Publications by authors named "Meghan L Marsac"

46 Publications

COVID-19 Unmasked Global Collaboration Protocol: longitudinal cohort study examining mental health of young children and caregivers during the pandemic.

Eur J Psychotraumatol 2021;12(1):1940760. Epub 2021 Aug 6.

Queensland Centre for Perinatal and Infant Mental Health (QCPIMH), Children's Health Queensland Hospital and Health Service (CHQ, HHS), Brisbane, Australia.

Background: Early empirical data shows that school-aged children, adolescents and adults are experiencing elevated levels of anxiety and depression during the COVID-19 pandemic. Currently, there is very little research on mental health outcomes for young children.

Objectives: To describe the formation of a global collaboration entitled, 'COVID-19 Unmasked. The collaborating researchers aim to (1) describe and compare the COVID-19 related experiences within and across countries; (2) examine mental health outcomes for young children (1 to 5 years) and caregivers over a 12-month period during the COVID-19 pandemic; (3) explore the trajectories/time course of psychological outcomes of the children and parents over this period and (4) identify the risk and protective factors for different mental health trajectories. Data will be combined from all participating countries into one large open access cross-cultural dataset to facilitate further international collaborations and joint publications.

Methods: COVID-19 Unmasked is an online prospective longitudinal cohort study. An international steering committee was formed with the aim of starting a global collaboration. Currently, partnerships have been formed with 9 countries (Australia, Cyprus, Greece, the Netherlands, Poland, Spain, Turkey, the UK, and the United States of America). Research partners have started to start data collection with caregivers of young children aged 1-5 years old at baseline, 3-months, 6-months, and 12-months. Caregivers are invited to complete an online survey about COVID-19 related exposure and experiences, child's wellbeing, their own mental health, and parenting.

Data Analysis: Primary study outcomes will be child mental health as assessed by scales from the Patient-Reported Outcomes Measurement Information System - Early Childhood (PROMIS-EC) and caregiver mental health as assessed by the Depression Anxiety Stress Scale (DASS-21). The trajectories/time course of mental health difficulties and the impact of risk and protective factors will be analysed using hierarchical linear models, accounting for nested effects (e.g. country) and repeated measures.
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http://dx.doi.org/10.1080/20008198.2021.1940760DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8354018PMC
August 2021

Topical Review: Medical Trauma During Early Childhood.

J Pediatr Psychol 2021 Aug;46(7):739-746

Department of Counseling and Clinical Psychology, Columbia University Teachers College.

Objective: Early childhood is a high-risk period for exposure to traumatic medical events due to injury/illness. It is also one of the most important and vulnerable periods due to rapid development in neurobiological systems, attachment relationships, cognitive and linguistic capacities, and emotion regulation. The aim of this topical review is to evaluate empirical literature on the psychological impact of medical trauma during early childhood (0-6 years) to inform models of clinical care for assessing, preventing, and treating traumatic stress following injury/illness.

Methods: Topical review of empirical and theoretical literature on pediatric medical traumatic stress (PMTS) during early childhood.

Results: There are important developmental factors that influence how infants and young children perceive and respond to medical events. The emerging literature indicates that up to 30% of young children experience PMTS within the first month of an acute illness/injury and between 3% and 10% develop posttraumatic stress disorder. However, significant knowledge gaps remain in our understanding of psychological outcomes for infants and young children, identification of risk-factors and availability of evidence-based interventions for medical trauma following illness.

Conclusions: This topical review on medical trauma during early childhood provides: (a) definitions of key medical trauma terminology, (b) discussion of important developmental considerations, (c) summary of the empirical literature on psychological outcomes, risk factors, and interventions, (d) introduction to a stepped-model-of-care framework to guide clinical practice, and (e) summary of limitations and directions for future research.
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http://dx.doi.org/10.1093/jpepsy/jsab045DOI Listing
August 2021

Opportunities to support emotional health in school-age children with food allergy.

Ann Allergy Asthma Immunol 2021 06 24;126(6):728-729. Epub 2021 Feb 24.

Division of Pulmonology, Department of Pediatrics, College of Medicine, University of Kentucky, Lexington, Kentucky.

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http://dx.doi.org/10.1016/j.anai.2021.02.017DOI Listing
June 2021

Development of an international data repository and research resource: the Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive.

Eur J Psychotraumatol 2020 10;11(1):1729025. Epub 2020 Mar 10.

Traumatic Stress Center, Summa Health System, Akron, OH, USA.

: Studies that identify children after acute trauma and prospectively track risk/protective factors and trauma responses over time are resource-intensive; small sample sizes often limit power and generalizability. The Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive was created to facilitate more robust integrative cross-study data analyses. : To (a) describe creation of this research resource, including harmonization of key variables; (b) describe key study- and participant-level variables; and (c) examine retention to follow-up across studies. : For the first 30 studies in the Archive, we described study-level (design factors, retention rates) and participant-level (demographic, event, traumatic stress) variables. We used Chi square or ANOVA to examine study- and participant-level variables potentially associated with retention. : These 30 prospective studies (N per study = 50 to 568; overall N = 5499) conducted by 15 research teams in 5 countries enrolled children exposed to injury (46%), disaster (24%), violence (13%), traffic accidents (10%), or other acute events. Participants were school-age or adolescent (97%), 60% were male, and approximately half were of minority ethnicity. Using harmonized data from 22 measures, 24% reported significant traumatic stress ≥1 month post-event. Other commonly assessed outcomes included depression (19 studies), internalizing/externalizing symptoms (19), and parent mental health (19). Studies involved 2 to 5 research assessments; 80% of participants were retained for ≥2 assessments. At the study level, greater retention was associated with more planned assessments. At the participant level, adolescents, minority youth, and those of lower socioeconomic status had lower retention rates. : This project demonstrates the feasibility and value of bringing together traumatic stress research data and making it available for re-use. As an ongoing research resource, the Archive can promote 'FAIR' data practices and facilitate integrated analyses to advance understanding of child traumatic stress.
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http://dx.doi.org/10.1080/20008198.2020.1729025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144287PMC
March 2020

Attending to the Not-so-Little "Little Things": Practicing Trauma-Informed Pediatric Health Care.

