I felt that in order to be a ‘good mother’ I needed to stay in the procedure room with my son. The nurse told me that I could leave for a few minutes until the IV was in, and then I could return to hold and comfort my son. I could not have left without her encouragement. I thank her to this day for recognizing my pain and my limitation.
Key Intervention Points in Medical Care:
Some children and families experience medical traumatic stress at the moment of a life-threatening injury or at the time of diagnosis. However, potentially traumatic events occur all along the continuum of care. Things that may seem routine or familiar to professionals can be viewed as threatening and traumatic by children and families.
By keeping a trauma-informed perspective in mind, health care providers can try to minimize the potentially traumatic aspects of care within their own environments, and reduce the likelihood of ongoing traumatic stress.
There are common critical junctures along the health care continuum where children and families can experience traumatic stress.
Each section below presents information on what may be traumatic at this point in care, and gives tips for minimizing traumatic stress reactions. By incorporating a few of these simple tips into routine care, providers can have a significant impact on the experience of children and families.
Click each heading below to expand:
Prehospital Care
Ambulance transport can be very frightening to children, especially when they are separated from parents / caretakers, and may cause them to over-estimate the life-threat or seriousness of their condition.
Exposure to additional elements at the scene – blood, injury of others, wreckage, etc. – can be especially traumatic to children.
- Provide simple explanations about what is happening and what will happen next.
- Minimize additional exposure to traumatic elements at the scene or during transport.
- Encourage parent presence. If not possible, remember you will be viewed by the child as a surrogate parent.
Emergency Care
The sights and sounds of the ER can be very frightening for children and may cause them to over-estimate life threat and the seriousness of their condition.
Being in pain and being separated from parents are two significant risk factors for persistent traumatic stress in children.
Children’s and providers’ perceptions of what is happening can differ. In the ER, children may not tell you what they are thinking or feeling, or that they are worried and anxious.
- Explain that feeling worried, mad, sad, or confused is common and expected.
- Ask about fears and worries and provide simple explanations for medical procedures.
- Talk with the child at his/her eye level.
- Encourage parent presence and support parents in comforting their child.
Admission
Research suggests that an unexpected hospital admission is associated with increased risk for posttraumatic stress in children and parents.
Children and families can feel disoriented or in a daze during the admissions process, due to traumatic stress.
- Provide simple explanations about what is happening and what will happen next.
- Explain that feeling worried, confused, or numb is common and expected.
- Slow down the pace of your dialogue to match the child’s or the parent’s.
- Ask open-ended questions to check their understanding.
- Be willing to repeat important information.
Diagnosis and Treatment Planning
The time of diagnosis can be especially traumatic for children and families and is influenced by their perception of life threat.
Most initial responses, including shock and disbelief, crying, feeling worried, angry, overwhelmed, or numb are common and often temporary.
Children and families are often able to absorb only some of the factual information they hear, due to emotional reactions.
Children and families may feel anxious and helpless during this process, but they may not admit it.
- Explain that feelings of shock, disbelief, or worry are common and expected.
- Slow down your pace when delivering factual information
- Be prepared to repeat important information.
- Ask open-ended questions about fears and worries (e.g. You look a little worried – what worries you the most?)
- Involve the child and parents as much as possible in treatment planning.
Inpatient Treatment
During an initial hospital stay, children and families often do not know what to expect. What may seem routine to providers, staff, and experienced families can seem awkward, frightening, and unfamiliar to newly admitted children and families.
Many newly admitted children and families may initially feel isolated, or isolate themselves as part of the adjustment process.
Parents may feel awkward or uncertain regarding how to be a parent to their seriously ill or injured child, not knowing what their role is in the hospital. They may also feel helpless at seeing their child in pain or hooked up to medical equipment.
- Patiently orient families to the hospital environment.
- Explain, and normalize sights (e.g. medical equipment, other sick children) and sounds (e.g. codes) they may encounter.
- Help families establish daily routines and behavioral expectations.
- Involve children and families as much as possible in daily care and decision-making.
- Recognize parents / caretakers as experts on their child.
- Identify and incorporate family strengths and coping resources into treatment plan.
Painful Treatment and Treatment Setbacks
Common emotional responses to painful treatment procedures and to treatment setbacks include feeling sad, depressed, irritable, angry, scared, or withdrawing from others.
Some children and families experience a setback as a failure rather than a “bump” in the road.
Setbacks can also trigger a renewal of earlier distress and regression in emotion and behavior.
- Explain that feelings of anger, sadness, frustration, and fear are common and expected.
- Be open to expressions of strong emotions (including anger).
- Don’t trivialize or dismiss worries or fears.
- Remember that "difficult" or angry parents are often scared or traumatized, trying to put up a tough front.
- Help children and families connect with their coping strengths and spiritual resources.
Rehabilitation
With the transition to rehab, children and families can become more anxious or upset. They may experience this transition period as a loss, especially if it involves a change providers or the treatment team.
Children can experience significant pain, emotional loss, anger, or frustration when challenged to do something that once came naturally, but is now more difficult.
Traumatic reminders of the event often get triggered during rehab.
Children and parents sometimes get angry at providers for what they perceive as “pushing too hard” or for triggering reminders.
Children with physical injuries and limitations can feel different from peers and might withdraw from friends and family as a result.
- Explain that feelings of loss and frustration are common and expected, with the physical and emotional demands of rehab.
- Ask about and validate the child’s or family’s feelings of frustrations.
- Anticipate that trauma reminders might get triggered during rehab.
- Plan in advance with the child and family about how they will cope with challenges.
- Identify the child’s strengths and coping resources and include in the rehab plan.
Discharge Planning
Some families experience discharge from the hospital as a time when they lose medical support and a sense of safety. They may become anxious, agitated, argumentative, or avoidant as discharge time nears.
Parents may feel uncertain or incompetent regarding how they will cope with the medical and treatment issues at home without frequent support.
Trauma triggers, flashbacks, and nightmares may intensify during this period.
- Remember that as discharge nears, children and families typically experience positive feelings, as well as negative - worry, fear, or loss of a safety net.
- Help the family anticipate the medical, social, and emotional challenges of returning to the home environment.
- Help families identify coping strategies and resources they will use.
- Ask parents about what knowledge or skills they need to support caring for their child at home.
Outpatient Treatment / General Pediatrics
The transition from the hospital to home can be difficult for some children and families. They may expect to return to “normal” very quickly -- many children and families do not anticipate the adjustment period that can be needed.
Family members may become irritable and anxious while trying to re-establish normal routines, and may try to rush the normal adjustment process.
Children who look and feel different may worry about how their friends and peers will react and may avoid interacting with them at first.
Siblings may be affected too. They may be resentful of their ill or injured brother or sister but also feel guilty, and worry in private about the future.
During the transition to home, parents might be especially watchful and hypervigilant about their child’s safety. They may go out of their way to avoid places and people that trigger upsetting memories, or dealing with feelings that they put on hold.
- Help families anticipate the need to adjust after illness or injury and to plan for it.
- For parents, explain that feelings of worry and hypervigilance are common.
- Encourage parents to gradually let go of unrealistic worries.
- Remind parents that siblings can be affected too and to address their worries.
- Stress the importance of setting normal behavioral limits with their children.
- Encourage ill or injured children to do things on their own, as appropriate.
- Help parents help their child reconnect with friends and plan activities as allowable.
- Help children prepare answers to common questions that their classmates might ask.
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