Torres, A.S Ms Rle Bibliography

Child Adolesc Psychiatric Clin N Am
12 (2003) 493 – 535
Psychological aspects of traumatic injury in

children and adolescents
Ernesto Caffo, MD*, Carlotta Belaise, PsyD
Department of Psychiatry and Mental Health, University of Modena, Largo del Pozzo 71,
41100 Modena, Italy
Origins of traumatology
In recent years there has been an upsurge of interest in the field of trauma
practice. This topic was reviewed recently by Figley, who defined traumatology as
‘‘the investigation and application of knowledge about the immediate and long
term consequences of highly stressful events and the factors which affect those
consequences’’ [1]. The field of traumatology is turning into a major area of the
social sciences and the helping professions. During the 1970s, the awareness of the
prevalence of posttraumatic symptomatology among Vietnam veterans [2],
battered woman [3], and rape victims [4] started involving the interest of special
groups. Terms such as ‘‘traumatology,’’ ‘‘posttraumatic symptomatology,’’ and
‘‘posttraumatic stress’’ were not yet in widespread use at that time. In 1980, a
turning point in the awareness of the prevalence and consequences of psycho-
logical trauma occurred with the publication of the third edition of the ‘‘Diagnostic
and Statistical Manual of Mental Disorders’’ (DSM-III) [5].
Throughout the nineteenth and twentieth centuries, the study of trauma
occurred in such established fields as psychiatry [6] and psychology [7]. Currently,
the range of traumatic stress studies extends from those that occur on a purely
random basis (eg, natural disasters and accidents, hurricanes and tornadoes) to
‘‘acts of humans’’ (transportation accidents and toxic spills) to acts that are
premeditated and involve interpersonal violation of some sort (eg, physical and
sexual assault, combat, genocide, physical relocation because of war, political/
social upheavals).
Trauma can involve large groups of people (eg, war, genocide, earthquakes,
toxic spills such as occurred at Chernobyl) or can occur in small groups or one on
* Corresponding author.
E-mail address: caffo@unimo.it (E. Caffo).
1056-4993/03/$ – see front matter D 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S1056-4993(03)00004-X
494 E. Caffo, C. Belaise / Child Adolesc Psychiatric Clin N Am 12 (2003) 493–535
one (eg, domestic abuse and violence, rape, physical assault, homicide). Trauma
can be directly or indirectly experienced through witnessing or other forms of
first- or second-hand exposure (including the exposure via the mass media) or
through individual relationships to the primary victim (eg, family members who
themselves are traumatized when they learn of the traumatization of a loved one,
especially when it results in serious injury or death) [8].
Experts have provided different definitions of psychological trauma, but a
good encompassing one that emphasizes the subjective impact of the stressor
event or experience was recently suggested by Saakvitne et al [9]:
‘‘. . .a traumatic event or situation creates psychological trauma when it
overwhelms the individual’s perceived ability to cope, and leaves that person
fearing death, annihilation, mutilation or psychosis. The individual feels
emotionally, cognitively and physically overwhelmed. The circumstances of
the event commonly include abuse of power, betrayal of trust, entrapment,
helplessness, pain, confusion or loss.’’
Incidence and prevalence of traumatic stress

Pfefferbaum reported that each year in the United States more than 5 million
children are exposed to some form of extreme traumatic stressor. These
traumatic events include natural disasters (eg, tornadoes, floods, hurricanes),
motor vehicle accidents, life-threatening illnesses and painful medical proce-
dures, physical abuse, sexual assault, witnessing domestic or community
violence, kidnapping, and sudden death of a parent [10,11]. Perry reported that
more than 30% of these children develop a clinical syndrome, called post-
traumatic stress disorder (PTSD), with emotional, behavioral, cognitive, social,
and physical symptoms [12].
The estimated lifetime prevalence of PTSD in the general population ranges
from 1% to 14% [13 – 15]. Giaconia et al [16] found that by the age of 18 years,
more than 40% of youths in a community sample met criteria for at least one
episode of trauma, and more than 6% met criteria for a lifetime diagnosis of PTSD.
Accidents
A 1996 report from the Child Accident Prevention Trust [17] reminds us that
‘‘Every year in the UK about 700 children die, 120,000 are admitted to hospital,
and over 200,000 attend accident and emergency departments as a result of
accidents.’’ The most common accidents were falls, followed by road traffic
accidents. Overall, 9% of the children who visited three accident and emergency
departments scored so highly on a screening scale for PTSD that a diagnosis of
PTSD was extremely likely. Half the children involved in road traffic accidents
were judged likely to have PTSD. Other larger studies of child survivors of road
traffic accidents [18,19] found that 33% met criteria for a diagnosis of PTSD, with
even more showing subthreshold clusters of distressing symptoms. After 6 months,
one in six children still presented with the full-blown syndrome. Cuffe et al
E. Caffo, C. Belaise / Child Adolesc Psychiatric Clin N Am 12 (2003) 493–535 495
[20] examined population prevalence of PTSD in a community sample of

adolescents. They found that 3% of girls and 1% of boys met the DSM-IV criteria
for PTSD. In this study, girls reported more traumatic events than boys. Being
female, experiencing rape or sexual abuse, and witnessing an accident or medical
emergency were associated with increased risk for PTSD. Children exposed to
various traumatic events have much higher incidence (from more than 15% to more
than 90%) and prevalence rates than the general population [10].
An excellent review of psychiatric consequences after injuries in children and
adolescents written by Stoddard and Saxe [21] suggested that injuries have been
the single largest cause of morbidity and mortality among children in the United
States for many years [22,23]. The Centers for Disease Control and Prevention
data reported that 8.7 million children under the age of 15 were seen in hospital
emergency departments for injuries in 1992 [24]. The US Department of
Transportation [25] reported that 894,000 children and adolescents were injured
in motor vehicle accidents in the United States in 1992. Analyzing these data,
Scheidt et al [26] noticed that nonfatal injuries that were medically attended
ranged from 12.9% for young children (aged 1– 4 years) to 22.5% for adolescents
(aged 14– 17 years). Their overall estimated adjusted injury rate was 27%.
Almost half of the young persons treated were between the ages of 14 and
17 years and had the most severe injuries. In the 10- to 13-year age group,
nonfatal injuries from sports were almost as common as those from falls and
being struck or cut. As suggested by Di Scala et al [27], in the 14- to 17-year age
group, sports-related injuries were the leading cause of nonfatal injuries. Motor
vehicle traffic injuries far exceeded all other causes of death but only accounted
for slightly more than 6% of nonfatal injuries.
Cancer
Thirty-five percent of a sample of adolescents in whom cancer was diagnosed
met criteria for PTSD [28]; 15% of children who survived cancer had moderate to
severe PTSD [29].
Witnessing violence
Ninety-three percent of a sample of children who witnessed domestic violence
had PTSD [30]; more than 80% of Kuwaiti children exposed to the violence of
the Persian Gulf crisis had PTSD [31].
Rape and physical and sexual abuse

Seventy-three percent of juvenile male rape victims develop PTSD [32];
34% of a sample of children who experienced sexual or physical abuse and
58% of children who experienced physical and sexual abuse met criteria for
PTSD [33]. In all of these studies, clinically significant symptoms, but not full
PTSD, were observed in essentially all of the children or adolescents after the
traumatic experiences.
Animal attacks
A report by Rossman et al suggested that animal attacks, primarily by dogs,
cause 1% of emergency room visits [34].
Suicide injuries
With regard to suicide, Bell and Clark declared that approximately 5% of
suicide attempters are injured and 2% to 3% seek medical attention. The authors
also suggested that suicide is the third leading cause of death for adolescents,
with firearms accounting for 67% of these [35].
Burns
As reported by Brigham and McLoughlin, burn injuries have dropped
approximately 50% to an estimated annual rate of 1.25 million in the United
States as a result of legislation, education, and burn prevention with devices such
as sprinkler systems and smoke alarms. Deaths from burns, the fourth leading
cause of accidental death, have dropped to 5500 deaths per year [36].
Important settings for injury ‘‘are juvenile detention and correction centers’’—
where 3.12 injuries per 100 juveniles and 2.4 suicidal acts per 100 juveniles
occurred in a 30-day survey [37]—and the workplace, where as many as 24% of
injuries to 14- to 19-year-old persons occur [38].
Fatal injuries
Regarding fatal injuries in 1998 (the most recent year for which data are
available), Guyer et al [39] reported that 16,349 children and teenagers aged 1
through 19 years died from injuries—a rate of 22.1 per 100,000 children. The age
distribution by number and rate per 100,000 is as follows: 1 through 4 years:
2249 (14.8); 5 through 9 years: 1640 (8.3); 10 through 14 years: 2208 (11.5); and
15 through 19 years: 10,245 (52.4). Further analysis of categories, available for
1997 only, revealed motor vehicle traffic and firearms to be the two major causes
of injury [40]. The death rate caused by motor vehicle traffic injuries in young
children (aged 1– 4) was 4.3 per 100,000. Motor vehicle traffic and firearm-
related injuries accounted for 79% of all deaths in adolescents (aged 15– 19).
Combining data from all age categories, suicide and homicide accounted for
2.9 and 4.4 deaths per 100,000 children, respectively, compared with uninten-
tional injuries, which accounted for 15.9 deaths per 100,000 children. Data anal-
ysis by Scheidt et al [26] demonstrated that the distributions of nonfatal medically
attended injuries differ vastly from those of fatal injuries. Adolescents are at the
highest risk for death. In 1997, adolescents aged 15 through 19 accounted for
62.8% of all deaths caused by injuries. Of these injuries, 10.5% were caused by
suicide, 14.2% were caused by homicide, 37.2% were unintentional, and 0.9%
were from other causes. The firearm-related death rate was nearly 12 times higher
in the United States than among 26 other industrial nations combined [41], and
prevention of violent injuries was a national goal for the year 2000 [42]. Recent
studies in the middle-income and economically emerging nations of Asia and
Latin America confirmed the prominence of accidents over infectious diseases as
a cause of death and disability [43 – 46]. Even in poorer areas, such as in Africa
and some parts of Asia, physical trauma has been found to be a major cause of
death and disability in older children and adults [44,47,48].
Recent Italian studies confirmed motor vehicle traffic accidents as a major cause
of death among the population. Data from the Istituto Superiore di Sanità and
Società Italiana di Medicina di Pronto Soccorso [49] revealed that from 1969 to
1994, 11,733 male children and 5928 female children (aged 0 –14 years) (total =
17,661) and 63,528 male subjects and 13,091 female subjects (aged 15– 29 years)
(total = 76,619) died from motor vehicle traffic accidents. Nonfatal injuries data
reported 400 children under the age of 13 with permanent disability, 4000 admitted
to hospital, and 12,000 seen in hospital emergency departments each year.
Overall, these data report that injuries occur to approximately one fourth of
children, with young children and adolescents at highest risk. Sports, falls, motor
vehicle traffic injuries, and burns are among the common causes. Juvenile
offenders in detention and correction environments also are among persons most
vulnerable psychiatrically and are at highest risk [21].
Psychiatric disorders after traumatic events and injuries are a large public
health problem and account for high rates of morbidity in children and
adolescents. Regarding physical injuries, adolescents are at particular risk.
As reported by the United States Department of Transportation, the economic
costs of injury, disability, and death of children are more than $16 billion each
year [25]. Despite high rate of injuries and death, the psychiatric aspects of
physical injuries in children have been neglected by research groups. In 1966, the
National Academy of Sciences labeled injuries as the ‘‘neglected disease of
modern society’’ [50]. The psychiatric sequelae of injuries continue to be
understudied, notwithstanding the fact that the incidence of injuries is increasing
in most developing nations [51] and by 2020 injuries and infectious disease are
projected by the World Health Organization to account for equal amounts of
potential life lost worldwide [52].
Risk for psychopathology after trauma
Two different lines of evidence

A major question that emerged from previous research concerns the degree to
which trauma represents a homogeneous risk factor for developmental psycho-
pathologies. This topic has been reviewed extensively and recently by Pine and
Cohen [53], who underlined two main lines of evidence in this research area.
One line of evidence is concerned with data that reveal heterogeneity in the
nature of associations between psychopathology and specific forms of trauma.
For example, compared with children who are exposed to accidents or natural
calamities, children who are exposed to physical or sexual abuse exhibit higher
rates of other risk factors for psychopathology, such as parental discord or
psychopathology [54 – 57]. Similarly, even among children who experience
specific forms of trauma, such as sexual abuse, some groups face higher risk
than others for adverse psychiatric outcomes based on heterogeneity in exposure
to other risks [55]. The other line of evidence encompasses the important
commonalities emphasized by several researchers in different studies. For
example, depressive symptoms exhibit strong associations with a range of
traumatic experiences, from physical or sexual abuse [54,56,57] to natural
disasters or accidents [58,59]. Clearly more research is needed that examines
commonalities and differences in psychiatric outcomes after childhood exposure
to various forms of trauma. Pine and Cohen summarized salient characteristics of
key longitudinal studies and examined the association between trauma during
childhood and psychiatric symptoms at various life stages. As suggested by the
authors, data from these studies support conclusions on the nature of associations
among various forms of trauma, adverse psychiatric outcomes, and predictors of
adverse psychiatric outcomes [53, see Table 1].
The nature of trauma-related psychopathology

The development of trauma practice among children has addressed some
fundamental questions and has contributed, in the last two decades, to a strong
change in the research area of trauma-related psychopathology. As extensively
reviewed by Pine and Cohen [53], studies in the early 1980s placed relatively
little emphasis on the role of trauma in common pediatric psychiatric syndromes
and gave somewhat more emphasis to children’s resilience in the face of trauma
[60]. Studies conducted more recently place a stronger emphasis on adverse
outcomes after trauma. In terms of specific psychiatric manifestations, DSM-IV
emphasizes the associations between trauma and symptoms of anxiety disorders,
as reflected in the diagnoses of acute stress disorder or PTSD. Studies among
children and adolescents described associations with a broad range of adverse
outcomes well beyond these conditions. Steinberg and Avenevoli suggested that
trauma and other contextual factors may act in children and adolescents as
nonspecific risk factors for various mental conditions [61]. Despite the hetero-
geneous nature of these data, studies described by Pine and Cohen [53, see
Table 1] supported the strong relationships between acute trauma and symptoms
of depressive and anxiety disorders, as opposed to other mental syndromes.
Among the anxiety disorders, symptoms of PTSD, acute stress disorder, separa-
tion anxiety, and generalized anxiety disorders each represent relatively common
problems after exposure to extreme stress. Shaw et al also emphasized associ-
ations with symptoms of behavior disorders, including attention deficit hyper-
activity disorder (ADHD) or oppositional-defiant disorder; however, such
associations seem less consistent than those with mood and anxiety disorders
[62]. Behavior disorders may represent a risk factor for exposure to some forms
of trauma [63,64]. As a result, the consistent direction driving potential associ-

ations between behavior disorders and trauma remains unclear [53].
Some investigators have suggested that manifestations of trauma-related
psychopathology exhibit meaningful developmental changes. Among adolescents,
psychiatric sequelae may most closely resemble those observed among adults, with
a predominance of specific depressive and anxiety disorder symptoms, whereas
among younger children a broader range of mood and anxiety and behavioral
symptoms may predominate [61,65]. These observations have led to suggestions
for altering diagnostic criteria for trauma-related syndromes based on devel-
opmental stage [66].
Regarding the overall rates, Pine and Cohen [53] reviewed studies among
adults that suggested that approximately 25% of individuals exposed to acute
trauma will develop symptoms of PTSD [67,68]. For children and adolescents,
variability in estimates is influenced by several different factors. Variation in rates
of adverse outcomes depends on definition of the outcome, severity of the
stressor, and length of time separating the trauma from the assessment. For acute
reactions to relatively severe stressors, such as living at the epicenter of the 1988
Armenian earthquake, PTSD-related symptoms can be diagnosed in 90% of the
children and adolescents. Regarding children exposed to less extreme or
relatively brief stressors, Brown et al [54], Dohrenwend et al [69], and Laor
et al [70] suggested that PTSD-related symptoms or even psychopathology in
general can fall below 20%. Pine and Cohen [53] declared that some available
research data show inconsistencies in terms of across-time variation in risk. At
least two studies noted a delay in symptom expression, recognizable as relatively
low rates of psychopathology, especially behavior problems, in the weeks
immediately after traumatic events followed by rising rates over the next 1 to
2 years [62,71]. Other long-term studies of children underlined that rates of
psychopathology tend to show acute increases followed by gradual reductions
with less evidence of a delay in symptoms expression [70,72 –75].
Regarding the long-term consequences, there is evidence that childhood
trauma also affects other aspects of physical health throughout life [76,77].
Adults victimized by sexual abuse in childhood are more likely to have difficulty
in childbirth, have various gastrointestinal and gynecologic disorders, and have
other somatic problems such as chronic pain, headaches, and fatigue [78].
The Adverse Childhood Experiences study [79] examined exposure to seven
categories of adverse events during childhood (eg, sexual abuse, physical abuse,
witnessing domestic violence, that is, events associated with increased risk for
PTSD). This study found a graded relationship between the number of adverse
events in childhood and the adult health and disease outcomes examined
(eg, heart disease, cancer, chronic lung disease, and various risk behaviors).
With four or more adverse childhood events, the risk for various medical con-
ditions increased fourfold to 12-fold. In a retrospective survey on the prevalence
and long-term impact of abuse, Romans et al found that several functional
medical disorders (chronic fatigue, pelvic pain, headache, chronic pain, asthma,
cardiovascular problems, diabetes, and bladder problems) significantly increased
in female victims of different types of abuse, both in childhood and in adult

