Current Psychiatry Reports

, 15:340

Assessment and Management of Pediatric Iatrogenic Medical Trauma

Child and Adolescent Disorders (TD Benton, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Child and Adolescent Disorders


Medically ill children are often exposed to traumatizing situations within the medical setting. Approximately 25-30 % of medically ill children develop posttraumatic stress symptoms and 10-20 % of them meet criteria for posttraumatic stress disorder. Parents of medically ill children are at even higher risk for posttraumatic stress symptoms. Most children and parents will experience resolution of mild trauma symptoms without formal psychological or psychiatric treatment. Posttraumatic stress symptoms are associated with medical nonadherence, psychiatric co-morbidities, and poorer health status. Therefore, evidenced-based trauma-focused treatment is indicated for those who remain highly distressed or impaired. This paper reviews approaches to the assessment and management of pediatric iatrogenic medical trauma within a family-based framework.


Assessment Management Pediatric Iatrogenic Medical Trauma Treatment Post traumatic stress disorder Cognitive behavioral therapy Medication Pharmacotherapy Children Adolescents Hospital Family-based Review Benzodiazepines Opiates SSRIs Psychiatry 


Papers of particular interest, published recently, have been highlighted as: • Of importance, •• Of major importance

  1. 1.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th edn., DSM-IV). Washington, DC: American Psychiatric Association; 1994. p. 424–32.Google Scholar
  2. 2.
    American Psychiatric Association: G 03 posttraumatic stress disorder, proposed revision. Available at Accessed September 2012.
  3. 3.
    Laor N, Wolmer L, Mayes LC, et al. Israeli preschoolers under scud missile attacks: a developmental perspective on risk-modifying factors. Arch Gen Psychiatry. 1996;53:416–23.PubMedCrossRefGoogle Scholar
  4. 4.
    Scheeringa MS, Gaensbauer TJ. Posttraumatic stress disorder. In: Zeanah CH, editor. Handbook of infant mental health. 2nd ed. New York: Guilford; 2000. p. 369–81.Google Scholar
  5. 5.
    De Young AC, Kenardy JA, Cobham VE. Diagnosis of posttraumatic stress disorder in preschool children. J Clin Child Adolesc Psychol. 2011;40:375–84.PubMedCrossRefGoogle Scholar
  6. 6.
    Winston FK, Kassam-Adams N, Garcia-España F, et al. Screening for risk of persistent posttraumatic stress in injured children and their parents. JAMA. 2003;290:643–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Scheeringa MS, Zeanah CH. Reconsideration of harm’s way: onsets and comorbidity patterns of disorders in preschool children and their caregivers following Hurricane Katrina. J Clin Child Adolesc Psychol. 2008;37:508–18.PubMedCrossRefGoogle Scholar
  8. 8.
    Scheeringa MS, Zeanah CH, Myers L, et al. New findings on alternative criteria for PTSD in preschool children. J Am Acad Child Adolesc Psychiatr. 2003;42:561–70.CrossRefGoogle Scholar
  9. 9.
    • Caplan R, Bursch B. Pediatric Iatrogenic Trauma Symptoms. In “How Many More Questions?” Techniques for Clinical Interviews of Young Medically Ill Children. Oxford University Press; 2012:275-286. This chapter guides the reader in how to effectively elicit information from young children about iatrogenic medical trauma. Google Scholar
  10. 10.
    Knoester H, Grootenhuis MA, Bos AP. Outcome of paediatric intensive care survivors. Eur J Pediatr. 2007;166:1119–28.PubMedCrossRefGoogle Scholar
  11. 11.
    Perry BD. The neurodevelopmental impact of violence in childhood. In: Schetky D, Benedek E, editors. Textbook of child and adolescent forensic psychiatry. Washington, D.C: American Psychiatric Press, Inc; 2009. p. 221–38.Google Scholar
  12. 12.
    Gaensbauer TJ, Siegel CH. Therapeutic approaches to posttraumatic stress disorder in infants and toddlers. Infant Ment Health J. 1995;16:292–305.CrossRefGoogle Scholar
