Posttraumatic stress disorder and injury

Concepts and definitions: PTSD and the range of normal responses to trauma 

In the first few days and weeks following a traumatic event (such as an injury), it is common for children and adults to have unwanted and upsetting thoughts or feelings about the trauma, and to feel more jumpy or on edge (a general sense of being on the lookout for possible danger). Many individuals want to avoid things that remind them of the traumatic event. These reactions appear to be normative: in a recent study, more than four fifths of injured children and their parents reported at least one of these symptoms in the first month post-trauma.1 Certain aspects of these early reactions may even play a role in promoting recovery. For example, repeated mental re-experiencing of the trauma may serve, over time, to reduce the emotional impact of reminders.

However, when these posttraumatic stress symptoms persist and impair an individual’s functioning, they may constitute a traumatic stress disorder. Acute stress disorder (ASD) describes particularly problematic early responses to trauma; posttraumatic stress disorder (PTSD) is diagnosed when severe symptoms persist for at least one month (Table 1). PTSD consists of a constellation of re-experiencing, avoidance, and hyper-arousal symptoms following a traumatic experience. While the definition of PTSD requires a specific number of symptoms in each of these symptom categories, individuals may be affected significantly even if their symptom picture does not meet official diagnostic criteria for the disorder.2 Examples of statements that reflect traumatic stress symptoms are provided in Table 2.

TABLE 1. Classification of ASD and PTSD

	Symptom	ASD	PTSD
	Dissociation	At least 3 symptoms	Not required
	Re-experiencing	Persistent	At least 1 symptom
	Avoidance	Marked	At least 3 symptoms
	Hyperarousal	Marked	At least 2 symptoms
	Duration of symptoms	2 days to 1 month	1 month or more

Acute stress disorder (ASD) is diagnosed when the individual experiences (or witnesses) a traumatic event and has a subjective response of fear, helplessness, or horror. Posttraumatic stress disorder (PTSD) occurs when those symptoms persist and impair the individual’s functioning. Adapted from DSM-IV.6

TABLE 2. Examples of Statements Reflecting Acute Stress Symptoms

	Category	Statement
	Fear, helplessness, horror	“I wanted to make it stop happening, but I couldn’t.”
	Dissociation	“My mind went blank.”
		“What was happening seemed unreal to me—like I was in a dream or watching a movie.”
	Re-experiencing	“Pictures or sounds from what happened keep popping into my mind.”
	Avoidance	“I am trying not to remember or think about what happened to me.”
	Arousal	“I feel jumpy.”

PTSD has been identified in the aftermath of experiences as disparate as combat, natural disasters, rape, witnessing violence, and childhood abuse.3, 4, 5 PTSD is not limited to directly experienced traumatic events and may follow vicarious traumatic exposure.6 For example, a parent can develop PTSD after witnessing or learning of his/her child’s injury. In injured adults, posttraumatic stress symptoms have been found to be one of the best predictors of poorer physical and functional recovery,7 highlighting the importance of identifying and treating these symptoms as part of comprehensive medical care.

Prevalence of PTSD after pediatric injury 

Significant posttraumatic symptoms have been identified in 22% to 50% of children assessed 1 to 3 months after an unintentional traumatic injury, and in 12% to 29% of children assessed up to one year after an injury.8, 9, 10, 11, 12, 13 Injury severity is not associated with the severity of posttraumatic stress responses.9, 10 Traffic crashes appear to be a primary precipitant for PTSD in children, regardless of the nature or severity of injuries sustained.10, 13

PTSD in children and youth from exposure to violence, including witnessing violence in the community, has been well documented, with prevalence rates ranging from 15% to 67%.14, 15, 16 Acute stress symptoms appear to be common among urban youth seen in an ED for violent injury, with more than 80% reporting some symptoms and about one third reporting significant acute posttraumatic distress.17 A recent prospective study found that symptoms of acute stress reported by violently injured youth during acute care in the ED correlate with future reporting of posttraumatic stress symptoms months after the event.15

Risk factors for PTSD after injury 

One month after his injury, Thomas’ initial reactions are beginning to resolve. He still jumps when he hears tires squealing, but he no longer has nightmares, and he has been able first to walk through the park with his grandmother, and then to play there with her nearby. He is beginning to think that he may even try to ride his bike again “real soon.”

