WHEN THE WORLD IS TURNED UPSIDE DOWN

New findings from child traumatic stress research

Eva Alisic, 17 May 2018

www.trauma-recovery.net

@EvaAlisic

Picture of floodsPicture of a firePicture of refugeesPicture of an injured childPicture of a funeral?

Picture of floodsPicture of a firePicture of refugeesPicture of an injured childPicture of a funeral?

Children & Trauma: What we know

67%

Children & Trauma: What we know

15%

Children & Trauma: What we know

Social support

Life threat appraisal

First

responders

Caregivers

Teachers

Friends

Mental

health pros

Psychological First Aid

contact and engagement

safety and comfort

stabilization (e.g. calming)

info gathering re needs

practical assistance

connection with social

support

informing about coping

linking w. collaborative

services

D – E – F model

Emergency professionals

▪ Knowledge

▪ Attitudes

▪ Confidence

▪ Training wishes

2648 emergency department staff

812 paramedics

Knowledge of child traumatic stress (% correct)

All age groups are at risk for traumatic stress 38.6%

Various behaviors (e.g. calm, frantic) can precede tr stress 31.1%

Pain experience is a risk factor 43.0%

> 50% of children report stress symptoms in 1st month 7.0%

• …

• …

• …

• …

• …

Significant predictors

• Experience (years)

• …

• … Non-significant

Knowledge of child traumatic stress

Staff were moderately confident (M = 3)

Explaining procedures to children and parents

Educating children and parents about traumatic stress

• …

• …

• Experience (years)

• …

Significant predictors

• …

• …

• …Non-significant

Confidence re psychosocial care

Appetite for training

93%

Thanks to a wonderful team & great supporters

Many, many young people, families, and colleagues who contributed and shared their experiences

Members of the team(s):

Sarah Curtis, Anupam Kharbanda, Mark Lyttle, Niccolo Parri, Rachel Stanley, Franz Babl, Anna Barret, Melita Giummarra, Laura Jobson, Rolf Kleber, Juul Gouweloos, Arend Groot, Hanneke Snetselaar, Tielke Stroeken, Elise v/d Putten, Lieve Hehenkamp, Revathi Krishna, John Frederick, Shaminka Gunaratnam, Rowena Conroy, Matthias Mehl, Vicki Anderson, Helen Jowett, Roderick McClure, Cameron Palmer, Prue Dunstan, Hayley Ayton, Jasmine Loo, Caitlin Arthur, Deborah Lewis,Scott McDonald, Caitlin Bishop, Peter Bowles, Georgina Johnstone, Naile Alangor, Claire Hoysted & Maggie Lam

Financial support:

The Australian National Health & Medical Research Council (NHMRC), Netherlands Organisation for Scientific Research, Monash University Larkins Program, Victorian Government’s Infrastructure Support Program, Royal Children’s Hospital Foundation, SAMSHA, Netherlands Ministry of Security & Justice; Prof. Weijersstichting, et al.

First

responders

Caregivers

Teachers

Friends

Mental

health pros

The EAR – Electronically Activated Recorder

EAR for Recovery study

▪ Prospective cohort study of 71 children aged 3-16 (hospitalized ≥ 24hrs)

▪ Children wore the EAR for 2 days after discharge,

30-second snippets every 5 mins

▪ Phone follow-up at 6 weeks & 3 months re child mental health (sub-sample)

EAR data collection

The child wore the EAR for 2 days

The 30-second snippets were downloaded

All snippets were transcribed and coded

≈20,000

Adult male: Oh my goodness oh what have you done?

Child: Had to go to hospital … because I fell over the top of my horse’s head…

Father: Face planted….

Adult male: Goodness me.

Father: Ended up a couple of days at the Children's. About a week off school.

Child: Two nights, three days.

Injury talk

• How much time do children spend interacting with others?

• How much of their interactions are about the injury?

• How much of their injury interactions are about emotions?

What’s your guess?

• How much time do children spend interacting with others?

• How much of their interactions are about the injury?

• How much of their injury interactions are about emotions?

What’s your guess?

47% (wake time)

• How much time do children spend interacting with others?

• How much of their interactions are about the injury?

• How much of their injury interactions are about emotions?

What’s your guess?

47% (wake time)

11% (46 minutes)

• How much time do children spend interacting with others?

• How much of their interactions are about the injury?

• How much of their injury interactions are about emotions?

What’s your guess?

