Trauma occurs when an event threatens or causes actual harm to physical or emotional well-being. According to the Centers for Disease Control (Centers for Disease Control and Prevention, 2012), each year, nearly 9 million children are seen in emergency departments after a traumatic event, and over 9,000 die as a result of their injuries. As trauma remains the leading cause of death in children 19 years old and younger, caring for the pediatric trauma patient in the clinical setting is a regular occurrence for clinicians who care for children.
In addition to the physical trauma, children will commonly experience psychological distress and develop acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) after the event (Odenback et al., 2014). After the injury, transient traumatic stress reactions occur in approximately one in six children and their parents leading to persistent posttraumatic symptoms that are linked to poor physical and functional recovery (Kassam-Adams, Marsac, Hildenbrand, & Winston, 2013).
The objective assessment of the risk of PTSD for the patient and family after a traumatic event should be an integral component of a complete trauma work-up. Often, decisions to provide structured psychological support for this population have been purely subjective and thus vary from provider to provider. By utilizing the Screening Tool for Early Predictors of PTSD (STEPP), a validated, brief screening measure designed for the acute care setting, each provider will have an objective means to evaluate all patients and families at potential risk for posttraumatic stress (Winston, Kassam-Adams, Garcia-Espana, Ittenbach, & Cnaan, 2003). Close analysis of the etiology of positive STEPP scores for both children and their caregivers has not yet been well examined. Comparison of STEPP positivity among varying mechanisms of trauma might help us best determine further implementation of this screening tool. In this study, mechanisms of injury included penetrating injury; sports-related trauma; motor vehicle crashes; animal bites; assaults; falls; nonmechanized bike-related trauma; and other including surf injuries, trauma sustained from tools, electrical injuries, and unknown etiologies. The purpose of this study was to evaluate our process for objective screening in an evidence-based manner and to identify mechanisms of trauma that might most benefit from further PTSD evaluation.
ASD AND PTSD
ASD occurs when symptoms including impairment in social, occupational, and other areas of functioning last less than 1 month after injury (Rzucidlo & Campbell, 2009). Acute responses can be disruptive but may lessen naturally over time (Langeland & Olff, 2008). Children with a strong sense of fear, life threat, and loss of control during or after the unintentional injury have been found to be at higher risk for the development of PTSD (Langeland & Olff, 2008). Additional risk factors in the development of PTSD include female gender, pretrauma psychopathology, perception of threat to life, and posttrauma parental distress (Simpson, Rivara, & Pham, 2012).
The diagnosis of PTSD requires symptoms persisting for at least 1 month and includes reexperiencing the inciting event by way of intrusive thoughts or images of the traumatic event that they may encounter in their day-to-day lives, avoidance of reminders of the event, and hyperarousal such as exaggerated startle response or hypervigilance (Rzucidlo & Campbell, 2009; Winston et al., 2003). These triggers may significantly alter the child’s ability to successfully function in home and school settings. Diagnostic criteria of PTSD include a specific traumatic event exposure and symptoms from the following four symptom clusters: intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity (American Psychiatric Association, 2013). Other victims may develop symptoms of depression, separation anxiety, and sleep or conduct disorders (Langeland & Olff, 2008). Some children who experience seemingly less traumatic events experience as much distress and impairment as those who undergo severe trauma. The severity of injury does not seem to impact these rates (Odenbach et al., 2014). Studies of PTSD incidence after natural disasters suggest the populations at greatest risk for PTSD are those without household incomes, those with damaged households, and those who experienced the death of a family member (Kun, Tong, Liu, Pei, & Luo, 2013). About 9% of children who experience low-energy, isolated upper extremity fractures show PTSD symptoms at 3 months after injury (Wallace, Puryear, & Cannada, 2013). Parents and guardians are also affected by the traumatic injury of a child. In a study of parents of burned children, the adults experienced more symptoms of PTSD than the general population when the child was a girl, the event was witnessed by the parent, and there was a history of a previous trauma or feelings of helplessness (McGarry et al., 2013).
Studies have shown that 10%–35% of children will experience PTSD after a traumatic event, whereas many more exhibit subclusters of distressing symptoms (Langeland & Olff, 2008). Several studies have suggested that injuries lead to higher risk of PTSD than other serious pediatric medical conditions such as diabetes and cancer (Simpson et al., 2012). Recognizing the magnitude of the risks of PTSD can catapult the members of the trauma team to take preventive action for children at risk.
Persistent PTSD symptoms can impair the day-to-day interpersonal and academic functioning whether the child meets full criteria for the disorder (Kassam-Adams et al., 2013). Rzudcidlo and Campbell (2009) reported that most children who experience PTSD after an incident are not diagnosed or treated. With this in mind, the entire trauma team is faced with the challenge of providing early identification of children and families at risk after injury.
