Pediatric Medical Traumatic Stress

Initial distress among children and families in medical settings is common, expected, and understandable. Many families cope well, with support and with time. However, some may develop persistent traumatic stress reactions, which can impede health and psychosocial functioning.

What is Pediatric Medical Traumatic Stress?

Pediatric medical traumatic stress is "a set of psychological and physiological responses of children and their families to pain, injury, medical procedures, and invasive or frightening treatment experiences" - National Child Traumatic Stress Network, 2003

Traumatic stress reactions can include psychological and physiological symptoms of re-experiencing, avoidance, and hyper-arousal, as well as changes in thinking and mood. These reactions may include:

having unwanted and intrusive thoughts about what happened,
strongly avoiding things that are reminders of the event,
feeling numb or detached, blaming oneself or others, and
having trouble sleeping, eating, or concentrating.

When a constellation of these symptoms persists and causes distress, the individual may have Post-traumatic Stress Disorder (PTSD).

Children may have other kinds of reactions to illness and injury as well, including behavioral changes or symptoms of depression or anxiety.

Traumatic stress reactions are common in the aftermath of an injury, a scary new diagnosis, or a difficult medical event. When they persist, these reactions may get in the way of a child's or parent’s everyday functioning and may warrant further attention.

Over the past several decades, a growing body of research has helped healthcare providers understand the development of traumatic stress reactions after a wide range of pediatric illness, injury, and medical experiences.

In the aftermath of a potentially traumatic event such as illness or injury, traumatic stress can be caused by a loss of a sense of personal safety, and by feelings of fear and helplessness. Children are especially vulnerable to the loss of safety that a medical experience may bring. Age and developmental stage impact how children understand illness, injury, and treatment, as well as their range of coping strategies.

What is traumatic about medical experiences?

Traumatic medical experiences are rarely a single event. All along the continuum of care, children and families in medical settings can experience multiple traumatic experiences (and things that will trigger feelings or remind them of those experiences).

A specific scary or shocking event (injury / initial diagnosis)
Pain / painful procedures
Treatment setbacks
Ongoing uncertainty about prognosis
The medical environment (hospital sights / sounds, etc.)
Sense of life threat (regardless of objective prognosis)
Separation from parents
Exposure to distress, pain, or death of others (e.g., other patients)
Reminders of past traumatic medical experiences
Physical limitations or impairment / visible changes in appearance

Research has shown that when a child is ill or injured, all family members can be affected - the ill or injured child, siblings, and parents. Research has also shown that children and parents may find different aspects of the experience traumatic.

What is most traumatic?

Kids and parents see things differently.*

Child cancer survivors:

Shots
Losing hair
Staying in the hospital
Pain
Bone marrow procedures
Know others that died
Scared about death
Worried about relapse
Feeling sad/scared
Diagnosis - Finding out

Moms of cancer survivors:

Worried about relapse
Pain
Scared about death
Diagnosis - Finding out
Know others that died
Feeling sad/scared
Staying in the hospital
Shots
Bone marrow procedures
Losing hair

*Findings from CHOP study funded by National Cancer Institute (CA63930)

Take-home message from the research data:

What counts in risk for traumatic stress is NOT the objective severity of the child's illness or injury, but the SUBJECTIVE experience of the child or parent.(Are they feeling scared or helpless? Do they think they might die?)

How does traumatic stress affect child health outcomes?

Traumatic stress symptoms (including post-traumatic stress disorder - PTSD) are associated with worse health outcomes in children preschool through adolescence.

Unaddressed, these reactions can have serious implications for medical treatment and can represent a "hidden cost" to the health care system. Traumatic stress symptoms have been associated with:

poorer adherence with needed treatment and medication
adverse health outcomes
worse functional outcomes

Important Finding:

In a study of injured adolescents followed for 2 years post-injury, teens with more severe PTSD symptoms had lower health-related quality of life at each assessment point across the 2 years.

Research has suggested several possible mechanisms, including:

Biological effects: PTSD symptoms might lead to poorer medical outcome in ill or injured children because of physiological changes (i.e., increased heart rate, changes in stress response) associated with PTSD.

Impact of avoidance symptoms on adherence and follow-up care: PTSD symptoms might indirectly lead to poor medical outcome due to avoidance (for example, a child not taking prescribed medications because taking the meds has become a traumatic reminder).

Common underlying risk factors: PTSD symptoms may also be linked with poorer medical outcomes because of important associated features (i.e., prior trauma exposure, experiences of systemic racism) that hamper optimal recovery.

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What is most traumatic?

Take-home message from the research data:

Important Finding: