Project TEACH

Project TEACH/NYS AAP February 2020 Newsletter


Project TEACH E-Newsletter
Psychological First Aid
Project TEACH has been working with pediatric practices in New York State since 2010. The project, funded by the New York State Office of Mental Health, has supported and strengthened the critical role that New York State pediatric primary care providers (PCP’s) can play in the early identification and treatment of mild-to-moderate mental health concerns for children ranging in age from 0 to 21.
One component of the Project TEACH /NYS American Academy of Pediatrics partnership in 2020 is a series of monthly newsletters touching on topics of concern to pediatricians and to parents.
                                                       
And now to our topic of this Project TEACH Pediatric Newsletter: “Psychological First Aid
Today’s youth are all too familiar with violence and trauma, and as a result, Psychological First Aid (PFA) was developed to assess a child’s mental health symptoms and provide interventions in the aftermath of a traumatic experience. While there are a number of ways to screen and intervene with youth following psychological trauma, Psychological First Aid is a practical and intuitive approach that can be adapted to a number of different settings and circumstances. PFA training and certification is now available online through the
NCTSN Learning Center.
It is estimated that 5 million children in the U.S.
each year are affected by psychic trauma, with millions more living in environments wrought with domestic violence.
1  Greater trauma exposure, perception of life threat, and personal injury are all associated with increased rates of Post-Traumatic Stress Disorder (PTSD). Children with PTSD are more likely to exhibit maladaptive behaviors in adolescence (including drug abuse, risky sexual activity, and anti-social behaviors).
2 They also have an increased risk of suicide attempts, dissociation, major depression, and impairment in global emotional functioning.
3
The DSM-5 includes expanded PTSD criteria, which may facilitate earlier identification and provision of support for children displaying signs of acute stress reactions. The new section,
Trauma- and Stressor-related disorders, encompasses PTSD, Acute Stress Disorder, Adjustment Disorder, Reactive Attachment Disorder, Disinhibited Social Engagement Disorder, and Other Specific Trauma-related disorders, along with a choice of additional qualifiers to more specifically describe the nature of the condition .
4 This change is due to increased recognition of the extreme variability in individual responses to trauma. Even with the expanded criteria, PTSD continues to be one of the most challenging disorders to diagnose accurately in children and adolescents.
5 The DSM-5 also includes alternative criteria for diagnosing PTSD in children under 6 years old, as young children might display atypical symptoms of PTSD. These symptoms include reenactment of trauma-specific themes or experiences during playtime, which may not even seem to be causing the child any distress. The DSM-5 also recognizes that PTSD symptoms can change over time, and full diagnostic criteria may not be met until many months after the trauma (if criteria is met >6 months after the trauma, it is called PTSD with delayed expression). Acute Stress disorder refers to persistence of stress responses for up to 1 month, with significant impairment in a child’s everyday functioning. If symptoms persist beyond one month, the child meets criteria for PTSD.
Children can develop PTSD in response to a number of traumas or stressors—ranging from natural disasters to domestic violence, physical and/or sexual abuse, death of a loved one, or even learning about trauma of a parent without directly experiencing or witnessing the trauma. Acute stress reactions can manifest in all different ways, but common behaviors include anhedonia, hypervigilance, nightmares, flashbacks, and avoidance of certain triggers. These symptoms are more likely to go unnoticed in young children, particularly in the wake of natural disasters or widespread crises.
There is mixed literature about the possibility that children with PTSD display “natural recovery” over time. Some studies have found a decrease in the overall percentage of children qualifying for a diagnosis of PTSD as more time elapses after a trauma.
6 Other studies support the opposite—concluding that symptoms of PTSD persist over time.
7 Individual traits, such as resilience and hardiness, have been proposed as protective factors against development of PTSD, but these traits are difficult to measure reliably. A more universally accepted finding is that strong family support improves a child’s prognosis after trauma. Children who are nurtured by their caregivers display more resilience in the face of adversity.
In addition, early intervention following trauma decreases a child’s likelihood of suffering long-term psychiatric symptoms. However, there are many barriers to early identification of high-risk children and early intervention after traumatic experiences. The shortage of trained mental health professionals for children is certainly one factor, but the lack of screening for mental health conditions also allows high-risk children to fall through the cracks. Many children suffer in silence for years due to lack of recognition by caregivers, parents, teachers, and primary care pediatricians. Even the few children recognized as having psychiatric disturbances often do not receive treatment because of resistance to mental health care. This could be due to stigma perceived by the children or by their parents. Other barriers to treatment include lack of access, lack of insurance, or lack of transportation.
