Role of the EMS Provider in Crisis Intervention:
Neurophysiological Aspects of Acute Trauma in Children

Bruce D. Perry, M.D., Ph.D.
G. Michael Gomez, M.D.

The ChildTrauma Academy
www.ChildTrauma.org

*This is an Academy version of Teaching Resource for Instructors in Prehospital Pediatrics.

Official Citation: Perry, B.D. Children?s Reaction to Stress. Section 21 in George L. Foltin, Michael G. Tunik, Arthur Cooper, David Markenson, Marsha Treiber, Regina Phillips, Tamia Karpeles. Teaching Resource for Instructors in Prehospital Pediatrics. New York, NY: Center for Pediatric Emergency Medicine, 1998.

Children?s Reaction to Stress

What You?ll Cover

Chapter Contents

Glossary

Learning Objectives and Key Points

Assessment and Management

Background

Assessment considerations

Management considerations

Transport considerations

Documentation

Communication with parents

Barriers to Learning

Practice Sessions

References

Tables
Stress Reaction Continuum

Handouts
Key Points: Children?s Reaction to Stress

Glossary

The following specialized terms are used in this chapter:

          augment?increase

          compliance?cooperation

          hypoperfusion?another name for shock

          mimic?imitate

          sensory?relating to the senses

          vigilance?a heightened state of alertness

Learning Objectives and Key Points

After teaching your students about children?s reaction to stress, they should be able to perform the learning objectives below. Each objective relates to a key point drawn from chapter content. Key points are repeated in a student handout at the end of the chapter.

Assessment and Management

Background

By the age of eighteen years, approximately one child in four experiences some form of traumatic event, such as a natural disaster, a motor vehicle crash, or abuse. When such an event occurs, the EMT is likely to serve as the child?s first point of contact with health care professionals. EMTs? activities, conduct, and skills can dramatically affect how readily the child accepts further medical interventions after reaching the hospital. EMTs can also be a positive force in helping the child cope with the traumatic event itself. This, in turn, will help the child regain normal emotional, behavioral, cognitive, and physiological function during later recovery.

To understand their role in this aspect of emergency care, EMTs must first understand how a child?s brain reacts to a traumatic event.

The stress response n When a child experiences a real or perceived danger, the brain activates a host of stress responses having to do with self-protection and survival. These interrelated responses affect the child?s physical functions, mental state, and thought processes. The brain?s purpose in activating these responses is to mobilize the entire body to survive a life-threatening danger.

During the initial stages of crisis, portions of the brain involved in arousal, attention, and concentration are activated. The brain tunes out all nonessential sensory input, focusing completely on the external threat. This is why children who are hurt during a traumatic event often do not feel pain or even realize that they have been hurt until the critical event is over.

The brain also sends signals to different parts of the body, preparing the child to fight, flee, or freeze. These signals can cause a variety of physical and emotional reactions that are grouped into two primary response patterns: the fight-or-flight response and the freeze-and-withdraw response. Characteristic findings associated with each type of stress response follow:

• fight-or-flight response: tense muscle tone, increased breathing rate, increased pulse rate; agitation, confusion, inability to concentrate, extreme anxiety, trembling, combative behavior; older children may be unable to give EMTs a clear history

• freeze-and-withdraw response: shallow breathing, slow pulse rate, pale or clammy skin, low blood pressure, decreased responsiveness; stunned, fearful, or unemotional appearance; inability to speak; extreme responses may include fainting or a total lack of reaction to external stimuli

Most children will display some combination of these two responses. For example, a child who appears stunned or unemotional might also have fast breathing, fast pulses, and trembling. Older children and males are likely to exhibit more characteristics of the fight-or-flight response. Infants, young children, and females are more likely to exhibit a freeze-and-withdraw response. Children may also shift back and forth between the two response patterns.

The body uses a tremendous amount of energy to sustain any type of fear reaction. If the threat is brief, the body returns to a normal state soon afterward. In a continuing or extremely traumatic threat, however, the stress response may last for days or weeks.

The stress continuum A child?s response to threat involves a continuum; that is, the child passes through a number of closely interrelated stages while reacting to the stressful event. The child?s mental state changes during each of these stages. From an initial state of calm, the child moves through arousal and alarm to fear and terror. These changes can affect the way the child processes information and reacts to events during a crisis.

Each mental state gives rise to specific behavioral reactions. The more threatened the child feels, the more primitive the child?s behavior and thinking becomes. The accompanying table summarizes the continuum.

The earliest stage of the stress response continuum involves vigilance accompanied by a mental state of arousal. At this point, the child is highly alert and the senses are focused entirely on the threat. A freeze-and-withdraw response to this state would be avoidance, in which the child refuses to acknowledge that the threat exists.