CLINICAL EVALUATION OF PTSD
Characteristically, nurses are trained to efficiently and effectively intervene clinically when a child is injured. Courses designed to prepare staff to give proficient pediatric trauma care include Pediatric Advanced Life Support, Emergency Nursing Pediatric Course, Trauma Nursing Core Course, and various in-service workshops. Despite these exemplary efforts to deliver evidence-based care to trauma victims, one important factor may be overlooked: the psychological impact after injury.
It is not arguable that evaluation and treatment of concurrent psychological maladies is essential in the holistic care of the trauma patient. However, with scarce mental healthcare resources, evidence-based identification of those most susceptible to PTSD is integral to efficient healthcare distribution (Winston et al., 2003).
The importance of early detection of psychological risk after unintentional physical injury has been well documented. Most injured children do not receive acute and long-term psychological care after injury, and approximately only 20% of trauma centers actively screen pediatric patients on the trauma service (Simpson et al., 2012). Even after correct identification of risk, it is estimated that only 20%–40% of children receive necessary evaluation and mental health services (Makley & Falcone, 2010).
The advance practice nurse (APN) group of our free-standing, pediatric Level I trauma center designated by the American College of Surgeon embarked on a project to identify and appropriately refer children and families at increased risk for PTSD. We recognized that our previous methods of evaluating the psychological care for specific patients were not objective, and multiple needs might not have been met effectively. To evaluate the implementation of STEPP screening, we performed a single-center retrospective review of eligible trauma patients from our institutional trauma databank.
From a systems approach, implementation of STEPP screening was a collaborative process. First, a multidisciplinary team was developed to gain input from designated subspecialists, including trauma physicians and APNs, nurses, social workers, psychologists, physical therapists, occupational therapists, and rehabilitation specialists. This group met weekly to review the screening program implementation and to critique the results. An extensive literature search was completed to determine which evaluation tool would be best utilized for a pilot project. The STEPP was chosen to identify children and families at risk. The STEPP is a brief, one-page tool developed for initial screening in the acute trauma setting (Duzinski et al., 2012). A predictive screener given soon after injury will identify who, in the future, will develop a diagnosis of depression or PTSD (Richmond et al., 2011).
For this study, every child who sustained any type of traumatic injury between the ages of 8 and 18 years and was admitted to this institution was eligible for screening, preferably within 24–48 hours of injury. In certain cases of more severe injury, this was delayed until the patient was able to participate. The parent was evaluated at the same time. One of three pediatric surgery/trauma APNs completed the screening. Barriers to completion can be because of parental absence at the bedside. To gain the colloquial most “bang for one’s buck,” a screening tool must be short, user-friendly, and easy to interpret. Validation of the STEPP tool provides just these components. Winston et al. (2003) described such a tool in the STEPP evaluation (Table 1).
A numerical score of 0–12 is calculated inclusive of all three sections: parent, child, and electronic medical record. The child STEPP score is the sum of Questions 4 through 10 and 12. A score of 4 or more is considered positive. The parent STEPP score is the sum of responses to Questions 1 through 4, 9, and 11. A parental score of 3 or greater is considered positive. This tool can be completed within minutes while providing significant benefits to direct the ongoing holistic trauma care. When a positive score is obtained for the parent and/or the child, a psychology consultation is ordered. At the time of consultation, the staff psychologist interviews both the child and the parent or primary care taker. Through this expanded evaluation, it is determined if further psychological intervention is warranted.
Before the collection of data, institutional review board approval was obtained. Review of all children eligible for STEPP evaluation was performed using data from the institutional trauma databank. Demographic information, mechanism of injury, and STEPP completion and results were also extracted from the electronic medical record. In addition to the STEPP data, the American Association for the Surgery of Trauma’s Injury Severity Score (ISS) was also evaluated. This score weights all injuries of a polytrauma patient by combining the squares of the three highest Abbreviated Injury Scale scores of the six possibly injured body systems. Abbreviated Injury Scale scores of 1–6 are based on severity of injury, with 1 representing a minor injury and 6 representing an unsurvivable injury. ISS scores range from 0 to 75.
SPSS for IBM (SPSS, Inc.) was used to perform statistical analysis. Normally distributed continuous variables were presented as mean ± standard deviation, and independent samples were compared by Student’s t test. Chi-square was used to compare categorical variables. A p value of <.05 was considered significant.
Between January and December 2013, 175 patients between the ages of 8 and 18 years were admitted to the trauma service. Of these eligible children, 142 (81%) underwent a complete STEPP evaluation. Mechanism of injury data fell into one of eight categories (Figure 1).
STEPP examinations were not completed in 19% of eligibly aged children because of lack of APN availability, patient or caregiver availability, severity of injury, or complex social situation. There were no significant differences among gender or patient age in STEPP completion. Of the children with a STEPP evaluation, 68.3% were male compared with those who did not complete STEPP evaluation who were 57.6% male (p = .24). Ages were similar among the two groups (12.6 years ± 2.8 STEPP evaluation vs. 11.7 years ± 3.1 no STEPP evaluation, p = .116).