life [80].
Predictors of response in child victims of trauma

Various factors influence response to trauma and affect recovery. As reviewed
by Pfefferbaum [10], these factors include characteristics of the stressor and
exposure to it; individual factors such as gender, age, developmental level, and
psychiatric history; family characteristics; and social factors. As reported by Pine
and Cohen, studies summarized [53, see Table 1] provide data from qualitatively
different kinds of traumatic events. Three studies investigated outcome after
physical or sexual abuse, whereas other studies examined various acute traumas,
including natural disasters or violence [53]. Prior reviews from cross-sectional
investigations link the nature of traumatic events to risk for psychopathology. In
general, it has been demonstrated that acute events that produce little change in
the social milieu tend to carry lower risks than either chronic, ongoing traumatic
events or other experiences that cause long-term disruptions in children’s social
environment [61,69,70,81]. As suggested by Pine and Cohen, despite these
general trends, efforts to compare precisely the rates of adverse psychiatric
outcomes across studies and stressors are made difficult by methodologic aspects.
Rates of disorder often vary because of the demography of the exposed groups,
differences in assessment techniques, or variations in the length of follow-up.
Such cross-study variations limit the use of an appropriate metaanalytic approach
to data on risk factors for adverse outcomes.
From the clinical perspective, knowledge about these factors may assist in the
effort to identify children or adolescents who are at high risk for adverse psychiatric
outcomes after exposure to trauma. Clinicians could observe these individuals
accurately and continuously or focus on factors that predict high degrees of
symptoms over time to facilitate efforts to address emergent psychiatric symptoms
before a pattern of chronic symptoms has emerged [53]. Prior research in this area,
as summarized by Pine and Cohen [53, see Table 1 ], reports three different factors
linked to ‘‘differential symptom trajectories’’ among traumatized children: (1)
characteristics of the individual, (2) the traumatic event, and (3) the social
environment in which the event took place. Level of exposure to acutely dangerous
events seems to predict high risk for later psychiatric symptoms [53]. This
association has been confirmed in all types of investigated trauma [53], including
physical and sexual abuse [54,56,57], exposure to a shipping disaster [82],
exposure to a sniper attack [74], and exposure to various war-related traumas
[61,83]. Several other studies demonstrated that social support exerts relatively
strong moderating influences on acute and long-term mental health problems in
children exposed to trauma. This also has been confirmed in long-term follow-up
studies [53], including studies of children exposed to SCUD missile attacks in
Israel [61,70,73] or other war-related trauma [83], children victims of physical
abuse [55], and children exposed to a shipping accident [84].
Beyond these two factors, characteristics of the individual also seem to play a
role in the prediction of outcomes [53]. Levels of psychopathology before or
immediately after trauma may constitute an important risk factor for later
psychiatric symptoms among exposed children, with trauma-related anxiety
symptoms seeming to be particularly strong predictors [53]. As among adults
[67,69], gender influences a child’s defensive style and coping, the availability
and use of social support, and expectation for response and recovery. As reviewed
by Pfefferbaum [10], among children in studies with large samples, girls
generally are more symptomatic than boys [16,85 –87]. In particular, girls tend
to show higher rates of later mood or anxiety symptoms after traumatic stress
[72,85,88], whereas boys may show higher rates of behavior symptoms [62]. On
the other hand, some studies found boys to be more symptomatic than girls, and
some studies found qualitative gender differences in symptoms and recovery
[16,89 –91]. With particular reference to the expression and development of
PTSD, clinical experience and recent studies suggest that girls tend to exhibit
more internalizing (ie, anxiety, dysphoria, dissociation, avoidance) and boys
exhibit more externalizing (ie, impulsivity, aggression, inattention, hyperactivity)
posttraumatic symptoms [33,92]. In epidemiologic studies of PTSD in the general
adult population, women have higher rates than men [93]. There seem to be
gender differences in adaptive response after the acute event (girls dissociate
more than boys) [92], which may be related to this observed difference in
development and expression of trauma-related symptoms.
As reported by Pine and Cohen, in terms of aspects of the trauma, chronic or
extreme traumatic experiences may carry the highest risk for psychopathology
when they cause disorder in social support networks through family displacement
or disruption [53]. For example, Laor et al reported consistently higher levels of
psychiatric symptoms among children whose families were displaced after having
being exposed to the SCUD missile attacks in Israel, compared with similarly
exposed children who lived in nondisplaced families. The same authors found
that aspects of parental mental health predicted changes in symptoms over time
[70]. Lynskey and Fergusson confirmed these results in epidemiologic studies of
children exposed to physical abuse. The mechanisms behind such associations
remain unclear [55].
In summary, research supports several risk factors for the development of
symptoms in children exposed to traumatic experiences, including level of
exposure, extent of disruption in social support systems, and pretrauma levels
of psychopathology.
As reviewed by Pfefferbaum, further important factors influence a child’s
exposure to risk, perception and understanding of trauma, susceptibility to
parental distress, quality of response, coping style, skills, and memory of the
event [10]. These factors are a child’s age and developmental level [94 – 97].
These two factors also influence the response of others to traumatized children,
with younger ones likely to be more protected. Trauma and the child’s response
to it have the potential to disrupt normal development [98] and may influence the
child’s adaptation and the subsequent development of cognition and attention,
social skills, personality style, self-concept, self-esteem, and impulse control [74].
There also may be age-related differences in the specific symptomatology.
Schwarz and Kowalski found that avoidance symptoms were more common in
younger children, whereas older children suffered more re-experiencing and
arousal after a school shooting [99]. Compared with adults, younger children
were more likely to experience spontaneous intrusive phenomena, whereas older
children and adults suffered greater distress with specific reminders. Weisenberg
et al noticed that adolescents who were in shelters during threatened missile
attacks in the Persian Gulf War used avoidance as a coping style more often than
younger children [97]. Despite difficulties in assessing PTSD in young children,
several investigators have demonstrated that even preschool children are affected
by trauma [61,66,96,100 – 102]. Scheeringa et al described the difficulty of
making a diagnosis of posttraumatic symptoms in infants and young children
though DSM-IV criteria because of their low sensitivity [66]. This difficulty
suggests the need for further research to discover more sensitive diagnostic
criteria for assessing young children.
Psychiatric consequences of physical injuries

This topic has been discussed extensively by Stoddard and Saxe in a
comprehensive review of the past 10 years of research relevant to psychiatry
regarding injuries in children and adolescents [21]. The authors suggested that
despite the progress that is occurring in injury prevention, pain management,
acute care, psychiatric treatment, and outcomes, many psychiatric aspects are still
neglected. The emotional and behavioral effects of injuries contribute to
morbidity and mortality among individuals, so that psychiatric assessment, crisis
intervention, psychotherapy, psychopharmacologic treatment, and interventions
for families have become fundamental. The need to include all these psychiatric
interventions has emerged as a crucial part of clinical investigation and injured
child care and the psychiatric collaboration with emergency, trauma, and
rehabilitation teams. These interventions must be adapted to the severity of
injury, comorbid psychopathology, anatomic location, and prognosis. Stoddard
and Saxe generally defined injuries by cause (eg, burns) and by anatomic location
(eg, face). The standardized classifications are ICD-9 and ICD-10. ICD-9-CM
[103] classifies injuries, poisonings, other effects of external causes, complica-
tions of trauma, and complications of medical and surgical care. ICD-10 [104] is
much more specific in its definitions and changes certain terms, such as replacing
the word ‘‘amputation’’ with ‘‘detachment’’ to be applicable to a wider range of
procedures. Stoddard and Saxe used the term ‘‘intentional injuries’’ to refer to
injuries caused by traumatic events, such as child abuse, homicide, and suicide,
and the term ‘‘unintentional injuries’’ to include all other causes [21]. According
to Peterson and Brown, this distinction in classification may not continue to be
useful because many ‘‘unintentional’’ injuries are found to be intentional on full
investigation [105].
Unfortunately, few studies of psychiatric outcomes after injuries exist.

Stoddard and Saxe summarized a series of psychiatric implications after particu-
lar anatomic locations of the injury [21, see Table 1].
A review of the literature indicates PTSD as the most common psychiatric
disorder after injuries. Comorbid diagnoses, such as mood, anxiety, and conduct
disorders, occur in trauma patients and affect outcome.
Prior trauma, particularly head trauma, may predispose a person to psychiatric
disorder, particularly ADHD. Stoddard and Saxe [21] extensively reviewed this
issue. They reported several studies that confirmed PTSD as the most common
child’s psychological reactions to a diverse range of injuries, such as motor
vehicle accidents, violent assaults, natural disasters, political violence, and burns
[85,106 –115]. According to the American Psychiatric Association, PTSD includes
symptoms such as intrusive recollections, numbing and avoidance, and hyper-
arousal [13]. PTSD presents severe clinical implications that interfere with a child’s
social, educational, and biologic development [116 –118]. Children with PTSD are
often so absorbed with intrusive recollections and are so hyperaroused that they
have difficulty processing social information. This preoccupation with the trauma
and extreme levels of arousal interfere with school performances. Traumatized
children frequently are so frightened about recurrence of the traumatic event that
they tend to avoid social situations and school. Intrusive recollections of the
traumatic event may push child victims of violence into ‘‘behavioral reenactments’’
so that they may themselves perpetrate violence [119].
Neurophysiologic core of posttraumatic stress disorder

Traumatic events such as natural disasters (eg, tornadoes, floods, hurricanes),
motor vehicle accidents, life-threatening illnesses and associated painful medical
procedures (eg, severe burns, cancer), physical abuse, sexual assault, witnessing
domestic or community violence, kidnapping, and sudden death of a parent
activate a stress response inside an individual.
As reported by Perry and Pollard, during the traumatic event, a child’s brain
orchestrates adaptive stress-mediating neural systems, including the hypothalamic-
pituitary-adrenal axis, central nervous system noradrenergic, and dopaminergic
systems, and associated central and peripheral nervous system mechanisms that
provide the adaptive emotional, behavioral, cognitive, and physiologic changes
necessary for survival [120]. Individual adaptive responses during traumatic stress
are heterogeneous [92,121]. Perry et al maintained that the ‘‘fight or flight’’
response of adults is less adaptive in young children [92]. When traumatized,
young children are likely to respond with initial hyperarousal, which should signal
the need for caretaker attention, but if the trauma or threat continues without aid, the
response is to immobilize or ‘‘freeze’’ and later to dissociate or ‘‘surrender.’’
Physiologic responses, such as heart rate, may normalize as a child begins to
dissociate. Ornitz and Pynoos demonstrated the loss of the normal inhibitory
modulation of the startle response in a small sample of children with PTSD [122].
Glod and Teicher outlined differences in circadian rhythm and activity level in
abused children with and without PTSD [123]. Perry stated that large increases in
neurotransmitter activity associated with severe and prolonged stress in children
actually may affect the development of the brain, which places them at risk for
developmental disorders [98]. Goenjian et al found a relationship between
intrusion symptoms and baseline cortisol levels and cortisol suppression by
dexamethasone in adolescents 5 years after an earthquake [124].
The specific nature of a child’s responses to a given traumatic event may vary
with the nature, duration, and pattern of traumatic stressor and the child’s
constitutional characteristics (eg, genetic predisposition, age, gender, history of
stress exposure, presence of attenuating factors such as supportive caregivers).
Whatever the individual response, however, the extreme nature of the external
threat is often matched by an extreme and persisting internal activation of the
neurophysiologic systems that mediate the stress response and their associated
functions [120]. As reviewed by Perry, a primary adaptive feature of the threat-
response system is single-trial ‘‘learning’’—the capacity to generalize from a
threatening event to other similar experiences. Unfortunately, this adaptive
capacity is at the core of the emotional, behavioral, and physiologic symptoms
that arise after a traumatic experience. Neural systems respond to prolonged,
repetitive activation by altering their neurochemical and, sometimes, micro-
architectural (eg, synaptic sculpting) organization and functioning. The neural
systems that mediate the stress response behave in the same way.
After any traumatic event, children likely experience some persisting emotional,
behavioral, cognitive, and physiologic signs and symptoms linked to the some-
times temporary shifts in their internal physiologic homeostasis. In general, the
longer the activation of the stress-response systems (ie, the more intense and
prolonged the traumatic event), the more likely there will be a ‘‘use-dependent’’
change in these neural systems [92,98,120]. Unfortunately, in some cases the
stress-response systems do not return to the pre-event homeostasis. In these cases,
the signs and symptoms become so severe, persistent, and disruptive that they reach
the level of a clinical disorder [121]. In a new situation and in the absence of any
real external threat, the abnormal persistence of a once-adaptive response becomes
maladaptive [12].
With particular reference to trauma-related outcomes after physical injuries,
Stoddard and Saxe [21] suggested the need to make two main distinctions:
(1) time after the trauma (the distinction between acute stress disorder [ASD]
and PTSD) and (2) the degree of comorbidity [21]. The first point refers to the
distinction between posttraumatic symptoms expressed in the proximal (ASD)
and distal (PTSD) aftermath of a trauma provided by the DSM-IV-TR [13].
More precisely, symptom duration of less than 1 month is referred to as ASD
(ie, the psychopathologic responses in the immediate aftermath of a traumat-
ic event). PTSD describes the psychopathologic responses that persist after
1 month.
In addition to the temporal distinction between ASD and PTSD, these
disorders are also distinguished by the presence of dissociative symptoms.
Individuals with ASD often report significant dissociative symptoms; they feel
detached from their bodies and describe their environment as ‘‘unreal and
dreamlike.’’ They often present a decrease in emotional responsiveness, numb-
ness, and difficulty in remembering features of the traumatic event. Other
investigations report that such individuals also tend to reexperience the traumatic
event, avoid reminders of the event, and are hyperaroused to stimuli linked to
the event [125 –127]. Dissociative symptoms may be the first manifestation of
psychopathology [21]. Evidence suggests that individuals who dissociate around
the time of trauma are at high risk of developing PTSD [128 – 131]. As
suggested by Marshall et al, there are concerns that the inclusion of dissociative
symptoms as a fundamental criterion of ASD may wrongly lower the rate of this
disorder, because less severe symptoms of reexperiencing, avoidance, and
hyperarousal frequently can characterize the acute phase of a trauma without
the presence of dissociative symptoms [132]. Traumatic events are often
associated with many comorbid diagnoses in addition to PTSD, including mood,
anxiety, sleep, conduct, elimination, learning, and attention problems
[115,118,133 – 136]. Stoddard and Saxe also reported that the greater the
complexities of the context of the injury, the more likely there will be an
increase in comorbid conditions [21]. In particular, children who have preexist-
ing psychiatric problems, have difficult family problems, or experience com-
munity or societal disruption are particularly at risk for more comorbid
responses [134,137].
Factors that increase risk for psychopathology after injuries
Context
The increase in comorbid conditions is related to the complexities of the context
in which injuries occur. Causes of injuries may vary. As reviewed by Stoddard and
Saxe [21], injuries may be the consequence of serious family problems, such as
child abuse and neglect. They also may result from serious societal problems, such
as poverty, community violence, and war. Injuries may follow a child’s behaviors,
such as impulsivity, hyperactivity, suicidality, and substance abuse. Sometimes
these various contextual factors may interact synergistically and increase the risk
of injury. According to Stoddard and Saxe, little research is designed to predict
the likelihood of injury based on risk factors, except for burns, which seem to
occur above all in young children with poverty backgrounds.
The psychiatric consequences of injury may be as linked to the contextual
factors related to the injury (child maltreatment, war, community violence) as to
the direct impact of the injury itself. Stoddard and Saxe suggested the term
‘‘simple injury’’ to describe situations that were at one time called accidents, that
is, single, unpredictable events that cause bodily damage and are minimally
related to factors within the child and his or her social environment. On the other
hand, with the term ‘‘complex injury’’ the authors refer to injuries that occur in
the context of preexisting problems, including familial, community, and societal
instability [21]. This approach is consistent with a psychosocial model of human

behavior in which the child’s mental health is linked to the dynamic interaction
between the child as individual and the various levels of his or her social
environment, such as family, school, neighborhood, society, and culture [138].
Individual factors
Unfortunately, there are a series of constitutional factors that increase a
child’s risk for injury. Examples include suicide attempts because of depression,
substance abuse, and inattentive and impulsive behavior. These factors also
may contribute to complicate a child’s postinjury course and place him or her
at increased risk for deleterious outcome. Stoddard and Saxe reviewed
extensively the literature about their main features [21]. It is briefly summa-
rized in this article.
Suicidality
Although many studies in psychiatry have documented suicide and suicide
attempt, much less is known about the physical injuries sustained as a result of
them. It seems that only approximately 5% of persons who attempt suicide
sustain any injury and only 2% to 3% seek medical attention [139]. Evidence
exists for an association among affective disorder, personality disorders, and
substance abuse and suicide [140]. Suicide also is considered an increasing cause
of adolescent death in many countries of the world, including the United States
[141]. The presence of guns in the home seems to constitute a significant risk
factor for adolescent suicide, as shown in the results of a case-control study of
67 adolescent suicide victims and 67 matched community controls. Research also
has demonstrated that substance abuse increases the risk of suicide by firearms, as
confirmed by positive alcohol levels after death [142]. One can find a wide range
of consequential injuries from suicide attempts, such as wrist slashing, fractures,
injuries from jumping from heights, injuries from hanging, effects of stabbing
oneself, and shooting injuries. Unfortunately, however, few data exist regarding
this issue. Injuries caused by violence (eg, self-inflicted gunshot wounds or
wounds caused by gang activities) require particular procedures, such as
assessment of pain and the effect on self-esteem from the injury (eg, paraplegia),
psychiatric diagnosis, and specific psychopharmacotherapeutic approaches
addressed to comorbid predisposing risks, such as aggressive impulsivity or
substance abuse and posttraumatic stress [21].
Substance abuse
A considerable body of evidence has suggested a relationship between alcohol
use or use of other substances and injuries in adolescents [143,144]. Several
studies that involved adults and children demonstrated that alcohol abuse is
associated with a series of other risky behaviors, such as speeding and not
wearing seat belts, which frequently are the main causes of injuries [145]. There
is also strong empirical support (mostly for older adolescents) for an association
between seriously injured trauma patients and psychoactive substance use
disorders, particularly alcoholism [146 –151]. Finally, many studies have docu-
mented an association between substance abuse and adolescent suicidal behavior.
Li et al analyzed data from the National Pediatric Trauma Registry for children
younger than age 15 admitted from 1988 to 1996 and found self-inflicted injuries
by firearms, hanging, and jumping from heights. Toxicologic tests were con-
ducted at the time of admission on 40 of the patients, of whom 8 tested positive
for alcohol or other illicit drugs. 29% had preexisting mental disorders, such as
conduct disorder or depression [152]. Crumley gave another important contri-
bution to the adolescent suicidal behavior topic by reporting that the increased
adolescent suicidal behavior was significantly related to increased incidence of
psychoactive substance use. He reviewed a series of studies from the literature
that showed associations as high as 35% to 40% of adolescent suicide attempters
having positive blood alcohol determinations [153].
Inattention and impulsive behavior