Glob Pediatr Health 2019 27;6:2333794X19879353. Epub 2019 Sep 27.

Center for Injury Research & Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

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http://dx.doi.org/10.1177/2333794X19879353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767707PMC
September 2019

Evaluating the Acceptability and Validity of Assessing Pain and Posttraumatic Stress Symptoms in an Adaptable eHealth System for School-Age Children.

Clin Pract Pediatr Psychol 2019 Mar;7(1):9-19

Kentucky Children's Hospital and University of Kentucky.

Objective: To provide initial evaluation of the acceptability of a new eHealth system incorporating personalized self-report assessment of multiple health domains in school age children, and assess convergent validity of two brief measures presented via this system.

Methods: Ill or injured children (N=167) age 6 to 14 recruited in two pediatric health care systems used the prototype eScreen interface on a mobile device to select an avatar and complete brief assessments of pain and posttraumatic stress symptoms (PTSS). Children rated technology acceptability and completed validated measures for pain and PTSS.

Results: Children's ratings indicated they found the eScreen interface easy to use (mean rating 4.4 on a 1-5 scale), potentially useful in helping them recover (mean=3.7), and would use / recommend it (mean=4.0). Among children age 6 to 8, mean ratings were: easy to use (3.7), usefulness (3.3), would use/recommend (3.4). Acceptability was largely consistent across child gender, family income, or usual access to mobile devices. eScreen measures showed strong convergent validity with established measures. The eScreen Pain Screener was highly correlated (r =.86 - .92) with, and evidenced strong agreement with, two validated pain measures. eScreen PTSS scores were strongly correlated with a validated PTSS measure (r=.67); a positive PTSS screen was associated with significantly higher PTSS severity.

Conclusions: Study results support the acceptability (ease of use, intention to use/recommend, perceived usefulness) of these tools for older school age children, and provide strong initial evidence for the validity of two brief measures presented in a novel digital modality.
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http://dx.doi.org/10.1037/cpp0000261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604622PMC
March 2019

A Prospective Examination of Child Avoidance Coping and Parental Coping Assistance After Pediatric Injury: A Mixed-Methods Approach.

J Pediatr Psychol 2019 09;44(8):914-923

University of Kentucky.

Objective: Millions of children experience injuries annually, and avoidance coping increases risk of negative emotional and physical outcomes after injury. Little is known about how children select avoidance coping strategies. Parents may help their children cope with an injury by encouraging or discouraging the use of specific strategies, such as avoidance coping. The present study examined parental influence of child use of avoidance coping post-injury.

Methods: Children ages 8-13 (65% male; 50% White) hospitalized for pediatric injury and their parents (N = 96 child-parent dyads) participated in an interview and discussion task about coping at baseline, and then completed coping/coping assistance measures at three time points: T1 (within 2 weeks post-injury), T2 (6-weeks post-injury), and T3 (12-weeks post-injury).

Results: When presented with an ambiguous situation in the observational interview and discussion task, the number of avoidance coping solutions offered by children independently as well as during a discussion with their parent predicted the child's ultimate avoidance versus non-avoidance coping choice. The number of avoidance coping solutions offered by parents did not predict children's final choice to use avoidance coping. Longitudinal data suggest that parent encouragement of avoidance coping predicted child avoidance coping within the first 6-weeks post-trauma.

Conclusions: Our study suggests that child avoidance coping is multifaceted and may result from both parent encouragement as well as independent decisions by children. Future research may explore additional factors that influence child avoidance coping, outside of parental suggestion, in response to trauma exposure.
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http://dx.doi.org/10.1093/jpepsy/jsz016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6705713PMC
September 2019

A parent-led intervention to promote recovery following pediatric injury: study protocol for a randomized controlled trial.

Trials 2019 Feb 18;20(1):137. Epub 2019 Feb 18.

Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Background: Injury is one of the most prevalent potentially emotionally traumatic events that children experience and can lead to persistent impaired physical and emotional health. There is a need for interventions that promote full physical and emotional recovery and that can be easily accessed by all injured children. Based on research evidence regarding post-injury recovery, we created the Cellie Coping Kit for Children with Injury intervention to target key mechanisms of action and refined the intervention based on feedback from children, families, and experts in the field. The Cellie Coping Kit intervention is parent-guided and includes a toy (for engagement), coping cards for children, and a book for parents with evidence-based strategies to promote injury recovery. This pilot research trial aims to provide an initial evaluation of the impact of the Cellie Coping Kit for Children with Injury on proximal targets (coping, appraisals) and later child health outcomes (physical recovery, emotional health, health-related quality of life).

Method / Design: Eighty children (aged 8-12 years) and their parents will complete a baseline assessment (T1) and then will be randomly assigned to an immediate intervention group or waitlist group. The Cellie Coping Kit for Injury Intervention will be introduced to the immediate intervention group after the T1 assessment and to the waitlist group following the T3 assessment. Follow-up assessments of physical and emotional health will be completed at 6 weeks (T2), 12 weeks (T3), and 18 weeks (T4).

