Pediatric Behavioral Health in Disasters

Kimberly Burkhart, Ph.D.

Introduction

Mental illness in children had been rising before the onset of the pandemic, with 75% of all mental health disorders presenting by age 24. Before the COVID-19 pandemic, 1 in 5 children had a diagnosed mental health disorder. Major depression increased 74% among adolescents between 2004 and 2019.

In spring 2021, results from the CDC National Syndromic Surveillance Program indicated that emergency department (ED) visits for suspected suicide attempts among females rose by 50% compared with the previous year. In contrast, visits among males rose more modestly, by 3.7%. The rise in mental health needs and shortage of providers has contributed to a national mental health crisis.

Key Content

The mental health crisis has contributed to increased boarding since the onset of the pandemic. Pediatric and adolescent psychiatric boarding has increased threefold over the last decade, with a 60% increase in the time spent boarding.

A landmark study using the Pediatric Research in Inpatient Settings network surveyed hospitals across the country. On a typical day, hospitals reported an average of four children boarding while awaiting definitive mental health treatment, with an average boarding duration of 48 hours per child.

The survey found that hospital resources for children who are boarding are limited. Only one-third of hospitals had a designated boarding space, 1 in 10 had a clinical practice guideline or care pathway, and few children received psychiatric medication initiation or changes (14%), psychotherapy from a mental health professional (18%), or a behavioral management plan (36%).

These data are specific to children’s hospitals, which are generally better equipped to manage pediatric mental health needs than community emergency departments. Prolonged boarding may be associated with increased self-harm, staff assault, risk of regression, interruption of therapy, and traumatization or retraumatization.

Children are particularly vulnerable to the effects of disasters, with as many as 14% experiencing a natural or human-caused disaster during childhood. Evidence is emerging about patterns and trajectories of posttraumatic stress symptoms (PTSS) among children who experience disasters.

PTSS include symptoms associated with and attributed to a traumatic event, such as reliving the event, experiencing nightmares or sleep problems, and other internalizing symptoms or externalizing behaviors that present after disaster exposure. Research suggests that 4% to 23% of disaster-exposed children experience chronic symptoms, with persistently elevated PTSS over time. Another 7% to 27% follow a recovery trajectory characterized by an initial elevation of PTSS followed by a decrease at later time points.

Factors associated with an increased risk of adjustment problems after a catastrophic event fall into three categories:

• Pre-existing factors: Psychopathology, previous traumatic exposures, and socioeconomic factors.
• Nature of the disaster experience: Injury to the child, extent of exposure, and the child’s perception of the event.
• Subsequent factors: Family support and communication, knowledge and use of coping skills, loss of property or other significant changes, and parenting challenges.

The Effects of Stress and Signs and Symptoms of Trauma

The Effects of Stress

The hypothalamic-pituitary-adrenal (HPA) axis is activated when the body confronts stress. This activation results in the secretion of cortisol, which elicits an infusion of glucose into the bloodstream.

Early childhood trauma may be particularly impactful because early childhood represents a sensitive period for development. The early years of a child’s life are characterized by rapid brain growth and increased plasticity. Trauma experienced during this critical period can result in an atypical shift in development, dysregulation, and changes in DNA.

Signs and Symptoms of Trauma

A young child’s response to trauma commonly includes the following symptoms and underlying causes:

Responses to trauma and effects on working memory, inhibitory control, and cognitive flexibility vary by age. The following table provides a summary:

Acute Stress Disorder and Posttraumatic Stress Disorder

Symptoms of acute stress disorder tend to occur immediately or shortly after a traumatic event. By definition, symptoms can present during the first 28 days after the event and last from three days to four weeks. Dissociative symptoms are common and may include feeling numb, detached, or emotionally unresponsive, or being unable to remember parts of the traumatic event.

These symptoms can manifest as displaying little emotion, expressing or showing distress related to loss, or not remembering critical aspects of the event, such as how the person was rescued or arrived at the hospital. Posttraumatic stress disorder (PTSD) may be diagnosed when symptoms persist for more than one month after the traumatic event. PTSD may last from one month to several years and may present as avoidance, heightened awareness, and changes in mood and cognition.