Attention deficit hyperactivity disorder has as its central characteristics inat-
tentiveness, impulsivity, and motor overactivity. Stoddard and Saxe [21] reviewed
the literature on children with ADHD and their risk for injury. Di Scala et al found
that children with ADHD (compared with children without ADHD) were more
likely to be boys, to be injured as pedestrians or bicyclists, to inflict injury on
themselves, to be injured in multiple places on their body, and to sustain head
injuries. These children with ADHD had a longer length of stay in the hospital, and
37% were admitted to the intensive care unit, compared with 24% of the non-
ADHD population [154]. Leibson et al confirmed these findings in a population-
based cohort study of 309 children with ADHD who, compared with children
without ADHD, showed a significant increase in major injuries (59% versus 49%;
P < 0.001) [155]. Data from another study of 140 children with ADHD and 120
normal control children suggested the diagnosis of bipolar disorder with comorbid
ADHD, which is associated with ‘‘explosiveness, aggression, impulsivity and poor
judgment’’ (and not the diagnosis of ADHD alone), as the most significant
predictor for trauma exposure over the next 4 years [156]. As reviewed by Stoddard
and Saxe [21] in a longitudinal study from Finland with subjects who were entered
at age 8 and followed up at ages 14 and 27, Pulkinnen found that noncompliance in
childhood and heavy drinking in adulthood were two behaviors associated with
high risk for accidents for men [157].
Another risk factor that may contribute to inattention and injuries is life stress.
After a comparison between 149 injured and 258 ill children (aged 13 –19 years)
admitted to the Children’s Hospital of Philadelphia from 1985 to 1988, Slap et al
found significant gender differences (with boys being at higher risk for injuries)
and other differences, such as previous serious injury, previous hospitalization for
injury, injury after alcohol or drug use and stressful event scores, particularly a
relative having been ill or died, school failure or suspension, getting a summer
job, or breaking up with a girlfriend or boyfriend. The two groups did not show
any difference in the use of drugs or alcohol [158].
Multiproblematic families
Cicchetti and Lynch [137] reported that children who grow up in chaotic and
disorganized families are at higher risk for injury. Child maltreatment encom-
passes physical abuse, sexual abuse, including rape, and neglect. Each may have
consequences such as physical injuries and disability. Disability may be physical,
psychological, or both. As reviewed by Stoddard and Saxe, once injury occurs,
attachment patterns developed in chaotic and disorganized families may create
problems that regulate affect, self-blame, and lack of trust in others. Such families
may have difficulties in assisting a child in the physical and psychological re-
covery from injury [21].
Studies refer to specific populations with different types of neglect or abuse.
Burn injuries as consequences of neglect or abuse range from 5.9% to 26% of
pediatric burn admissions [159,160], but psychiatric disorders linked to this
population of young burned children have not been studied much in the literature.
Physical injuries also can be consequences of intrafamiliar sexual abuse,
especially when assault on the genitals or other parts of the body, infection,
and—in a few cases—pregnancy have occurred. Physical injury also can be a
severe additional compounding complication of rape [161,162]. As reported by
Reece, the study of sudden infant death syndrome has differentiated this from
fatal child abuse. The number of infant deaths caused by fatal infant abuse
probably exceeds one in ten cases of unexplained, unexpected deaths [163].
Family problems and disruption are important risk factors for many types of
injury, and accurate interventions that address familial risk factors may reduce
this risk for children [21].
Psychological effects of natural disasters and war on children

and adolescents
In the wake of devastating natural disasters (eg, hurricanes, earthquakes, floods,
and brushfire), human-made disasters (eg, airplane crashes, ferry sinking, and
toxic waste accidents) and recent acts of violence (eg, school shootings, bombings,
and terrorist activities), there is an upsurge of concern among individuals who
interact or work with children (parents, teachers, mental health professionals)
regarding the impact of disasters on youth. Recent statistics from the International
Federation of Red Cross and Red Crescent Societies indicated that a staggering
number of people are affected by disasters worldwide. For example, in 1997 alone,
5.9 million people in Africa, 1.7 million in the United States and the Americas,
24.5 million in Asia, 0.5 million in Europe, and 0.8 million in Oceania (including
Australia and New Zealand) were affected by disasters, for a total of more that
33.4 million. The statistics included many children and families [164].
Injuries and pervasive psychiatric responses after disasters and war are the
main areas of study. In these traumatic situations, children who grow up in
poverty have ongoing and sustained disruptions of their social environments.
Children injured in situations of such extreme environmental disruption may not

have access to appropriate medical attention or have sufficient attention and care
from parents and guardians who themselves may be injured, overwhelmed, or
dead [165]. Alternatively, the community often can support the injured child,
even in the face of devastating loss.
Some victims, including youths, do organize, adapt, and rebound in a
surprising way despite the horrific and frightful experience that they experienced
or witnessed [166]. Early studies of communities in disaster showed lower levels
of PTSD and suggested that the shared experience allowed individuals to seek
and obtain community support [21]. As reported by Green et al, parental or other
adult participation in a child’s emotional recovery from physical trauma can be
useful and alleviate the more serious aspects of PTSD. Adults can provide
accurate explanations to a child and appropriate responses to trauma rather than
silence [85].
A significant proportion of children show reactions after exposure to disasters
that can lead to substantial levels of interference or impairment in their daily
lives. Studies of psychiatric sequelae of these events generally have not assessed
physical injury [21]. Children who have been injured in disasters such as
earthquakes [167], hurricanes, bus or train or boat crashes, airplane crashes,
bombings, or other major disasters have experienced complex psychological
stress in addition to the physical injuries. Unfortunately, injuries related to war are
tragically common worldwide and related to major societal disruption and
consequential psychiatric morbidity [70,168 – 173].
In natural disasters, as in other traumatic events, children’s psychological
reactions and any physical injuries depend on the severity of the disaster, degree
of home damage, and displacement [109].
Children’s and adolescents’ reaction to disasters may vary [174], but the most
frequently studied reactions are those associated with PTSD and related symp-
toms. Some research has focused on other disorders, such as depression,
academic problems, anxiety, sleep disorders, and separation anxiety. In describing
children’s reactions to disaster, it is critical to consider the timing of the
postdisaster assessment. This topic has been reviewed by Silverman and La
Greca, and the main features are listed later [175].
As reported by Valent [176], the time periods around disasters can be divided
into phases that can be associated with different types of reactions:
Preimpact: the period before the disaster

Impact: when the events occur
Recoil: immediately after the event
Postimpact: days to weeks after the event
Recovery and reconstruction: months to years after the events
Regarding the recoil phase, little is known about children’s and adolescents’
immediate responses to disasters. Trauma researchers suggest the term ‘‘psychic
shock’’ to describe people’s immediate response (ie, shock, disbelief, and being
stunned). Victims described their feelings as ‘‘blow to the face,’’ ‘‘being knocked
out,’’ ‘‘I felt overwhelmed,’’ and ‘‘unreal’’ [176]. Other studies found biologic
reactions and ‘‘general adaptation syndrome’’ [177] and differences in physio-
logic reactivity [178]. Regarding the postimpact phase, the most common clinical
diagnoses that emerge in the short-term period after the traumatic event are
‘‘adjustment disorder’’ and ASD. Within the recovery and reconstruction period,
the most widely studied reaction to disaster has been that of PTSD and related
symptoms [175].
Shaw et al [62] reviewed several studies that investigated the psychological
responses of children and adolescents to hurricanes, fire, earthquakes, and floods
[179 –185]. The two most studied hurricanes have been Hugo and Andrew. In
1989, Hurricane Hugo, classified as a category 4 storm, caused 60 deaths in
South Carolina. In 1992, Hurricane Andrew, also classified as a category 4 storm,
killed 40 people in Dade County, Florida. As reviewed by Goenjian et al,
different studies show a high rate of heterogeneity in their outcomes [186].
Shannon et al [87], using the Child PTSD Reaction Index, found mild reaction
scores (mean = 21.7) among children and adolescents 3 months after Hurricane
Hugo and estimated that 5% had PTSD. Similar results of children’s reactions
after Hurricane Hugo have been reported by Belter et al [187] and Garrison et al
[182]. The latter study reported that only 5% of the adolescents examined met
DSM-III-R criteria for PTSD. Vernberg et al found moderate (mean = 29.6) Child
PTSD Reaction Index scores in children 3 months after Hurricane Andrew [188].
Garrison et al, using the Diagnostic Interview Schedule in a population-based
study 6 months after Hurricane Andrew, found that 7.3% of a mixed-exposure
group of adolescents met the criteria for PTSD [189].
Shaw et al, using the Child PTSD Reaction Index 32 weeks after Hurricane
Andrew, reported that 51% of the children in the high-impact area had moderate
levels of PTSD and 38% had severe to very severe levels [91]. La Greca et al
reported mild to moderate scores (mean = 24.4) on the Child PTSD Reaction
Index 7 months after Hurricane Andrew; 23% experienced moderate levels and
18% experienced severe to very severe levels of symptoms [190]. Shaw et al
reported that 70% of the children in high-impact areas continued to score in the
moderate to severe range 21 months after Hurricane Andrew [62]. With the
exception of the study by Belter et al, the studies did not find depression as a
comorbid condition [187]. Belter et al found no differences in depression scores
between the different exposure groups and those reported for nonpatient
standardization samples. Follow-up studies in Armenia after the 1988 Spitak
earthquake indicated that extreme disaster-related traumatic experiences have
been associated with severe and prolonged posttraumatic stress and depressive
responses among adolescents [58,167].
Groenjian et al [186] found severe levels of posttraumatic stress and
depressive reactions among Nicaraguan adolescents in the two most heavily
affected cities after Hurricane Mitch. Severity of posttraumatic stress and
depressive reactions and features of objective hurricane-related experiences
followed a ‘‘dose-of-exposure’’ pattern that was congruent with the rates of
death and destruction across cities. Level of impact (city), objective and
subjective features, and thoughts of revenge accounted for 68% of the variance
in severity of posttraumatic stress reaction. Severity of posttraumatic stress
reaction, death of a family member, and gender accounted for 59% of the
variance in severity of depression. These findings strongly indicated the need for
public mental health professionals to use different approaches, including sys-
tematic screening and trauma/grief-focused interventions, within a comprehens-
ive disaster recovery program [186].
Regarding war victims, data from UNICEF showed an estimated 2 million
children being killed in war during the past decade and another 10 million being
traumatized by war [172]. Of children exposed to war trauma, a surprising
percentage meet criteria for PTSD or experience subclinical levels of the disorder.
Allowood et al extensively reviewed the literature on this subject and reported
several studies that confirmed exposure to war as a risk factor for PTSD and other
adjustment problems [191]. Data from Kinzie et al, for example, indicate that in
1984, 50% of Cambodian children who had been exposed to war and genocide
during the Pol Pot regime (1975 – 1979) met diagnostic criteria for PTSD [192].
Follow-up studies reported PTSD rates of 48% and 38% in 1987 and 1990,
respectively [113]. Of 364 displaced children (6- to 12-year-old children in a rural
refugee camp) examined during the Bosnian war, 93.8% met criteria for PTSD
and sadness feelings (90.6%) and anxiety (95.5%) [193]. Even brief periods of
exposure to war trauma may lead to substantial posttraumatic stress reactions.
After the 5-month military occupation of Kuwait, more than 70% of children
showed moderate to severe trauma reactions [90]. War trauma also includes
indirect experiences, such as witnessing violent acts (eg, killings, rape, torture) or
the results of violent acts (eg, seeing dead bodies or bombed buildings), and
homelessness or starvation.
What is not clear from the current literature is the relative impact of different
forms of war trauma exposure on children’s adjustment. The more general
children’s trauma literature suggests that children who are exposed to violent
trauma, such as witnessing murders, are particularly vulnerable to posttraumatic
stress reactions [194,195]. Regarding nonviolent trauma, such as natural disas-
ters, the literature reports much lower rates of PTSD symptoms [87,189].
Relocation and food shortage because of a hurricane may be different from the
same issues experienced in the context of war. UNICEF data [172] suggest that in
war, children exposed to deprivations and forced relocation may fare much worse
than children exposed to violence. According to UNICEF, ‘‘most children who
die in wartime have not been hit by bombs or bullets but have succumbed to
starvation or sickness. In African wars, lack of food and medical services,
combined with the stress of flight, have killed about 20 times more people than
armaments’’ [172].
Allwood et al examined the relationship of violent and nonviolent war
experiences to children’s trauma reactions and adjustment in 791 children aged
6 to 16 years from Bosnia. In this sample, 41% had clinically significant PTSD
symptoms. Children were adversely affected by exposure to violent and non-
violent war traumas. An additive effect of trauma exposure on trauma reactions

also was found. Many war experiences were not associated with children’s
adjustment and trauma reactions, however. These findings indicated that additive
effects of violence and deprivations during war may overwhelm the coping skills
of children and leave them vulnerable to externalizing and internalizing adjust-
ment difficulties and symptoms of PTSD [191].
The recent wave of terrorism that affected the United States (September 11,
2001), subsequent events such as the war in Afghanistan, and the unceasing
terrorist attacks in the Middle East raised concerns about the welfare of children
and adolescents and posed many particularly salient questions for clinicians who
treat mental health problems among children. Such salience derives at least
partially from the myriad potential effects on children. Much like adults, children
and adolescents could be faced with traumatic grief or be traumatized by
witnessing the destruction of the World Trade Center directly or through re-
peated media portrayals. Support from adults is important for children who live
through these traumatic situations. Any effects on adults can carry a rever-
berating impact on children. Similarly, changes in contextual factors can exert
particularly profound effects on children and adolescents [61,196]. Such
changes include alterations in the nature of one-to-one relationships with peers
and adults and broader changes in schools, neighborhoods, and families. To the
extent that the recent attacks markedly impacted many individuals and institu-
tions, their effects might be particularly strong and long-lasting on children and
adolescents [53].
In summary, PTSD, other anxiety disorders, and depressive disorders constitute
the most common types of clinical problems documented in children and
adolescents after disasters, and they may be comorbid conditions. What is less
clear from existing research is the extent to which those symptoms interfere with
children’s daily life and functions and may be pathologic or, alternatively, whether
the symptoms may be considered to be ‘‘normal’’ reactions to abnormal events.
Given the potential effects of disasters on children and adolescents and the
likelihood of comorbid symptoms, mental health professionals must be careful
in assessing a child’s predisaster levels of psychopathology and functioning after
disasters, which may increase the psychobiologic mechanism of vulnerability.
The concept of resilience

