Statement on Post-Traumatic Stress Disorder in Pediatric Trauma Patients

The American College of Surgeons (ACS) Committee on Trauma (COT), through its Subcommittee on Injury Prevention and Control, prepared the following Statement on Post-Traumatic Stress Disorder in Pediatric Trauma Patients to educate surgeons and other medical professionals on the significance of post-traumatic stress disorder (PTSD) and the mental health impact of trauma in children. The ACS Board of Regents approved this statement at its October 2017 meeting in San Diego, CA.

The ACS recognizes the following facts:

• PTSD is a state of emotional and behavioral disorder that can result from witnessing or experiencing an event involving actual or possible death, serious injury, or physical or sexual violence.
• PTSD is defined as a set of four symptom clusters that include intrusive memories, thoughts, or sensations relating to the event; avoidance of people, places, objects, or sensations associated with the event; negative alterations in mood and thought patterns; as well as hyperarousal, anxiety, and unhealthy reactivity to stress. Symptoms lasting longer than 30 days after the event are considered to be PTSD, whereas symptoms observed soon after the event (lasting at least three days and up to 30 days) are considered acute stress disorder (ASD).¹
• Epidemiologic investigation at U.S. trauma centers demonstrates that approximately 20–40 percent of injured trauma survivors experience high levels of PTSD and/or depressive symptoms in the year following injury.^2-4
• A relationship has been found between the symptoms of PTSD, depression, and functional impairment, as well as quality of life during the first year after injury in adolescents.^4,5
• Victims of interpersonal forms of trauma, such as domestic or community violence and child physical and sexual abuse, have increased risk of developing PTSD.^6-8
• Well-disseminated, evidence-based behavioral interventions exist for treating pediatric PTSD, which can serve as resources for children and adolescents who score positive on screening protocols.^9,10

The ACS supports efforts to promote, enact, and sustain legislation and policies that encourage the following:

• Implementing a screening/referral protocol into the care of pediatric trauma patients for ASD/PTSD using an evidence-based tool, such as www.HealthCareToolbox.org (National Child Traumatic Stress Network), and integration of the protocol into the electronic health record.^8,11-15
• Implementing hospital-based violence intervention programs with a mental health component specific for children in hospitals that care for those patients affected by interpersonal violence.¹⁶
• Enhanced research funding to better understand PTSD and other trauma-related disorders in children following injury, and to identify best methods of alleviating the symptoms and their sequelae.
• Parents of trauma-exposed children also may experience emotional and behavioral consequences related to the event, which may influence children’s recovery; thus, attending to the parents’ needs also is critical.

References

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-5^®), Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
2. Holbrook TL, Hoyt DB, Coimbra R, Potenza B, Sise M, Anderson JP. Long-term posttraumatic stress disorder persists after major trauma in adolescents: New data on risk factors and functional outcome. J Trauma. 2005;58(4):764-769.
3. Shih RA, Schell TL, Hambarsoomian K, Belzberg H, Marshall GN. Prevalence of posttraumatic stress disorder and major depression after trauma center hospitalization. J Trauma. 2010;69(6):1560-1566.
4. Zatzick D, Jurkovich GJ, Fan MY, et al. Association between posttraumatic stress and depressive symptoms and functional outcomes in adolescents followed up longitudinally after injury hospitalization. Arch Ped Adolescent Med. 2008;162(7):642-648.
5. Holbrook TL, Hoyt DB, Coimbra R, Potenza B, Sise M, Anderson JP. High rates of acute stress disorder impact quality of life outcomes in injured adolescents: Mechanism and gender predict acute stress disorder risk. J Trauma. 2005;59:1126-1130.
6. Alarcon LH, Germain A, Clontz AS, et al. Predictors of acute posttraumatic stress disorder symptoms following civilian trauma: Highest incidence and severity of symptoms after assault. J Trauma. 2012;72(3):629-635.
7. Resse C, Pederson T, Avila S, et al. Screening for traumatic stress among survivors of urban trauma. J Trauma Acute Care Surg. 2012;73(2):462-468.
8. Kassam-Adams N, Marsca ML, Hildenbrand A, Winston F. Posttraumatic stress following pediatric injury update on diagnosis, risk factors and intervention. JAMA Pediatrics. 2013;167(12):1180-1187.
9. Gillies D, Taylor F, Gray C, O’Brien L, D’Abrew N. Psychological therapies for the treatment of post‐traumatic stress disorder in children and adolescents (Review). Evid Based Child Health. 2013;8(3):1004-1116.
10. de Arellano MA, Lyman DR, Jobe-Shields L, et al. Trauma-focused cognitive-behavioral therapy for children and adolescents: Assessing the evidence. Psychiatr Serv. 2014;65(5):591-602.
11. Gaines BA, Hansen K, McKenna C, et al. Report from the Childress Summit of the Pediatric Trauma Society, April 22–24, 2013. J Trauma Acute Care Surg. 2014;77(3):504-509.
12. Wong EC, Schell TL, Marshall GN, Jaycox LH, Hambarsoomians K, Belzberg H. Mental health service utilization after physical trauma: The importance of physician referral. Med Care. 2009;47(10):1077-1083.
13. Kassam-Adams N, García-España F, 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.
14. Kenardy JA, Cox CM, Brown FL. A web-based early intervention can prevent long-term PTS reactions in children with high initial distress following accidental injury. J Trauma Stress. 2015;28(4):366-369.
15. Zatzick D, Russo J, Lord SP, et al. Collaborative care intervention targeting violence risk behaviors, substance use, and posttraumatic stress and depressive symptoms in injured adolescents: A randomized clinical trial. JAMA Pediatr. 2014;168(6):532-539.
16. Purtle J, Dicker R, Cooper C, et al. Hospital-based violence intervention programs save lives and money. J Trauma Acute Care Surg. 2013;75(2):331-333.