Child Mental Health for Pediatric Clinicians

11. Kids get PTSD, too: How to recognize it and get help w/ Dr. Brooks Keeshin

• Elise Fallucco • Season 1 • Episode 11

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Did you know that 10% of kids in primary care are suffering from post-traumatic stress? We talk with Dr. Brooks Keeshin, child abuse pediatrician and child psychiatrist, about how to use the Pediatric Traumatic Stress Screening Tool to recognize the signs of PTSD, intervene and get kids the help they need.

Key points include:
1. Some kids with PTSD can seem like they are doing fine
2. PTSD  symptoms can be confused with ADHD, anxiety, and/or depression
3. Screen all kids 11 years and older using the Pediatric Traumatic Stress Screening Tool
4. Assess all kids with a positive screen for safety
5. Refer kids with PTSD to Trauma-focused CBT
6.  Try to address 1 impairing symptoms (usually sleep) at the visit

To access the Pediatric Traumatic Stress Screening Tool, visit https://utahpips.org/cpm/

Our guest: Brooks Keeshin, M.D., is a child abuse pediatrician and child psychiatrist in the Division of Child Protection and Family Health at the University of Utah and the Center for Safe and Healthy Families at Intermountain Healthcare’s Primary Children’s Hospital.

Check out our website PsychEd4Peds.com for more resources.
Follow us on Instagram @psyched4peds

Dr. Elise Fallucco:

Welcome back to PsychEd4Peds, the child mental health podcasts for pediatric clinicians. I'm your host, Dr. Elise Fallucco,. child psychiatrist and mom. When you hear about post-traumatic stress disorder, you think about war military, veterans, adults. But about 10% of kids experience traumatic stress. That we may be missing or even misdiagnosing because traumatic stress can present a lot like ADHD and can look like anxiety and depression. Today, we talked to Dr. Brooks Keeshin about ways we can recognize post-traumatic stress disorder in kids and teens. Dr Keishon is both a child abuse pediatrician and a child psychiatrist in the division of child protection and family health at the University of Utah. Dr Brooks Keeshin welcome to psyched for paeds

Dr. Brooks Keshin:

Great to be here.

Dr. Elise Fallucco:

So let's start with the basics. Traumatic stress happens as a consequence of a traumatic experience and trauma in kids and teens includes physical or sexual abuse or assault. It can also include things. We might not think of like witnessing violence at home or in the community school shootings and natural disasters. So how would you define trauma in kids what counts as a traumatic experience?

Dr. Brooks Keshin:

Defining trauma is a little tricky. There definitely are the big types of trauma. Someone's gonna be seriously hurt or think they're gonna die, or a sexual assault. Those still count, but I think the pediatric lens of this is, what are other things that children experience that developmentally are are really a big deal. Whereas an adult, we might think of it more as a level of adversity, whereas a child might see it as more like a really a, big T trauma. When we're screening teenagers for trauma in primary care of those that identify a trauma, about 20% identify some type of either illness or loss. That adult getting sick and just being hospitalized as an example.

Dr. Elise Fallucco:

Adults have a tendency to underestimate how scary something is to kids because we're looking at it oftentimes from an adult lens. And so that's why it is so important to ask them what to them have they experienced as incredibly scary or frightening? What proportion of the population would you say is at risk for developing traumatic stress Trauma causing a profound impact on their day-to-day life or on their mood and emotions in our child and adolescent population?

Dr. Brooks Keshin:

If you look at David Finkelhor and others' data, 80% of kids are at risk for traumatic stress because they've had at least one potentially traumatic experience in childhood. We know from population data and actually from our own primary care research, that, one in 10 actually have moderate or high risk traumatic stress symptoms that are coming into primary care.

Dr. Elise Fallucco:

That's much higher than people expect. I would guess that we're largely under identifying these kids or perhaps misidentifying them.

Dr. Brooks Keshin:

and Both. And both really. Yeah. Really it's both.

Dr. Elise Fallucco:

So when these kids, these like one out of 10 kids with moderate to severe symptoms of potential traumatic stress come into pediatrics, what are the signs and symptoms that we should be out on the lookout for?

Dr. Brooks Keshin:

Kids with really bad P T S D can look totally normal and you can have a totally cogent conversation with them and feel like, oh yeah, this kid's got it going and they're probably doing fine in school. Or maybe a little difficulty here and there, but nothing that kind of tips off one's radar. I think similar to a lot of pediatricians who might be listening I pride myself on being family centered engaging with kids. When you do that, you're often not gonna see a lot of the symptoms of P T S D. They're in a comfortable place, they're in a trusted environment. You're not asking about the bad, scary thing that happened, whether it was an assault or a dog bite or a car crash. So why wouldn't they look normal? And frankly, that's what they do. They look normal. So I think that's part of our big reason for not picking it up.

