Dr. Sharon L. Hirsch describes the effects of stress on the developing brain and identifies patients most at risk for the development of PTSD. Dr. Hirsch also recites the basics of psychological first aid and treatment options and details when the right time to refer is and who to refer to.
[MUSIC PLAYING] SHARON HIRSCH: So I think what we really need to be looking at with our patients is making sure they're happy, right? We want people to be happy, healthy, content. That's what we want. We've been talking about how to prevent seizures. We've been talking about how to prevent injury, recovering from injury. And now we're going to talk about how to make sure that everything keeps moving forward. So why is this important, and why is it is especially important in children and teens? And that's because, as you know, your brain is still developing. And one of the things that we know is just like any other organ, if you injure that organ, that brain, repeatedly at a young age, then you're going to end up having permanent damage. And I want to get across to you the fact that psychiatric trauma or acute trauma of an emotional kind is just as damaging for the organism, for the child, as any other kind of medical problem. So we look at imaging studies that show that volumes are smaller in abused, neglected youth. I think you may have had some of that information this morning. But these smaller cerebral volumes are significantly associated with the onset of post-traumatic stress disorder. This is really a long-term, significant problem. We're here on the South Side, and we have a lot of abuse, a lot of trauma that happens all around us. I don't know about you, but I was walking over here today, and someone ran into somebody on the sidewalk. And usually, we'd stop. We'd say I'm sorry, and we'd move on. But the woman that was run into was yelling and screaming. And I thought there was going to be a fight. And it's just those simple things that demonstrate to me how prevalent PTSD can be. Because I don't think that for most people, if you had one simple bump on the shoulder, you would have that reaction. But if you've been traumatized repeatedly in the past, you react in a much different way. I'm not going through all the criteria of PTSD, but this reactivity is really a hallmark of that. Nightmares, problems sleeping-- all of those other issues occur with PTSD. It's a long standing, chronic disorder that has been actually moved out of anxiety disorders and DSM-5. Wait until you see ICD-10, and you'll see it there. But that is really significant. You have neuronal loss, specifically in the medial prefrontal cortex. The executive functioning, that ability to plan through and be able to organize your life in your day, is really impacted. And that's specific in pediatric maltreatment-related PTSD. The most consistent gray matter abnormalities here are in the relatively late developing ventralateral prefrontal, limbo temporal regions known to mediate late developing functions of affective and cognitive control. So basically, it's a long way of saying that you're going to injure things that may not be those early onset, early developing things they regulate breathing or other essential functions, but the more sophisticated parts of your brain that talk about your thinking, your cognition, and your emotions. And so we have to worry about this all the way through your development. So the limbic-hypothalamic-pituitary axis, I know you're familiar with the HPA axis. But the limbic system, we have here, and I'll just remind you is a corpus callosum, a cingulate gyrus. And then really down in here, you have all these areas in here that really talk about where you have emotions, where you have memory. And how you have that interaction is really fascinating. And I'm not going to go-- let's see. I'm not going to go back I think here. Yes, OK. So this is the processing disruptions. We talked about this as well, demonstrated-- and actually, there's a lot of research that's been done on this both in animal models-- and I've taken the time here to cite just a couple of references for you. One is Sanchez, and looking at more of rodent and primate models, and then McEwen, who looked at this also in humans. So these long-term consequences are not just something that we see in how emotions play out, but they're present in the development of the brain, again, in your gray matter as well as all your other tracts. They are present in your corticosteroids and how your ACTH system functions. And you basically are reset. And this can happen whether you experience trauma in utero, whether it goes on and that you have this recurring later on. But it's really something to think about. And I bring up the in utero because I know we're doing a lot of work here. Kate Keenan's doing some with pregnant women and looking at their stress during pregnancy and then the outcomes of their youth, their children, as they grow older. And so that's something to kind of keep looking at. But we know that stress can occur in utero or later on can really affect not only how you feel and your emotions, but your actual function of your brain, your structure of your brain. And this just again shows you a little bit about the smaller parts of the brain. They're lighting up here as the yellow. And you can see the differences between here and your more normal counterparts. So this is, again, just an example of that. I'm not going to go through and show you all of these. But I want to really get into the meat of this, which is really, how can you help us? Because as you know, child psychiatry is a rare and endangered breed. And I am counting on all the pediatricians here in the audience and all my colleagues at the University of Chicago to help me identify people who have been exposed to trauma and who may benefit from interventions. Not everybody will. Some of those interventions you may do in your office, which would be great, wonderful. Then I never have to see them. You prevent a problem from developing. But we live in an area of Chicago that has a significant amount of trauma. And this is your round [INAUDIBLE], around our hospital, is some of the most racially and economically segregated areas in the US. And this has been studied repeatedly. Violent crimes, child abuse, domestic violence, you've been hearing about today. I'm going to talk a little bit of some of Dr. Stolbach's work on the burn unit here. And then Carl Bell and Jenkins, here in their classic study, 75% of elementary school children here on the South Side reported having witnessed a robbery, a shooting, a stabbing, or a killing. I think if you go to a lot of other school districts out in the suburbs, you're not going to have that same population. So I just want you to be sensitive to that, that it's more prevalent than I think we even imagine here in our emergency room. Extreme violence continues, and those-- one of the things that's really, really important, and that's the message that I think you all get out. But it's, turn off the TV. Do not let kids see the evening news, because all it does is reinforce what they saw in their neighborhoods. And that is not helpful. This just talks about-- and NTCSN is a wonderful resource if you have not ever gone to that site-- National Child Traumatic Stress Network. There's a lot of training tools, a lot of pamphlets, a lot of other handouts that you can give to your patients and their families. And this is just from one of their core data sets that we use a lot and talks about how many of the children that they've studied have not one, not two, but three or four, or even more traumas, up to 15 in this study. Here, this is just an example of what we've seen here at the University of Chicago Child Trauma Center. And these are stressors experienced by children that we treated in 2012. And here, the average or mean number of stressors was three. And clearly, 3/4 of them, again that 75% that we talked about before-- but this time, they've been exposed to two or more. And over half are sexual abuse. That could be within family or from outside the family. Domestic violence, I want to just point out. This does not include emotional abuse. Emotional abuse is very, very rarely reported. But if you have parents telling you you're stupid, you'll never amount to anything-- you're hearing that day after day, that's bullying. That's trauma. That, again, eats away at your self-esteem and is really very bad for your brain and your psyche. So these are other risk that are high-risk. We learned about ADHD being associated with more concussions. And I'm going to put in a plug here. Make sure your patients that you have on stimulants are on stimulants 24/7. At least while they're awake, they need to be on meds, and if they're driving especially. But don't give them those breaks on the weekends, because that's when they're most likely to get in trouble and have problems becoming impulsive and having accidents if they're using medications, drugs, other problems that can affect their brains. We're in Illinois about to have legalized marijuana, at least for medical problems. I can tell you from my friends in Colorado who have now had legalized marijuana for quite some time, legalized marijuana in Colorado is packaged in gummy bears. It's packaged in cookies. And the amounts of THC in those products is very high. And so when kids get a hold of that thinking it's a regular cookie, they have major problems. Think of it as a risk factor for further trauma, for further problems with PTSD down the line, and make people aware of that. Bullying I'm going to bring up here because we've heard a lot about that, but that's certainly a risk factor for PTSD, for depression, and for suicide. People who are bullies and who have been victims of bullying are at the highest risk for suicide, have previous traumas, obviously. Lack of structure and routine I'm going to throw in there, because those are people that don't have this kind of structure, this kind of support to fall back on. If you never know who's going to be home, who's going to be giving you your meal, who's going to be tucking you into bed, that's not very comforting. And if you can come home at the end of the day and know that your mom's going to be there, there's going to be a dinner on the table-- maybe being them frankfurters again, but there's dinner on the table-- she's going to go over your homework, you're going to go into bed, at least you had that part of your today is regulated. And that is supportive. So that kind of feeds into the poor supports. But if you don't have anybody there, you don't have people in the neighborhood to help, that's not helpful. And then if you have problems with school, that is an issue. This just gives you some more statistics from Dr. Stolbach's work. And this is, again, from our work in 2007 was published. But we've been in the burn unit since I got here in 2005. I know he was there helping out before that. But if you think about, again, people who have a burn, a major burn, end up in the hospital, almost half of those had experienced a traumatic death or serious injury. Over almost a third had witnessed neighborhood violence. Now, that's lower than what we talked about before. But if you combine all of these, you see that you get to 75% pretty quickly. And this correlated to the risk of trauma-related emotional symptoms following burns. And it really didn't relate so much to their objective understanding of how much of their body was burned. So if you have been traumatized, you don't deal as well with your injury, and you have more emotional lability. This is just another study by Sternthal and Earls and Wright in 2010. And this was analyzing some data from Chicago again, and looking at asthma and how much violence had happened in those. And we know that in emergency pediatric settings, that that's a place where you can really step in. Kids who come in with asthma may end up in the ER. If you can screen for prior history of trauma, you can help identify these kids and help facilitate the healing and help hopefully prevent some trauma to their brain. I like this quote. I just threw that in there. It's your break from studying. Well, think of it as a concussion break. "For the world