  13. 13.
    Nooner KB, Linares LO, Batinjane J, et al. Factors related to posttraumatic stress disorder in adolescence. Trauma Violence Abuse. 2012;13:153–66.PubMedCrossRefGoogle Scholar
  14. 14.
    Giedd JN, Blumenthal J, Jeffries NO, et al. Brain development during childhood and adolescence: a longitudinal MRI study. Nat Neurosci. 1999;2:861–3.PubMedCrossRefGoogle Scholar
  15. 15.
    Lenroot RK, Giedd JN. Brain development in children and adolescents: insights from anatomical magnetic resonance imaging. Neurosci Biobehav Rev. 2006;30:718–29.PubMedCrossRefGoogle Scholar
  16. 16.
    Paus T. Mapping brain maturation and cognitive development during adolescence. Trends Cognit Sci. 2005;9:60–8.CrossRefGoogle Scholar
  17. 17.
    Graham-Bermann SA, Howell K, Habarth J, et al. Toward assessing traumatic events and stress symptoms in preschool children from low-income families. Am J Orthopsychiatry. 2008;78:220–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Klein TP, Devoe ER, Miranda-Julian C, et al. Young children’s responses to September 11th: The New York City experience. Infant Mental Health J. 2009;30:1–22.CrossRefGoogle Scholar
  19. 19.
    Levendosky AA, Huth-Bocks AC, Semel MA, et al. Trauma symptoms in preschool-age children exposed to domestic violence. J Interpers Violence. 2002;17:150–64.CrossRefGoogle Scholar
  20. 20.
    Saylor CF, Swenson CC, Powell P. Hurricane Hugo blows down the broccoli: preschoolers’ post-disaster play and adjustment. Child Psychiatr Hum Dev. 1992;22:139–49.CrossRefGoogle Scholar
  21. 21.
    Scheeringa MS, Peebles CD, Cook CA, et al. Toward establishing procedural, criterion, and discriminant validity for PTSD in early childhood. J Am Acad Child Adolesc Psychiatr. 2001;40:52–60.CrossRefGoogle Scholar
  22. 22.
    Zerk DM, Mertin PG, Proeve M: Domestic violence and maternal reports of young children’s functioning. J Fam Viol. 2009;24(7):423–432.Google Scholar
  23. 23.
    Landolt MA, Vollrath M, Ribi K, et al. Incidence and association of parental and child posttraumatic stress symptoms in pediatric patients. J Child Psychol Psychiatry. 2003;44:1199–207.PubMedCrossRefGoogle Scholar
  24. 24.
    Kean EM, Kelsay K, Wamboldt F, et al. Posttraumatic stress in adolescents with asthma and their parents. J Am Acad Child Adolesc Psychiatr. 2006;45:78–86.Google Scholar
  25. 25.
    Mintzer LL, Stuber ML, Seacord D, et al. Traumatic stress symptoms in adolescent organ transplant recipients. Pediatrics. 2005;115:1640–4.PubMedCrossRefGoogle Scholar
  26. 26.
    Connolly D, McClowry S, Hayman L, et al. Posttraumatic stress disorder in children after cardiac surgery. J Pediatr. 2004;144:480–4.PubMedCrossRefGoogle Scholar
  27. 27.
    Rennick JE, Johnston CC, Dougherty G, et al. Children's psychological responses after critical illness and exposure to invasive technology. J Dev Behav Pediatr. 2002;23:133–44.PubMedCrossRefGoogle Scholar
  28. 28.
    Rennick JE, Morin I, Kim D, et al. Identifying children at high risk for psychological sequelae after pediatric intensive care unit hospitalization. Pediatr Crit Care Med. 2004;5:358–63.PubMedCrossRefGoogle Scholar
  29. 29.
    Colville G, Kerry S, Pierce C. Children's factual and delusional memories of intensive care. Am J Respir Crit Care Med. 2008;177(9):976–82.PubMedCrossRefGoogle Scholar
  30. 30.
    Taylor LK, Weems CF. What do youth report as a traumatic event? Toward a developmentally informed classification of traumatic stressors. Psychol Trauma. 2009;1:91–106.PubMedCrossRefGoogle Scholar
  31. 31.
    • Cohen JA, Scheeringa MS. Post-traumatic stress disorder diagnosis in children: challenges and promises. Dialogues Clin Neurosci. 2009;11:91–9. This paper describes developmental considerations for accurately diagnosing PTSD in preschool and school-age children.PubMedGoogle Scholar