47% (wake time)

11% (46 minutes)

20% (9 minutes)

• More specific analyses and coding

• Databank for future research

• Use as a clinical tool

Follow the action via www.trauma-recovery.net

Next steps

Intimate Partner Homicides

• More than 1/3 of female homicides

• Often children involved

• Professionals with little experience

• Far-reaching consequences of decisions

Study to understand children’s and families’…

1. Characteristics

2. Experiences

3. Well-being and mental health outcomes

Design

3. Mixed methods study: in-depth assessment

2. Case file study

1. Incidence study

Assessbias

Child & family characteristics

7.4 years old

Child & family characteristics

Child & family characteristics

83%

Child & family characteristics

43% (16% unclear)

Characteristics of the homicide

• Mother is victim: 87%

• Homicide at home of child: 80%

• Child certainly not on location: 41%

• Cutting weapon: 51% Fire-arm: 20%

Insights from the interviews (re 40 youth)

Fragile balance:

• Functioning but still major influence on daily life

• Grief symptoms among caregivers

• Lack of continuity in professional support

• Variation & pressure regarding contact with perpetrator; stress due to legal procedures

Preliminary conclusions

• Cliche but true: each case is unique

• Burden is exceptionally high

• Mental health professionals should be involved

• Continuity of support & mediation are important

• Need for culture-sensitive support

• Need to give children a voice re their wishes

First

responders

Caregivers

Teachers

Friends

Mental

health pros

In conclusion…

Gaps in knowledge & desire for training

In conclusion…

46 minutes & counting…

In conclusion…

Improving detection &

providing more care

Thank you!

Key references (I)Children & Trauma – exposure, PTSD, predictors• Copeland WE, Keeler G, Angold A, Costello EJ. Traumatic events and posttraumatic stress in

childhood. Arch Gen Psychiatry. 2007;64:577-84.

• Trickey, D., Siddaway, A.P., Meiser-Stedman, R., Serpell, L., & Field, A.P. (2012). A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Clinical Psychology Review, 32, 122-138

• Marsac, M.L., Kassam-Adams, N., Delahunty, D.L., Widaman, K.F., & Barakat, L.P., (2014). Posttraumatic stress following acute medical trauma in children: A proposed model of bio-psycho-social processes during the peri-trauma period. Clinical Child and Family Psychology Review, 17, 399-411

• Alisic , E., Boeije, H.R., Jongmans, M.J., & Kleber, R.J. (2011) ‘Children's perspectives on dealing with traumatic events, Journal of Loss and Trauma, 16, 477-496.

• Alisic, E, Boeije, HR, Jongmans, MJ & Kleber, RJ 2012, ‘Supporting children after single-incident trauma parents’ views’, Clinical Pediatrics, vol. 51, pp. 274-282.

• Alisic, E, Jongmans, MJ, van Wesel, F & Kleber, RJ 2011b, ‘Building child trauma theory from longitudinal studies: a meta-analysis’, Clinical Psychology Review, vol. 31, pp. 736-747.

• Alisic, E., Zalta, A.K., Van Wesel, F., Larsen, S.E., Hafstad, G.S., Hassanpour, K., & Smid, G.E. (2014). Rates of post-traumatic stress disorder in trauma-exposed children and adolescents: meta-analysis. British Journal of Psychiatry, 204, 335-340.

• Gunaratnam, S. & Alisic, E. (2017). Epidemiology of trauma and trauma-related disorders in children and adolescents. In Landolt, Schnyder & Cloitre (Eds.) Evidence Based Treatments for Trauma-Related Disorders in Children and Adolescents, Springer

Key references (II)Psychosocial Care / Psychological First Aid / D-E-F model• Brymer M, Jacobs A, Layne C, Pynoos R, Ruzek J, Steinberg A, et al. Psychological first aid field

operations guide, 2nd Edition. National Child Traumatic Stress Network and National Center for PTSD. 2006.

• Psychological First Aid online course. Available from: http://learn.nctsn.org/course/index.php?categoryid=11

• Stuber ML, Schneider S, Kassam-Adams N, Kazak AE, Saxe G. The medical traumatic stress toolkit. CNS Spectr 2006; 11:137-42

• Kassam-Adams, N., Marsac, M.L., Hildenbrand, A., & Winston, F. (2013). Posttraumatic stress following pediatric injury: Update on diagnosis, risk factors, and intervention. JAMA Pediatrics167, 1158-1165. doi: 10.1001/jamapediatrics.2013/2741

• Alisic, E., Hoysted, C., Kassam-Adams, N., Landolt, M.A., Curtis, S., Kharbanda, A.B., Lyttle, M.D., Parri, N., Stanley, R., & Babl, F.E. (2016). Psychosocial care for injured children: worldwide survey among hospital Emergency Department staff. Journal of Pediatrics 170: 227-33

• Alisic, E., Tyler, M.P., Giummarra, M.J., Kassam-Adams, R., Gouweloos, J., Landolt, M.A., & Kassam-Adams, N. (2017). Trauma-informed care for children in the ambulance: International survey among pre-hospital providers. European Journal of Psychotraumatology. doi: 10.1080/20008198.2016.1273587

• Hoysted, C., Babl, F.E., Kassam-Adams, N., Landolt, M.A., Jobson, L., Curtis, S., Kharbanda, A.B., Lyttle, M.D., Parri, N., Stanley, R., & Alisic, E. (in press). Perspectives of Hospital Emergency Department Staff on Trauma-informed Care for Injured Children: An Australian and New Zealand Analysis. Journal of Paediatrics and Child Health.