As the mental state progresses from arousal to alarm, the child?s senses become overloaded by a situation that appears out of control, giving rise to the "freeze" stage of the continuum. This stage arises from indecision?the child is more anxious and less able to concentrate than a calm child, and may be unable to decide on any behavioral reaction. Children in this state are highly aware of nonverbal cues, such as tone of voice, body posture, and facial expressions. The fight-or-flight response is to resist any action, while the freeze-and-withdraw response is compliance (cooperation) with orders or suggestions from others.

A child who feels increasingly threatened enters the next stage of the continuum, flight. The child?s mental state at this point is fear. For most children, actually running from the threat is not a realistic response, so the child may enter a state of dissociation, which involves daydreaming or staring off into space. Dissociation is a mental flight from a source of pain or anxiety that is too great for the child to manage. It is considered a freeze-and-withdraw response. Children engaged in a fight-or-flight response may act defiant at this stage.

The final stage in the stress response continuum is the "fight" reaction, which arises from a mental state of terror. Crying and yelling are frequent terror responses to an unavoidable threat. When these actions fail to ease the terror, the child resorts to physical tantrums. EMTs may have to restrain the child during this stage until the child is calmer. They must be careful to do this in a manner that will not be interpreted as punishment for the aggressive behavior, which would only worsen the child?s reaction. A child who is engaged in a freeze-and-withdraw response may react to the extreme terror of the fight stage by fainting.

Assessment Considerations

Stress reactions present an additional assessment consideration for EMTs. Children?s responses to stress can mask (cover up), mimic (imitate), or augment (increase) assessment findings caused by physical injury. The changes in breathing rate, pulse rate, skin color, blood pressure, and mental status seen in stress reactions are very similar to signs of shock, respiratory distress, and altered mental status resulting from physical injury. For example, an extremely fearful child may have a greatly increased pulse rate, which is usually a sign of early shock, but there may be no indication of illness or injury likely to cause loss of blood or fluid. It is often impossible for EMTs to distinguish physical findings caused by injury from those due to the brain?s stress response.

When caring for a traumatized child, EMTs should follow normal initial assessment priorities for airway, breathing, circulation, and mental status as described in Patient Assessment. However, they should watch carefully for assessment findings associated with the fight-or-flight response or the freeze-and-withdraw response throughout the initial assessment. Special considerations affecting management, transport, documentation, and parent teaching will be necessary for children who exhibit these response patterns.

Management Considerations

Children are most comfortable when their surroundings appear predictable and safe. They like to feel that the adults around them are in control. During a crisis, the world is suddenly frightening and unknown. Therefore, maintaining a calm, reassuring manner is one of EMTs? most important management actions. The child?s mental state will reflect the reactions of surrounding adults, and an EMT who appears calm and in control will significantly ease a child?s fears.

Because of this, EMTs must learn to control their own emotional responses during a traumatic event. While children do not expect adults to act as if nothing unusual has happened, they find it frightening if they sense that the people caring for them are disorganized and confused. EMTs should explain that even adults can feel anxious or irritable under the circumstances, and help the child see that these normal reactions will pass.

The following techniques can help EMTs calm a fearful child:

• EMTs should begin by introducing themselves to the child.

• Enlist the aid of a calm parent or other family member to comfort the child. If the parents are excessively distressed, take a moment to address their fears so that they can focus on providing necessary support.

• Tell the child what happened in simple, age-appropriate words. If family members or friends were hurt during in the traumatic event, explain that someone is taking care of them. Be prepared to repeat even simple explanations. Under stressful circumstances, children are unlikely to understand what they are told as well as they normally would. Be honest and open, even when this is emotionally difficult. Never mislead the child if the answer to a question or the outcome to a situation is unknown.
  

Enrichment point

The importance of an honest approach: Many adults think that children should be protected from the truth when something bad happens. However, failing to explain the situation to the child can actually worsen stress symptoms. When children do not understand something that has happened, they will make up their own explanations. These made-up explanations may be even more frightening than what actually occurred, adding to the child?s fears. By providing clear, truthful information in age-appropriate terms, EMTs will help children develop realistic mental images they can more easily accept.

• If appropriate for the child?s age (generally preschoolers and older), EMTs should explain what they are doing. This distraction will help the child feel less fearful.

• Children who are old enough to participate in their own care should be allowed to make choices whenever possible. Even a small thing, such as picking out a bandage, can have a reassuring effect, as it gives children some sense of control over an unpredictable situation.

• Be aware of nonverbal cues. When stressed, children often react more strongly to body language and tone of voice than to the words they hear.

• EMTs should be nurturing and comforting. Speak softly at all times. Try touching the child on the shoulder or holding the child?s hand. Stay close by if this seems to help calm the child.