Discussion: This will be one of the first randomized controlled trials to examine an intervention tool intended to promote full recovery after pediatric injury and be primarily implemented by children and parents. Results will provide data on the feasibility of the implementation of the Cellie Coping Intervention for Injury as well as estimations of efficacy. Potential strengths and limitations of this design are discussed.

Trial Registration: Clinicaltrials.gov, NCT03153696 . Registered on 15 May 2017.
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http://dx.doi.org/10.1186/s13063-019-3207-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380044PMC
February 2019

Opportunities for nurses to support recovery after pediatric injury: Relationships among posttraumatic stress, hope, and quality of life.

J Spec Pediatr Nurs 2019 01 13;24(1):e12234. Epub 2019 Feb 13.

College of Medicine, Pediatrics, University of Kentucky, Kentucky Children's Hospital, Lexington, Kentucky.

Purpose: Nurses are at the forefront of children's postinjury recovery; this unique role provides an opportunity for nurses to recognize and screen for symptoms that may interfere with children's quality of life (QOL). As such, aims of the present investigation were to explore selected variables (e.g., posttraumatic stress symptoms [PTSS], hope) that have the potential to impact QOL after pediatric injury, with a larger goal of contributing to recommendations for nursing practice to support children's full (physical and emotional) recovery during the peritrauma period following injury.

Design And Methods: Sixty children (aged 7-13) completed measures of PTSS, hope, and QOL while receiving injury treatment.

Results: PTSS significantly predicted concurrent QOL, β = -0.42, p = 0.001. Exploratory results demonstrated that specific PTSS clusters (re-experiencing [ β = -0.39; p = 0.003), avoidance [ β = -0.35; p = 0.009], arousal [ β = -0.34; p = .012]) all significantly predicted QOL. Specific PTSS were explored. Hope (overall, domains of pathways, general agency, goal setting) did not significantly predict concurrent QOL.

Practice Implications: While this study is exploratory and more research is needed, current results suggest that nurses' awareness of PTSS (including symptoms of re-experiencing, avoidance, arousal) may help medical teams in identifying children that are at risk for impaired functional recovery (e.g., QOL) during the peritrauma period. Nurses may want to consider advocating for the integration of PTSS screeners into standard medical care. In addition, nurses have the opportunity to serve as key medical professionals in the delivery of trauma-informed medical care (which aims to minimize further trauma or re-traumatization). Nursing leadership may want to consider offering training in how nurses can identify and respond to children who have experienced an injury (such as trauma-informed care).
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http://dx.doi.org/10.1111/jspn.12234DOI Listing
January 2019

Introduction to the special issue: Trauma-informed care for children and families.

Psychol Serv 2019 Feb;16(1):1-6

College of Medicine, University of Kentucky.

This special issue of Psychological Services includes 18 articles describing efforts to promote and provide trauma-informed care for children and families. Trauma-informed care is an approach to providing services that is sensitive to the possibility that children and families have experienced past or ongoing traumatic situations with implications for their current functioning and response to interventions. Installing and maintaining a trauma-informed approach in organized care settings requires effective planning, initial assessment, implementation, reassessment, and support that reflects an ongoing commitment to recognizing the impact of trauma on those being served. The articles contained in this special issue span a range of efforts in each of these areas, including the development and refinement of models of care and specific interventions, establishing quality assessment tools, and providing illustrations of lessons learned from attempts to implement and sustain trauma-informed initiatives. This introduction to the special issue provides a brief overview of these articles. The purpose of this special issue is to share current data and models of trauma-informed care and to encourage further development of collaborative models, interventions, measurement tools, and implementation efforts that lead to better services and outcomes for children and families who experience trauma. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/ser0000330DOI Listing
February 2019

Let's Talk About It: Supporting Family Communication during End-of-Life Care of Pediatric Patients.

J Palliat Med 2018 06 18;21(6):862-878. Epub 2018 May 18.

1 Department of Pediatrics, Kentucky Children's Hospital , Lexington, Kentucky.

Background: Communication is key in optimizing medical care when a child is approaching end of life (EOL). Research is yet to establish best practices for how medical teams can guide intrafamily communication (including surviving siblings) when EOL care is underway or anticipated for a pediatric patient. While recommendations regarding how medical teams can facilitate communication between the medical team and the family exist, various barriers may prevent the implementation of these recommendations.

Objective: This review aims to provide a summary of research-to-date on family and medical provider perceptions of communication during pediatric EOL care.

Design: Systematic review.

Results: Findings from a review of 65 studies suggest that when a child enters EOL care, many parents try to protect their child and/or themselves by avoiding discussions about death. Despite current recommendations, medical teams often refrain from discussing EOL care with pediatric patients until death is imminent for a variety of reasons (e.g., family factors and discomfort with EOL conversations). Parents consistently report a need for honest complete information, delivered with sensitivity. Pediatric patients often report a preference to be informed of their prognosis, and siblings express a desire to be involved in EOL discussions.

Conclusions: Families may benefit from enhanced communication around EOL planning, both within the family and between the family and medical team. Future research should investigate a potential role for medical teams in supporting intrafamily communication about EOL challenges and should examine how communication between medical teams and families can be facilitated as EOL approaches.
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http://dx.doi.org/10.1089/jpm.2017.0307DOI Listing
June 2018

Posttraumatic Stress in Children After Injury: The Role of Acute Pain and Opioid Medication Use.

Pediatr Emerg Care 2020 Oct;36(10):e549-e557

Department of Pediatrics, Kentucky Children's Hospital; Department of Pediatrics, University of Kentucky, Lexington, KY.