is hell, and the men are on the one hand the tormented souls, and on the other, the devils in it." So you may be the bully. You may be a victim of bullying. It's not new. It's been going on for a long time, but we need to be aware of it. You guys are all familiar with the Adverse Childhood Experiences study? This is really important. I think that we can revisit it here, but just be aware of it. Here's the reference on the CDC website, cdc.gov/violence prevention/acestudy, adverse childhood experiences. And 2/3 almost of the study participants had at least one adverse experience, and more than 20% reported three or more. So again, it's consistent with what we've seen as far as the trauma or the exposures to trauma. And the more the score increases, the more the risk for health problems increases, including early death. This again doesn't even really talk specifically about psychiatric disorders. It's down here. So adverse childhood experiences are not just related to PTSD and poor functioning emotionally, but actually increase your problems in relations to disease and early death. So although BB King didn't prove that right, did he? He lived a ripe old age. Health problems may be alcoholism, alcohol abuse, depression, ischemic heart disease. You may have other problems-- STDs, smoking, suicide attempts. These are just some of the health problems we talk about. And the relationship between your dysfunction in your house, violence, maltreatment really runs rampant. This is the only city I could really find looking at trying to start screening. And I'm going to move you into screening to really talk about what we can do with this. And I don't know if you're familiar with Kaiser. It's a huge HMO started out in California. This particular study was in the San Diego Kaiser. And when the patients were asked about their exposure to any adverse childhood experiences-- they did this on a form. It can be done in your office. You can give that to them. And then looking at that later and just asking about that, these kids should 35% reduction in office visits and 11% reduction in the ER visits and hospitalizations. So if you can just identify those-- this isn't even really treating. It just saying, hi, what's going on? How are you doing with it-- you can make actually a change in their experience of illness, hospitalization, and ER visits. So you guys are really a powerful force in children's lives. Don't forget it. It's great. It's really wonderful. That's why we're doctors. Current screenings in the community and the ER, we really don't have a lot of what's going on. We know that we don't have a routine screening, but we do know that-- again, this is just more statistics about problems with the assaults. One of the things I'm going to say is in the ER, we can kind of take that lesson that we learned from Kaiser, and just remember-- and I'll get to this in a minute. It's a little treatment. It's the ABCs of trauma treatment that you can use. But a simple, I know this has been a really hard day for you and things are really not going well-- or maybe don't want to say that. You just say, how have you been doing up until today? You been doing OK? Find out if this child was OK pre-morbidly, or were they having a tough time before this? You doing OK now? Is everybody getting you what you need? It can be really powerful, even in an emergency setting. I want to make you aware of this brief screening for trauma. It's a child stress disorders checklist form. and the acronym that you can remember is PTSD, OK-- physical complaints when reminded of trauma, tries to avoid things reminding them of trauma, startles easily, distress if reminded of trauma. And you rate this on a zero, one, or two scale. And then you can kind of follow symptoms of trauma. Clearly, the higher the score, the more you want to think about referring this child for more treatment. But it's the CSDC short form. There's a long form if you want it. Here's your other break. You can have a nice break in here. We were at the lab school the other day and talking about mental health. And a kid came up to me and said, well, what is mental health? And there's all these wonderful, long, erudite descriptions of mental health from the CDC, from psychiatry, from the American Psychiatric Association, the American Psychological Association. But I really couldn't give that to a five-year-old. And so I just said, well, you know, it's being happy. And so are you feeling happy? And he said, yeah. And I said, well, good, you're mentally healthy. And so I think it does a little bit beyond that. But it's a state of well-being and contentment. So how do we get people to that who have been through trauma, who've been exposed to all these violent attacks on their person or their psyche? And so we've got this-- Charlotte Rosner was a woman I greatly admired and taught me a lot. As she founded the Gestalt Institute here, which is a specific type of psychotherapy but really incorporated a lot of what we know now as cognitive behavioral therapy and dialectical behavior therapy. So resilience is what I want you to think about with patients that you can create and you can identify in your patients. Because people who are resilient do well despite adversity. Because we know that not everybody that's traumatized has problems. Resilience, a critical attribute of that. And I haven't come up with a great acronym. I'm still working on it. This kind of rebound-- it's people that can just bounce off of anything. You can throw anything at them, and they'll just bounce right back. And a lot of that is they have a real sense of who they are. They're not washed around by the tides, but they have a great self-esteem. And it doesn't matter what you do them. You're not going to convince them otherwise. They have a pro-social attitude. This is really critical. When we look at kids on the street who have come in-- we deal with kids who are in homeless shelters, people who have gotten out of homeless shelters, out of abusive situations-- and they go on, they use supports. They look at it everywhere. And I want to remind you that as pediatricians, you