Not all children exposed to traumatic events develop PTSD or other
psychiatric disorders. A major research area has been concerned with identifying
factors (mediating factors) that are associated with increased risk (vulnerability)
or decreased risk (resilience) for developing PTSD after exposure to traumatic
stress [30]. As discussed by Perry, each of these mediating factors can be related
to the degree to which they either prolong or attenuate the child’s stress-response
activation that results from the traumatic experience. Factors that increase stress-
related reactivity (eg, family chaos, lack of support) make children more
vulnerable, whereas factors that provide structure, predictability, care, and sense
of safety decrease vulnerability. ‘‘Persistently activated stress-response neuro-

physiology in the dependent, fearful child will predispose to ‘use-dependent’
changes in the neural systems mediating the stress response, thereby resulting in
posttraumatic stress symptoms’’ [12]. Pelcovitz et al discovered that adolescents
with cancer who developed PTSD rated their families as more chaotic than
adolescents with cancer who did not develop PTSD. 85% of mothers of children
with PTSD also developed PTSD related to their child’s cancer [28]. The
capacity to provide a consistent, predictable, and supporting environment is
compromised if the family is disorganized and the child’s primary caregiver is
traumatized by an event [12].
The concept of resilience in development was discussed extensively by
Masten and Reed in a recent book on positive psychology [197]. During the
1970s, the systematic study of resilience in psychology emerged from the study
of children at risk for problems and psychopathology [198,199]. Some inves-
tigators were surprised to discover that some children at high risk for problems
were reacting and developing well. Subsequent researchers defined these high-
risk children as ‘‘invulnerable’’ and ‘‘stress resistant’’ and finally labeled them as
‘‘resilient’’ [197]. Why do some people fare better than others in the context of
adversity? The answer requires the analysis of individual and environmental
factors. To explain the phenomena of resilience, Masten and Reed provided
definitions of concepts such as assets, resources, and protective factors. ‘‘Assets’’
have been defined as the opposite of risk factors, and their presence predicts
better outcomes for one or more domains of good adaptation, regardless of level
of risk. ‘‘Resources’’ stand for the human, social, and material wealth used in
adaptive processes. ‘‘Protective factors’’ are measurable characteristics of indi-
viduals or their situation that predict positive outcome in the context of high risk
or adversity. Protective processes explain how protective factors work when
development is threatened.
The most common potential protective factors against developmental hazard
found in studies measure differential attributes of the child, family, other
relationships, and the major context in which the child grows up and develops,
such as school and neighborhood. Masten and Reed reported the following as
protective factors within a child: good cognitive abilities, including problem-
solving and attention skills; positive self-perceptions and self-efficacy; faith and
self-meaning in life; and talents valued by self and society. The authors
identified the following as protective factors within the family: a close
relationship with caregiving adults; authoritative parenting, including high/
warmth, structure/monitoring and expectations; organized home environment;
parents involved in child’s education; and socioeconomic advantages. Close
relationships to competent, prosocial, and supportive adults and connections to
prosocial and rule-abiding peers were described as important protective factors
within family or other relationships. Within the community, factors such as
effective school, high level of public safety, good public health, and health care
availability seem to protect a child against developmental hazards in various
situations [197].
The findings on resilience suggest that the greatest threats for children are the
unfavorable conditions that weaken the basic human protective systems for
development. Consequently, efforts to promote competence and resilience in
children at risk should focus on strategies that prevent damage to, repair, or com-
pensate for threats to these basic systems [197]. Specific psychotherapeutic strat-
egies are described in the section reserved for psychological treatment of
traumatized children.
Assessment and treatment of the injured child

During the assessment of the injured child, clinicians and mental health
professionals should evaluate two different aspects: whether the time course is
acute or chronic and whether the injury is simple or complex [21]. Regarding the
acute phase of postinjury treatment, clinical research offers several useful
procedures to assess children. Some of them, which are reviewed extensively
by Stoddard and Saxe [21], are described later.
A qualitative assessment of the injured child includes two main steps. First, an
important approach to diagnosis is to elicit the narrative review of the trauma (from
the child if possible) and recognize the stage of postinjury adaptation. Peterson and
Bell found that children aged 2 to 12 years are able to recall details of stressful
events after injury [200]. During the child’s description of the injury, it is important
to pay attention to his or her description of associated memories, feelings, and
thoughts, including the presence of distortions, recurring themes, and, rarely,
hallucinations or nightmares [81]. Subsequently, in addition to current symptoms, a
correct assessment of the injured child includes the investigation of the child’s
developmental history and preexisting psychopathology. Children who are injured
in the context of a suicide attempt, inattention, impulsive behavior, or substance
abuse may have a more complicated course of recovery and more comorbid
responses. Assessment requires an understanding of other contextual factors, such
as child abuse and neglect, family disorganization, and other traumatic events.
There is evidence for association between specific environments (eg, parental
mental illness or substance abuse), poverty or societal upheaval (eg, disaster or
war), and a slow and complicated recovery process for a child after injury [21].
The assessment of the injured child can support the child’s adaptation to an
injury, in which he or she usually had little control, or it may reveal fears of death
and feelings of shame or guilt. It also can provide hope to the child and create the
right atmosphere for a good therapeutic relationship [21]. In response to injury
and treatment, children also may experience some physiologic changes, generally
caused by changes in neurobiology and mental status, with the emergence of
pain, adjustment disorders, sleep disorders, delirium, depression, and ASD [201].
As reported by Blakeney and Meyer [202] and confirmed by Sheridan et al [203],
current treatments are able to guarantee a child’s rapid body recovery after injury.
The emerging research database on burns, which is the most extensive on
injuries, indicates that emotional recovery is slower but apparently successful for
most children.
The child and adolescent psychiatrist or psychologist assesses injury severity

to plan interventions to alleviate pain and to reinforce coping strategies to manage
the risk of death, disability, and effects on body image [21].
For major trauma, several physical scoring methods for adults and children
evaluate areas such as the severity and anatomy of the injury, resulting functional
disability, and degree of cosmetic disfigurement [204,205]. The Injury Severity
Score, a well-validated index of the severity of the traumatic injury, is inter-
nationally used by trauma surgeons and other medical staff. The Injury Severity
Score is related to the likelihood of survival after injury and is determined
through rating the severity of injury on a five-point scale in each body area
injured (head or neck, face, chest, abdominal or pelvic contents, extremities or
pelvic girdle, and general). The five-point scale ranges from 1 (minor injury) to
5 (critical injury). For severe burn injuries, the standard scoring is by percentage
of the total body surface area burned, specifying anatomic locations on a human
figure chart front and back and including delineation of specific areas of facial
burns and burns to genital, perianal, and other areas. If still conscious, children
with high Injury Severity Scores need specific interventions for pain, fear, and
preparation for major surgery, whereas children with low scores require pain
relief and support in coping with the injury to a specific location (eg, face, back,
hand) [21].
Stoddard and Saxe also suggested some procedures for the psychiatric care of
the injured child: pain management, brief consultation, and crisis intervention
followed by brief psychotherapeutic techniques [21]. Pain management is a
technique used in the acute phase after injury to diminish the impact of the
traumatic event. This procedure is particularly indicated for injured children who
must experience ongoing painful medical procedures (eg, dressing changes in
burned children) [206]. Pain management reduces confusion, fear, anxiety, and
suffering. The assessment and monitoring of pain follow different steps. Most
injury pain is acute and transient, but it is often long remembered. Progress is
being made in research on the metabolic, genetic, and neural pathways that
control endogenous opioids and, in turn, pediatric pain [207,208]. ‘‘Preempting
the memory of pain’’ is an important strategy to prevent possible neurophysio-
logic damage such as reduced hippocampal size and amygdala-modulated fear
conditioning [209 –211]. Consistent with this idea, researchers recently found
that the higher the dose of morphine a burned child receives while in the hospital,
the more significantly the PTSD is attenuated over 6 months [212]. For children
on neuromuscular blockade in most burn centers, medical staff usually use
various analgesic drugs. The level of sedation is increasingly monitored with
bispectral electroencephalographic assessment to ensure adequate sedation [213].
In the rare cases in which a patient has recall after neuromuscular blockade or
after surgery, validation of his or her accurate memories may relieve milder
symptoms [214].
Melzack and Wall defined pain as a multidimensional and subjective experi-
ence characterized by physiologic, affective, cognitive, behavioral, and socio-
cultural dimensions [215]. Consequently, treatment of an injured child’s pain
requires clinical assessment of all these dimensions. Assessing pain is a process

that involves history taking and clinical observations. Measuring pain is quan-
titative. A series of observer-rated scales and structured ratings that use behav-
ioral and physiologic measures for infants and self-ratings for older children are
available [21]. Matthews et al suggested a self-rating scale called the Visual
Analogue Scale [216].
The first intervention consists in differentiating types of pain by anatomic
location, as suggested by Stoddard and Saxe [21, see Table 1]. Pain also is
differentiated by nerve pathways, effects of central nervous system injury, and
the type of tissue damage. Stoddard and Saxe described different types of pain:
(1) acute pain of the injury, (2) continuing injury pain not fully relieved (eg,
amputation site), (3) pain related to medical devices (eg, intravenous line, chest
tube), (4) procedural pain (eg, bone marrow aspiration), (5) repeated proce-
dural pain (eg, venipuncture, burn dressings, physical therapy), and (6) chronic
pain [21].
Pain management
Pain management involves psychological and pharmacologic treatment.
Psychological treatment
The psychiatric care of injured children in medical-surgical settings encom-
passes a series of psychological interventions, such as preparation for procedures,
patient participation, cognitive therapies, relaxation, and hypnosis. These tech-
niques have essential therapeutic roles in reducing pain [217] and comprise
procedures such as brief consultation and crisis intervention [21].
As discussed by Sheridan et al and Stoddard, children’s concepts of pain
follow developmental progression from simpler and less precise understanding to
more complex and accurate understanding. Parental participation that involves
explaining a child’s temperament and usual response to pain is useful for pain
relief. For acutely burned children, for instance, pain management during acutely
ventilated through rehabilitative stages after the burn may be guided by protocols
[201,218]. Brief consultation and crisis intervention procedures use interviewing
techniques to obtain the child’s narrative review of the trauma experience
initially [81]. Although exclusive focus on procedures and avoidance of the emo-
tional consequences of the injury necessarily may occur, it is balanced with the
benefit of obtaining the narrative, facilitating the recovery process, and starting
rehabilitation [21].
The two main psychotherapeutic techniques used for an injured child’s
treatment are psychodynamic psychotherapy and cognitive behavioral therapy
(CBT). They are usually combined and specifically oriented to pain [219], the
injury, assisting coping with surgery and other medical care, grieving losses, and
treating reactions to disfigurement or disability. CBT has not been studied formally
with injured children, but the principles of CBT for PTSD (eg, anxiety manage-
ment, exposure-based interventions, coping with anger, and cognitive restructur-
ing) are the main features of CBT with injured children with PTSD [220] and
children with facial disfigurement [221]. Beyond the acute postinjury phase, there
is less psychiatric and psychological research specific to injured children [21].
After a child’s acute hospitalization after injury, a child can be overwhelmed
by several difficulties. Children face family and friends and are asked questions
repeatedly about the nature of the injury, and they must adjust to permanent
changes in bodily function or appearance. They may be worried about their
prognosis or need for further surgery or rehabilitative intervention. It is crucial to
assess any difficulties in transition to the community and support the child in this
delicate ‘‘reentry’’ phase into family and school. The child is at high risk for
anxiety disorders, depression, PTSD, and exacerbation of preexisting psycho-
pathology. Children with complex injuries are at increased risk [21]. Stoddard
and Saxe suggested that preexisting psychopathology requires aggressive treat-
ment, as do any posttraumatic symptoms consequent to the injury. Children with
self-inflicted injuries require psychotherapy to help manage feelings—such as
guilt related to how they inflicted their bodily damage—that may have long-term
consequences. Children whose injuries were related to child abuse or neglect may
need help adjusting to a new accommodation simultaneous to their adjustment to
the injury [21]. Injuries that occurred in disruptive environments such as chaotic
and disorganized families require interventions, such as family therapy, and
family support is essential during the adjustment after injury [222]. Parents and
guardians also may face difficulties coping and may develop PTSD [223].
Psychiatric intervention to help stabilize families at risk, either through fam-
ily therapy or individual parent treatment, could be one means of helping the
child [21].
Pharmacologic treatment
Stoddard and Saxe reviewed a series of pharmacologic interventions used for
injured children, including EMLA (lidocaine and prilocaine) cream, nonsteroidal
antiinflammatory drugs, oral morphine, midazolam, propofol, patient-controlled
analgesia, and methods such as regional analgesia. These procedures help to
relieve brief episodes of pain and chronic pain. The trend of modern procedures
after injuries such as burns, traumatic amputations, and other surgeries is to use
larger dosages and more prescriptions for analgesic agents [208]. Stoddard and
Saxe discussed the presence of current new methods, agents, and protocols for
pain management, with opiates and short-acting benzodiazepines as the main
drugs chosen to relieve severe pain and anxiety for injured children of all ages
[21]. Stoddard et al extensively reviewed the literature supporting and detailing
different agents, methods of administration, and effectiveness [224].
Although burned children are the subjects of ongoing studies that document
assessment and treatment guidelines, there is a need for expansion of research to
other types of injuries [21]. Stoddard and Saxe reviewed the literature on this topic
for special populations, such as severely burned children and children who require
limb amputation [21]. Children with severe burns present many specialized issues,
beginning with the threat to survival, pain, and familial stress. The child with severe
facial and other burns is at high risk for identity problems, social stigmatization,
and loss of attractiveness. These children, if followed in a specialized center,
commonly survive even massive burns, and interventions such as reconstructive
surgery, psychiatric care, and broad support are used widely to resume devel-
opment and lead productive lives [201,203]. A wider use of social skills training for
cognitively coping with stigma and learning to manage teasing and other reactions
to facial disfigurement is required among mental health professionals [221]. The
psychiatrist can play a fundamental role in preparation for limb and other
amputations. His or her contribution is indispensable for treating pain, depression,
and PTSD and providing postoperative support in grieving the loss.
In the United States, pediatric amputations may be necessary because of cancer,
trauma from burns, or congenital malformations [225]. In other countries they can
be caused by injury from land mines. The main psychological and psychiatric
consequences of limb and other amputations are denial and grief, depression,
stress disorders, and body image disorder (phantom limb pain) [21]. Krane and
Heller defined phantom limb phenomena, which are reported by nearly all patients
asked about them, as a ‘‘normal’’ consequence of amputation [226]. They are
characterized by continued sensation or pain as if the limb were present; this
feeling may persist throughout life [227]. Patients mentally can have the
perception of an arm swinging when they are walking or a leg straightening
when they are standing. These patients usually report ‘‘cramping, squeezing,
lancinating, ‘electrical’ or burning sensations, by aberrant proprioception, or by a
sensation of postural displacement in a nonexistent extremity’’ [225]. The
phantom limb pain may provoke high levels of distress and greatly interfere with
a patient’s daily life. There is evidence for association between increased phantom
limb pain and cancer, preamputation limb pain, and chemotherapy [226,228].
Few data exist regarding specific treatments for children with amputations.
Pharmacologic treatments with nonsteroidal antiinflammatory drugs and opiates
are often useful to alleviate stump site pain. For phantom limb pain, adult studies
suggest that tricyclic antidepressants, anticonvulsants, and many other analgesics
can be useful [225]. Psychotherapeutic treatments for young children, such as
active facilitation of coping skills, are useful clinical tools to provide clarifica-
tions, decrease anxiety, and enhance mastery [229]. Varni et al suggested that es-
sential interventions for children with limb amputations and congenital limb loss
include education regarding the medical options and the usual course of recovery,
provision of choice of prosthesis, and supportive psychotherapy [230].
Psychotherapeutic approaches for children who develop PTSD after trauma