Objectives: After injury, many children experience posttraumatic stress symptoms (PTSS) that negatively impact recovery. Acute pain and PTSS share neurobiological pathways, and acute dosage of morphine has been linked to reduced PTSS in naturalistic studies. However, the complex interactions between pain, morphine and other opioid use, and PTSS have yet to be investigated in robust pediatric samples.This prospective, longitudinal study examined relationships between acute pain, opioid medications, and PTSS after pediatric injury.

Methods: Ninety-six children aged 8 to 13 years (mean = 10.60, SD = 1.71), hospitalized for unintentional injury, completed assessments at baseline (T1) and 12 weeks (T2) later. Pain ratings and opioid administration data were obtained via chart review.

Results: Structural equation modeling revealed that worst pain endorsed during hospitalization was positively associated with concurrent and later PTSS when controlling for evidence-based risk factors (ie, age, sex, prior trauma history, traumatic appraisals of injury event, heart rate). Neither opioid medications overall nor morphine specifically (milligram/kilogram/day) administered during hospitalization mediated the relationship between pain and T2 PTSS.

Conclusions: Pain during hospitalization may increase susceptibility for persistent PTSS above and beyond the influence of other empirical risk factors. Findings suggest that pain assessment may be a useful addition to pediatric PTSS screening tools and highlight the need for additional research on pharmacological secondary prevention approaches. Given that inadequate pain control and persistent PTSS each hinder recovery and long-term functioning, better understanding of interactions between acute pain and PTSS after injury is essential for improving screening, prevention, and early intervention efforts.
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http://dx.doi.org/10.1097/PEC.0000000000001404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047932PMC
October 2020

An initial application of a biopsychosocial framework to predict posttraumatic stress following pediatric injury.

Health Psychol 2017 08 26;36(8):787-796. Epub 2017 Jun 26.

Division of Oncology, The Children's Hospital of Philadelphia.

Objective: Each year millions of children suffer from unintentional injuries that result in poor emotional and physical health. This study examined selected biopsychosocial factors (i.e., child heart rate, peritrauma appraisals, early coping, trauma history) to elucidate their roles in promoting emotional recovery following injury. The study evaluated specific hypotheses that threat appraisals (global and trauma-specific) and coping would predict subsequent posttraumatic stress symptoms (PTSS), that coping would mediate the association between early and later PTSS, and that heart rate would predict PTSS and appraisals would mediate this association.

Method: Participants were 96 children hospitalized for injury and assessed at 3 time points: T1 (within 2 weeks of injury), T2 (6-week follow-up), and T3 (12-week follow-up). Participants completed measures of trauma history and appraisals at T1, coping at T2, and PTSS at T1, T2, and T3. Heart rate was abstracted from medical records. Structural equation modeling was employed to evaluate study hypotheses.

Results: Heart rate was not associated with PTSS or appraisals. Models including trauma history, appraisals, coping, and PTSS were constructed to test other study hypotheses and fit the data well. T1 global and trauma-specific threat appraisals were associated with T1 PTSS; T2 avoidant coping was a significant mediator of the relation between T1 and T3 PTSS.

Conclusion: Findings confirm a role for appraisals and coping in the development of PTSS over the weeks following pediatric injury. Early appraisals and avoidant coping may be appropriate targets for prevention and early intervention. Future researchers should further explicate the utility of a biopsychosocial framework in predicting PTSS. (PsycINFO Database Record
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http://dx.doi.org/10.1037/hea0000508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5673123PMC
August 2017

Application of a Framework to Implement Trauma-Informed Care Throughout a Pediatric Health Care Network.

J Contin Educ Health Prof 2017 ;37(1):55-60

Ms. Weiss: Research Assistant, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA. Dr. Kassam-Adams: Research Associate Professor of Clinical Psychology in Pediatrics, Perelman School of Medicine, University of Pennsylvania, Associate Director for Behavioral Research, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, and Director of the Center for Pediatric Traumatic Stress; Past President, International Society for Traumatic Stress Studies. Ms. Murray: Training Manager, Violence Prevention Initiative, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA. Ms. Kohser: Research Coordinator, Center for Injury Research and Prevention; Project Coordinator, Center for Pediatric Traumatic Stress, The Children's Hospital of Philadelphia, Philadelphia, PA. Dr. Fein: Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Director, Violence Prevention Initiative, The Children's Hospital of Philadelphia, and Director of Advocacy & Health Policy, The Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. Dr. Winston: Professor of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Attending Physician, Founder and Scientific Director, Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, and Director of the National Science Foundation Industry, University Cooperative Research Center, the Center for Child Injury Prevention Studies. Dr. Marsac: Assistant Professor of Pediatrics, College of Medicine, Kentucky University, and Kentucky Children's Hospital, Lexington, KY.

Introduction: To evaluate the initial application of a recently published three-step framework for implementing trauma-informed care (TIC) in a pediatric health care network by applying Framework for Spread.

Methods: In steps 1 and 2 of the framework, we established commitment from the health care network leadership and initial interest in TIC among clinical providers (step 1), set evidence-based training goals and created the associated TIC training content (step 2). In step 3, 440 health care professionals (from 27 health care teams) participated in single-session, 1-hour training that covered the psychological impact of injury- and illness-related trauma, identification of traumatic stress symptoms, and how to respond to children exposed to potentially traumatic events. A concomitant quality improvement project allowed us to assess potential changes in training participants' favorable attitudes toward the integration of TIC and confidence in delivering TIC.

Results: Compared with pretraining, participants demonstrated increases in attitude toward TIC, t(293) = 5.8, P < .001, Cohen's d = 0.32, and confidence in delivering TIC, t(293) = 20.9, P < .001, Cohen's d = 1.09.

