Identifying and Responding to Child Traumatic Stress in Primary Care

Background and Purpose: One-third of U.S. children experience a potentially traumatic event (PTE) by age 11 years. Childhood PTEs are associated with increased risk for traumatic stress, PTSD, and physical, mental, and socioeconomic harms into adulthood. Despite recommendations for screening and responding to childhood trauma and traumatic stress in primary health care settings, pediatric providers have not had access to simple, validated screening tools for childhood traumatic stress or response guidelines. Our team developed and trialed a care process model (CPM) for child traumatic stress to fill this gap and to increase the identification of and response to child traumatic stress in primary care settings. The CPM includes a pediatric traumatic stress screening tool and guided decision-making, including brief, targeted intervention and referrals to evidence-based trauma treatment, when indicated.

Methods. This pilot was introduced in two pediatric clinics served by 18 pediatric providers in urban and suburban settings in the Intermountain West. Primary participants were children 6-17 years of age presenting for a well-child check. Clinics administered the paper screener, using a parent/caregiver report for children 6-10 and self-report for children ≥11 years. Outcomes included the prevalence of parent- and child-reported PTEs, the prevalence of suicidality, the prevalence of clinically significant traumatic stress symptoms, and observed associations between childhood traumatic stress and selected demographic characteristics, health history, and mental health risks.

Results: Across both clinics, 2359/4959 (47.6%) children 6-17 years of age were offered pediatric traumatic stress screening during a well-child check during the study timeframe. Of 2,359 screeners offered during eligible visits, 1,472 (62.4%) were completed. Of completed screeners, 32.1% captured a history of at least one PTE. Traumatic stress symptoms were reported in 187/488 patients with a history of PTE compared to just 51/1027 of those without a history of PTE (p≤0.001). The absence of a history of PTE predicted minimal traumatic stress symptoms on full screening (NPV 95.2%). Two-thirds of patients with traumatic stress symptoms were classified as having moderate and 5.2% as having severe symptoms of traumatic stress. In a fully adjusted model, moderate and severe symptoms of traumatic stress were associated with a 1.3 (95% CI 0.9, 2.1) times and 5.4 (95% CI 3.5, 8.2) increased risk of suicidality. Of the 310 adolescents dually-screened for traumatic stress and depressive symptoms (PHQ-A), 42 reported clinical symptoms of depression. Among these 42 adolescents, two-thirds also reported a history of PTE.

Conclusions and Implications. Screening for child traumatic stress in a pediatric primary care setting is both feasible and effective in identifying children at-risk for traumatic stress. Our findings support first screening for PTEs, decreasing the time a family may spend filling out forms. Screening for traumatic stress does not replace screening for suicide and depression, but screening for depression and suicide also does not capture PTE or traumatic stress. Ultimately, screening for child traumatic stress symptoms identifies children most at-risk for adverse responses to trauma and informs pediatric primary care response, including brief, targeted intervention and referrals to evidence-based trauma treatment, when indicated.