Special considerations: The abused child n Children who have been physically abused will experience stronger stress reactions than children who come from supportive family situations. Counseling and critical incident stress management techniques may help these children lower their reactions and minimize long-term symptoms. If EMTs suspect child abuse, they should be sure to report this to hospital personnel so that the child will receive appropriate care. See Child Abuse and Neglect for more information.

Enrichment point

Mental and physical responses to stress usually have a rapid onset and resolve quickly after the crisis. However, abused children who are subjected to frequent traumatic experiences seem to develop a sensitized fear response, which may not be reversible. This fear response arises from permanent changes affecting brain systems that control the stress response, making the brain more sensitive to future stressful events. It is critical that EMTs report suspected child abuse so that these children can receive appropriate interventions before such permanent changes occur.

Transport Considerations

Children can become confused and frightened when EMTs remove them from their home or from an injury scene. The child is being taken from everything that is familiar and comforting, and delivered to an unknown environment. Children who are already anxious and agitated about a traumatic event will have a harder time understanding where they are going, why they must go, and who is taking them, which increases their distress. Whenever possible, encourage a parent, older brother or sister, or familiar adult to accompany the child in the ambulance.

Documentation

Children who have experienced a traumatic event may require counseling during their recovery to help them cope with the aftereffects of the crisis. The child?s family and health care team will find it helpful if they have detailed information about the type, intensity, and duration of the child?s response to the crisis. This makes it important for EMTs to document the following items:

• observations about the child?s behavioral and emotional responses during prehospital care

• vital signs, skin color, and other physical findings that can arise from stress reactions

• the specific nature of the trauma
  

Communication with Parents

Teaching the family about children?s normal responses to a traumatic event is an important role for all EMTs. It allows family members to help the child cope with the aftereffects of the event in an appropriate manner.

There are many misunderstandings about how children cope with severe injury, death, and other traumatic events. Some adults believe that children bounce back easily if they simply put the event behind them. Adults who hold this view may completely avoid discussing the traumatic event and discourage the child from talking about it. Others think that children need to let their feelings out as soon as possible. Adults who hold this view may push the child to talk about the event before the child is ready and able to discuss it.

Children do not benefit from either of these extremes. They do need to talk about stressful events, but they must be allowed to do so at their own pace. While parents should try not to bring up the subject before the child is ready, they should also try not to avoid the subject or overreact to it when the child brings it up. At that time, the parents should listen carefully, answer questions, and provide support. While there may not be any way to explain why something happened, parents can have a positive effect simply by listening and then comforting the child.

EMTs should try to explain these issues so that parents will know what to expect and how they can help the child during recovery. Provide oral and written information explaining children?s predictable responses following a traumatic event. This information will help the entire family promote a better healing process.

Barriers to Learning

EMTs traditionally focus on physical conditions during a medical emergency. They may not realize the importance of addressing additional factors related to a child?s mental state. Your teaching should emphasize that proper management actions for stress responses are an essential part of an EMT?s responsibilities when caring for children. Make sure your students understand that stress responses to trauma have considerable impact on the child?s current medical condition and eventual recovery. Interventions designed to calm the child can improve immediate and long-term outcome.

Practice Sessions

Discussion

The following group discussions may help EMTs manage children?s reactions to stress more effectively:

• Explain the physiological processes involved in stress responses as outlined in this chapter. It is important for EMTs to understand that stress responses involve true physical reactions?they are not simply emotional responses.

• Most EMTs have experienced significant crisis situations. Encourage your students to relate their personal experiences and discuss their physical and psychological reactions during traumatic events.

• Invite children or young adults who have experienced traumatic events to talk to your students about what they were thinking and feeling during the crisis and how emergency personnel may have helped them cope with the situation. Ask parents to come in and talk about their experiences interacting with EMTs who cared for their children during a traumatic incident.
  

Role Playing

Have students split up into small groups and practice the following roles and situations:

• Managing the patient: While immobilizing an injured child, an EMT uses age-appropriate techniques to explain management actions and help calm the child. Practice this repeatedly using different techniques for a three-year-old child, a seven-year-old child, and a fourteen-year-old child.

• Managing a parent: During a traumatic event, the EMTs use appropriate techniques to calm an emotionally distressed parent.

• Teaching the parents: Speaking with the parents after a traumatic emergency, an EMT describes normal mental and physical responses that the child may experience during the recovery period.

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References

Pynoos, R., and S. Eth. "Children Traumatized by Witnessing Acts of Personal Violence." In Posttraumatic Stress Disorder in Children, edited by S. Eth and R. Pynoos. Washington, DC: American Psychiatric Press, 1985, 17?44.