  32. 32.
    Laor N, Wolmer L, Mayes LC, et al. Israeli preschool children under scuds: a 30-month follow-up. J Am Acad Child Adolesc Psychiatr. 1997;36:349–56.CrossRefGoogle Scholar
  33. 33.
    Laor N, Wolmer L, Cohen DJ. Mothers’ functioning and children’s symptoms 5 years after a SCUD missile attack. Am J Psychiatry. 2001;158:1020–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Meiser-Stedman R, Smith P, Glucksman E, et al. The posttraumatic stress disorder diagnosis in preschool- and elementary school-age children exposed to motor vehicle accidents. Am J Psychiatry. 2008;165:1326–37.PubMedCrossRefGoogle Scholar
  35. 35.
    Scheeringa MS, Zeanah CH, Myers L, et al. Predictive validity in a prospective follow-up of PTSD in preschool children. J Am Acad Child Adolesc Psychiatr. 2005;44:899–906.CrossRefGoogle Scholar
  36. 36.
    Stuber ML, Meeske KA, Leisenring W, et al. Defining medical posttraumatic stress among young adult survivors in the Childhood Cancer Survivor Study. Gen Hosp Psychiatr. 2011;33(4):347–53.CrossRefGoogle Scholar
  37. 37.
    Lieberman AF, Knorr K. The impact of trauma: a development framework for infancy and early childhood. Pediatr Ann. 2007;36:209–15.PubMedGoogle Scholar
  38. 38.
    Pynoos RS, Steinberg AM, Layne CM, et al. DSM-V PTSD diagnostic criteria for children and adolescents: a developmental perspective and recommendations. J Trauma Stress. 2009;22:391–8.PubMedCrossRefGoogle Scholar
  39. 39.
    Saxe G, Stoddard F, Courtney D, et al. Relationship between acute morphine and the course of PTSD in children with burns. J Am Acad Child Adolesc Psychiatr. 2001;40(8):915–21.CrossRefGoogle Scholar
  40. 40.
    American Academy of Pediatrics Child Life Council and Committee on Hospital Care, Wilson JM. Child life services. Pediatrics. 2006;118(4):1757–63.PubMedCrossRefGoogle Scholar
  41. 41.
    Zohar J, Juven-Wetzler A, Sonnino R, et al. New insights into secondary prevention in post-traumatic stress disorder. Dialogues Clin Neurosci. 2011;13(3):301–9.PubMedGoogle Scholar
  42. 42.
    Shemesh E, Lurie S, Stuber ML, et al. A pilot study of posttraumatic stress and nonadherence in pediatric liver transplant recipients. Pediatrics. 2000;105(2):E29.PubMedCrossRefGoogle Scholar
  43. 43.
    • Lester P, Saltzman W, Woodward K, et al. Evaluation of a family centered prevention intervention for military children and families facing wartime deployments. Am J Public Health. 2012;102:S48–54. This paper provides research support for a strength-based, trauma-informed family prevention program that provides individual and family level training in resiliency skills and is designed to mitigate the impact of stress on children and families.PubMedCrossRefGoogle Scholar
  44. 44.
    Levitt JT, Malta LS, Martin A, et al. The flexible application of a manualized treatment for PTSD symptoms and functional impairment related to the 9/11 World Trade Center attack. Behav Res Ther. 2007;45:1419–33.PubMedCrossRefGoogle Scholar
  45. 45.
    Gelpin E, Bonne O, Peri T, et al. Treatment of recent trauma survivors with benzodiazepines: a prospective study. J Clin Psychiatr. 1996;57:390–4.Google Scholar
  46. 46.
    Mellman TA, Bustamante V, David D, et al. Hypnotic medication in the aftermath of trauma. J Clin Psychiatr. 2002;63:1183–4.CrossRefGoogle Scholar
  47. 47.
    Cohen H, Zohar J, Matar M. The relevance of differential response to trauma in an animal model of post-traumatic stress disorder. Biol Psychiatry. 2003;53:463–73.PubMedCrossRefGoogle Scholar
  48. 48.
    Matar M, Zohar J, Kaplan Z, et al. Alprazolam treatment immediately after stress exposure interferes with the normal HPA-stress response and increases vulnerability to subsequent stress in an animal model of PTSD. Eur Neuropsychopharmacol. 2009;19:283–95.PubMedCrossRefGoogle Scholar