For children with PTSD, several empirically validated psychotherapy models
have been developed. CBT emerges as the most clearly beneficial treatment for
children who suffer mood, anxiety, and PTSD disorders. This section briefly
reviews literature on the use of CBT with traumatized children.
March et al evaluated the efficacy of a group-administered CBT 18-week
protocol for a single-incident stressor. The sample was made up of a peer group of
children who were treated in the school setting with individual sessions that dealt
with issues related to each participant’s traumatic experience. A parallel group
design, with random assignment to different treatments, was not used. Authors
found that children and adolescents treated with CBT showed significant
improvement on all main dependent measures and that these findings, which
were clinically and statistically significant, persisted for the duration of the study
[220]. Similarly, Goenjian et al provided a brief trauma/grief-focused psychother-
apy to early adolescents exposed to the 1988 Armenian earthquake. The treatment
included school-based and individual treatments that used several techniques
beyond those typical of CBT. By the end of the study, adolescents who received
psychotherapy showed significant improvements in intrusion, avoidance, and
arousal symptoms of PTSD [58]. Deblinger et al evaluated the efficacy of a CBT
program in a group of sexually abused children with PTSD. The results of this
study revealed significant improvements across all PTSD subcategories, exter-
nalizing and internalizing behaviors, anxiety, and depression [231].
All of these treatments have demonstrated efficacy for PTSD in children, but
they have not been specifically tested for children who have experienced injuries.
Stoddard and Saxe reported that the three different models described previously
might be effective for PTSD related to different kinds of injuries [21]. The March
et al model [220], for example, which was created for single-incident stressors,
might be effective for PTSD related to the kind of injuries Stoddard and Saxe
defined as ‘‘simple’’ but not for the ‘‘complex’’ ones. The Goenjian et al model
[58] is more focused on grieving and loss related to traumatic events. This model,
according to the authors, could be suitable for treating an injured child who has
lost a loved one as a consequence of the injury and for an injured child who is
grieving the loss of functioning or appearance of his or her body. Finally, the
Deblinger et al model [231], which was designed explicitly for sexually abused
children, probably can be adapted to the injured child whose PTSD is related to
sexual trauma and physical abuse. Its main focus is on the interpersonal nature of
the trauma and the guilt and shame related to abuse experiences. On the basis of
these suggestions, further research in this area is needed [21].
Excellent randomized, controlled psychotherapy trials have examined efficacy
in groups of sexually abused children. Pine and Cohen [53, see Table 2]
extensively described six of them and summarized their data [232 –239]. All
six psychotherapy trials used CBT to target symptoms of PTSD or anxiety among
children exposed to sexual abuse. Each trial applied accurate methodologic
designs in examining treatment effects using a detailed manual to ensure
treatment fidelity and random assignment and accepted clinical measures to
document the effects of treatment [53].
In these studies, investigators used different comparison groups. In one trial
CBT was compared with a wait-list control condition; in four trials investigators did
a comparison between CBT in some form and a community comparison or active

treatment condition; one trial compared CBT with exposure to CBT without
exposure. The trials targeted children in a wide age range, from 3 to 17 years,
and with a relatively wide range of symptoms, from specific symptoms of PTSD to
symptoms of various mood, anxiety, and behavioral disorders.
The results of each study showed relatively strong evidence of the efficacy of
CBT in children who exhibited psychiatric symptoms after sexual abuse. In all
five studies that compared CBT to either a non-CBT active comparison or a wait-
list condition, clear success of CBT emerged on at least one clinical measure but
usually on many measures. CBT emerged as the most clearly beneficial treatment
for children who suffered symptoms of mood or anxiety disorders.
These data pertain only to victims of sexual or physical abuse who show
meaningful differences from victims of other traumas in terms of exposure
lengths and degrees of other social or contextual risk factors for psychopathology
[56,57,81,240]. Similar studies have not been applied to child victims of other
traumatic events, such as natural disasters or wars. The degree to which results
from these CBT trials can be extended to children in other traumatic scenarios
remains to be discovered. On one hand, available trials use techniques that focus
explicitly on anxiety-provoking circumstances associated with exposure to
physical or sexual abuse. These circumstances may provide easier targets for
CBT interventions, which could be extended to symptoms associated with
exposure to terrorism and natural disasters or even the threat of them [53].
There is evidence for the strong efficacy of CBT on symptoms of mood and
anxiety disorders in children who exhibit symptoms in various contexts,
independent of trauma exposure [241,242]. The presence of robust treatment
effects across diverse settings suggests the potential use of CBT in children
exposed to various types of trauma. There is a need for researchers to focus
future randomized, controlled trials on children’s symptoms associated with
diverse stressors that are different from physical or sexual abuse, such as grief or
potential loss of loved ones, interpersonal conflicts with peers, separation fears,
or social concerns [53].
Single-session psychological interventions, such as psychological debriefing,
have become widely used after traumatic events, but the evidence for their
effectiveness has been widely debated. A recent systematic review found evi-
dence to suggest that this kind of intervention should not be advocated for routine
use [243]. Intervention approaches for children and adolescents after disasters
have been developed and designed for each particular phase of the traumatic
event (preimpact phase, impact and recoil disaster phase, postimpact phase, and
recovery and reconstruction phase) [244].
Strategies for fostering resilience

The work on resilience suggests that we need to move toward positive goals.
‘‘Promoting healthy development and competence is at least as important as
preventing problems and will serve the same end’’ [197]. Improvement of
psychological well-being by means of a specific psychotherapeutic model,
defined as well-being therapy [245,246], could be an effective strategy for
clinicians who deal with child and adolescent victims of trauma, in view of the
protective effects of well-being for life adversities [247]. Well-being therapy
could not necessarily be used by itself; it might become a part of a more complex,
symptom-orientated cognitive behavioral strategy. The well-being therapy is
based on Carol D. Ryff’s cognitive multidimensional model of psychological
well-being [248]. It is structured, directive, and problem-orientated and based on
an educational model.
Ryff and Singer remarked that historically, mental health research was
dramatically weighted on the side of psychological dysfunction and that health
was equated with the absence of illness rather than the presence of wellness. They
suggested that the absence of well-being creates a condition for vulnerability to
possible future adversities and that the route of recovery lies not exclusively in
alleviating the negative but in engendering the positive [249]. There is substantial
evidence [250 – 252] that psychological well-being plays a buffering role in
coping with stress, has a favorable impact on disease course, and has important
immunologic and endocrine connotations [253]. It also plays a fundamental role
in the complete definition of recovery. It is conceivable that well-being therapy
may yield clinical benefits in improving quality of life, coping style, and social
support in chronic and life-threatening illnesses such as depression, PTSD, and
anxiety disorders, as was shown for cognitive behavioral strategies [254]. It is
also conceivable, although it has yet to be tested, that well-being therapy may be
particularly valuable in patients whose disease has determined a loss. In this
context, loss refers not only to body parts (limb or other amputations) and
functions actually lost but also to deprivations of personally significant needs and
values, such as self-esteem, security, and satisfaction [255].
Viktor Frankl, a proponent of the existentialist movement in psychology, has
argued that a crucial, motivating force in people’s behavior is a ‘‘will to
meaning’’ [256,257]. This topic was discussed extensively by Nolen-Hoeksema
and Davis [258] in a recent book on positive psychology. The authors reported
that experiencing loss in general can lead people to change how they see
themselves, how they perceive the world around them and where they are going
with their lives. Loss events, especially those that are sudden and unexpected,
often seem to initiate a personal evaluation or stocktaking of the meaning of
one’s life. Frankl challenged his clients who had experienced a loss to create new
life meanings as a way to defeat the feelings of loss and suffering. ‘‘It is the
attitude one adopts to adversity that is critical for adjustment’’ [256]. This
challenge includes the process of finding something positive in the trauma by the
use of positive coping strategies. Seeking something positive after a loss is not
simply a form of denial or defensiveness but belongs to a package of positive and
active coping strategies [258]. Positive coping strategies include searching for
positive reappraisal of events, engaging in active problem solving, seeking social
support, and engaging in constructive expression of emotions [259]. Three
benefits commonly reported across studies are growth in character, a gain in

perspective, and a strengthening of relationships. The strongest and most
consistent predictor of finding benefit in trauma is dispositional optimism
[260 –264]. Further studies regarding treatment for children with amputations
or other severe injuries should evaluate the role of these positive coping strategies
in a child’s complete recovery process to create new and effective psychother-
apeutic models for this specific population.
Still focused on protective factors, Masten and Reed [197] described three
major kinds of strategies for promoting resilience in children and adolescents:
1. Risk-focused strategies (providing prenatal care to prevent premature births,

creating school reforms to reduce young adolescents’ stress because of
transitions, spearheading community efforts to prevent homelessness) with
the aim to remove or reduce a child’s threat exposure.
2. Asset-focused strategies (providing tutors, building recreation centers,
strengthening the social or financial position of the child by establishing job
programs for parents, creating programs to reinforce parental and teachers’
skills) with the intent to increase (or increase access to) a child’s resources
necessary for developing competence.
3. Process-focused strategies (building programs to improve attachment
relationships and sustaining efforts to activate the mastery motivation
system to enable a child to be self-sufficient and motivated to succeed in
life) aim to influence processes that will change a child’s life.
Crisis intervention and networking in child abuse and neglect: the ‘‘Treviso
Emergency Team’’ experience
A recent experience may exemplify how the insights derived from traumatology
may be translated into health care systems. The ‘‘Emergency Team’’ Project was
launched in Treviso, Italy in 1998 as an experimental partnership between Telefono
Azzurro and the community agency for children’s and adolescents’ safeguard
[265]. The project has been performed with partnership of the Child Study
Center of Yale University (United States), which has been running the Child
Development and Community Policing Program (CD-CP) since 1991. Their com-
mons goals are as follows:
To provide better understanding of the relationship between a child’s or

adolescent’s involvement with or exposure to a crisis situation and the
following traumatic stress symptoms
To create a multiagency and interdisciplinary network that is able to
face emergencies
To arrange a care strategy on clinical, legal, and social levels to be focused
on child perspective
To promote community activities aimed at increasing public and pro-

fessional awareness of the effects of crisis situations on children and
adolescents, to give useful advice to prevent emergencies, and to organize
training courses
The Treviso Emergency Team works with several emergency cases, such as
abused or neglected children and adolescents who engage in self-destructive or
dangerous behaviors or harmful or destructive behaviors toward other people,
children and adolescents who are victims of catastrophic situations, and children
and adolescents involved in new social emergencies.
The abuse and neglect cases encompass sexual abuse (with or without
contact, molestation, incest), physical abuse (with or without bruises, risk of
infanticide), severe neglect (health, eating habits, general care, severe family cri-
sis), and psychological abuse (including witnessing violence). The self-destruc-
tive or dangerous behaviors refer to suicide attempts or gestures (especially if
connected with marked depression, severe withdrawal, active suicidal thoughts,
self-harming and self-destructive behaviors), running away (running away from
home, especially if based on past experience of runaway behavior), drug and
alcohol abuse (including severe abuse of toxic agents such as glue, paint, and
gasoline), sensation seeking (extreme sports, irresponsible driving, unsafe sex),
and medical-psychiatric emergencies (anorexia nervosa, diabetes with refusal to
take insulin).
The harmful or destructive behaviors toward other people encompass aggres-
siveness (threatening to kill or seriously harm someone, going beyond the control
of significant adults, serious antisocial behaviors such as sexual assault),
destructiveness (violent, destructive behaviors against things, fire setting, sen-
sation seeking), and violent psychotic behaviors (acute psychotic episodes and
other severe forms of psychotic confusion).
Catastrophic and stressful situations refer to accidents (personal or external
involvement in car accidents, train or plane disasters, domestic accidents), natural
disasters (earthquake, flood, fire, volcanic eruption), kidnapping or robbery
(involvement and witnessing), and war traumas (migrant children from countries
in war). New social emergencies encompass juvenile prostitution that involves
immigrated adolescents, traffic of children (usually for illegal adoptions inside
nomadic communities), pedo-pornography (often by Internet with risk of luring),
and young immigrants without parents. The Treviso Emergency Team intervenes
in these emergency situations through following steps:
Identifying the emergency

Contacting other specific agencies and professionals
Evaluating resources, limits, and role of each agency
Evaluating a child’s or adolescent’s personal and environmental cop-
ing abilities
Planning and conducting an intervention on a clinical or legal or social level
Providing joint follow-up
Table 1
Treviso emergency team data, 2001
Sexual Physical Psychological Behavior Other
Intervention abuse abuse abuse Neglect Runaway at risk Emergency Total
Counseling 15 11 2 8 7 37 18 98
Emergency 4 1 2 5 — 3 15
in-take
Protected hearing, 11 2 3 — — — 2 18
supervised
meetings
Total 30 14 5 10 12 37 23 131
The Treviso Emergency Team consists of a staff of trained psychologists who