are one of those people that is their support. And you may not be able to do everything for them, but you can certainly hook them up with places. And it may be as simple as posting something you may have seen in-- they certainly are in women's shelters, but also in other places on college campuses. You may see, in an abusive relationship, call this hotline. You can set up something as simple as that in your office somewhere. Being abused, being hit, call this. Or it could be your nurse's number, whatever you want to do. But using that support is important. And then determination-- it's that kid, no matter what, you can say, well, I don't know if you're really going to be able to get into U of C for college. And they go, I'm going to get in. You go, OK. Michael Rutter-- Sir Michael Rutter is a wonderful psychiatrist who's based out of England. But he's written a textbook, and a lot of this is in there. I got this from one of his articles-- and helping develop resilience, just being aware that it exists. In medical and surgical situations, think about incorporating and finding out, just like who's going to have problems with asthma, with healing from a bone, with having seizures, having concussions, think about who's going to have problems psychiatrically. If you go into the room and the kid goes, oh man, I'm going to have to miss prom tomorrow, you know they're thinking ahead. You know that they're doing well. If you've got somebody that's just laying there, going I'm never going to get better, you don't need to do a screening exam. You know who's going to be resilient, and you know who you're going to need to refer. And so if we can do that and make sure that everybody has some supports in place at home, if they don't-- I had somebody in my office the other day, and it was clear that I think she didn't have a lot of what she perceived as support in her community. And there were simple things that we wanted to do to help her out. And I said, well, just why don't you text me tonight? Let me know if they happened. And she texted me. She said, I got your phone number. This is me. This is my number. Didn't happen. And I said, OK. Well, let's do it tomorrow. And sure enough, the things that we'd asked her parents to do the next day, they did-- not until the next day, but they did. And she reported back to me. I haven't heard back from her. I think I'm going to have to check in with her again. But those are simple things. You can have your nurse do it. You can do-- put a checklist. And they're fun. These kids were fun. And preventing psychiatric disorders, if you can help me do that, then we can keep these kids out of the ER, keep them out of your office, and keep them out of the hospital. Renee Mehlinger came Wednesday and was giving us the stats on the state of Illinois and how expensive mental health care is. And it totally blew me away. But we don't do a lot of prevention in this state for mental health. And what we do is a lot of hospitalization, emergency room visits, which is, when you look at it, I think the stats-- I may get this wrong. But the stats were that we use I think-- if you put the budget for all mental health care in all the states across the country, Illinois uses 2/3 of that budget just for our kids. And I can guarantee that we have more problems with mental health than a lot of those other states, but they do more prevention. Now, they may just not be reporting mental illness. I don't know. That wasn't in the presentation. OK, I promised you psychological first aid. You know your basic ABCs for Airway, Breathing, Circulation. And I want you to think about first aid for psychiatric disorders or psychological first aid. And that is when you walk in the room, you're calm. And you guys know that. But you have to get other people calm. If the parents cannot be calm, get them out of the room. Get somebody to help them be calm, because parents have to be calm. This is all on the CTSN website. You can write it down if you like, but you can just as easily go to ctsn.gov. I don't know. I don't think it's NIH. I think it's just .gov. It's on the resource sheet next. You want to make sure people are safe and comfortable, so ask them. Are you OK in here? If they were just in a gang shooting, are they feeling safe in your ER? Are they worried that the gang members are coming to get them. I don't know how many of you have been in ERs where there's been gang shootings, but it happens. I trained in LA. This is University of Chicago, and I don't know that we've had that in our yard, but certainly Cook County has. Stabilization-- these are kids. They don't know if they're OK or not. You may know that they have a minor injury. But as we all know, young kids can not always understand what a minor injury is, and they may think they're dying. So we need to really reassure them, have someone they trust reassure them. And then what do they need? Their house just burned down. They had a fire. As a doc, that's not your job to provide those things. But I think it is our job just to check in and say, are you going to be able to get everything you need tonight? Do you have a safe place to go? Are you understanding that? Have you been able to find your mom? We heard on the news this morning that a 13-year-old had been dropped off at lacrosse practice. His dad was in the train accident in Philadelphia. He still hasn't found his dad. Remember that PTSD for kids can be secondary. It doesn't have to affect them. It can affect loved ones. So that child has been traumatized and may go on to develop PTSD. We need to help him figure out how not to do that. Information on coping, living, linkage with collaborative services-- these are all what we as physicians, as the team leaders, need to do to improve mental health. So I'm going to leave you with some of these resources. NTCSN that I've been talking about is down here. But there's lots of things that can link to that. The American Academy of Child and Adolescent Psychiatry has a lot of resources as well as AAP. You have your tool kit for trauma in there, and for mental health. So make sure you use those.