Six months later, Thomas’ grandmother reports that his physical injuries seem completely healed. He has resumed riding his bike, although he appears to be more cautious and no longer rides in the street. With Thomas’ return to bike riding, his grandmother continues to feel somewhat more anxious about his safety than before the injury, but feels able to cope with this, and even jokes about it with her friends and with her grandson.

One month after the car crash, Keisha has returned to school and is getting around on crutches. She rides the school bus with no problem, but is extremely anxious whenever she must ride in a car. She no longer wants to hang out with the friends she was traveling with to the dance. Keisha’s mother reports that even though she tries not to think about it, she often has vivid mental images of her daughter trapped and bleeding in the car. She states that her husband is also having difficulty coping.

Six months later, Keisha finds that thoughts of the crash frequently intrude, even when she is relaxing with friends. She feels anxious when anything reminds her of the night she was injured, and though she can manage to ride in a car, she tries to avoid sitting in the back seat. To distract herself, she tries to stay busy with work and activities, though she is having a hard time concentrating on her schoolwork. Keisha’s mother frequently thinks about the crash, and feels very anxious whenever Keisha is away from home. Her father tries to avoid the stretch of road where the crash occurred, and states that he still can’t “get over what happened.”

Because not every individual exposed to a potentially traumatic event will develop a traumatic stress disorder, it is particularly important to identify associated risk factors (Table 3). The broad empirical literature on posttraumatic stress in adults and children suggests that the following elements are associated with increased risk of PTSD development after any sort of traumatic event: history of prior traumatic experience, perceived life threat during the traumatic event, severity of exposure to the trauma, signs of hyperarousal (eg, elevated heart rate) post-trauma, and (for children) increased parental acute distress.3, 4, 18, 19 Both cases presented here have elements that might point to a risk for poor outcome: Thomas has a history of neglect and abuse, and showed acute symptoms of re-experiencing and avoidance; Keisha was separated from her parents at the time of her injury, was frightened that her friends were hurt, and showed early sleep disturbance, re-experiencing symptoms, and social isolation. The interplay between these risk factors and each child’s resources (his/her psychological resources as well as family and social context) will help to determine the course of psychological recovery after injury.

TABLE 3. Elements Associated With Increased Risk of PTSD Development After A Traumatic Event

	History of prior traumatic experience(s)
	Perceived life threat during the traumatic event
	Severity of exposure to the trauma
	Signs of posttraumatic hyperarousal (eg, elevated heart rate)
	Increased parental acute stress responses

In traumatically injured adults, the research literature indicates that prior trauma, female gender, alcohol use, acute stress disorder symptoms, and physiological arousal (elevated heart rate in the first week after injury) are associated with increased risk of developing PTSD.20, 21, 22, 23, 24 The smaller research literature regarding children’s psychological reactions to traumatic injury generally echoes the risk factors found for adults, and also suggests a key role for parents in children’s recovery. If a child or his/her parent exhibit acute stress reactions soon after the event, the child is more likely to develop PTS symptoms or PTSD.9, 11, 15 Conversely, it has been shown that emotional disclosure between family members after a trauma can promote more positive post-trauma outcomes.25

Parent reactions to pediatric injury 

Traumatic stress responses have been reported in parents of children with unintentional injuries1, 10 or burns.26 In one of the few studies to assess parent symptoms prospectively after pediatric injury, 23% of parents had significant acute stress responses within one month of their child’s injury.1 Importantly, a strong relationship has been reported between parent and child posttraumatic stress symptoms after diverse types of traumatic experiences.18, 27, 28 More specifically, for children with traumatic injuries, parents’ acute stress symptoms have been shown to be highly associated with later child PTSD outcomes.9, 11, 29 The potential reasons for this association are many. Children and parents may share an underlying temperamental propensity for anxiety symptoms; parents may model more or less anxious responses that affect the child’s budding repertoire of coping skills; and the parent’s own posttraumatic stress symptoms may adversely affect his/her ability to provide effective support for the child in the aftermath of a traumatic event.