8
The lack of training in crisis intervention skills has led to a dire shortage of qualified responders in times of disaster.
9 Natural disasters inevitably lead to a surge in the demand for mental health support
10, which exacerbates the discrepancy between supply and demand of mental healthcare. Children may suffer in silence for years, and providers too often miss opportunities to identify and intervene with children and youth suffering from trauma-related conditions
11. The instability in today’s world has led to an increased rate of emotional problems in today’s youth. Six months after 9/11, an estimated 75,000 New York City public school children suffered from PTSD
12, though this figure may be under-estimated given the heterogeneity of PTSD symptomatology in children.
The goal of PFA is to limit distress and negative health behaviors in the aftermath of a traumatic event. Proper use of PFA can empower the survivor, and encourage self-efficacy and resilience in the face of adversity.
13 PFA is
not a substitute for counseling or therapy, but is simply intended to be a way to identify patients needing extra support after a traumatic event. The main goal of PFA is to minimize isolation, reduce stress-related responses, and promote self-sufficiency. Focusing on the patient’s strengths can help them to identify the qualities they possess that will help them move forward with hope.
PFA is shown to reduce acute distress and can increase a child’s resilience in the wake of a tragedy or trauma. Much like a Band-Aid is placed over a cut to prevent further damage, PFA is the “quick-fix” that can be put in place before a child can get stitches. PFA aims for immediate stabilization, but is not intended to diagnose or treat mental health disorders. It is merely a skill set that can be taught quickly, increasing the number of people trained to provide compassionate care in times of crisis.
The skills necessary for delivery of effective PFA are different from the skills needed to provide psychiatric care. This is because the goals of PFA are different from the goals of counseling. PFA is intended to stabilize and mitigate acute distress in the immediate aftermath of a traumatic event, while psychotherapy is a longitudinal process requiring introspection and self-analysis. It is neither practical nor effective to provide psychotherapy in the immediate aftermath of a trauma, and the survivor is unlikely to respond to such attempts until their basic needs are met. In fact, attempting to provide psychotherapy too soon after a traumatic event can lead to a breakdown of trust between the provider and the patient.
14 Much of the therapeutic value of Psychological First Aid lies in merely providing a comforting presence, showing compassion for the patient, and listening to what the patient needs most in the immediate aftermath of a trauma.
The 5 evidence-informed principles (safety, calmness, connectedness, self-efficacy, and hope) are based on the observation that survivors often experience fear, anxiety, and a need to connect with others after a traumatic experience. They may feel extremely overwhelmed after experiencing the trauma, and often express hopelessness about their ability to resume a normal life. PFA’s 5 basic guiding principles progress logically, starting with the most fundamental need—safety. Without feeling safe, one cannot feel calm, connected, self-efficacious, or hopeful. Therefore, it is important to address the 5 guiding principles sequentially, starting with the fundamental need of safety.
Children and adolescents tend to worry most about their personal safety or the safety of their family. In situations involving loss of a loved one, a primary care provider should assess the child’s needs and provide a safe environment for the child to grieve. Often the best way to start the conversation is with an open-ended question, or invitation to the survivor to talk. The PCP should practice reflective listening, a communication strategy involving 2 key steps: seeking to understand the patient’s idea, and then offering the idea back to the speaker to confirm you have correctly and completely understood the patient. Throughout the encounter, listen to the patient and show that you care by maintaining good eye contact. Reflect and legitimize their emotions, and assure them they are not alone. Be wary of providing solutions or promising to resolve any safety concerns that are beyond your control. Ensure privacy and give the child your full attention. Simple efforts to make the patient more physically comfortable can go a long way—for example, offering a blanket, tissue, or simply a cup of water.
Each of the 8 core actions of PFA should be approached in the context of the 5 guiding PFA principles: safety, calmness, connectedness, self-efficacy, and hope.
8 Core Actions of PFA
Suggestions for Primary Care Providers
Contact and Engagement 
First, introduce yourself and explain your role. Elicit specific concerns, remain non-judgmental, and be a reflective listener.