are available 24 hours a day, 365 days per year. They coordinate a multiagency
intervention that operates a professional counseling service to other network
operators and provides a protected hearing, supervised meetings, and emergency
in-take (Table 1).
Summary
Each year millions of children are exposed to some form of extreme traumatic
stressor. These traumatic events include natural disasters (eg, tornadoes, floods,
hurricanes), motor vehicle accidents, life-threatening illnesses and associated
painful medical procedures (eg, severe burns, cancer, limb amputations), physical
abuse, sexual assault, witnessing domestic or community violence, kidnapping,
and sudden death of a parent. During times of war, violent and nonviolent trauma
(eg, lack of fuel and food) may have terrible effects on children’s adjustment. The
events of September 11, 2001 and the unceasing suicidal attacks in the Middle East
underscore the importance of understanding how children and adolescents react to
disasters and terrorism. The body of literature related to children and their
responses to disasters and trauma is growing. Mental health professionals are
increasing their understanding about what factors are associated with increased risk
(vulnerability) and affect how children cope with traumatic events. Researchers
recognize that children’s responses to major stress are similar to adults’ (reexper-
iencing the event, avoidance, and arousal) and that these responses are not
transient. A review of the literature indicates that PTSD is the most common
psychiatric disorder after traumatic experiences, including physical injuries. There
is also evidence for other comorbid conditions, including mood, anxiety, sleep,
conduct, learning, and attention problems. In terms of providing treatment, CBT
emerges as the best validated therapeutic approach for children and adolescents
who experienced trauma-related symptoms, particularly symptoms associated with
anxiety or mood disorders. The best approach to the injured child requires injury
and pain assessment followed by specific interventions, such as pain management,
brief consultation, and crisis intervention immediately after the specific traumatic
event. Family support also may be necessary to help the family through this
difficult period.
The main conclusion that arises from the research on resilience in devel-
opment is that extraordinary resilience and recovery power of children depend on
basic human protective systems operating in their favor. This finding has
produced a fundamental change in the framework for understanding and helping
children at high risk or already in trouble. This shift is evident in a changing
conceptualization of the goals of prevention and intervention that currently
address competence and problems. Strategies for fostering resilience described
in this article should be tested in future controlled psychotherapy trials to verify
their efficacy on children’s protective factors.
References
[1] Figley CR. Origins of traumatology and prospects for the future. Journal of Trauma Practice
2002;1:17 – 32.
[2] Figley CR. Stress disorders among Vietnam veterans: theory, research and treatment implica-
tions. New York: Brunner/Mazel; 1978.
[3] Walker L. The battered women. New York: Harper and Row; 1979.
[4] Burgess AW, Holstrom L. Rape trauma syndrome. Am J Psychiatry 1974;131:981 – 6.
[5] American Psychiatric Association. Diagnostic and statistical manual of mental disorders
(DSM-III). Washington, DC: American Psychiatric Association; 1980.
[6] Kardiner A. The traumatic neuroses of war. New York: Paul B. Hoeber; 1941.
[7] Grinker RR, Spiegel JP. Men under stress. New York: Irvington Press; 1945.
[8] Courtois CA. Traumatic stress studies: the need for curricula inclusion. Journal of Trauma
Practice 2002;1:33 – 57.
[9] Saakvitne KW, Gamble S, Pearlman LA, Lev BT. Risking connection: a training curriculum for
working with survivors of childhood abuse. Lutherville (MD): Sidran Press; 2000.
[10] Pfefferbaum B. Posttraumatic stress disorder in children: a review of the past 10 years. J Am
Acad Child Adolesc Psychiatry 1997;36:1503 – 11.
[11] Pfefferbaum B. Stress in children. Child Adolesc Psychiatr Clin N Am1998;7.
[12] Perry B. Posttraumatic stress disorder in children and adolescents. Curr Opin Pediatr 1999;11:
310 – 20.
[13] American Psychiatric Association. Diagnostic and statistical manual of mental disorders.
4th edition (DSM-IV). Washington, DC: American Psychiatric Association; 1994.
[14] Helzer JE, Robins LN, McEvoy L. Post-traumatic stress disorder in the general population:
findings of the Epidemiologic Catchment Area survey. N Engl J Med 1987;317:1630 – 4.
[15] Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the
national comorbidity survey. Arch Gen Psychiatry 1995;52:1048 – 60.
[16] Giaconia RM, Reinherz HZ, Silverman AB, Pakiz B, Frost AK, Cohen E. Traumas and post-
traumatic stress disorder in a community population of older adolescents. J Am Acad Child
Adolesc Psychiatry 1995;34:1369 – 80.
[17] Heptinstall E. Healing the hidden hurt: the emotional effects of children’s accidents. London:
Child Accident Prevention Trust; 1996.
[18] DiGallo A, Barton J, Parry-Jones W. Road traffic accidents: early psychological consequences
in children and adolescents. Br J Psychiatry 1997;170:358 – 62.
[19] Mirza KAH, Bhadrinath BR, Goodyer I, Gilmour C. Post-traumatic stress disorder in children
and adolescents following road traffic accidents: a preliminary study. Br J Psychiatry 1998;
172:443 – 7.
[20] Cuffe SP, Addy CL, Garrison CZ, Waller JL, Jackson KL, McKeown RE, et al. Prevalence of
PTSD in a community sample of older adolescents. J Am Acad Child Adolesc Psychiatry 1998;
37:147 – 54.
[21] Stoddard FJ, Saxe G. Ten-year research review of physical injuries. J Am Acad Child Adolesc
Psychiatry 2001;40:1128 – 45.
[22] Baker SP, O’Neil B, Karpt RS. The injury fact book. Lexington (MA): Lexington Books; 1984.
[23] Dershewitz RA, Williamson JW. Prevention of childhood household injuries: a controlled
clinical trial. Am J Public Health 1977;67:1148 – 53.
[24] Burt CW. Injury related visits to hospital emergency departments: United States, 1992. Vital
and health statistics. Hyattsville (MD): US Department of Health and Human Services; 1995.
[25] US Department of Transportation. Traffic safety facts (National Highway Traffic Safety Admin-
istration report DOTHS 808022). Washington, DC: US Department of Transportation; 1993.
[26] Scheidt PC, Harel Y, Trumble AC, Jones DH, Overpeck MD, Bijur PE. The epidemiology of
nonfatal injuries among US children and youth. Am J Public Health 1995;85:932 – 8.
[27] DiScala C, Gallagher SS, Schneps SE. Causes and outcomes of pediatric injuries occurring at
school. J Sch Health 1997;67:384 – 9.
[28] Pelcovitz D, Libov BG, Mandel F, Kaplan S, Weinblatt M, Septimus A. Posttraumatic stress
disorder and family functioning in adolescent cancer. J Trauma Stress 1998;11:205 – 21.
[29] Stuber ML, Kazak AE, Meeske K, Barakat L, Guthrie D, Garnier H, et al. Predictors of
posttraumatic stress symptoms in childhood cancer survivors. Pediatrics 1997;100:958 – 64.
[30] Kilpatrick KL, Williams LM. Potential mediators of post-traumatic stress disorder in child
witnesses to domestic violence. Child Abuse Negl 1998;22:319 – 30.
[31] Hadi FA, Llabre MM. The Gulf crisis experience of Kuwaiti children: psychological and
cognitive factors. J Trauma Stress 1998;11:45 – 56.
[32] Ruchkin VV, Eisemann M, Hagglof B. Juvenile male rape victims: is the level of post-traumatic
stress related to personality and parenting? Child Abuse Negl 1998;22:889 – 99.
[33] Ackerman PT, Newton JE, McPherson WB, Jones JG, Dykman RA. Prevalence of post trau-
matic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual,
physical, and both). Child Abuse Negl 1998;22:759 – 74.
[34] Rossman BBR, Bingham RD, Emde RN. Symptomatology and adaptive functioning for children
exposed to normative stressors, dog attack, and parental violence. J Am Acad Child Adolesc
Psychiatry 1997;36:1089 – 97.
[35] Bell CC, Clark DC. Adolescent suicide. Pediatr Clin North Am 1998;45:365 – 80.
[36] Brigham PA, McLoughlin E. Burn incidence and medical care in the United States: estimates,
trends, and data sources. J Burn Care Rehabil 1996;17:95 – 103.
[37] Parent DG, Lieter V, Kennedy S, Livens L, Wentworth D, Wilcox S. Conditions of confine-
ment: juvenile detention and corrections facilities (research report NCJ 145793). Washington,
DC: Office of Justice Programs, US Department of Justice; 1994.
[38] Runyan CW, Gerken EA. Epidemiology and prevention of adolescent injury. JAMA 1989;
262:2273 – 9.
[39] Guyer B, Hoyert DL, Martin JA, Ventura SJ, MacDorman MF, Strobino DM. Annual summary
of vital statistics: 1998. Pediatrics 1999;104:1229 – 46.
[40] Guyer B, MacDorman MF, Martin JA, Peters KD, Strobino DM. Annual summary of vital
statistics: 1997. Pediatrics 1998;102:1333 – 49.
[41] MMWR. Rates of homicide. suicide, and firearm-related death among children: 26 industrial-
ized countries. MMWR Morb Mortal Wkly Rep 1997;46:101 – 5.
[42] Durkin MS, Kuhn L, Davidson LL, Laraque D, Barlow B. Epidemiology and prevention of
severe assault and gun injuries to children in an urban community. J Trauma 1996;41:667 – 73.
[43] Wu SI, Malison MD. Motor vehicle injuries in Taiwan. Asia Pac J Public Health 1990;4:72 – 5.
[44] Elechi EN, Etamo SU. Pilot study of injured patients seen in the University of Port Harcourt
Teaching Hospital, Nigeria. Injury 1990;21:234 – 8.
[45] Weston PM. Care of the injured on the Third World: what can we learn? Injury 1987;18:297 – 303.
[46] Lee SI, Lu T, Chang C, et al. Features of head injury in a developing country: Taiwan (1977 –
1987). J Trauma 1990;30:194 – 9.
[47] Mohan D. Childhood injury in India: extent of problems and strategies for control. Indian J
Pediatr 1986;53:607 – 15.
[48] Adesunkanmi ARK, Oginni LM, Oyelami AO, Badru OS. Epidemiology of childhood injury.
Journal of Trauma Injury Infection and Critical Care 1998;44:506 – 11.
[49] Taggi F, Giustini M. Gli incidenti stradali in Italia: il punto di vista epidemiologico. In: Taggi
F, Di Cristofaro Longo G, editors. I dati socio-sanitari della sicurezza stradale (progetto
DATIS): dai fattori di rischio degli incidenti stradali alla cultura della sicurezza stradale.
Rome (Italy): Istituto Superiore di Sanità, Laboratorio di Epidemiologia e Biostatistica; 2001.
p. 55 – 61.
[50] National Academy of Sciences Injury in America. A continuing public health problem. Wash-
ington, DC: National Academy Press; 1985.
[51] Smith GS, Barss P. Unintentional injuries in developing countries: the epidemiology of a
neglected problem. Epidemiol Rev 1991;13:228 – 66.
[52] Murray CJ, Lopez AD. Evidence-based health policy: lessons from the Global Burden of
Disease Study. Science 1996;274:740 – 3.
[53] Pine DS, Cohen JA. Trauma in children and adolescents: risk and treatment of psychiatric
sequelae. Biol Psychiatry 2002;51:519 – 31.
[54] Brown J, Cohen P, Johnson JG, Smailes EM. Childhood abuse and neglect: specificity of
effects on adolescent and young adult depression and suicidality. J Am Acad Child Adolesc
Psychiatry 1999;38:1490 – 6.
[55] Fergusson DM, Lynskey TL. Physical punishment/maltreatment during childhood and adjust-
ment in young adulthood. Child Abuse Negl 1997;21:617 – 30.
[56] Fergusson DM, Lynskey TL, Horwood LJ. Childhood sexual abuse and psychiatric disorder in
young adulthood: I. Prevalence of sexual abuse and factors associated with sexual abuse. J Am
[57] Fergusson DM, Lynskey TL, Horwood LJ. Childhood sexual abuse and psychiatric disorder in
young adulthood: II. Psychiatric outcomes of childhood sexual abuse. J Am Acad Child Adolesc
Psychiatry 1996;35:1365 – 74.
[58] Goenjian AK, Karayan I, Pynoos RS, et al. Outcome of psychotherapy among early adolescents
after trauma. Am J Psychiatry 1997;154:536 – 42.
[59] Tyano S, Iancu I, et al. Seven-year follow-up of child survivors of a bus-train collision. J Am
[60] Garmezy N, Rutter D. Acute reactions to stress. In: Rutter M, Hersov L, editors. Child and
adolescent psychiatry: modern approaches. 2nd edition. Oxford: Blackwell; 1985. p. 152 – 76.
[61] Steinberg L, Avenevoli S. The role of context in the development of psychopathology:
a conceptual framework and some speculative propositions. Child Dev 2000;71:66 – 74.
[62] Shaw JA, Applegate B, Schorr C. Twenty-one-month follow-up study of school-age children
exposed to hurricane Andrew. J Am Acad Child Adolesc Psychiatry 1996;35:359 – 64.
[63] Helzer JE, Robins LN, McEvoy L. Post-traumatic stress disorder in the general population:
findings of the Epidemiologic Catchment Area survey. N Engl J Med 1987;317:1630 – 4.
[64] Pine DS, Johnson J, Cohen P, Brook J. Adolescent life events as predictors of adult depression.
J Affect Disord 2002;68:49 – 57.
[65] Yule W. Posttraumatic stress disorder in the general population and in children. J Clin Psy-
chiatry 2001;62:23 – 8.
[66] Scheering MS, Zeanah CH, Drell MJ, et al. Two approaches to the diagnosis of posttraumatic
stress disorder in infancy and early childhood. J Am Acad Child Adolesc Psychiatry 1995;34:
191 – 200.
[67] Breslau N, Davis GC, Andreski P, et al. Traumatic events and posttraumatic stress disorder in an
urban population of young adults. Arch Gen Psychiatry 1991;48:216 – 22.
[68] Green B. Psychosocial research in traumatic stress: an update. J Trauma Stress 1994;7:341 – 62.
[69] Dohrenwend BP, Dohrenwend BS, Warheit GJ, Bartlett GS, Goldsteen RL, Goldsteen K, et al.
Stress in the community: a report to the President’s commission on the accident at three mile
island. Ann N Y Acad Sci 1981;365:159 – 74.
[70] Laor N, Wolmer L, et al. Mother’s functioning and children’s symptoms 5 years after a SCUD
missile attack. Am J Psychiatry 2001;58:1020 – 6.
[71] McFarlane AC. Posttraumatic phenomena in a longitudinal study of children following a

