildenbrand, Winston.

Study supervision: Kassam-Adams, Marsac.

Conflict of Interest Disclosures: None reported.

Funding/Support: Portions of this work were supported by grant 1U79SM061255 from the Substance Abuse and Mental Health Services Administration to the Center for Pediatric Traumatic Stress at the Children’s Hospital of Philadelphia and by Mentored Career Award grant 1K23MH093618-01A1 to Dr Marsac from the National Institute of Mental Health.

Role of the Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Scheeringa  MS, Zeanah  CH, Cohen  JA.  PTSD in children and adolescents: toward an empirically based algorithma. Depress Anxiety. 2011;28(9):770-782.
PubMed   |  Link to Article
Kassam-Adams  N, Palmieri  PA, Rork  K,  et al.  Acute stress symptoms in children: results from an international data archive. J Am Acad Child Adolesc Psychiatry. 2012;51(8):812-820.
PubMed   |  Link to Article
Pailler  ME, Kassam-Adams  N, Datner  EM, Fein  JA.  Depression, acute stress and behavioral risk factors in violently injured adolescents. Gen Hosp Psychiatry. 2007;29(4):357-363.
PubMed   |  Link to Article
Meiser-Stedman  R, Smith  P, Glucksman  E, Yule  W, Dalgleish  T.  The posttraumatic stress disorder diagnosis in preschool- and elementary school-age children exposed to motor vehicle accidents. Am J Psychiatry. 2008;165(10):1326-1337.
PubMed   |  Link to Article
Saxe  GN, Stoddard  F, Hall  E,  et al.  Pathways to PTSD, part I: children with burns. Am J Psychiatry. 2005;162(7):1299-1304.
PubMed   |  Link to Article
Stoddard  FJ, Ronfeldt  H, Kagan  J,  et al.  Young burned children: the course of acute stress and physiological and behavioral responses. Am J Psychiatry. 2006;163(6):1084-1090.
PubMed   |  Link to Article
De Young  AC, Kenardy  JA, Cobham  VE, Kimble  R.  Prevalence, comorbidity and course of trauma reactions in young burn-injured children. J Child Psychol Psychiatry. 2012;53(1):56-63.
PubMed   |  Link to Article
Ji  L, Xiaowei  Z, Chuanlin  W, Wei  L.  Investigation of posttraumatic stress disorder in children after animal-induced injury in China. Pediatrics. 2010;126(2):e320-e324.
PubMed   |  Link to Article
Levi  RB, Drotar  D, Yeates  KO, Taylor  HG.  Posttraumatic stress symptoms in children following orthopedic or traumatic brain injury. J Clin Child Psychol. 1999;28(2):232-243.
PubMed   |  Link to Article
O’Connor  SS, Zatzick  DF, Wang  J,  et al.  Association between posttraumatic stress, depression, and functional impairments in adolescents 24 months after traumatic brain injury. J Trauma Stress. 2012;25(3):264-271.
PubMed   |  Link to Article
Iselin  G, Le Brocque  R, Kenardy  J, Anderson  V, McKinlay  L.  Which method of posttraumatic stress disorder classification best predicts psychosocial function in children with traumatic brain injury? J Anxiety Disord. 2010;24(7):774-779.
PubMed   |  Link to Article
Le Brocque  RM, Hendrikz  J, Kenardy  JA.  The course of posttraumatic stress in children: examination of recovery trajectories following traumatic injury. J Pediatr Psychol. 2010;35(6):637-645.
PubMed   |  Link to Article
Zatzick  D, Russo  J, Grossman  D,  et al.  PTSD and depressive symptoms, alcohol use, and recurrent traumatic life events in a representative sample of hospitalized injured adolescents and their parents. J Pediatr Psychol. 2006;31(4):377-387.
PubMed   |  Link to Article
Landolt  MA, Buehlmann  C, Maag  T, Schiestl  C.  Brief report: quality of life is impaired in pediatric burn survivors with posttraumatic stress disorder. J Pediatr Psychol. 2009;34(1):14-21.
PubMed   |  Link to Article
Kenardy  J, Le Brocque  R, Hendrikz  J, Iselin  G, Anderson  V, McKinlay  L.  Impact of posttraumatic stress disorder and injury severity on recovery in children with traumatic brain injury. J Clin Child Adolesc Psychol. 2012;41(1):5-14.