Safety and Comfort
Enhance immediate and ongoing safety, provide physical and emotional comfort. Use a calm, soothing voice, and offer reassurance. Guide the patient through grounding/relaxation techniques.
Information Gathering
Find out if there are concerns about an ongoing threat, if the patient has a history of prior trauma/loss, and if the patient has any thoughts of harming self or others.
Practical Assistance
Identify what the patient needs immediately. Also consider offering items to increase comfort (i.e. blankets, tissues, pillows, warmth).
Links to Social Supports
When possible, encourage interaction and support seeking from family members. Strong family support is the most powerful predictor of a youth’s resilience after a traumatic event. 
Information on Coping
Educate the patient (and family, if possible) about the variety of possible acute stress reactions, and normalize these responses as part of the recovery process. Encourage social contacts and if possible, arrange for family support. 
Information on Available Services
Promote continued care by offering contact information and handouts to appropriate services. Referrals can range from local disaster agencies to mental health services, medical treatment, clergy/religious leaders, or family therapy.
By Victor Fornari, M.D. & Carmel Foley, M.D.
Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, NY
& The Zucker Hillside Hospital, Glen Oaks, New York
  1. Perry, B.D. (2014). “Helping Traumatized Children”. Online Booklet. Child Trauma Academy. https://childtrauma.org/wp-content/uploads/2014/01/Helping_Traumatized_Children_Caregivers_Perry1.pdf 
  2.  Hoven, C.W., Duarte, C.S., Lucas, C.P., Wu, P., Mandell, D.J., Goodwin, R.D., et al. (2005). sychopathology among New York City public school children 6 months after September 11. Archives of General Psychiatry, 62, 545-552.
  3. Cohen, J.A. and Mannarino, A.P. (2015). Posttraumatic Stress Disorder and Persistent Complex Bereavement Disorder. Dulcan’s Textbook of Childhood and Adolescent Psychiatry, chapter 16. Accessed online on October 8, 2016. 
  4. American Psychiatric Association.  Trauma- and Stressor-Related Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5. ) http://dx.doi.org.medproxy.hofstra.edu/10.1176/appi.books.9780890425596.dsm07
  5. Cohen, J.A. and Mannarino, A.P. (2015). Posttraumatic Stress Disorder and Persistent Complex Bereavement Disorder. Dulcan’s Textbook of Childhood and Adolescent Psychiatry, chapter 16. Accessed online on October 8, 2016. http://psychiatryonline.org.medproxy.hofstra.edu/doi/full/10.1176/appi.books.9781615370306.md16 
  6. La Greca AM, Silverman WK, Wasserstein SB: Children’s predisaster functioning as a predictor of posttraumatic stress following Hurricane Andrew. J Consult Clin Psychol 66(6):883–892, 1998.
  7. Scheeringa MS, Zeenah CH, Myers L, et al: Predictive validity in a prospective follow-up of PTSD in preschool children. J Am Acad Child Adolesc Psychiatry 44(9): 899-906, 2005.
  8. Boscarino, Adams, and Figley, 2011, J Nerv Mental Disorders 
  9. Galea et al (2005). The epidemiology of post-traumatic stress disorder after disasters. Epidemiology Rev. 27; 78-91.
  10. Lating, J. (2005) Psychological contagion effect. In G.Everly, Jr. & C. Parker, eds. Mental Health Aspects of Disasters, 51-58.
  11. Hanson, T. C.; Hesselbrock, M.; & Tworkowski, S. H. (2002). The prevalence and management of trauma in the public domain: An agency and clinician perspective. The Journal of Behavioral Health Services & Research, 29(4), pp. 365-380.
  12. http://www.apa.org/about/gr/issues/cyf/disaster.aspx
  13. OL McCabe; N Semon; JM Lating; GS Everly, Jr; et al. (In press). Developing an academic-government-faith partnership to build disaster mental health preparedness and community resilience: program description and lessons learned. Public Health Reports.
  14. GS Everly, Jr; OL McCabe, N Semon, CB Thompson, J Links. (2014). The development of a model of psychological first aid (PFA) for non-mental health trained public health personnel: The Johns Hopkins RAPID-PFA. Journal of Public Health Management and Practice (online).
Overview of Project TEACH Services
Current initiatives in Medicaid and Commercial insurance and the NYS PCMH incentive project, all create an environment that encourages pediatric practices to work toward integrating children’s behavioral healthcare into pediatric primary care. Behavioral health integration has the potential to enhance the value proposition for most practices.
Project TEACH Child and Adolescent Psychiatrists are available through the Project TEACH warm lines to provide guidance on assessment of a children’s and adolescents’ mental health symptoms and evidence-based treatment following traumatic events. You can also find the Child PTSD Symptom Scale (CPSS) on the Project TEACH website:
https://projectteachny.org/rating-scales/
 
Project TEACH direct services to pediatricians include:
 
Accessing the educational and supportive services of Project TEACH can help your practice contract for higher payments, while also supporting you and your team in providing more comprehensive higher quality care to your patients with mild-to-moderate mental health concerns.
Funded by a grant from the New York State Office of Mental Health’s Project TEACH.