Key references (III)

EAR & Ear for Recovery Study

• Mehl, MR, Pennebaker, JW, Crow, DM, Dabbs, J & Price, JH 2001, ‘The Electronically Activated Recorder (EAR): a device for sampling naturalistic daily activities and conversations’, Behavior Research Methods Instruments and Computers, vol. 33, pp. 517.

• Mehl, MR, Robbins, ML & Deters, Fg 2012, ‘Naturalistic observation of health-relevant social processes: the Electronically Activated Recorder methodology in psychosomatics’, Psychosomatic Medicine, vol. 74, pp. 410-417.

• Mehl, MR, Vazire, S, Ramírez-Esparza, N, Slatcher, RB & Pennebaker, JW 2007, ‘Are women really more talkative than men?’, Science, vol. 317, no. 5834, p. 82.Robbins et al

• Alisic, E, Barrett, A, Bowles, P, Conroy, R, & Mehl, MR 2016, ‘Families coping with child trauma: A naturalistic observation methodology’, Journal of Pediatric Psychology, vol. 41, pp. 117-127.

• Alisic, E, Barrett, A, Bowles, P, Babl, FE, Conroy, R, McClure, RJ, Anderson, V & Mehl, MR 2015, ‘Ear for recovery: protocol for a prospective study on parent–child communication and psychological recovery after paediatric injury,’ BMJ Open, vol. 5, e007393

• Alisic, E., Gunaratnam, S., Barrett, A., Conroy, R., Jowett, H., Bressan, S., Babl, F.E.,McClure, R.J., Anderson, V. & Mehl, M.R. (2017). Injury talk: spontaneous parent-child conversations in the aftermath of a potentially traumatic event, working paper on PsyArXiv

Key references (IV)

Intimate partner homicide & ‘Care for Children after IPH’ study

• Stöckl, H., Devries, K., Rotstein, A., Abrahams, N., Campbell, J., Watts, C., & Moreno, C. G. (2013). The global prevalence of intimate partner homicide: a systematic review. The Lancet, 382, 859-865.

• Lewandowski, L. A., McFarlane, J., Campbell, J. C., Gary, F., & Barenski, C. (2004). "He killed my mommy!" Murder or attempted murder of a child's mother. Journal of Family Violence, 19, 211-220.Alisic et al BMC Psychiatry

• Alisic, E., Krishna, R.N., Groot, A., & Frederick, J.W. (2015). Children's mental health and wellbeing after parental intimate partner homicide: a systematic review. Clinical Child and Family Psychology Review, 18, 328-345

• Alisic, E., Groot, A., Snetselaar, H., Stroeken, T., & Van de Putte, E. (2015). Parental intimate partner homicide and its consequences for children: protocol for a population-based study. BMC Psychiatry, 15, 177

• Alisic, E., Groot, A., Snetselaar, H., Stroeken, T., & Van de Putte, E.M. (in press) Children Bereaved by Fatal Intimate Partner Violence: A Population-Based Study into Demographics, Family Characteristics and Homicide Exposure. PLOS One

Pictures

Christian Gonzalez Alfonso, CC BY-NC 2.0 https://www.flickr.com/photos/cristyanlaison/2608123006/

IHH Humanitarian Relief Foundation, CC BY-NC-ND 2.0 http://bit.ly/2v3Oxaf

Douglas Sprott, CC BY-NC 2.0, http://bit.ly/2u4EgGj

Roberto Volterra (CC BY-NC 2.0) https://www.flickr.com/photos/cater87/8244447915/in/photolist-dywX8H-tdrpxn-7VZzT7-qgDX4m-dZHZhJ-dZChe2-UkEjCD-7Y39ax-aRmqa4-dZHXWQ-7yQtHq-5Xodfg-5XodsK-7yX18Y-dZChH8-umxjz-6a7zNN-dyZu7M-oE1tQH-dz5Vfj-S3rowL-dZHY9J-JrpHq-hh3E-bjuUYq-eSKNYH-qgE96w-4Win59-91YUFH-4MFf8j-9ZGjS4-ewcYth-4346k8-qgN3Da-98aWYm-qgDvWL-tiFcm-6z3CBk-dz61bG-6z7HyG-5tjCC6-a5Mz3e-7KDEvV-6FPTS9-qgLm3e-5WAa5i-dywXrH-5JhpMy-6TSNEW-4kNr7K

Other pictures via Wikimedia commons or personal pictures.