PubMed   |  Link to Article
Kraemer  HC, Kazdin  AE, Offord  DR, Kessler  RC, Jensen  PS, Kupfer  DJ.  Coming to terms with the terms of risk. Arch Gen Psychiatry. 1997;54(4):337-343.
PubMed   |  Link to Article
Feldner  MT, Monson  CM, Friedman  MJ.  A critical analysis of approaches to targeted PTSD prevention: current status and theoretically derived future directions. Behav Modif. 2007;31(1):80-116.
PubMed   |  Link to Article
Cox  CM, Kenardy  JA, Hendrikz  JK.  A meta-analysis of risk factors that predict psychopathology following accidental trauma. J Spec Pediatr Nurs. 2008;13(2):98-110.
PubMed   |  Link to Article
Alisic  E, Jongmans  MJ, van Wesel  F, Kleber  RJ.  Building child trauma theory from longitudinal studies: a meta-analysis. Clin Psychol Rev. 2011;31(5):736-747.
PubMed   |  Link to Article
Trickey  D, Siddaway  AP, Meiser-Stedman  R, Serpell  L, Field  AP.  A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Clin Psychol Rev. 2012;32(2):122-138.
PubMed   |  Link to Article
Nugent  NR, Christopher  NC, Delahanty  DL.  Initial physiological responses and perceived hyperarousal predict subsequent emotional numbing in pediatric injury patients. J Trauma Stress. 2006;19(3):349-359.
PubMed   |  Link to Article
Kassam-Adams  N, Garcia-España  JF, Fein  JA, Winston  FK.  Heart rate and posttraumatic stress in injured children. Arch Gen Psychiatry. 2005;62(3):335-340.
PubMed   |  Link to Article
Winston  FK, Kassam-Adams  N, Garcia-España  F, Ittenbach  R, Cnaan  A.  Screening for risk of persistent posttraumatic stress in injured children and their parents. JAMA. 2003;290(5):643-649.
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Olff  M, Langeland  W, Gersons  BP.  The psychobiology of PTSD: coping with trauma. Psychoneuroendocrinology. 2005;30(10):974-982.
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PubMed   |  Link to Article
Meiser-Stedman  R, Dalgleish  T, Glucksman  E, Yule  W, Smith  P.  Maladaptive cognitive appraisals mediate the evolution of posttraumatic stress reactions: a 6-month follow-up of child and adolescent assault and motor vehicle accident survivors. J Abnorm Psychol. 2009;118(4):778-787.
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Landolt  MA, Ystrom  E, Sennhauser  FH, Gnehm  HE, Vollrath  ME.  The mutual prospective influence of child and parental post-traumatic stress symptoms in pediatric patients. J Child Psychol Psychiatry. 2012;53(7):767-774.
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Kassam-Adams  N, García-España  JF, Miller  VA, Winston  F.  Parent-child agreement regarding children’s acute stress: the role of parent acute stress reactions. J Am Acad Child Adolesc Psychiatry. 2006;45(12):1485-1493.
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Marsac  ML, Mirman  JH, Kohser  KL, Kassam-Adams  N.  Child coping and parent coping assistance during the peritrauma period in injured children. Fam Syst Health. 2011;29(4):279-290.
PubMed   |  Link to Article
Alisic  E, Boeije  HR, Jongmans  MJ, Kleber  RJ.  Supporting children after single-incident trauma: parents’ views. Clin Pediatr (Phila). 2012;51(3):274-282.
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Cohen  JA, Bukstein  O, Walter  H,  et al; AACAP Work Group On Quality Issues.  Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry. 2010;49(4):414-430.
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Smith  P, Perrin  S, Dalgleish  T, Meiser-Stedman  R, Clark  DM, Yule  W.  Treatment of posttraumatic stress disorder in children and adolescents. Curr Opin Psychiatry. 2013;26(1):66-72.
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Kazak  AE, Kassam-Adams  N, Schneider  S, Zelikovsky  N, Alderfer  MA, Rourke  M.  An integrative model of pediatric medical traumatic stress. J Pediatr Psychol. 2006;31(4):343-355.
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Amstadter  AB, Broman-Fulks  J, Zinzow  H, Ruggiero  KJ, Cercone  J.  Internet-based interventions for traumatic stress-related mental health problems: a review and suggestion for future research. Clin Psychol Rev. 2009;29(5):410-420.