Discussion: Trainings were effective in achieving proximal goals targeting attitudes and confidence, thereby demonstrating the feasibility and clinical relevance of TIC training when implemented according to the three-step framework. Future research should examine methods of training to reach wide audiences to promote systematic change and evaluate changes in patient outcomes associated with providers' implementation of TIC.
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http://dx.doi.org/10.1097/CEH.0000000000000140DOI Listing
February 2018

Brief Practical Screeners in English and Spanish for Acute Posttraumatic Stress Symptoms in Children.

J Trauma Stress 2016 12;29(6):483-490

Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

With millions of children experiencing acute traumatic events, validated screening tools are needed in both research and service contexts. We aimed to identify and evaluate short forms of the Acute Stress Checklist for Children in English (ASC-Kids) and Spanish (Cuestionario de Estrés Agudo-Niños [CEA-N]), using data from 4 samples (Ns of 254, 225, 176, and 80) of children with recent acute trauma. Confirmatory factor analyses of the full checklist in the largest sample guided item selection for 6-item and 3-item short forms. Across samples, both short forms (ASC-6/ASC-3 in English; CEA-6/CEA-3 in Spanish) were correlated with acute stress disorder (ASD) symptom severity on the full checklist (r = .79 to .92), and on an interview measure (r = .52 to .62). Receiver operating curve analyses for each short form detecting current ASD status showed high areas under the curve (.76 to .95). Cutoff scores identified based on Sample 1 provided acceptable sensitivity (.59 to 1.00) and specificity (.57 to .86) across samples. Children scoring above the cutoff on each screener reported greater concurrent impairment from ASD symptoms and more severe posttraumatic stress 3 months later. These very brief measures could expand clinicians' and researchers' ability to screen for acute posttraumatic stress in children.
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http://dx.doi.org/10.1002/jts.22141DOI Listing
December 2016

Coping and posttraumatic stress symptoms in children with food allergies.

Ann Allergy Asthma Immunol 2016 11 22;117(5):561-562. Epub 2016 Sep 22.

Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Kentucky Children's Hospital, College of Medicine, University of Kentucky, Lexington, Kentucky. Electronic address:

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http://dx.doi.org/10.1016/j.anai.2016.08.022DOI Listing
November 2016

A novel adaptation of a parent-child observational assessment tool for appraisals and coping in children exposed to acute trauma.

Eur J Psychotraumatol 2016 20;7:31879. Epub 2016 Sep 20.

The Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Background: Millions of children worldwide are exposed to acute potentially traumatic events (PTEs) annually. Many children and their families experience significant emotional distress and/or functional impairment following PTEs. While current research has begun to highlight a role for early appraisals and coping in promoting or preventing full recovery from PTEs, the exact nature of the relationships among appraisals, coping, and traumatic stress reactions as well as how appraisals and coping behaviors are influenced by the child's environment (e.g., parents) remains unclear; assessment tools that reach beyond self-report are needed to improve this understanding.

Objective: The objective of the current study is to describe the newly created Trauma Ambiguous Situations Tool (TAST; i.e., an observational child-parent interview and discussion task that allows assessment of appraisals, coping, and parent-child processes) and to report on initial feasibility and validation of TAST implemented with child-parent dyads in which children were exposed to a PTE.

Method: As part of a larger study on the role of biopsychosocial factors in posttraumatic stress reactions, children (aged 8-13) and parents (n=25 child-parent dyads) completed the TAST during the child's hospitalization for injury.

Results: Children and parents engaged well with the TAST. The time to administer the TAST was feasible, even in a peri-trauma context. The TAST solicited a wide array of appraisals (threat and neutral) and coping solutions (proactive and avoidant). Forced-choice and open-ended appraisal assessments provided unique information. The parent-child discussion portion of the TAST allowed for direct observation of parent-child processes and demonstrated parental influence on children's appraisals and coping solutions.

Conclusions: The TAST is a promising new research tool, which may help to explicate how parents influence their child's developing appraisals and coping solutions following a PTE. More research should examine the relationships of appraisals, coping, and parent-child processes assessed by the TAST with traumatic stress outcomes.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5031795PMC
http://dx.doi.org/10.3402/ejpt.v7.31879DOI Listing
September 2016

A Qualitative Analysis of Children's Emotional Reactions During Hospitalization Following Injury.

J Trauma Nurs 2016 Jul-Aug;23(4):194-201

Department of Psychology, Virginia Tech, Blacksburg (Ms Ramsdell); Department of School Psychology, Temple University, Philadelphia, Pennsylvania (Ms Morrison); The Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Drs Kassam-Adams and Marsac); and Departments of Pediatrics (Dr Kassam-Adams) and Psychiatry, University of Pennsylvania (Dr Marsac), Perelman School of Medicine, Philadelphia.

Children who sustain injuries are at risk for experiencing traumatic stress reactions. Few studies have obtained detailed, qualitative information regarding children's and parents' own understanding of their experiences during the peritrauma period. Understanding children's injury and early hospital experiences is crucial to inform the development of early interventions during the peritrauma period, which speak to these concerns. The primary purpose of this study was to understand child and parent views of the stressors experienced by children hospitalized for an injury. A secondary aim was to identify children's feelings and thoughts about injury- and hospital-related stressors. Ten children and their parents participated in semistructured interviews. Interviews were audio-recorded, transcribed, and coded. Stressors were classified into 5 domains: procedural concerns, uncertainty, sleep and nutrition challenges, being confined to the hospital, and home preparation. Children and parents were more likely to articulate feelings about stressors than thoughts about stressors. Feelings reported by children and parents were predominantly negative. Children and parents may have an easier time expressing feelings than thoughts, which has implications for communicating with medical teams as well as for psychological treatment. Future research should examine how children's perceptions of their injury- and hospital-related experiences relate to later outcomes such as traumatic stress reactions.
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http://dx.doi.org/10.1097/JTN.0000000000000217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4948941PMC
September 2017

The role of appraisals and coping in predicting posttraumatic stress following pediatric injury.