Each parent may cope with their own posttraumatic responses differently, as illustrated in the cases presented above. Keisha’s parents were understandably anxious, and because of their own worries had great difficulty assisting their daughter to approach situations she feared. Thomas’ grandmother was able to find ways to manage her increased anxiety concerning his safety, and to assist him in regaining a sense of security and overcoming his desire to avoid the place in which he had been injured. Her help appears to have been pivotal in promoting his resilience in the face of this traumatic experience.

PTSD treatment 

While it is beyond the scope of this paper to provide a detailed description of treatment for PTSD, we will outline empirically validated treatment approaches. Pharmacological approaches have been studied for adults. Two selective serotonin reuptake inhibitors are currently approved for treatment of PTSD in adults; however, there are currently no published controlled studies of pharmacological treatment for PTSD in children.30 First-line treatment for PTSD in children or adults involves cognitive behavioral therapy (CBT), a specific psychotherapeutic approach that includes exposure therapy, anxiety management training, and “cognitive restructuring.”31, 32, 33

Exposure therapy is provided by a mental health professional who is trained in CBT. Its key element is a carefully guided re-experiencing of the traumatic event within the safe environment of therapy. The therapist first teaches the individual specific anxiety management skills (eg, breathing exercises), and then assists the individual to construct a detailed narrative about the trauma, including events, thoughts, and emotions as they unfolded in the individual’s awareness. This narrative is often written down or recorded on audiotape. In therapy sessions and as homework, the individual reads or listens to the narrative repeatedly, until his/her subjective level of anxiety begins to diminish. When exposure is used with children, it may involve play or other creative methods of re-telling the traumatic experience. Exposure is usually accompanied by cognitive restructuring, in which the therapist assists the individual to identify and challenge maladaptive thoughts (eg, “No matter what I do, I can again be safe”) that help to maintain PTSD symptoms.

There is strong empirical evidence that a time-limited course of psychotherapy (typically 10-20 sessions over several months) that includes these elements reduces PTSD symptoms. Randomized controlled trials have shown that it is superior to both a wait list control condition and to supportive counseling.34, 35

PTSD prevention 

There are currently no empirically validated interventions for preventing posttraumatic stress in injured children. The adult literature on secondary prevention post-trauma provides some ideas in this regard.36 However, this literature also contains an important note of caution, in that some early interventions have been shown to have no effect on posttraumatic stress responses and perhaps even to exacerbate these responses for some individuals.37 Current evidence strongly suggests that we screen trauma-exposed individuals and target interventions only to those at most risk. It may, in fact, be ineffective or harmful to apply intensive preventive interventions to all injured patients.36

For all trauma-exposed individuals, caring acknowledgement of their experience and the provision of information about normal stress responses are appropriate and helpful. For individuals assessed to be at risk or experiencing acute distress, we can provide psychoeducation that encourages the natural processes of coping and social support.36, 38 In addition, we can educate about specific reactions, such as hyperarousal, and coach children and parents how to cope with these reactions.39 It is important to promote child and parent responses that increase social support and reduce counter-productive coping strategies (such as avoidance or increased alcohol use).40 For individuals with acute stress disorder, there is growing support for brief CBT approaches.41 The cutting edge of current research and practice in early posttraumatic intervention is a systematic investigation of which interventions work, for whom, during which time period post-trauma, and in which service delivery context.36

Implications for emergency physicians 

Children with traumatic injuries in the ED offer us the opportunity to screen and provide early interventions for the secondary prevention of PTSD. ED physicians can play a pivotal role in promoting resilience and emotional recovery for injured children in their care.42

Screen to identify children at risk for PTSD 

Identifying and addressing a child’s risk for future psychological sequelae during an ED visit for traumatic injury presents several challenges. Chief among these are time limitations and the difficulty of differentiating normal reactions to trauma from the reactions that presage continuing problems. The majority of injured children will experience some acute trauma-related stress symptoms, but only a portion of these children will develop PTSD or other sequelae.1 A particular challenge is that, by definition, symptoms must persist for at least one month for PTSD to be diagnosed.

