Research Evidence about the Etiology of Medical Traumatic Stress
A systematic review of 216 studies of traumatic stress related to pediatric medical events found the following average prevalence rates for significant traumatic stress symptoms:
- In children, teens and parents, roughly 30% experience subclinical post-traumatic stress symptoms (PTSS) and PTSD.
- PTSS/PMTS symptoms have been found to decline over time (Price et al, 2015).
Cancer: The prevalence of PTSD symptoms in child cancer survivors ranges from –8-75%. In parents, within the first month post diagnosis PTSD rates range from 40-83%, dropping to 18-33% six months post diagnosis and 7-27% over 10 months post diagnosis. Higher rates are found among samples of older children, suggesting a developmental trajectory. Persistent PTSD symptoms in child cancer survivors have been associated with other psychosocial concerns in young adulthood.
Injuries: The prevalence of PTSD varies dependent on time elapsed since the injury. Within in the first month post injury, child PTSD rates range from 22-42%, from 1-38% two to nine months post injury, and 10-19% ten months or more post injury. Parental PTSD rates range from 10-22% in the first month post injury, 5-11% within 6 months post injury, and 0-18% ten or more months post injury.
Other conditions: A number of smaller studies suggest the occurrence of longer-term traumatic stress symptoms and PTSD in children and parents facing other conditions and a range of medical treatments, such as intensive care admission, diabetes, or organ transplantation. For example, 12-84% parents of children admitted to intensive care report some PTSD symptoms within the first 6 weeks and 13-30% continue to experience symptoms at 6+ months post discharge. In teens 1 year post transplant (heart, liver or kidney), approximately 16% met PTSD criterion in two of three symptom clusters (Mintzer et al., 2005). In parents of children diagnosed with diabetes, 5-24% of parents within the first 6 weeks of diagnosis experiences PTSS symptoms, rising to 10-42% of parents 6+ months after diagnosis.
Family members: Persistent traumatic stress symptoms have been documented in parents and siblings of childhood cancer survivors, parents of transplant recipients, parents of children with epilepsy, parents of burn patients, and parents of injured children. (See studies by Alderfer, et al. 2003; DeVries et al, 1997; Farley et al, 2007; Hall et al. 2004; Iseri et al., 2006; Manne et al. 2004; Young et al., 2003). PTSD prevalence rates of approximately 20% have been found in parents of chronically ill children (Cabizuca et al., 2009). A systematic review of the effects of cancer on siblings found PTSS and poorer quality of life (Alderfer et al., 2010).
Research evidence about the etiology of medical traumatic stress
Subjective experience vs. objective characteristics
Research evidence consistently indicates that objective characteristics of illness or injury (e.g. severity, complexity) are not strongly related to subsequent traumatic stress symptoms.
Across both injury and illness, evidence suggests that it is the perception of life threat, and the subjective appraisal of severity of injury / illness and intensity of treatment that lead to greater traumatic stress reactions.
However, there is some evidence that the severity or intensity of procedures during intensive care, or the scarring or disfigurement associated with some injuries, can be associated with more severe traumatic stress reactions.
Research to date has identified a range of other risk and protective factors associated with the development of persistent traumatic stress.
Risk factors for traumatic stress in ill or injured children
Pre-existing child, parental or family factors
- Pre -existing anxiety and/or other psychological difficulties
- History of trauma exposure or past traumatic stress symptoms
Early physiological and psychological responses
- More severe acute traumatic stress symptoms (emerging within a few hours or days of a medical event)
- Early physiological arousal in injured children (e.g., elevated heart rate in the ED or hospital)
Aspects of the medical condition or resulting treatment experiences
- Length of hospitalization and intensity of treatment in intensive care
- Separation from parents (and separation anxiety) during emergent care or hospital treatment
- Specific upsetting experiences and perceptions during treatment
Maladaptive coping strategies
- Social and emotional withdrawal
- Extreme avoidance of things that are reminders of a traumatic event
Protective factors that may reduce the development of traumatic stress
- Parent presence and support
- Maintaining, or re-establishing, age-appropriate social activities and friendships
- Availability of family or friends who can listen and understand
- A range of coping strategies seem to be adaptive - each individual may be a bit different. (See studies by Bryant et al.2007; Daviss et al. 2000 Meiser-Steadman, et al. 2005; Phipps, Larson et al 2006)
Risk and protective factors of parents of ill and injured children:
- Among parents of children with cancer, the parent’s own anxiety during treatment, fearing that their child would die, and worrying about relapse is related to persistent parental traumatic stress reactions. (Best, Streisand et al. 2001; Kazak & Barakat, 1997)
- Among parents of children in the PICU, the presence and severity of parental acute traumatic stress responses during their child’s ICU admission, the parent’s subjective appraisal of life threat, and the unexpectedness of the admission are all predictive of persistent parental traumatic stress. (Balluffi et al. 2004)
Post Traumatic Growth after Injury or illness
- Some research suggests children and families experience positive changes after diagnosis with cancer (Barakat, Alderfer, & Kazak, 2006).
- Conflicting evidence exists between PMTS and Post Traumatic Growth (PTG), according to other studies (Barakat et al., 2006; Klosky et al., 2014).