  49. 49.
    Owens J. Pharmacotherapy of pediatric insomnia. J Am Acad Child Adolesc Psychiatr. 2009;48(2):99–107.CrossRefGoogle Scholar
  50. 50.
    Smith, Fuchs, Pandharapande, et al: Delirium: an emerging frontier in the management of critically ill children. Crit Care Clin. 2009;29(4):593–614.Google Scholar
  51. 51.
    Stoddard Jr FJ, Luthra R, Sorrentino EA, et al. A randomized controlled trial of sertraline to prevent posttraumatic stress disorder in burned children. J Child Adolesc Psychopharmacol. 2011;21(5):469–77.PubMedCrossRefGoogle Scholar
  52. 52.
    Seedat S, Stein DJ, Ziervogel C, et al. Comparison of response to selective serotonin reuptake inhibitor in children, adolescents, and adults with PTSD. J Child Adolesc Psychopharmacol. 2002;12(1):37–46.PubMedCrossRefGoogle Scholar
  53. 53.
    Yorbik O, Dikkatli S, Cansever A, et al. The efficacy of fluoxetine treatment in children and adolescents with posttraumatic stress disorder symptoms [in Turkish]. Klin Psikofarmakol Bulteni. 2001;11:251–6.Google Scholar
  54. 54.
    Robb AS, Cueva JE, Sporn J, Yang R, et al. Sertraline treatment of children and adolescents with posttraumatic stress disorder: a double-blind, placebo-controlled trial. J Child Adolesc Psychopharmacol. 2010;20(6):463–71.PubMedCrossRefGoogle Scholar
  55. 55.
    Cohen JA, Mannarino AP, Perel JM, et al. A pilot randomized controlled trial of combined trauma-focused CBT and sertraline for childhood PTSD symptoms. J Am Acad Child Adolesc Psychiatr. 2007;46(7):811–9.CrossRefGoogle Scholar
  56. 56.
    •• Cohen JA, Bukstein O, Walter H, et al. Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatr. 2010;49(4):414–30. This paper reviews significant advances and evidence related to the assessment and treatment of posttraumatic stress disorder in children.Google Scholar
  57. 57.
    De Bellis MD, Putnam FW. The psychobiology of childhood maltreatment. Child Adolesc Psychiatr Clin Nth Am. 1994;3(4):663–78.Google Scholar
  58. 58.
    Nugent NR, Christopher NC, Crow JP, et al. The efficacy of early propranolol administration at reducing PTSD symptoms in pediatric injury patients: a pilot study. J Trauma Stress. 2010;23(2):282–7.PubMedGoogle Scholar
  59. 59.
    Sharp S, Thomas C, Rosenberg L, et al. Propranolol does not reduce risk for acute stress disorder in pediatric burn trauma. J Trauma. 2010;68(1):193–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Ornitz E, Pynoos R. Startle modulation in children with post-traumatic stress disorder. Am J Psychiatry. 1989;146:866–70.PubMedGoogle Scholar
  61. 61.
    Perry BD. Neurobiological sequelae of childhood trauma: PTSD in children. In: Murburg M, editor. Cathecholamine function in post traumatic stress disorder: emerging concepts. Washington D.C: American Psychiatric Press; 1994. p. 233–55.Google Scholar
  62. 62.
    Harmon RJ, Riggs PD. Clinical perspectives: clonidine for post traumatic stress disorder in preschool children. J Am Acad Child Adolesc Psychiatr. 1996;35:1247–9.CrossRefGoogle Scholar
  63. 63.
    Famularo R, Kinscherff R, Fenton T. Propranolol treatment for childhood posttraumatic stress disorder, acute type. A pilot study. Am J Dis Child. 1988;142(11):1244–7.PubMedGoogle Scholar
  64. 64.
    De Bellis MD, Keshevan MS, Clark DB, et al. Developmental traumatology, part II: brain development. Biol Psychiatry. 1999;45(10):1271–84.PubMedCrossRefGoogle Scholar
  65. 65.
    Reich DB, Winternitz S, Hennen J, et al. A preliminary study of risperidone in the treatment of posttraumatic stress disorder related to childhood abuse in women. J Clin Psychiatr. 2004;65:1601–6.CrossRefGoogle Scholar
  66. 66.
    Bartzokis G, Lu PH, Turner J, et al. Adjunctive risperidone in the treatment of chronic combat-related posttraumatic stress disorder. Biol Psychiatry. 2005;57:474–9.PubMedCrossRefGoogle Scholar