There are a few evidence-based early markers that are easily assessed by ED and trauma clinicians. Empirical evidence has shown that some common-sense markers (eg, injury severity) are useful predictors of psychological outcomes. On the other hand, for violently injured adolescents, acute stress symptoms in the ED appear to be predictive of risk for later PTSD symptomology.15 The Screening Tool for Early Predictors of PTSD (STEPP) may be a useful tool for children with unintentional injuries.43 The STEPP is an empirically-derived tool consisting of 4 yes/no questions for the child, 4 for the parent, and 4 items easily obtained from the medical record. STEPP items predicting child PTSD include female gender, prior behavior or attention problems, having an elevated heart rate at the time of ED triage, having an extremity fracture, the child’s exposure to others injured at the same time, separation from parents at the time of injury and ED treatment, and whether the child was extremely frightened or thought that s/he might die (Table 4). The STEPP has demonstrated excellent predictive qualities for children with unintentional injuries and for their parents.43

TABLE 4. Acute Predictors of Child PTSD After Injury

	Female gender
	Prior behavior or attention problems (reported by parent)
	Elevated heart rate at the time of ED triage
	Child’s exposure to others injured at the same time
	Separation from parents at the time of injury and ED treatment
	The child was extremely frightened or thought that s/he might die.

Anticipatory guidance for parents and patients 

When the opportunity exists for a more extended conversation with the child or adolescent patient or his/her parent, it is useful to provide anticipatory guidance regarding posttraumatic stress reactions to a traumatic injury (Table 5). Such guidance is particularly important for children, teens, or parents with multiple risk factors (see TABLE 3, TABLE 4), or evident acute distress. The following are core messages to be incorporated whenever possible: (1) it is normal for children to have reactions to an injury. They may think about it a lot, and may try to stay away reminders of what happened. These reactions are often the child’s or teen’s way of trying to deal with what happened. (2) Sometimes the reactions last too long or are too extreme, and they become problems. (3) Parents can help children recover well by talking openly about the injury event, answering the child’s questions, and gently encouraging the child to talk about it. Older children and teens may benefit from writing down their experiences and feelings. (4) Parents should have the child resume normal activities as much as possible given physical recovery from the injury. (5) Parents should ask for help if a child has intense or persisting reactions that get in the way of returning to normal activities allowed by the child’s physical recovery. (6) Finally, parents should be encouraged to seek support for themselves if talking about what happened makes the parent tense or upset.

TABLE 5. Discussion Points for Use With Families and Patients After an Injury

	1. It may be normal for a child to try to deal with what happened by:
	• Thinking a lot about their injury event;
	• Staying away from reminders of what happened.
	2. These reactions may become problems if they last too long or are too extreme.
	3. To help your child recover:
	• Talk openly about the injury event;
	• Answer your child’s questions, and gently encourage him or her to talk about it;
	• Older children and teens may benefit from writing down their experiences and feelings;
	• Have your child resume normal activities as much as physically possible.
	4. Ask for help if:
	• Your child has intense or persisting reactions that get in the way of normal activities;
	• Talking about what happened makes you tense or upset.
	• If you think that you or your child needs help, please call________

Conclusions 

Clinicians should be aware of the psychological ramifications of even minor injuries in children. Evaluation of these sequelae can begin in the immediate post-injury time period. We are beginning to learn how to identify high-risk individuals, and how to provide effective targeted secondary prevention for injury-related posttraumatic stress. Emergency physicians can offer appropriate anticipatory guidance to families to help reduce the persistence and severity of these posttraumatic stress reactions.