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Cox  CM, Kenardy  JA, Hendrikz  JK.  A randomized controlled trial of a web-based early intervention for children and their parents following unintentional injury. J Pediatr Psychol. 2010;35(6):581-592.
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Marsac  ML, Kassam-Adams  N, Hildenbrand  AK, Kohser  KL, Winston  FK.  After the injury: initial evaluation of a web-based intervention for parents of injured children. Health Educ Res. 2011;26(1):1-12.
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Kenardy  J, Cobham  V, Nixon  RD, McDermott  B, March  S.  Protocol for a randomised controlled trial of risk screening and early intervention comparing child- and family-focused cognitive-behavioural therapy for PTSD in children following accidental injury. BMC Psychiatry. 2010;10:92.
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Cobham  VE, March  S, De Young  A,  et al.  Involving parents in indicated early intervention for childhood PTSD following accidental injury. Clin Child Fam Psychol Rev. 2012;15(4):345-363.
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Stoddard  FJ  Jr, Luthra  R, Sorrentino  EA,  et al.  A randomized controlled trial of sertraline to prevent posttraumatic stress disorder in burned children. J Child Adolesc Psychopharmacol. 2011;21(5):469-477.
PubMed   |  Link to Article
Nugent  NR, Christopher  NC, Crow  JP, Browne  L, Ostrowski  S, Delahanty  DL.  The efficacy of early propranolol administration at reducing PTSD symptoms in pediatric injury patients: a pilot study. J Trauma Stress. 2010;23(2):282-287.
PubMed
Drury  SS, Henry  C.  Evidence-based treatment of PTSD in children and adolescents: Where does psychopharmacology fit? Child Adolesc Psychopharmacol News. 2012;17(3):1-8. doi:10.1521/capn.2012.17.3.1.
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Nixon  RD, Ellis  AA, Nehmy  TJ, Ball  SA.  Screening and predicting posttraumatic stress and depression in children following single-incident trauma. J Clin Child Adolesc Psychol. 2010;39(4):588-596.
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Zatzick  D, Roy-Byrne  P, Russo  J,  et al.  A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Arch Gen Psychiatry. 2004;61(5):498-506.
PubMed   |  Link to Article
Kassam-Adams  N, García-España  JF, Marsac  ML,  et al.  A pilot randomized controlled trial assessing secondary prevention of traumatic stress integrated into pediatric trauma care. J Trauma Stress. 2011;24(3):252-259.
PubMed   |  Link to Article
Cohen  JA, Kelleher  KJ, Mannarino  AP.  Identifying, treating, and referring traumatized children: the role of pediatric providers. Arch Pediatr Adolesc Med. 2008;162(5):447-452.
PubMed   |  Link to Article
Ziegler  MF, Greenwald  MH, DeGuzman  MA, Simon  HK.  Posttraumatic stress responses in children: awareness and practice among a sample of pediatric emergency care providers. Pediatrics. 2005;115(5):1261-1267.
PubMed   |  Link to Article
Laraque  D, Boscarino  JA, Battista  A,  et al.  Reactions and needs of tristate-area pediatricians after the events of September 11th: implications for children’s mental health services. Pediatrics. 2004;113(5):1357-1366.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
D-E-F Pocket Cards (Revised 2011) From the Pediatric Medical Traumatic Stress Toolkit for Health Care Providers17
Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Summary of Diagnostic Criteria for Traumatic Stress Diagnoses

References

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Kassam-Adams  N, Palmieri  PA, Rork  K,  et al.  Acute stress symptoms in children: results from an international data archive. J Am Acad Child Adolesc Psychiatry. 2012;51(8):812-820.
PubMed   |  Link to Article
Pailler  ME, Kassam-Adams  N, Datner  EM, Fein  JA.  Depression, acute stress and behavioral risk factors in violently injured adolescents. Gen Hosp Psychiatry. 2007;29(4):357-363.
PubMed   |  Link to Article
Meiser-Stedman  R, Smith  P, Glucksman  E, Yule  W, Dalgleish  T.  The posttraumatic stress disorder diagnosis in preschool- and elementary school-age children exposed to motor vehicle accidents. Am J Psychiatry. 2008;165(10):1326-1337.