Psychol Trauma 2016 07 11;8(4):495-503. Epub 2016 Apr 11.

Center for Injury Research and Prevention, The Children's Hospital of Philadelphia.

Objective: Given the millions of children who experience potentially traumatic injuries each year and the need to maximize emotional and physical health outcomes following pediatric injury, the current study examined the individual and collective contributions of the malleable variables of appraisals and coping in predicting posttraumatic stress symptoms (PTSS) in children following injury.

Method: This study combined data from 3 prospective investigations of recovery from pediatric injury (N = 688) in which children ages 8-17 years were recruited shortly after an injury (within 4 weeks). At baseline (T1), children completed measures of their threat appraisals of the injury event and PTSS. Six to twelve weeks later (T2), children completed a measure of coping and PTSS. Finally, PTSS was assessed again 6 months post-injury (T3).

Results: Structural equation modeling analyses provide evidence that appraisals and coping contribute to PTSS. Furthermore, results suggest that escape coping mediates the relationship between threat appraisals and PTSS.

Conclusions: Early interventions designed to prevent or reduce PTSS after pediatric injury may be more successful if they primarily target modifying escape coping behaviors. To best inform clinical practice, future research should examine factors influencing the development of children's appraisals and coping behaviors in the context of potentially traumatic events. (PsycINFO Database Record
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http://dx.doi.org/10.1037/tra0000116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4925202PMC
July 2016

Evaluating predictive screening for children's post-injury mental health: New data and a replication.

Eur J Psychotraumatol 2015 14;6:29313. Epub 2015 Dec 14.

Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Background: Recommended approaches for secondary prevention of posttrauma mental health difficulties in children require empirically sound predictive screening to determine which children require more intensive monitoring or targeted intervention. Although there are several promising screening tools for injured children, none has emerged as the gold standard, and little replication data are available regarding their performance.

Objective: To evaluate a predictive screening protocol for risk of later posttraumatic stress (PTS) and depression outcomes and address a crucial lack of replication studies by examining performance of two previously published screening tools (Screening Tool for Early Predictors of PTSD [STEPP] and Child Trauma Screening Questionnaire [CTSQ]).

Method: The study enrolled 290 children hospitalized after acute injury. A three-part screening protocol, including acute PTS and depression symptoms and other empirically derived risk factors, was administered in hospital as part of a stepped care study. PTS and depression symptoms and health-related quality of life (HRQoL) were assessed 6 months post-injury.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696458PMC
http://dx.doi.org/10.3402/ejpt.v6.29313DOI Listing
December 2015

Implementing a Trauma-Informed Approach in Pediatric Health Care Networks.

JAMA Pediatr 2016 Jan;170(1):70-7

Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania3Department of Pediatrics, University of Pennsylvania, Philadelphia5Division of Emergency Medicine, Department of Pediatrics, University of Penns.

Pediatric health care networks serve millions of children each year. Pediatric illness and injury are among the most common potentially emotionally traumatic experiences for children and their families. In addition, millions of children who present for medical care (including well visits) have been exposed to prior traumatic events, such as violence or natural disasters. Given the daily challenges of working in pediatric health care networks, medical professionals and support staff can experience trauma symptoms related to their work. The application of a trauma-informed approach to medical care has the potential to mitigate these negative consequences. Trauma-informed care minimizes the potential for medical care to become traumatic or trigger trauma reactions, addresses distress, provides emotional support for the entire family, encourages positive coping, and provides anticipatory guidance regarding the recovery process. When used in conjunction with family-centered practices, trauma-informed approaches enhance the quality of care for patients and their families and the well-being of medical professionals and support staff. Barriers to routine integration of trauma-informed approaches into pediatric medicine include a lack of available training and unclear best-practice guidelines. This article highlights the importance of implementing a trauma-informed approach and offers a framework for training pediatric health care networks in trauma-informed care practices.
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http://dx.doi.org/10.1001/jamapediatrics.2015.2206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939592PMC
January 2016

Traumatic Stress, Depression, and Recovery: Child and Parent Responses After Emergency Medical Care for Unintentional Injury.

Pediatr Emerg Care 2015 Nov;31(11):737-42

From the *Center for Injury Research and Prevention, Children's Hospital of Philadelphia; and †Division of Emergency Medicine, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; ‡Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam; and §Association of Dutch Burns Centres, Beverwijk, The Netherlands; and ∥Department of Psychiatry and ¶Division of General Pediatrics, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Objective: To assess psychological symptoms in injured children (aged 8-17 years) and their parents after emergency department (ED) care to examine the relationship between posttraumatic stress and depression symptoms, co-occurrence of symptoms within families, and the relationship of these symptoms to parent-reported overall recovery.

Methods: Children and parents (n = 263 child-parent dyads) were enrolled during ED treatment for unintentional injury. Approximately 5 months later, children and parents (n = 178 dyads) completed standardized measures of posttraumatic stress and depression symptoms and parents reported on child overall recovery.

Results: Follow-up assessments found significant posttraumatic stress symptoms in 15% of children and 5% of parents, significant depression symptoms in 13% of children and 16% of parents, and problematic overall recovery in 17% of children. For both children and parents, posttraumatic stress and depression symptom severity were strongly associated. Child and parent symptoms were only modestly associated with each other, and there were few families in which both child and parent had significant posttraumatic stress or depression. Parent symptoms, but not child symptoms, were inversely associated with children's overall recovery.

