Tool ensures follow-up for traumatized children

Survey predicts post-traumatic stress disorder

A child comes in for an injury in a traffic accident in which others were hurt and killed. The ED clinicians take care of the physical injuries, and the patient is discharged. Still, the staff members feel uneasy about the impact of the accident on the child’s mental health.

"One thing we hear from nurses is that they see kids all the time they worry about, thinking the kid is likely to have trouble down the road," says Nancy Kassam-Adams, MD, associate director for behavior research at TraumaLink, a pediatric trauma research center based at Children’s Hospital.

Identifying problems before child goes home

When the child goes home, the nurse has no way to help, she says. However, a newly developed simple screening tool gives staff a means to identify children and parents who suffer post-traumatic stress disorder (PTSD), according to clinicians at the Children’s Hospital of Philadelphia.

"The nurses tell us that the screening tool gives them a way to provide some sort of follow-up to those kids they worry about," she adds. "It can provide a kind of closure for the ED staff."

While only about one in six children develop PTSD from injuries, the effects for those children can be serious, Kassam-Adams points out.

The Screening Tool for Early Predictors of PTSD (STEPP) should help ensure that the parents and kids who screen positive would receive a visit or a follow-up call from a social worker, she explains.

EDs also could include an extra sentence in the discharge instructions that the parents take back to their primary care doctor. This could be a short note suggesting that the child and parents be watched for signs of PTSD because they tested positive on the screening tool, Kassam-Adams says.

ED staff skeptical: Is it easy to use?

Current field research shows the tool is practical for use in the ED, which allays some initial fears that it might be a good idea on paper but not so easy to use in a real ED, says one of the developers.

When physicians developed the tool, the published report was met with some interest but also skepticism by ED staff, Kassam-Adams says.

She says many ED staff thought it sounded like a nice idea, but they weren’t so sure it could be implemented effectively without creating an unwelcome burden.

After publication of the STEPP tool, Kassam-Adams and her colleagues went on to test the idea in the ED at Children’s Hospital.

"I can tell you that the process of using the tool was very acceptable to nurses and parents," she says. "This confirmed that using the STEPP tool is something you can add to your ED without creating much of a ripple."

In the second-phase research aimed at assessing feasibility, Kassam-Adams says 70 nurses administered the STEPP screen to about 300 patients and their parents older than six months in the ED.

When the child is registered, the staff identify those who meet two criteria: The injury was accidental, and the child is between 8 and 17 years old. (The tool was developed for children in that age range because research supported the ability to predict PTSD in them but not necessarily younger children.) Those patient charts are flagged so that the nurse knows to use the STEPP screen, and a one-page form with the 12 questions is added to the chart.

One of the nurses who used the tool in the ED says it only takes about two minutes. Christine Macaulay, RN, MSN, emergency department project coordinator and chair of the hospital’s unit-based research committee, says the STEPP tool was welcomed by the nurses as a way to fulfill their obligation to educate the patient and family.

"This is something the typical ED could use without it being a real burden," she says. "It helps with flagging these patients who may have a problem later on because it is an education tool for the more novice staff, and it gives them a real quick format for doing it. Anything that quickens the job will be welcome in the ED."

Results prompt referral to social workers

To create the screening tool, the researchers had 171 families complete a 50-question risk factor survey at the initial treatment and complete a three-month follow-up assessment.1

The STEPP questions were derived from the combination of responses from participants that most often predicted persistent post-traumatic stress at three months.

The initial study results suggested that the STEPP tool is an effective screen for PTSD, Kassam-Adams says.

Of children who screened positive, 25% went on to present with PTSD. Of children who screened negative, only 5% developed PTSD. Of parents who screened positive, 27% developed PTSD symptoms compared to only 1% of parents who screened negative, she states.

The screening tool can help ED staff determine when a referral to psychological care is warranted and when they should recommend that the parents watch for symptoms of PTSD in the child, she says.

However, Kassam-Adams and her colleagues are not suggesting ED staff take on a mental health role in addition to everything else they already do, she says. Instead, it triggers the next step in the care process after patients leave your ED, she says.

"You can send some basic messages that can have a tremendous impact on the patient and the parents months later," Kassam-Adams says.

She offers this example of the kind of message ED staff can provide: "It’s OK to be upset about this accident for a while, but things will get better. If your child is still very upset six months from now and afraid to cross the street, you might want to seek some counseling. And if you find that you’re still worried all the time and overprotective, there is help available."

Why not just recommend counseling for the most severely injured children and their parents? Kassam-Adams says that approach would ensure that those most likely to suffer PTSD get help, but it would miss many who have less severe injuries but are nonetheless at high risk because of other factors.

"This is empirically based triaging rather than just common-sense triaging or relying on your gut instinct," she adds.


1. Winston FK, Kassam-Adams N, Garcia-España F, et al. Screening for risk of persistent post-traumatic stress in injured children and their parents. JAMA 2003; 290:643-649.


For more information, contact:

  • Nancy Kassam-Adams, MD, Associate Director for Behavior Research, TraumaLink, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399. Telephone: (215) 590-1000.
  • Christine Macaulay, RN, MSN, Emergency Department, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4399. Telephone: (215) 590-3488.