Children with chronic and/or serious illnesses are exposed to many potentially traumatizing situations. Examples include receiving a frightening diagnosis, exposure to painful procedures, coping with unfamiliar and complex medical technologies, being separated from a parent, and watching one’s body change and abilities decrease.

Pediatric Iatrogenic Medical Trauma refers to 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. Children with such symptoms may meet criteria for a diagnosis of posttraumatic stress disorder or acute stress disorder.

It is important to recognize and address trauma symptoms in medically ill children for several reasons.  Traumatic experiences change brain structures and functions, potentially causing long-term problems with memory, emotions, or behavior. Most importantly, trauma symptoms can lead to fear related avoidance of medical recommendations, increased risky behaviors, and poorer health status.  Fear related avoidance of medical recommendations can lead to life-threatening medical problems.

The most commonly reported trauma symptoms among children include refusing or avoiding medical care, persistently talking about the traumatic event, distress when exposed to reminders of the trauma (syringes, the hospital, pills, doctors, etc), nightmares, new separation anxiety or clinginess, new fears or worries, crying, sleep disturbance, increased motor activity, and increased irritability or tantrums. Young children may display emotional numbing by withdrawing from family members and from play. In an extreme state, the child might curl up in a ball and completely refuse to engage. Those children with other past unrelated traumas in their life are at higher risk for developing medical trauma symptoms.

Children fare best when they have learned and can use effective coping skills and when they have supportive parents who encourage their children to use coping skills. Children do less well if they feel helpless (do not know any skills they could use to help themselves) or when they have little helpful social support.

Parents can advocate for trauma prevention in several ways. First, parents can ask for their children to be trained in effective coping skills by Child Life Specialists or mental health clinicians. Second, parents can model calm and effective coping skills.  Third, they can remind their children to use distraction and relaxation skills to prepare for medical procedures. Fourth, parents can talk to clinicians to ensure that distressing symptoms, such as pain or delirium, are immediately addressed.

Most children and adults will experience resolution of mild trauma symptoms with family support.  Trauma-focused treatment is indicated for those who remain highly distressed or impaired. Such treatment typically includes education about trauma and coping skills training focused on emotion identification and regulation, communication, problem-solving and trauma trigger management.  Because parents are such an important source of support, a family-based treatment approach is most effective.

 

Communication tips for parents

  • Provide your child with honest information about what is happening or about to happen, at pace set by him or her;
  • Provide realistic choices and engage your child in treatment decisions, if they desire;
  • Listen carefully for your child’s understanding, ask your child questions, and clarify misconceptions;
  • Ask your child directly about his or her fears and worries;
  • Provide realistic reassurance and hope to your child;
  • Encourage your child to use distraction, relaxation or other of his or her effective coping techniques;
  • Use your own coping resources and support in order to optimally assist your child.

Other recommendations for parents:

  • Provide a calm, consistent environment and a predictable routine.
  • Recognize the emergence of new oppositional or baby-like behaviors as possible signs of distress.
  • Encourage all family members to express themselves, reminding them it is normal to feel sad and cry.
  • Encourage your child to talk to someone outside of the family, ideally a professional from the health care team, so they also have support from someone they will not feel the need to protect.
  • When you cannot be present in the hospital with your child, provide your child with comforting items from home as well as scheduled opportunities for communication, such as by phone or computer.
  • To improve his or her mood & feelings of accomplishment, encourage your child to participate in an activity or hobby he or she enjoys and does well.
  • Expect that your child may to need to think about and discuss his or her trauma experiences again and again as they grow up and can see their experiences from a more mature perspective.

Based on: Forgey M, Bursch B.  Assessment and management of pediatric iatrogenic medical trauma.  Curr Psychiatry Rep. 2013 Feb;15(2):340.

Brenda Bursch
Brenda Bursch, PhD is a Professor of Clinical Psychiatry & Biobehavioral Sciences, and Pediatrics Clinical Director, Pediatric Psychiatry Consultation Liaison at David Geffen School of Medicine at UCLA.

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