STEPP evaluations were positive for children and/or parents in 30.3% (n = 43) of those who were screened after traumatic injury. STEPP evaluations were positive in 17.6% of children between the ages of 8 and 18 years. Children with a positive STEPP evaluation were more likely to be female. Of children with a positive STEPP evaluation, 44% (n = 11) were male compared with 73.5% (n = 86) of children with a negative STEPP evaluation (p = .004; Table 2). There were no significant differences in age or ISS among results of STEPP evaluations. Parents and guardians had positive STEPP evaluations 25.3% of the time after their child experienced a traumatic injury. There were no significant differences among the age and gender of the child who sustained traumatic injury for the positivity of the adult portion of the STEPP evaluation.
Discordance was present in 17.5% (n = 25) of caregiver and child STEPP evaluations. In seven instances, the child’s evaluation was positive when the adult’s evaluation was negative (6.6%). In 18 instances, the adult’s evaluation was positive when the child’s STEPP was negative (50%; p < .001).
Age, gender, ISS, and positivity for both child and parent STEPP evaluations were compared among mechanism of injury (Table 3). This study was underpowered to detect significant differences among groups. ISS and STEPP positivity did vary among groups. Groups ranged from 25% to 100% male. Mean ISS per group ranged from 3.4 to 9.6. Positive child STEPP evaluations ranged from 0% to 31.2%.
At our institution, implementation of STEPP screening has improved the overall care of patients and families on the trauma service. It has proven to be a user-friendly, time-sensitive addition to the overall assessment and holistic care provided to children and families. Although the completion of the screening has been an additional task added to the surgical/Trauma APNs’ daily work load, the results have supported our original hypothesis: an objective method of assessment is what was needed to effectively address the global needs of each patient. We have ordered more psychology consultations than in previous years when only a subjective decision related to provider perceived need was the norm. By openly discussing risk of PTSD, we have also had an increased opportunity to provide anticipatory guidance to children and families related to the far-reaching sequelae of a traumatic event. A team approach that includes the psychological impact of various injuries has been fostered and is now routinely discussed as a part of family-centered patient care rounds. According to Winston et al. (2003), the sensitivity of the STEPP tool was noted to be STEPP 0.88 for children and 0.96 for parents. It is estimated that up to 25% of those with a positive STEPP screen will develop PTSD. In our population, this suggests that PTSD symptoms were identified early in about 11 patients. Anecdotally, families have expressed gratitude that the issues related to posttraumatic stress has been addressed during hospitalization.
GREATER EFFECTS OF TRAUMA
The impact of pediatric trauma does not occur in isolation; it affects the entire family unit. Posttraumatic stress is common in both children and caretakers. Parental PTSD can occur whether the parent witnessed the event or sustained an injury themselves (Kassam-Adams et al., 2013). Coping strategies that were utilized might be impacted by the experience of trauma alone, and care takers may not possess sufficient available resources to provide adequate support to the patient. Some early parental anxiety levels can be elevated to near panic reactions, which can range from anguish and helplessness to aggravation (Shudy et al., 2006).
Studies have shown that parents are at least as symptomatic, if not more than their children, a fact that could negatively impact the child’s recovery from PTSD (Langeland & Olff, 2008). This was also shown in our review. Parents with known anxiety can negatively influence the child’s future risk for persistent PTSD symptoms especially if they were present at the time of injury (Duzinski et al., 2012). If unrecognized and untreated, this can hamper full recovery and lead to worse functional outcomes and a poorer health-related quality of life for the trauma victim (Kassam-Adams et al., 2013). Failure to identify and treat ASD and PTSD can lead to a lifetime risk of poor performance, risk-taking behaviors, aggression, depression, suicidal ideation, and increased physical and psychological adult illnesses (Odenback et al., 2014).
Although it is beyond the scope of this article to discuss long-term follow-up of patients with positive STEPP evaluations, further study in this realm is important. Further research needs to be done on the implications of positive parental STEPP evaluations. In our experience, parents’ STEPP evaluations were more likely to be positive than their children’s; although this was not statistically significant, the evaluation of both parent and child is clinically significant, and best practices in the further treatment of these families needs to be established. Screening parents is a key component of the STEPP evaluation, especially when there is discordance in the evaluation between the two groups.
Once the screen was completed, follow-up discussions related to consultative findings were then shared through multidisciplinary rounds. Decisions related to ongoing services were determined utilizing a team approach. Securing the data early in the treatment plan can ensure implementation of adequate support systems for both the child and the care provider in a time-sensitive manner. Recognizing the potential risk factors related to PTSD can lead to early recognition and appropriate interventions to address ongoing symptoms, thus decreasing the potential for negative future outcomes.