PubMed   |  Link to Article
Saxe  GN, Stoddard  F, Hall  E,  et al.  Pathways to PTSD, part I: children with burns. Am J Psychiatry. 2005;162(7):1299-1304.
PubMed   |  Link to Article
Stoddard  FJ, Ronfeldt  H, Kagan  J,  et al.  Young burned children: the course of acute stress and physiological and behavioral responses. Am J Psychiatry. 2006;163(6):1084-1090.
PubMed   |  Link to Article
De Young  AC, Kenardy  JA, Cobham  VE, Kimble  R.  Prevalence, comorbidity and course of trauma reactions in young burn-injured children. J Child Psychol Psychiatry. 2012;53(1):56-63.
PubMed   |  Link to Article
Ji  L, Xiaowei  Z, Chuanlin  W, Wei  L.  Investigation of posttraumatic stress disorder in children after animal-induced injury in China. Pediatrics. 2010;126(2):e320-e324.
PubMed   |  Link to Article
Levi  RB, Drotar  D, Yeates  KO, Taylor  HG.  Posttraumatic stress symptoms in children following orthopedic or traumatic brain injury. J Clin Child Psychol. 1999;28(2):232-243.
PubMed   |  Link to Article
O’Connor  SS, Zatzick  DF, Wang  J,  et al.  Association between posttraumatic stress, depression, and functional impairments in adolescents 24 months after traumatic brain injury. J Trauma Stress. 2012;25(3):264-271.
PubMed   |  Link to Article
Iselin  G, Le Brocque  R, Kenardy  J, Anderson  V, McKinlay  L.  Which method of posttraumatic stress disorder classification best predicts psychosocial function in children with traumatic brain injury? J Anxiety Disord. 2010;24(7):774-779.
PubMed   |  Link to Article
Le Brocque  RM, Hendrikz  J, Kenardy  JA.  The course of posttraumatic stress in children: examination of recovery trajectories following traumatic injury. J Pediatr Psychol. 2010;35(6):637-645.
PubMed   |  Link to Article
Zatzick  D, Russo  J, Grossman  D,  et al.  PTSD and depressive symptoms, alcohol use, and recurrent traumatic life events in a representative sample of hospitalized injured adolescents and their parents. J Pediatr Psychol. 2006;31(4):377-387.
PubMed   |  Link to Article
Landolt  MA, Buehlmann  C, Maag  T, Schiestl  C.  Brief report: quality of life is impaired in pediatric burn survivors with posttraumatic stress disorder. J Pediatr Psychol. 2009;34(1):14-21.
PubMed   |  Link to Article
Kenardy  J, Le Brocque  R, Hendrikz  J, Iselin  G, Anderson  V, McKinlay  L.  Impact of posttraumatic stress disorder and injury severity on recovery in children with traumatic brain injury. J Clin Child Adolesc Psychol. 2012;41(1):5-14.
PubMed   |  Link to Article
Kraemer  HC, Kazdin  AE, Offord  DR, Kessler  RC, Jensen  PS, Kupfer  DJ.  Coming to terms with the terms of risk. Arch Gen Psychiatry. 1997;54(4):337-343.
PubMed   |  Link to Article
Feldner  MT, Monson  CM, Friedman  MJ.  A critical analysis of approaches to targeted PTSD prevention: current status and theoretically derived future directions. Behav Modif. 2007;31(1):80-116.
PubMed   |  Link to Article
Cox  CM, Kenardy  JA, Hendrikz  JK.  A meta-analysis of risk factors that predict psychopathology following accidental trauma. J Spec Pediatr Nurs. 2008;13(2):98-110.
PubMed   |  Link to Article
Alisic  E, Jongmans  MJ, van Wesel  F, Kleber  RJ.  Building child trauma theory from longitudinal studies: a meta-analysis. Clin Psychol Rev. 2011;31(5):736-747.
PubMed   |  Link to Article
Trickey  D, Siddaway  AP, Meiser-Stedman  R, Serpell  L, Field  AP.  A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Clin Psychol Rev. 2012;32(2):122-138.
PubMed   |  Link to Article
Nugent  NR, Christopher  NC, Delahanty  DL.  Initial physiological responses and perceived hyperarousal predict subsequent emotional numbing in pediatric injury patients. J Trauma Stress. 2006;19(3):349-359.
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