natural disaster. J Am Acad Child Adolesc Psychiatry 1987;26:764 – 9.
[72] Green B, Grace MC, et al. Children of disaster in the second decade: a 17-year follow-up of
Buffalo Creek survivors. J Am Acad Child Adolesc Psychiatry 1994;33:71 – 9.
[73] Laor N, Wolmer L, et al. Israeli preschool children under SCUDs: a 30-month follow-up. J Am
[74] Nader K, Pynoos R, Fairbanks L, Frederick C. Children’s PTSD reactions one year after a
sniper attack at their school. Am J Psychiatry 1990;147:1526 – 30.
[75] Yule W. Post-traumatic stress disorder in child survivors of shipping disasters: the sinking of the
Jupiter. Psychother Psychosom 1992;57:200 – 5.
[76] Orr SP, Lasko NB, Metzger LJ, Berry NJ, Ahern CE, Pitman RK. Psychophysiologic assess-
ment of women with posttraumatic stress disorder resulting from childhood sexual abuse.
J Consult Clin Psychol 1998;66:906 – 13.
[77] Hertzman C, Wiens M. Child development and long-term outcomes: a population health per-
spective and summary of successful interventions. Soc Sci Med 1996;43:1083 – 95.
[78] Rhodes N, Hutchinson S. Labor experiences of childhood sexual abuse survivors. Birth 1994;
21:213 – 20.
[79] Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship
of childhood abuse and household dysfunction to many of the leading causes of death in adults:
the adverse childhood experiences (ACE) study. Am J Prev Med 1998;14:245 – 58.
[80] Romans S, Belaise C, Martin J, Morris E, Raffi AR. Childhood abuse and later medical
disorders in women: an epidemiological study. Psychother Psychosom 2002;71:141 – 50.
[81] Terr LC. Childhood traumas: an outline and overview. Am J Psychiatry 1991;148:10 – 20.
[82] Yule W, Bolton D, et al. The long-term psychological effects of a disaster experienced in ado-
lescence: I: The incidence and course of PTSD. J Child Psychol Psychiatry 2000;41:503 – 11.
[83] Smith P, Perrin S, Yule W, Rabe-Hesketh S. War exposure and maternal reactions in the
psychological adjustment of children from Bosnia-Herzegovina. J Child Psychol Psychiatry
2001;42:395 – 404.
[84] Udwin O, Boyle S, Yule W, Bolton D, O’Ryan D. Risk factors for long term psychological
effects of a disaster experienced in adolescence: predictors of post traumatic stress disorder.
J Child Psychol Psychiatry 2000;41:969 – 79.
[85] Green BL, Korol M, Grace MC, et al. Children and disaster: age, gender, and parental effects on
PTSD symptoms. J Am Acad Child Adolesc Psychiatry 1991;30:945 – 51.
[86] Lonigan CJ, Shannon MP, Finch AJ, Daugherty TK, Taylor CM. Children’s reactions to a natural
disaster: symptom severity and degree of exposure. Advanced Behavioral Research and Therapy
1991;13:135 – 54.
[87] Shannon MP, Lonigan CJ, Finch AJ, Taylor CM. Children exposed to disaster. I: Epidemiology
of post-traumatic symptoms and symptom profiles. J Am Acad Child Adolesc Psychiatry 1994;
33:80 – 93.
[88] Pynoos RS, Goenjian A, et al. Post-traumatic stress reactions in children after the 1988 Arme-
nian earthquake. Br J Psychiatry 1993;163:239 – 47.
[89] Blom GE. A school disaster: intervention and research aspects. J Am Acad Child Psychiatry 1986;
25:336 – 45.
[90] Nader KO, Pynoos RS, Fairbanks LA, Al-Ajeel M, Al-Asfour A. A preliminary study of PTSD
and grief among the children of Kuwait following the Gulf crisis. Br J Clin Psychol 1993;
32:407 – 16.
[91] Shaw JA, Applegate B, Tanner S, et al. Psychological effects of hurricane Andrew on an
elementary school population. J Am Acad Child Adolesc Psychiatry 1995;34:1185 – 92.
[92] Perry BD, Pollard RA, Blakley TL, Baker WL, Vigilante D. Childhood trauma, the neuro-
biology of adaptation and use-dependent development of the brain: how states become traits.
Infant Mental Health Journal 1995;16:271 – 91.
[93] Breslau N, Davis GC, Andreski P, Peterson EL, Schultz LR. Sex differences in posttraumatic
stress disorder. Arch Gen Psychiatry 1997;54:1044 – 8.
[94] Handford HA, Mayes SD, Mattison RE, et al. Child and parent reaction to the Three Mile Island
nuclear accident. J Am Acad Child Psychiatry 1986;25:346 – 56.
[95] Realmuto GM, Masten A, Carole LF, Hubbard J, Groteluschen A, Chhun B. Adolescent
survivors of massive childhood trauma in Cambodia: life events and current symptoms.
J Trauma Stress 1992;5:589 – 99.
[96] Terr L. What happens to early memories of trauma? A study of twenty children under age five at
the time of documented traumatic events. J Am Acad Child Adolesc Psychiatry 1988;27:96 – 104.
[97] Weisenberg M, Schwarzwald J, Waysman M, Solomon Z, Klingman A. Coping of school-age
children in the sealed room during SCUD missile bombardment and postwar stress reactions.
J Consult Clin Psychol 1993;61:462 – 7.
[98] Perry BD. Neurobiological sequelae of childhood trauma: PTSD in children. In: Murburg MM,
editor. Catecholamine function in posttraumatic stress disorder: emerging concepts. Washing-
ton, DC: American Psychiatric Press; 1994. p. 233 – 55.
[99] Schwarz ED, Kowalski JM. Malignant memories: PTSD in children and adults after a school
shooting. J Am Acad Child Adolesc Psychiatry 1991;30:936 – 44.
[100] Kiser LJ, Ackerman BJ, Brown E, et al. Post-traumatic stress disorder in young children:
a reaction to purported sexual abuse. J Am Acad Child Adolesc Psychiatry 1988;27:
645 – 9.
[101] Saylor CF, Swenson CC, Powell P. Hurricane Hugo blows down the broccoli: preschoolers’
post-disaster play and adjustment. Child Psychiatry Hum Dev 1992;22:139 – 49.
[102] Sullivan MA, Saylor CF, Foster KY. Post-hurricane adjustment of preschoolers and their
families. Advanced Behavioral Research and Therapy 1991;13:163 – 71.
[103] World Health Organization. The ICD-9 classification of mental and behavioural disorders,
Ninth Revision. Clinical Modification. Geneva: World Health Organization; 1979.
[104] World Health Organization. The ICD-10 classification of mental and behavioural disorders.
Geneva: WHO; 1992.
[105] Peterson L, Brown D. Integrating child injury and abuse-neglect research: common histories,
etiologies, and solutions. Psychol Bull 1994;116:293 – 331.
[106] Daviss WB, Mooney D, Racusin R, Ford JD, Fleischer A, McHugo GJ. Predicting posttraumatic
stress after hospitalization for pediatric injury. J Am Acad Child Adolesc Psychiatry 2000;39:
576 – 83.
[107] Daviss WB, Racusin R, Fleischer A, Mooney D, Ford JD, McHugo GJ. Acute stress disorder
symptomatology during hospitalization for pediatric injury. J Am Acad Child Adolesc Psy-
chiatry 2000;39:569 – 75.
[108] De Vries AP, Kassam-Adams N, Cnaan A, Sherman-Slate E, Gallagher PR, Winston FK.
Looking beyond the physical injury: posttraumatic stress disorder in children and parents after
pediatric traffic injury. Pediatrics 1999;104:1293 – 9.
[109] Lonigan CJ, Shannon MP, Taylor CM, Finch AJ, Sallee FR. Children exposed to disaster. II:
Risk factors for the development of post-traumatic symptomatology. J Am Acad Child Adolesc
Psychiatry 1994;33:94 – 105.
[110] Martini DR, Ryan C, Nakayama D, Ramenofsky M. Psychiatric sequelae after traumatic injury:
the Pittsburgh Regatta accident. J Am Acad Child Adolesc Psychiatry 1990;29:70 – 5.
[111] McFarlane AC. Posttraumatic morbidity of a disaster. J Nerv Ment Dis 1986;174:4 – 14.
[112] Pynoos RS, Frederick C, Nader K, et al. Life threat and posttraumatic stress in school age
children. Arch Gen Psychiatry 1987;44:1057 – 63.
[113] Sack WH, Clarke G, Him C, et al. A 6-year follow-up study of Cambodian refugee adolescents
traumatized as children. J Am Acad Child Adolesc Psychiatry 1993;32:431 – 7.
[114] Stallard P, Velleman R, Baldwin S. Prospective study of post-traumatic stress disorder in
children involved in road traffic accidents. BMJ 1998;317:1619 – 23.
[115] Stoddard FJ, Norman DK, Murphy JM, Beardslee WR. Psychiatric outcome of burned children.
J Am Acad Child Adolesc Psychiatry 1989;28:589 – 95.
[116] Cicchetti D, Rogosche FA. The toll of child maltreatment on the developing child: insights from
developmental psychopathology. Child Adolesc Psychiatr Clin N Am 1994;3:759 – 76.
[117] Cicchetti D, Toth SL. A developmental psychopathology perspective on child abuse and
neglect. J Am Acad Child Adolesc Psychiatry 1995;34:541 – 65.
[118] Pynoos RS. Traumatic stress and developmental psychopathology in children and adolescents.
In: Oldham J, Riba M, Tasman A, editors. Review of psychiatry. Washington, DC: American
Psychiatric Press; 1993. p. 205 – 38.
[119] Lewis DO. From abuse to violence: psychophysiological consequences of child maltreatment.
[120] Perry BD, Pollard R. Homeostasis, stress, trauma, and adaptation: a neurodevelopmental view
of childhood trauma. Child Adolesc Psychiatr Clin N Am 1998;7:33 – 51.
[121] Perry BD. Anxiety disorders. In: Coffee CE, Brumback RA, editors. Textbook of pediatric
neuropsychiatry. Washington, DC: American Psychiatric Press; 1998. p. 580 – 94.
[122] Ornitz EM, Pynoos RS. Startle modulation in children with post-traumatic stress disorder. Am J
Psychiatry 1989;146:866 – 70.
[123] Glod CA, Teicher MH. Relationship between early abuse, post-traumatic stress disorder, and
activity levels in prepubertal children. J Am Acad Child Adolesc Psychiatry 1996;35:1384 – 93.
[124] Goenjian AK, Yehuda R, Pynoos RS, et al. Basal cortisol, dexamethasone suppression of cortisol,
and MHPG in adolescents after the 1988 earthquake in Armenia. Am J Psychiatry 1996;153:
929 – 34.
[125] Cardena E, Spiegel D. Dissociative reactions to the San Francisco Bay area earthquake of 1989.
Am J Psychiatry 1993;150:474 – 8.
[126] Koopman C, Classen C, Cardena E, Spiegel D. When disaster strikes, acute stress disorder may
follow. J Trauma Stress 1995;8:29 – 45.
[127] Spiegel D, Koopman C, Classen C. Acute stress disorder and dissociation. Australian Journal of
Clinical and Experimental Hypnosis 1994;22:11 – 23.
[128] Dancu CV, Riggs DS, Hearst-Ikeda D, Shoyer BG, Foa EB. Dissociative experiences and post-
traumatic stress disorder among female victims of criminal assault and rape. J Trauma Stress
1996;9:253 – 67.
[129] Koopman C, Classen C, Spiegel D. Predictors of posttraumatic stress symptoms among survi-
vors of the Oakland/Berkeley, Calif, firestorm. Am J Psychiatry 1994;151:888 – 94.
[130] Marmar C, Weiss DS, Schlenger WE, et al. Peritraumatic dissociation and posttraumatic stress
in male Vietnam theater veterans. Am J Psychiatry 1994;151:888 – 94.
[131] Shalev AY, Peri T, Canetti L, Schreiber S. Predictors of PTSD in injured trauma survivors:
a prospective study. Am J Psychiatry 1996;153:219 – 25.
[132] Marshall RD, Spitzer R, Liebowitz MR. Review and critique of the new DSM-IV diagnosis of
acute stress disorder. Am J Psychiatry 1999;156:1677 – 85.
[133] Pelcovitz D, Kaplan S. Post-traumatic stress disorder in children and adolescents. Child Ado-
lesc Psychiatr Clin N Am 1996;5:449 – 71.
[134] Pynoos RS. Exposure to catastrophic violence and disaster in childhood. In: Pfeffer CR, editor.
Severe stress and mental disturbance in children. Washington, DC: American Psychiatric Press;
1996. p. 181 – 211.
[135] Stoddard FJ, Stroud L, Murphy JM. Depression in children after recovery from severe burns.
J Burn Care Rehabil 1992;13:340 – 7.
[136] Van der Kolk BA. The body keeps the score: memory and the evolving psychobiology of
PTSD. Harv Rev Psychiatry 1994;1:253 – 65.
[137] Cicchetti D, Lynch M. Toward an ecological/transactional model of community violence and
child maltreatment: consequences for children’s development. Psychiatry 1993;56:96 – 118.
[138] Bronfenbrenner U. The ecology of human development: experiences by nature and design.
Cambridge (MA): Harvard University Press; 1979.
[139] Bell CC, Clark DC. Adolescent suicide. Pediatr Clin North Am 1998;45:365 – 80.
[140] Holinger PC. The causes, impact, and preventability of childhood injuries in the United States:
childhood suicide in the United States. Am J Dis Child 1990;144:670 – 6.
[141] Borges G, Anthony JC, Garrison CZ. Methodological issues relevant to epidemiologic inves-
tigations of suicidal behaviors of adolescents. Epidemiol Rev 1995;17:228 – 39.
[142] Brent DA, Perper JA, Moritz G, Baugher M, Schweers J, Roth C. Firearms and adolescent
suicide: a community case control study. Am J Dis Child 1993;147:1066 – 71.
[143] Li G, Baker SP, Smialek JE, Dischinger PC, Soderstrom CA. A comparative analysis of alcohol
in fatal and nonfatal bicycling injuries. Alcohol Clin Exp Res 1996;20:1553 – 9.
[144] Spirito A, Rasile DA, Vinnick LA, Jelalian E, Arrigan ME. Relationship between substance use
and self-reported injuries among adolescents. J Adolesc Health 1997;21:221 – 4.
[145] Li G, Ling J, DiScala C, Nordenholz K, Sterling S, Baker SP. Characteristics and outcomes of
self-inflicted pediatric injuries: the role of method of suicide attempt. Inj Prev 1997;3:115 – 9.
[146] Barnas C, Miller CH, Sperner G, et al. The effects of alcohol and benzodiazepines on the
severity of ski accidents. Acta Psychiatr Scand 1992;86:296 – 300.
[147] Brickley MR, Shepherd JP. The relationship between alcohol intoxication, injury severity and
Glasgow Coma Score in assault patients. Injury 1995;26:311 – 4.
[148] Rivara FP, Gurney JG, Ries RK, Seguin DA, Copass MK, Jurkovich GJ. A descriptive study of
trauma, alcohol, and alcoholism in young adults. J Adolesc Health 1992;13:663 – 7.
[149] Soderstrom CA, Kufera JA, Dischinger PC, Kerns TJ, Murphy JG, Lowenfels A. Predictive
model to identify trauma patients with blood alcohol concentrations 50 mg/dl. J Trauma
1997;42:67 – 73.
[150] Spain DA, Boaz PW, Davidson DJ, Miller FB, Carillo EH, Richardson JD. Risk-taking behav-
iors among adolescent trauma patients. J Trauma 1997;43:423 – 6.
[151] Tabares R, Peck MD. Chemical dependency in patients with burn injuries: a fortress of denial.
J Burn Care Rehabil 1997;18:283 – 6.
[152] Li G, Keyl PM, Smith GS, Baker SP. Alcohol and injury severity: reappraisal of the continuing
controversy. J Trauma 1997;42:562 – 9.
[153] Crumley FE. Substance abuse and adolescent suicidal behavior. JAMA 1990;263:3051 – 6.
[154] DiScala C, Lescohier I, Barthel M, Guohua L. Injuries to children with attention deficit hyper-
activity disorder. Pediatrics 1998;102:1415 – 21.
[155] Leibson CL, Katusie SK, Barbaresi WJ, Ransom J, O’Brien PC. Use and costs of medical care
for children and adolescents with and without attention-deficit/hyperactivity disorder. JAMA
2001;285:60 – 6.
[156] Wozniak J, Crawford MH, Biederman J, et al. Antecedents and complications of trauma in boys
with ADHD: findings from a longitudinal study. J Am Acad Child Adolesc Psychiatry 1999;
38:48 – 55.
[157] Pulkkinen L. Behavioral precursors to accidents and resulting physical impairment. Child Dev
1995;66:1660 – 79.
[158] Slap GB, Chaudhuri S, Vorters DF. Risk factors for injury during adolescence. J Adolesc Health
1991;12:263 – 8.
[159] Renz BM, Sherman R. Abusive scald burns in infants and children: a prospective study. Am
Surg 1993;59:329 – 34.
[160] Yeoh C, Nixon JW, Dickson W, Kemp A, Sibert JR. Patterns of scald injuries. Arch Dis Child
1994;71:156 – 8.
[161] Holmes WC, Slap GB. Sexual abuse of boys: definition, prevalence, correlates, sequelae and
management. JAMA 1998;280:1855 – 64.
[162] Parrish M, Bernstein AS, Felice ME. Rape. In: Hoekelman RA, editor. Primary pediatric care.
St Louis: Mosby; 1997. p. 1751 – 7.
[163] Reece RM. Fatal child abuse and sudden infant death syndrome. In: Reece RM, editor. Child
abuse: medical diagnosis and management. Philadelphia: Lea & Febiger; 1994. p. 107 – 37.
[164] International Federation of Red Cross and Red Crescent Societies. World disaster report. New
York: Oxford University Press; 1998.
[165] Blakeney P, Moore P, Broemeling L, Hunt R, Herndon D, Robson M. Parental stress as a cause
and effect of pediatric burn injury. J Burn Care Rehabil 1993;14:73 – 9.
[166] Salzer MS, Bickman L. The short and long.term psychological impact of disasters: implication for
mental health interventions and policy. In: Gist R, Lubin B, editors. Response to disaster: psy-
chosocial, community and ecological approaches. Philadelphia: Brunner/Mazel; 1999. p. 63 – 82.
[167] Goenjian AK, Pynoos RS, Steinberg AM, et al. Psychiatric comorbidity in children after the
1988 earthquake in Armenia. J Am Acad Child Adolesc Psychiatry 1995;34:1174 – 84.
[168] Aboutanos MB, Baker SP. Wartime civilian injuries: epidemiology and intervention strategies.
J Trauma 1997;43:719 – 26.
[169] Crossette B. UN council looks at rise in number of children in combat. New York Times June 30,
1998;A3.
[170] Eisenberg C. The effects of war on children. Presented at the Plenary Session of the XXII
International Congress of Pediatrics. Amsterdam, August 9 – 14, 1998.
[171] UNICEF. The state of the world’s children. New York: Oxford University Press; 1996.
[172] Ladd GW, Cairns E. Children: ethnic and political violence. Child Dev 1996;67:14 – 8.
[173] Toole MJ, Galson S, Brady W. Are war and public health compatible? Lancet 1993;34:1193 – 6.
[174] Vogel JM, Vernberg EM. Children psychological responses to disaster. J Clin Child Psychol
1993;22:464 – 84.
[175] Silverman WK, La Greca AM. Children experiencing disasters: definitions, reactions and
predictors of outcomes. In: La Greca AM, Silverman WK, Vernberg EM, Roberts MC, editors.
Helping children cope with disasters and terrorism. 1st edition. Washington, DC: American
Psychological Association; 2002. p. 11 – 33.
[176] Valent P. Disaster syndrome. In: Fink G, editor. Encyclopedia of stress. San Diego: Academic
Press; 2000. p. 706 – 9.
[177] Selye H. The general adaptation syndrome and the diseases of adaptation. J Clin Endocrinol
1946;6:117 – 96.
[178] Vernberg EM, Varela RE. Posttraumatic stress disorder: a developmental perspective. In: Vasey
MV, Dadds MR, editors. The developmental psychopathology of anxiety. New York: Oxford
University Press; 2001. p. 386 – 406.
[179] Bloch DA, Silber E, Perry AB. Some factors in the emotional reaction of children to disaster.
Am J Psychiatry 1956;113:416 – 22.
[180] Bradburn IS. After the earth shook: children’s stress syndrome 6 – 8 months after a disaster.
Advanced Behavioral Research and Therapy 1991;13:173 – 80.
[181] Burke J, Moccia P, Borus J, Burns B. Emotional distress in fifth grade children ten months after
a natural disaster. J Am Acad Child Psychiatry 1986;25:536 – 41.
[182] Garrison CZ, Weinrich MW, Hardin SB, Weinrich S, Wang L. Posttraumatic stress disorder in
adolescents after a hurricane. Am J Epidemiol 1993;136:522 – 30.
[183] Honig RG, Grace MC, Lindy GD, Newman CJ, Titchener JL. Portraits of survival: a twenty
year follow up of the children of Buffalo Creek. Psychoanal Study Child 1993;48:327 – 56.
[184] Newman CJ. Children of disasters: clinical observations at Buffalo Creek. Am J Psychiatry 1976;
133:306 – 12.
[185] Yacoubian VV, Hacker FJ. Reaction to disaster at a distance: the first week after the earthquake
in Soviet Armenia. Bull Menninger Clin 1989;53:331 – 9.
[186] Goenjian AK, Molina L, Steinberg AM, Fairbanks LA, Alvarez ML, Goenjian HA, et al.
Posttraumatic stress and depressive reactions among Nicaraguan adolescents after Hurricane
Mitch. Am J Psychiatry 2001;158:788 – 94.
[187] Belter RW, Dunn SE, Jeney P. The psychological impact of Hurricane Hugo on children:
a needs assessment. Advances in Behaviour Research and Therapy 1991;13:155 – 61.
[188] Vernberg EM, La Greca AM, Silverman WK, Prinstein MJ. Prediction of posttraumatic stress
symptoms in children after Hurricane Andrew. J Abnorm Psychol 1996;105:237 – 48.
[189] Garrison CZ, Bryant ES, Addy CL, Spurrier PG, Freedy JR, Kilpatrick DG. Posttraumatic stress
disorder in adolescents after Hurricane Andrew. J Am Acad Child Adolesc Psychiatry 1995;
34:1193 – 201.
[190] La Greca AM, Silverman WK, Vernberg EM, Prinstein MJ. Symptoms of posttraumatic stress
in children after Hurricane Andrew: a prospective study. J Consult Clin Psychol 1996;64:
712 – 23.
[191] Allwood MA, Bell-Dolan D, Husain SA. Children’s trauma and adjustment reactions to violent
and nonviolent war experiences. J Am Acad Child Adolesc Psychiatry 2002;41:450 – 7.
[192] Kinzie JD, Sack WH, Angell RH, Manson S, Rath B. The psychiatric effects of massive trauma
on Cambodian children. I: The children. J Am Acad Child Adolesc Psychiatry 1986;25:370 – 6.
[193] Goldstein RD, Wampler NS, Wise PH. War experiences and distress symptoms of Bosnian
children. Pediatrics 1997;100:873 – 8.
[194] Horowitz K, Weine S, Jekel J. PTSD symptoms in urban adolescent girls: compounded com-
munity trauma. J Am Acad Child Adolesc Psychiatry 1995;34:1353 – 61.
[195] Pynoos RS, Eth S. Children traumatized by witnessing acts of personal violence: homicide, rape
or suicide behavior. In: Eth S, Pynoos RS, editors. Post traumatic stress disorder in children.
Washington, DC: American Psychiatric Press; 1985. p. 17 – 43.
[196] Collins WA, Maccoby EE, Steinberg L, Hetherington EM, Bornstein MH. Contemporary
research on parenting: the case for nature and nuture. Am Psychol 2000;55:218 – 32.
[197] Masten AS, Reed MGJ. Resilience in development. In: Snyder CR, Lopez SJ, editors. Hand-
book of positive psychology. New York: Oxford University Press; 2002. p. 74 – 88.
[198] Masten AS. Resilience comes of age: reflections on the past and outlook for the next generation
of research. In: Glantz MD, Johonson J, Huffman L, editors. Resilience and development:
positive life adaptations. New York: Plenum; 1999. p. 282 – 96.
[199] Masten AS, Garmezy N. Risk, vulnerability and protective factors in developmental psycho-
pathology. In: Lahey BB, Kazdin AE, editors. Advances in clinical child psychology. New
York: Plenum; 1985. p. 1 – 51.
[200] Peterson C, Bell M. Children’s memory for traumatic injury. Child Dev 1996;67:3045 – 70.
[201] Stoddard FJ. Care of infants, children and adolescents with burn injuries. In: Lewis M, editor.
Child and adolescent psychiatry: a comprehensive textbook. 3rd edition. Baltimore: Lippincott
Williams & Wilkins, in press.
[202] Blakeney PE, Meyer WJ, Tomas C. Psychosocial recovery patients with burn injuries.
In: Herndon DN, editor. Total burn care. London: Saunders; 1996. p. 783 – 98.
[203] Sheridan RL, Hinson MI, Liang MH, et al. Long-term outcome of children surviving massive
burns. JAMA 2000;283:69 – 73.
[204] Lund CC, Browder NC. The estimate of areas of burns. Surg Gynecol Obstet 1944;79:352.
[205] Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric risk of mortality score.
Crit Care Med 1996;24:743 – 52.
[206] Stoddard FJ, Sheridan RL, Saxe G, et al. Treatment of pain in acutely burned children. J Burn
Care Rehabil 2002;23:135 – 56.
[207] Hyman SE, Nestler EJ. Initiation and adaptation: a paradigm for understanding psychotropic
drug action. Am J Psychiatry 1996;153:151 – 62.
[208] Schechter NL. The status of pediatric pain control. Child Adolesc Psychiatr Clin N Am 1997;6:
687 – 702.
[209] Carr DB. Preempting the memory of pain. JAMA 1998;279:1114 – 5.
[210] Sapolsky RM. Glucocorticoids and hippocampal atrophy in neuropsychiatric disorders. Arch
Gen Psychiatry 2000;57:925 – 35.
[211] Wintgens A, Boileau B, Robaey P. Traumatic stress symptoms and medical procedures in
children. Can J Psychiatry 1997;42:611 – 6.
[212] 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 Psychiatry 2001;40:915 – 21.
[213] Johansen JW, Sebel PS. Development and clinical application of electroencephalographic bis-
pectrum monitoring. Anesthesiology 2000;93:1336 – 44.
[214] Aitkenhead AR. Awareness during anesthesia: what should the patient be told? Anesthesia
1990;45:351 – 2.
[215] Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150:971 – 9.
[216] Matthews JR, McGrath PJ, Pigeon H. Assessment and measurement of pain in children.
In: Schechter NL, Berde CB, Yaster M, editors. Pain in infants, children, and adolescents.
Baltimore: Williams & Wilkins; 1993. p. 97 – 112.
[217] Leith PJ, Weisman SJ. The management of painful procedures in children. Child Adolesc
Psychiatr Clin N Am 1997;6:829 – 42.
[218] Sheridan R, Stoddard F, Querzoli B, et al. Background pain and anxiety medication require-
ments in critically burned children. J Burn Care Rehabil 2000;21:S250.
[219] Berde CB, Masek BJ. Pain in children. In: Wall P, Melzack R, editors. Textbook of pain.
4th edition. London: Churchill-Livingstone; 1999. p. 1463 – 78.
[220] March JS, Amaya-Jackson L, Murray MC, Schulte A. Cognitive-behavioral psychotherapy for
children and adolescents with post-traumatic stress disorder after a single-incident stressor.
[221] Robinson E, Rumsey N, Partridge J. An evaluation of the impact of social interaction skills
training for facially disfigured people. Br J Plast Surg 1996;49:281 – 9.
[222] Kaslow NJ, Koon-Scott K, Dingle AD. Family considerations and interventions. In: Tarnowski
KJ, editor. Behavioral aspects of pediatric burns. New York: Plenum; 1994. p. 193 – 215.
[223] Rizzone L, Stoddard FJ, Murphy JM, Kruger LJ. Posttraumatic stress disorder in mothers of
children and adolescents with burns. J Burn Care Rehabil 1994;15:158 – 63.
[224] Stoddard FJ, Martyn J, Sheridan R. Psychiatric issues in pain of burn injury. Current Review of
Pain 1997; 1:130 – 6.
[225] Gallagher RM, Verma S. Treatment and rehabilitation of chronic orthopedic pain syndrome.
In: Stoudemire A, Fogel BS, Greenberg DB, editors. Psychiatric care of the medical patient.
2nd edition. New York: Oxford University Press; 2000. p. 242.
[226] Krane EJ, Heller LB. The prevalence of phantom sensations and pain in pediatric amputees.
J Pain Symptom Manage 1995;10:21 – 9.
[227] Stoddard FJ, Sheridan RL, Selter LF, Greenberg DB. General surgery: basic principles of
patient assessment. In: Stoudemire A, Fogel BS, Greenberg DB, editors. Psychiatric care of
the medical patient. 2nd edition. New York: Oxford University Press; 2000. p. 979 – 81.
[228] Smith J, Thompson JM. Phantom limb pain and chemotherapy in pediatric amputees. Mayo
Clin Proc 1995;70:357 – 64.
[229] Atalar KD, Carter BD. Pediatric limb amputation: aspects of coping and psychotherapeutic
intervention. Child Psychiatry Hum Dev 1992;23:117 – 29.
[230] Varni JW, Setoguchi Y, Rappaport LR, Talbot D. Effects of stress, social support, and self esteem
on depression in children with limb deficiencies. Arch Phys Med Rehabil 1991;72:1053 – 8.
[231] Deblinger E, McLeer SV, Henry D. Cognitive behavioral treatment for sexually abused children
suffering post-traumatic stress: preliminary findings. J Am Acad Child Adolesc Psychiatry
1990;29:747 – 52.
[232] King NJ, Tonge BJ, Mullen P, Myerson N, Heyne D, Rollings S. Treating sexually abused
children with posttraumatic stress symptoms: a randomized clinical trial. J Am Acad Child
Adolesc Psychiatry 2000;39:1347 – 55.
[233] Cohen JA, Mannarino AP. A treatment outcome study of sexually abused preschool children:
initial findings. J Am Acad Child Adolesc Psychiatry 1996;35:1402 – 10.
[234] Cohen JA, Mannarino AP. Factors that mediate treatment outcome of sexually abused preschool
children: six- and 12-month follow-up. J Am Acad Child Adolesc Psychiatry 1998;37:44 – 51.
[235] Cohen JA, Mannarino AP. Interventions for sexually abused children: initial treatment findings.
Child Maltreatment 1998;3:53 – 62.
[236] Deblinger E, Heflin AH. Treating sexually abused children and their non-offending parents:
a cognitive behavioral approach. Thousand Oaks (CA): Sage; 1996.
[237] Deblinger E, Steer RA, Lippman J. Two-year follow-up study of cognitive behavioral therapy
for sexually abused children suffering post traumatic stress symptoms. Child Abuse Negl 1999;
23:1371 – 8.
[238] Celano M, Hazzard A, Webb C, McCall C. Treatment of traumatogenic beliefs among sexually
abused girls and their mothers: an evaluation study. J Abnorm Child Psychol 1996;24:1 – 17.
[239] Berliner L, Saunders B. Treating fear and anxiety in sexually abused children: results of a
two-year follow up study. Child Maltreatment 1996;1:294 – 309.
[240] DeBellis MD. Posttraumatic stress disorder and acute stress disorder. In: Ammerman RT,
Hersen M, editors. Handbook of prevention and treatment with children and adolescents:
intervention in the real world context. New York: John Wiley & Sons, Inc.; 1997. p. 455 – 94.
[241] Curry JF. Specific psychotherapies for childhood and adolescent depression. Biol Psychiatry
2001;49:1091 – 100.
[242] Klein RG, Pine DS. Anxiety disorders. In: Rutter M, Taylor E, Hersov M, editors. Child and
adolescent psychiatry. 3rd edition. New York: Blackwell Scientific; 2002.
[243] Rose S, Bisson J, Wessely S. A systematic review of single session psychological interventions
(‘‘debriefing’’) following trauma. Psychother Psychosom, in press.
[244] Vernberg EM. Intervention approaches following disasters. In: La Greca AM, Silverman WK,
Vernberg EM, Roberts MC, editors. Helping children cope with disasters and terrorism. Wash-
ington, DC: American Psychological Association; 2002. p. 55 – 72.
[245] Fava GA, Rafanelli C, Cazzaro M, Conti S, Gransi S. Well-being therapy. Psychol Med 1998;
28:475 – 80.
[246] Fava GA. Well-being therapy: conceptual and technical issues. Psychother Psychosom 1999;
68:171 – 9.
[247] Ramirez AJ, Craig TKJ, Watson JP, Fentiman IS, North WR, Rubens RD. Stress and relapse of
breast cancer. BMJ 1989;298:291 – 4.
[248] Ryff CD. Happiness is everything, or is it? Explorations on the meaning of psychological well-
being. J Pers Soc Psychol 1989;57:1069 – 81.
[249] Ryff CD, Singer B. Psychological well-being: meaning, measurement and implication for
psychotherapy research. Psychother Psychosom 1996;65:14 – 23.
[250] Fava GA. The concept of recovery in affective disorders. Psychother Psychosom 1996;65:
2 – 13.
[251] Fava GA. The concept of psychosomatic disorder. Psychother Psychosom 1992;58:1 – 12.
[252] Ryff CD, Singer B. The contours of positive human health. Psychological Inquiry 1998;9:1 – 28.
[253] Fava GA, Sonino N. Psychosomatic medicine: emerging trends and perspectives. Psychother
Psychosom 2000;69:184 – 7.
[254] Emmelkamp PGM, Van Oppen P. Cognitive intervention in behavioral medicine. Psychother
Psychosom 1993;59:116 – 30.
[255] Lipowski ZJ. Psychosocial aspects of disease. Ann Intern Med 1969;71:1197 – 296.
[256] Frankl VE. Man’s search for meaning: an introduction to logotherapy. Boston: Beacon; 1962.
[257] Frankl VE. The doctor and the soul: from psychotherapy to logotherapy. 3rd edition. New York:
Vintage; 1986.
[258] Nolen-Hoeksema S, Davis CG. Positive response to loss: perceiving benefits and growth.
In: Snyder CR, Lopez SJ, editors. Handbook of positive psychology. Oxford: Oxford University
Press; 2002. p. 598 – 607.
[259] Nolen-Hoeksema S, Larson J. Coping with loss. Mahwah (NJ): Lawrence Erlbaum Asso-
ciates; 1999.
[260] Affleck G, Tennen H. Construing benefits from adversity: adaptational significance and disposi-
tional underpinnings. J Pers 1996;64:899 – 922.
[261] Davis CG, Nolen-Hoeksema S, Larson J. Making sense of loss and benefiting from the expe-
rience: two construals of meaning. J Pers Soc Psychol 1998;75:561 – 74.
[262] Park CL, Cohen LH, Murch RL. Assessment and prediction of stress-related growth. J Pers
1996;64:71 – 105.
[263] Tedeschi RG, Calhoun LG. Trauma and transformation: growing in the aftermath of suffering.
Thousand Oaks (CA): Sage; 1995.
[264] Tennen H, Affleck G. Finding benefits in adversity. In: Snyder CR, editor. Coping: the psy-
chology of what works. New York: Oxford University Press; 1999. p. 279 – 304.
[265] Caffo E, Cohen D, Vitulano L. Childhood and emergency: integrated intervention strategies to
prevent and treat trauma. Proceedings of the Treviso Emergency Team Project Inauguration,
Sala Congressi, Ospedale regionale Cà Foncello. Treviso, Italy, November 9 – 11, 1998.
1st Term AY 2022-2023
Medicine Surgery Related Learning Experience
Bibliography
TORRES, Andrea Sarah E.