Our ability to provide psychological care to children and their families who are at increased risk for PTSD continues to evolve. Our next steps include evaluating the implementation of best practices for inpatient assessment and outpatient follow-up, which are targets for future study.
Along with psychology, further support services for children and families during the acute phase may include consultations with child life specialists, healing touch providers, massage therapists, music therapy and pet therapy. Reputable Web-based resources including www.healthcaretoolbox.org and www.aftertheinjury.org were identified as useful references.
OPPORTUNITIES FOR CLINICAL PRACTICE
There are multiple opportunities to improve the process of this important postinjury screening. We realize that there is a substantial educational opportunity for APN students, medical students, and residents to become actively involved in STEPP screening and follow-through. There is also a critical need for the primary care team to be notified of the results of these evaluations and the current plans for follow-up. If definitive psychological care is declined by the patient or family, the primary team is in a pivotal position to be alert for signs of persistent PTSD and/or depression over time. Outreach efforts describing the global risk of PTSD symptoms after pediatric trauma would be beneficial for teachers, school nurses, and coaches as they continue to interact with children and adolescents after injury.
Objective evaluation of children and families after a traumatic event with a standardized PTSD risk assessment tool (i.e., STEPP) should be instituted as a critical element of pediatric trauma care. Although certain mechanisms of injury, gender, and age increased positive results in children, we postulated that all patients with traumatic injuries are at risk for PTSD. Screening with a short-form tool, such as STEPP, is an easy and effective way to better identify pediatric trauma patients at risk for development of PTSD.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Centers for Disease Control and Prevention (CDC). (2012). Vital signs: Unintentional injury deaths among persons aged 0–19 years - United States, 2000–2009. Morbidity and Mortality Weekly Report, 61, 270–276.
Duzinski S. V., Lawson K. A., Maxson R. T., Garcia N. M., Calfa N., Metz K., … Stark K. (2012). The association between positive screen for future persistent posttraumatic stress symptoms and injury incident variables in the pediatric trauma
care setting. Journal of Trauma Acute Care Surgery, 72 (6), 1640–1646. doi:10.1097/TA.0b
Kassam-Adams N., Marsac M. L., Hildenbrand A., & Winston F. (2013). Posttraumatic stress following pediatric injury: Update on diagnosis risk factors, and interventions. JAMA Pediatrics, 167 (12), 1158–1165. doi:10.1001/jamapediatrics .2013.2741
Kun P., Tong X., Liu Y., Pei X., & Luo H. (2013). What are the determinants of posttraumatic stress disorder
: Age, gender, ethnicity or other? Evidence from 2008 Wenchaun Earthquake. Public Health, 127, 644–652.
Langeland W., & Olff M. (2008). Psychobiology of posttraumatic stress disorder
in pediatric injury patients: A review of the literature. Neuroscience and Biobehavioral Reviews, 32, 161–174. doi:10.1016/j.neurobiorev.2007.07.002
Makley A. T., & Falcone R. A. (2010). Posttraumatic stress disorder
in the pediatric trauma
patient. Seminars in Pediatric Surgery, 19, 292–299. doi:10.1053/j.sempedsurg.2010.06.006
Odenbach J., Newton A., Gokiert R., Falconer C., Courchesne C., Campbell S., & Curtis S. J. (2014). Screening for post-traumatic stress disorder after injury in the pediatric emergency department—A systematic review protocol. Systematic Review, 3, 19. doi:10.1186/2046-4053-3-19
Richmond T. S., Ruzek J., Ackerson T., Wiebe D. J., Winston F., & Kassam-Adams N. (2011). Predicting the future development of depression or PTSD after injury. General Hospital Psychiatry, 53 (4), 327–335. doi:10.1016/j.genhosppsych.2011 .05.003
Shudy M., deAlmeida M., Ly S., Landon C., Groft S., Jenkins T., & Nicholson C. E. (2006). Impact of pediatric critical illness and injury on families: A systematic literature review. Pediatrics, 118, S203–S218.
Simpson A. J., Rivara F. P., & Pham T. N. (2012). Quality care in pediatric trauma
. International Journal of Critical Illness and Injury Science, 2 (3), 149–155. doi:10.4103/2229-5151- 100893. doi:10.1542/peds.2006-0951B
Wallace M., Puryear A., & Cannada L. (2013). An evaluation of posttraumatic stress disorder
and parent stress in children with orthopedic injuries. Journal of Orthopedic Trauma, 27 (2), e38–e41.
Winston F. K., Kassam-Adams N., Garcia-Espana F., Ittenbach R., & Cnaan A. (2003). Screening for risk of persistent posttraumatic stress in injured children and their parents. Journal of the American Medical Association, 290 (5), 643–649.