Diagnostic criteria for PTSD in children age 6 and older include exposure to actual or threatened death or serious injury, intrusive symptoms, persistent avoidance associated with the traumatic event, negative alterations in cognition and mood, and marked alterations in arousal and reactivity associated with the traumatic event. Dissociative symptoms such as depersonalization and derealization may also be present.

The DSM-5 includes a developmental subtype of PTSD for preschool children. This subtype accounts for emerging abstract cognitive and verbal expression by using criteria that are more behavioral in nature.

Although distress reactions are common in young children, overt distress may not be present. Young children may instead present with increased excitement, constricted play, and social withdrawal.

Signs and Symptoms of Posttraumatic Stress Disorder in Children and Adolescents

• Problems sleeping
• Feeling sad or grouchy
• Feeling nervous, jittery, or unusually alert
• Having trouble feeling affectionate
• Being more aggressive
• Having flashbacks that may include images, sounds, smells, or feelings
• Reenacting the trauma
• Worrying about dying at a young age
• Acting younger than one’s age
• Having physical symptoms such as headaches and stomachaches
• Having trouble focusing or experiencing problems at school

Events that can elicit acute stress disorder or PTSD include exposure to actual or threatened death or serious injury; witnessing or learning about such events or experiences; and repeated exposure to aversive details of an event through media, photographs, television, or movies.

Females are at greater risk of both direct and indirect exposure and are more likely to report bereavement. Males are more likely to be exposed to nonsexual physical violence, witness violence, and be involved in serious accidents. Younger age and adolescence are also associated with increased risks. When assessing for trauma, it is helpful to evaluate changes in cognitive, emotional, social, and behavioral functioning.

Screening, Assessment, and Takeaway Points

Screening and Assessment Options for Child and Adolescent Trauma

• Child Behavior Checklist (CBCL): Achenbach and Rescorla (2001); ages 1½–5.
• Posttraumatic Stress Disorder Semi-Structured Interview and Observation Record: Scheeringa and Zeanah (1994); ages 0–4.
• Posttraumatic Symptom Inventory for Children (PT-SIC): Eisen (1997); ages 4–8.
• Preschool Age Psychiatric Assessment (PAPA): Egger and Angold (1999); ages 2–5.
• PTSD Symptoms in Preschool-Aged Children (PTSD-PAC): Levendosky, Huth-Bocks, Semel, and Shapiro (2002); ages 3–5.
• Traumatic Events Screening Inventory—Parent Report Revised (TESI-PRR): Ghosh et al. (2002); ages 0–6.
• Trauma Symptom Checklist for Young Children (TSCYC): Briere et al. (2001); ages 3–12.
• Violence Exposure Scale for Children—Preschool Version (VEX-PV): Shahinfar, Fox, and Leavitt (2000); ages 4–10.
• Violence Exposure Scale for Children—Revised Parent Report (VEX-RPR): Shahinfar, Fox, and Leavitt (2000); for parents of children ages 4–10.
• UCLA Child/Adolescent PTSD Reaction Index for DSM-5 (PTSD-RI): Includes the Child/Adolescent Self-Report, Parent/Caregiver Report, Parent/Caregiver Report for Children Age 6 and Younger, and Brief Screen for Trauma and PTSD.
• Adolescent Primary Care Traumatic Stress Screen (APCTSS): Ng et al. (2022); a five-question screener for primary care settings; ages 13–22.
• Child PTSD Symptom Scale (CPSS): 2021; ages 8–18.

Additional Information

Books

• Treating Traumatic Stress in Children and Adolescents: How to Foster Resilience Through Attachment, Self-Regulation, and Competency, Margaret E. Blaustein and Kristine Kinniburgh.
• Trauma-Informed Assessment with Children and Adolescents: Strategies to Support Clinicians, Cassandra Kisiel et al.

Journal Articles

• A Scoping Review of Trauma-Informed Pediatric Interventions in Response to Natural and Biologic Disasters
• Perceived Life Threat in Children During the COVID-19 Pandemic: Associations with Posttraumatic Stress, Anxiety, and Depressive Symptoms
• Posttraumatic Stress Symptom Trajectories Among Children After Disaster Exposure
• Trajectories of Tornado-Related Posttraumatic Stress Symptoms and Pre-Exposure Predictors in a Sample of At-Risk Youth

Handouts

• About Child Trauma
• Medical Traumatic Stress: What Health Care Providers Need to Know