Conclusions: For about 1 in 6 children and parents, unintentional injury treated in the ED can be associated with negative psychological sequelae and suboptimal recovery. Within families, child and parent responses may differ; their relative association with overall recovery deserves additional research. To promote emotional recovery, ED clinicians should be aware of the potential psychological impact of unintentional injury, provide timely evidence-based anticipatory guidance, and communicate these concerns to primary care clinicians.
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http://dx.doi.org/10.1097/PEC.0000000000000595DOI Listing
November 2015

Posttraumatic stress in school-age children and adolescents: medical providers' role from diagnosis to optimal management.

Pediatric Health Med Ther 2015 3;6:167-180. Epub 2015 Oct 3.

University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Millions of children and adolescents each year are exposed to potentially traumatic events (PTEs), placing them at risk for posttraumatic stress (PTS) disorder symptoms. Medical providers play an important role in the identification and treatment of PTS, as they are typically the initial point of contact for families in the wake of a PTE or during a PTE if it is medically related (eg, injury/illness). This paper offers a review of the literature focused on clinical characteristics of PTS, the assessment and diagnosis of PTS, and current effective treatments for PTS in school-age children and adolescents. The clinical presentation of PTS is often complex as symptoms may closely resemble other internalizing and externalizing disorders. A number of screening and evaluation tools are available for medical providers to assist them in the accurate diagnosis of PTS. Treatment options are available for youth at minimal risk of PTS as well as for those with more intensive needs. Additional training regarding trauma-informed medical care may benefit medical providers. By taking a trauma-informed approach, rooted in a solid understanding of the clinical presentation of PTS in children and adolescents, medical providers can ensure PTS does not go undetected, minimize the traumatic aspects of medical care, and better promote health and well-being.
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http://dx.doi.org/10.2147/PHMT.S68984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683267PMC
October 2015

Pilot Randomized Controlled Trial of a Novel Web-Based Intervention to Prevent Posttraumatic Stress in Children Following Medical Events.

J Pediatr Psychol 2016 Jan-Feb;41(1):138-48. Epub 2015 Jun 18.

Children's Hospital of Philadelphia, University of Pennsylvania.

Objective: To assess feasibility and estimate effect size of a self-directed online intervention designed to prevent persistent posttraumatic stress after acute trauma.

Methods: Children aged 8-12 years with a recent acute medical event were randomized to the intervention (N = 36) or a 12-week wait list (N = 36). Posttraumatic stress, health-related quality of life, appraisals, and coping were assessed at baseline, 6, 12, and 18 weeks.

Results: Most children used the intervention; half completed it. Medium between-group effect sizes were observed for change in posttraumatic stress severity from baseline to 6 weeks (d = -.68) or 12 weeks (d = -.55). Exploratory analyses suggest greatest impact for at-risk children, and a small effect for intervention initiated after 12 weeks. Analysis of covariance did not indicate statistically significant group differences in 12-week outcomes.

Conclusions: This pilot randomized controlled trial provides preliminary evidence that a self-directed online preventive intervention is feasible to deliver, and could have an effect in preventing persistent posttraumatic stress.
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http://dx.doi.org/10.1093/jpepsy/jsv057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4723670PMC
August 2016

A new method for assessing content validity in model-based creation and iteration of eHealth interventions.

J Med Internet Res 2015 Apr 15;17(4):e95. Epub 2015 Apr 15.

Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, United States.

Background: The advent of eHealth interventions to address psychological concerns and health behaviors has created new opportunities, including the ability to optimize the effectiveness of intervention activities and then deliver these activities consistently to a large number of individuals in need. Given that eHealth interventions grounded in a well-delineated theoretical model for change are more likely to be effective and that eHealth interventions can be costly to develop, assuring the match of final intervention content and activities to the underlying model is a key step. We propose to apply the concept of "content validity" as a crucial checkpoint to evaluate the extent to which proposed intervention activities in an eHealth intervention program are valid (eg, relevant and likely to be effective) for the specific mechanism of change that each is intended to target and the intended target population for the intervention.

Objective: The aims of this paper are to define content validity as it applies to model-based eHealth intervention development, to present a feasible method for assessing content validity in this context, and to describe the implementation of this new method during the development of a Web-based intervention for children.

Methods: We designed a practical 5-step method for assessing content validity in eHealth interventions that includes defining key intervention targets, delineating intervention activity-target pairings, identifying experts and using a survey tool to gather expert ratings of the relevance of each activity to its intended target, its likely effectiveness in achieving the intended target, and its appropriateness with a specific intended audience, and then using quantitative and qualitative results to identify intervention activities that may need modification. We applied this method during our development of the Coping Coach Web-based intervention for school-age children.

Results: In the evaluation of Coping Coach content validity, 15 experts from five countries rated each of 15 intervention activity-target pairings. Based on quantitative indices, content validity was excellent for relevance and good for likely effectiveness and age-appropriateness. Two intervention activities had item-level indicators that suggested the need for further review and potential revision by the development team.

Conclusions: This project demonstrated that assessment of content validity can be straightforward and feasible to implement and that results of this assessment provide useful information for ongoing development and iterations of new eHealth interventions, complementing other sources of information (eg, user feedback, effectiveness evaluations). This approach can be utilized at one or more points during the development process to guide ongoing optimization of eHealth interventions.
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http://dx.doi.org/10.2196/jmir.3811DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414959PMC
April 2015

Systematic, theoretically-grounded development and feasibility testing of an innovative, preventive web-based game for children exposed to acute trauma.