  67. 67.
    Hamner MB, Faldowski RA, Ulmer HG, et al. Adjunctive risperidone treatment in post-traumatic stress disorder: a preliminary controlled trial of effects on comorbid psychotic symptoms. Int Clin Psychopharmacol. 2003;18:1–8.PubMedCrossRefGoogle Scholar
  68. 68.
    Horrigan JP, Barnhill LJ. Risperidone and PTSD in boys. J Neuropsychiatry Clin Neurosci. 1999;11:126–7.Google Scholar
  69. 69.
    Meigen KG, Hines LA, Lagges AM. Risperidone treatment of preschool children with thermal burns and acute stress disorder. J Child Adolesc Psychopharmacol. 2007;17(2):223–32.CrossRefGoogle Scholar
  70. 70.
    Keeshin BR, Strawn JR. Risperidone treatment of an adolescent with severe posttraumatic stress disorder. Ann Pharmacother. 2009;43(7):1374.PubMedCrossRefGoogle Scholar
  71. 71.
    U.S. Food and Drug Administration: News Release. Available at: Accessed September 2012.
  72. 72.
    U.S. Food and Drug Administration: News Release. Available at: Accessed September 2012.
  73. 73.
    Stein MB, Kline NA, Matloff JL. Adjunctive olanzapine for SSRI-resistant combat-related PTSD: a double blind placebo controlled study. Am J Psychiatry. 2002;159(10):1777–9.PubMedCrossRefGoogle Scholar
  74. 74.
    Pivac N, Kozaric-Kovacic D, Muck-Seler D. Olanzapine versus fluphenazine in an open trial in patients with psychotic combat-related post traumatic stress disorder. Psychopharmacology (Berl). 2004;175(4):451–6.Google Scholar
  75. 75.
    Petty F, Brandon S, Casada J, et al. Olanzapine treatment for posttraumatic stress disorder: an open label study. Int Clin Psychopharmacol. 2001;16(6):331–7.PubMedCrossRefGoogle Scholar
  76. 76.
    Sattar SP, Ucci B, Grant K, et al. Quetiapine therapy for posttraumatic stress disorder. Ann Pharmacother. 2002;36(12):1875–8.PubMedCrossRefGoogle Scholar
  77. 77.
    Hamner MB, Deitsch SE, Brodrick PS, et al. Quetiapine treatment in patients with posttraumatic stress disorder: an open trial of adjunctive therapy. J Clin Psychopharmacol. 2003;23(1):15–20.PubMedCrossRefGoogle Scholar
  78. 78.
    Ahearn EP, Mussey M, Johnson C, et al. Quetiapine as an adjunctive treatment for posttraumatic stress disorder: an 8-week open label study. Int Clin Psychopharmacol. 2006;21(1):29–33.PubMedCrossRefGoogle Scholar
  79. 79.
    Stathis S, Martin G, McKenna JG. A preliminary case series on the use of quetiapine for posttraumatic stress disorder in juveniles within a youth detention center. J Clin Psychopharmacol. 2005;26(6):539–44.CrossRefGoogle Scholar
  80. 80.
    Robert R, Blakeney PE, Villarreal C, et al. Imipramine treatment in pediatric burn patients with symptoms of acute stress disorder: a pilot study. J Am Acad Child Adolesc Psychiatr. 1999;38(7):873–82.CrossRefGoogle Scholar
  81. 81.
    Domon SE, Anderson MS. Nefazodone for PTSD. J Am Acad Child Adolesc Psychiatr. 2000;39(8):942–3.CrossRefGoogle Scholar
  82. 82.
    Looff D, Grimley P, Kuller F, et al. Carbamazepine for PTSD. J Am Acad Child Adolesc Psychiatr. 1995;34(6):703–4.CrossRefGoogle Scholar
  83. 83.
    Steiner H, Saxena KS, Fuller F, et al. Divalproex sodium for the treatment of PTSD and conduct disordered youth: a pilot randomized controlled clinical trial. Child Psychiatry Hum Dev. 2007;38(3):183–93.PubMedCrossRefGoogle Scholar
  84. 84.
    North Carolina Child Response Initiative: Recognizing Symptoms of Child Trauma. Available at Accessed September 2012.

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  1. 1.Division of Child Psychiatry, Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human BehaviorDavid Geffen School of Medicine at UCLALos AngelesUSA
  2. 2.Division of Child Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Department of Pediatrics, UCLA Semel Institute for Neuroscience and Human BehaviorDavid Geffen School of Medicine at UCLALos AngelesUSA

Personalised recommendations