3NUR-7 November 4, 2022
Psychological aspects of traumatic injury in children and adolescents
I. Reason Why You Chose The Article
“A child’s mental health is just as important as their physical health”, a quote by Kate Middleton. Each
year there are millions of children who are exposed to a traumatic event – including natural disasters,
life-threatening illnesses, scary medical procedures, physical abuse, vehicular accidents and many more.
In my case, my 15 year old patient was involved in an accident he did not expect due to an intoxicated
driver. This caused him serious fractures and injuries that may take weeks to months to recover from. The
mother of the patient showed us a CCTV video, showing how the accident unfolded and it was
heartbreaking. One minute the child was just quietly sitting down on a motorcycle then in a blink of an
eye, he was already flying due to the impact. Considering the patient is at a young age, he could bring this
trauma and may affect his daily living as he ages. As nurses, it is our responsibility to not only provide
care physically but also, emotionally, psychologically and socially. This is the reason why I chose this
article – I want to better understand the psychological consequences of traumatic injury to young children
and adolescents, help them cope with the overwhelming events and let them know that they are not alone.
Moreover, I want to advocate the importance of being able to be there as a care provider and as a friend to
these children. We can help them regain a sense of emotional and physical safety, let them feel protected
and comforted.
II. Findings
Through an intensive assessment, the study was able to identify relationships, factors, consequences,
coping mechanisms, strategies and interventions that can be incorporated into providing care to these
children. According to the study, after exposure to extreme stress, the symptoms of PTSD, acute stress
disorder, separation anxiety and anxiety disorders are the most common problems. Specifically, PTSD is
the most common child’s psychological reactions to a diverse range of injuries, such as motor vehicle
accidents, violent assaults, natural disasters, political violence, and burns. With four or more adverse
childhood events, the risk for various medical conditions increased fourfold to 12-fold such as heart
disease, cancer, chronic lung disease and others. According to the study, trauma and the child’s response
to it have the potential to disrupt normal development and may influence the child’s adaptation and the
subsequent development of cognition and attention, social skills, personality style, self-concept,
self-esteem, and impulse control. The resilience or the capacity to recover quickly from difficulties are
hindered when there are unfavorable conditions that weaken the basic human protective systems for
development. Consequently, efforts to promote competence and resilience in children at risk should focus
on strategies that prevent damage to, repair, or compensate for threats to these basic systems
After an intensive qualitative assessment of the injured child consisting of eliciting the narrative review of
the trauma from the child (if possible) and investigating the child’s developmental history and preexisting
psychopathology. This led them to some procedures for the psychiatric care of the injured child: pain
management, brief consultation, crisis intervention, psychotherapeutic techniques. There are three major
kinds of strategies for promoting resilience in children and adolescents. Risk-focused strategies with the
aim to remove or reduce a child’s threat exposure like an advocate for accident prevention. Then,
asset-focused strategies with the intent to increase a child’s resources necessary for developing
competence and lastly, process-focused strategies aim to influence processes that will change a child’s
life. It was also found that children’s responses to major stress are similar to adults’ (re-experiencing the
event, avoidance and arousal.
III. Conclusion
Mental health professionals are increasing their understanding about what factors are associated with
increased risk (vulnerability) and affect how children cope with traumatic events. Through the findings on
resilience, it suggests that we need to provide care with positive goals. It plays a fundamental role in
recovery. It was also highlighted that a well-being therapy can improve quality of coping style, and social
support in chronic and life-threatening illnesses such as depression, PTSD, and anxiety disorders. In
conclusion, the research on resilience in development is that extraordinary resilience and recovery power
of children depend on basic human protective systems operating in their favor.
IV. Significance of the Article
A. Nursing education
The study serves as a new information source to keep healthcare professionals up-to-date
with new interventions and risk factors that are applicable to pediatric patients and their family
members. Specific interventions and learning how to build up a child’s resilience could be part of
the nursing education to allow patient development in the healthcare institution. Trauma can
cause serious consequences, however this is preventable. Thus, being educated on the issues
through the subjects in the article could help us in providing a patient-centered care wherein we
could provide care and support to the client.
B. Nursing practice
Nurses may be able to implement evidence-based nursing interventions in their nursing

practice with the article used as a basis. The article helps nurses to determine effective best
practices and enhance patient care. With this new information, the nursing practice can be
improved by lessening the development of a long-term trauma and providing optimal care to
these pediatric patients. We want to give them the best quality care that they would need.
However, this could be a difficult task for it is not our field of study but being able to
communicate and interact with them could be a help.
C. Nursing research
The article was able to disseminate evidence, share knowledge, find new interventions
and provide up to date information to nurses which they can incorporate into their nursing
practice to improve patient outcomes. When there is improvement in the nursing research, there is
also improvement in the nursing practice. Thus, the article was able to contribute to all nursing
research with the importance of the consequences of trauma and ways on how to help them which
is based on evidence.

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Child Adolesc Psychiatric Clin N Am

12 (2003) 493 – 535

Psychological aspects of traumatic injury in

Incidence and prevalence of traumatic stress

[20] examined population prevalence of PTSD in a community sample of

Rape and physical and sexual abuse

Risk for psychopathology after trauma

Two different lines of evidence

The nature of trauma-related psychopathology

of trauma [63,64]. As a result, the consistent direction driving potential associ-

in female victims of different types of abuse, both in childhood and in adult

Predictors of response in child victims of trauma

Psychiatric consequences of physical injuries

Unfortunately, few studies of psychiatric outcomes after injuries exist.

Neurophysiologic core of posttraumatic stress disorder

Factors that increase risk for psychopathology after injuries

instability [21]. This approach is consistent with a psychosocial model of human

Inattention and impulsive behavior

Psychological effects of natural disasters and war on children

Children injured in situations of such extreme environmental disruption may not

 Preimpact: the period before the disaster

violent war traumas. An additive effect of trauma exposure on trauma reactions

The concept of resilience

of safety decrease vulnerability. ‘‘Persistently activated stress-response neuro-

Assessment and treatment of the injured child

The child and adolescent psychiatrist or psychologist assesses injury severity

requires clinical assessment of all these dimensions. Assessing pain is a process

Psychotherapeutic approaches for children who develop PTSD after trauma

a comparison between CBT in some form and a community comparison or active

Strategies for fostering resilience

benefits commonly reported across studies are growth in character, a gain in

1. Risk-focused strategies (providing prenatal care to prevent premature births,

 To provide better understanding of the relationship between a child’s or

 To promote community activities aimed at increasing public and pro-

 Identifying the emergency

The Treviso Emergency Team consists of a staff of trained psychologists who

[71] McFarlane AC. Posttraumatic phenomena in a longitudinal study of children following a

TORRES, Andrea Sarah E.

Psychological aspects of traumatic injury in children and adolescents

I. Reason Why You Chose The Article

IV. Significance of the Article

Nurses may be able to implement evidence-based nursing interventions in their nursing

You might also like

Preimpact: the period before the disaster

To provide better understanding of the relationship between a child’s or

To promote community activities aimed at increasing public and pro-

Identifying the emergency