Clin Pract Pediatr Psychol 2015;3(1):12-24

The Center for Injury Research and Prevention, The Children's Hospital of Philadelphia Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania.

Background: Millions of children are affected by acute medical events annually, creating need for resources to promote recovery. While web-based interventions promise wide reach and low cost for users, development can be time- and cost-intensive. A systematic approach to intervention development can help to minimize costs and increase likelihood of effectiveness. Using a systematic approach, our team integrated evidence on the etiology of traumatic stress, an explicit program theory, and a user-centered design process to intervention development.

Objective: To describe evidence and the program theory model applied to the Coping Coach intervention and present pilot data evaluating intervention feasibility and acceptability.

Method: Informed by empirical evidence on traumatic stress prevention, an overarching program theory model was articulated to delineate pathways from a) specific intervention content to b) program targets and proximal outcomes to c) key longer-term health outcomes. Systematic user-testing with children ages 8-12 (N = 42) exposed to an acute medical event and their parents was conducted throughout intervention development.

Results: Functionality challenges in early prototypes necessitated revisions. Child engagement was positive throughout revisions to the Coping Coach intervention. Final pilot-testing demonstrated promising feasibility and high user-engagement and satisfaction.

Conclusion: Applying a systematic approach to the development of Coping Coach led to the creation of a functional intervention that is accepted by children and parents. Development of new e-health interventions may benefit from a similar approach. Future research should evaluate the efficacy of Coping Coach in achieving targeted outcomes of reduced trauma symptoms and improved health-related quality of life.
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http://dx.doi.org/10.1037/cpp0000080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4383172PMC
January 2015

Acute Pain and Posttraumatic Stress After Pediatric Injury.

J Pediatr Psychol 2016 Jan-Feb;41(1):98-107. Epub 2015 Mar 29.

The Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania.

Objective: Using a prospective, longitudinal design, we examined the relationship between acute pain and posttraumatic stress symptoms (PTSS) in youth following injury.

Methods: Children aged 8-17 years who sustained an injury (N = 243) and their parents participated in baseline interviews to assess children's worst pain since injury. 6 months later, participants completed follow-up interviews to assess child PTSS.

Results: Pain as assessed by the Color Analogue Pain Scale (CAS) predicted PTSS 6 months after injury, even when controlling for demographic and empirically based risk factors. On the other hand, pain as assessed by the Faces Pain Rating Scale was not a significant independent predictor of PTSS.

Conclusions: The CAS may be a useful addition to existing screening tools for PTSS among children. Additional research is warranted to understand underlying mechanisms linking acute pain and PTSS to improve assessment, prevention, and treatment approaches and promote optimal recovery after pediatric injury.
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http://dx.doi.org/10.1093/jpepsy/jsv026DOI Listing
August 2016

The Cellie Coping Kit for Sickle Cell Disease: Initial acceptability and feasibility.

Clin Pract Pediatr Psychol 2014 Dec;4(2):389-399

Division of Oncology, The Children's Hospital of Philadelphia; Department of Pediatrics, University of Pennsylvania.

Sickle Cell Disease (SCD) and its treatment can place physical and psychosocial strain on children and their families, underlining the need for behavioral and emotional support. Much of SCD is often managed at home, which may prevent children from obtaining supportive services from medical and psychosocial teams. Children with SCD report a restricted number of coping strategies specific to managing SCD and may benefit from education on adaptive coping. To address this unmet need, a coping tool for children with cancer (Cellie Cancer Coping Kit) was adapted for children with SCD. The Cellie Coping Kit for SCD (Cellie Coping Kit) includes a stuffed "Cellie" toy, coping cards for children, and a book for caregivers. This study sought to assess the acceptability and feasibility of an intervention utilizing the Cellie Coping Kit. Fifteen children with SCD (ages 6-14) and their caregivers participated in a baseline assessment including semi-structured interviews to examine SCD-related stressors and coping strategies. Next, families received a brief introduction to the Cellie Coping Kit and were provided with a kit to use independently over the next four weeks before completing a follow-up assessment. Results indicated strong intervention acceptability overall. While families reported using and learning information and skills from the Cellie Coping Kit, several challenges were identified (e.g., child's living situation, busy schedules). The Cellie Coping Kit is a promising tool to support children with SCD and their families. Future research should examine whether use of the Cellie Coping Kit impacts behavioral change and improved health outcomes.
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http://dx.doi.org/10.1037/cpp0000062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4315192PMC
December 2014

Posttraumatic stress following acute medical trauma in children: a proposed model of bio-psycho-social processes during the peri-trauma period.

Clin Child Fam Psychol Rev 2014 Dec;17(4):399-411

The Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, 3535 Market, Suite 1150, Philadelphia, PA, 19104, USA,

Millions of children worldwide experience acute medical events. Children's responses to these events range from transient distress to significant posttraumatic stress disorder symptoms (PTSS). While many models suggest explanations for the development and maintenance of PTSS in adults, very few have focused on children. Current models of child PTSS are primarily restricted to the post-trauma period, thus neglecting the critical peri-trauma period when screening and preventive interventions may be most easily implemented. Research on PTSS in response to pediatric medical trauma typically examines predictors in isolation, often overlooking potentially important interactions. This paper proposes a new model utilizing the bio-psycho-social framework and focusing on peri-trauma processes of acute medical events. Understanding the relationships among bio-psycho-social factors during peri-trauma can inform early identification of at-risk children, preventive interventions and clinical care. Recommendations for future research, including the need to examine PTSS in the context of multiple influences, are discussed.
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http://dx.doi.org/10.1007/s10567-014-0174-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4319666PMC
December 2014
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