Schwarz, E., and B. D. Perry. "The Post-Traumatic Response in Children and Adolescents." Psychiat Clin N America 17 (1994): 311?326.

The following is a sample listing of products described in the EMSC Products Catalog. You may obtain these items by contacting the EMSC Program of the National Maternal and Child Health Clearinghouse at 703/356-1964 or by e-mail nmchc@circsol.com.

Item 0318. Annotated Bibliography on Psychological Aspects of Emergency Medical Services for Children. (CA)

Item 0492. Psychological First Aid Packet. (MO)

Item 0502. Children and Trauma Lecture Videotape. (MO)

Item 0503. Foot Soldiers (News Story) Videotape. (MO)

DHHS Publication SMA 95-3022. "Psychosocial Issues for Children and Families in Disasters: A Guide for the Primary Care Physician." US Department of Health and Human Services, 1995.

Enrichment

Perry, B. D. "Neurobiological Sequelae of Childhood Trauma: Post-Traumatic Stress Disorders in Children." In Catecholamines in PTSD, edited by M. Murburg. Washington, DC: American Psychiatric Press, 1994, 253?276.

Perry, B. D., and J. E. Pate. "Neurodevelopment and the Psychobiological Roots of Post-Traumatic Stress Disorders." In The Neuropsychology of Mental Disorders: A Practical Guide, edited by C. Stout and L. F. Koziol. Springfield, IL: Charles C. Thomas, 1994, 129?147.

Putnam, F. "Dissociative Disorders in Children and Adolescents: A Developmental Perspective. Psychiat Clin N America 14 (1991): 519?531.

Terr, L. "Childhood Traumas: An Outline and Overview." American Journal of Psychiatry 148 (1991): 10?20.

TRIPP Handout

Key Points: Children?s Reaction to Stress

• Any child will experience a fear response during an emergency situation. The two primary responses are the fight-or-flight response and the freeze-and-withdraw response. Most children exhibit some combination of these two responses.

• Physical findings arising from a fight-or-flight response may include tense muscle tone, increased breathing rate, and increased pulse rate. Mental and emotional responses may include agitation, confusion, inability to concentrate, extreme anxiety, trembling, and combative behavior.

• Physical findings arising from a freeze-and-withdraw response may include shallow breathing, slow pulse rate, pale or clammy skin, low blood pressure, and decreased responsiveness. The child may appear stunned, fearful, or unemotional. Sometimes the child cannot speak or react.

• Stress responses can mask (cover up), mimic (imitate), or augment (increase) assessment findings caused by physical injury. Stress reactions can lead to changes in the child?s breathing rate, pulse rate, skin color, blood pressure, and mental status. These changes may be very similar to signs of shock, respiratory distress, and altered mental status resulting from physical injury. It is often impossible to distinguish physical findings that are caused by the injury from those that arise from the child?s stress response.

• When a traumatic event occurs, EMTs usually provide the child?s first contact with health care professionals. If you are calm and reassuring, you can decrease a child?s stress reaction and enhance the child?s acceptance of later medical interventions. This will also help the child regain normal emotional and physiological function during recovery.

• By maintaining a calm, deliberate manner, you can significantly ease a child?s fears. Enlist the aid of a calm parent or family member to comfort the child. Throughout assessment and management, explain what you are doing using age-appropriate terms. Older children should be allowed to make choices about their care whenever possible.

• During transport, children who have experienced a traumatic event may find it difficult to understand where they are going, why they must go, and who is taking them. This increases their distress. It will help if a parent, older brother or sister, or familiar adult can accompany the child in the ambulance.

• To assist in the child?s recovery, the family and health care team need detailed information about the type, intensity, and duration of the child?s response to the crisis. Therefore, you should document your observations about the child?s physical, behavioral, and emotional responses to the crisis as well as the specific nature of the traumatic event.

The Teaching Resource for Instructors in Prehospital Pediatrics is not copyrighted. Readers are free to duplicate and use all or part of the information contained in this publication. In accordance with accepted publishing standards, the Center for Pediatric Emergency Medicine (CPEM) requests acknowledgment, in print, of any information reproduced in another publication.

The mission of the Center for Pediatric Emergency Medicine (CPEM) is to improve emergency medical services for children in the United States through education, research, and systems development. Established in 1985 at New York University Medical Center and Bellevue Hospital Center in New York City, CPEM is funded primarily by the US Department of Health and Human Services through its Maternal and Child Health Bureau, EMSC Program.

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212/562-4470
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This manual was supported by project grant MCH-364004 from the Emergency Medical Services for Children Program as provided by Section 1910 of the US Public Health Service Act. Emergency Medical Services for Children is administered by Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health Service, US Department of Health and Human Services in cooperation with the National Highway Traffic Safety Administration.