Dr. Elise Fallucco:

Kids with PTSD can look completely normal on exam, which can be misleading. So it makes it even more important to ask about a history of trauma and symptoms of post-traumatic stress. But these symptoms can include difficulty sleeping problems, concentrating irritability, anger, outbursts. And our friends and colleagues listening may be thinking, whoa, some of these symptoms overlap with signs of depression or anxiety. Or even adhd

Dr. Brooks Keshin:

Those kids do look depressed or those kids do look anxious. It's just, it might not be a like that biological depression or that biological anxiety that's actually driving things. It actually could be that we're seeing trauma, and that's part of the broader traumatic stress continuum that's really manifesting as kind of things that are also gonna be very positive on the PHQ two or positive on the GAD. Those are the ones that we might go down that anxious, depressed, or suicidal pathway. If we're not looking for trauma, we could miss the Boat. I've had hundreds, if not many hundreds of people say that, oh, my kid has panic attacks. A panic attack. In the context of P T S D, when it is driven by a trauma reminder is not a classic panic attack. It is a physiologic or psychological distress to a trauma reminder, I'll just tell you two quick stats again, right From primary care, from the work we're doing here at Intermountain Healthcare for the kids who have high risk P HQ nine, so 20 and above, about 45% of those actually meet criteria for P T S D. Among the kids that I have a GAD-7 score, like 15 or higher, 30% meet criteria for P T S D. So it's not to say that it's all trauma, and it's not to say that some kids with trauma can't also have a major depressive disorder or a true generalized anxiety disorder. But if we're trying to figure out what the right next step is, boy, it's so helpful to know this kid's trauma history and trauma symptoms because that might take you in a very different direction

Dr. Elise Fallucco:

So for kids with symptoms of depression or anxiety or ADHD, we really need to be assessing them systematically for trauma, which brings us to the point that probably led you guys to develop the pediatric traumatic stress screening tool. Tell us how does your tool work and in which population would you recommend using it?

Dr. Brooks Keshin:

So we're funded by SAMHSA to be part of the National Child Traumatic Stress Network, and about six and a half years ago we started working on this process to better identify and respond to kids at risk for traumatic stress. We modified a validated trauma symptom screening tool the brief U C L A P T S D reaction index. And we did it in such a way that it could be used as a two-step screening tool in primary care. So the first two questions are open-ended about has a traumatic experience happened to you recently or in the past, and that's after there's this little stem that describes, what a traumatic experience is. But then it's only if either of those are positive. Then you go through and ask the 12 symptom questions. The response process starts with looking at what the kid or parent identified as the exposure and before we get all concerned about symptoms, I. Just investigating, making sure that the kid is actually physically safe.'cause some things that have happened to kids continue to pose a threat to them. And so that's actually the first step of response. The second step is then making sure the kid is safe from any suicidality. We didn't talk about this earlier, but high correlation between our suicidal kids in primary care and high trauma symptoms. Once the kid is physically safe from their environment and they are physically safe from themselves, or you've got a safety plan in place to keep them safe. That's where we then take the objective results from the tool and we use it to stratify based on kind of low risk, moderate risk, and high risk. If we've got high trauma symptoms, We really want to connect this family with someone who can actually deliver a trauma treatment that is shown to be effective like trauma focused cognitive behavioral therapy is one that's widely available. Kids get much better when they get access to T F C B T or other evidence-based trauma focused therapies And then lastly, we do advise on utilizing the tool to focus on what we can do in the office right now to try to help address what's going on with this kid or this family. And so if you look at the screening tool, you can see that the first two questions are about sleep well, if they're high focus on sleep. And it doesn't have to be complex but it's something that could certainly be meaningful to, to try to help that family start to feel better even tonight. There's other guidance around how to utilize education on coping strategies to help with some of the hyper arousal or intrusive symptoms avoidance or negative cognitions and negative mood, which can be very meaningful in P T S D as well.

Dr. Elise Fallucco:

To summarize you and your team developed this incredible tool and have been using it routinely universally at well visits for kids 11 and older. And breaking it down the first step we're thinking about safety. Making sure they're not at risk of being harmed by somebody else. And also, checking on suicidal thoughts or risk of self harm. And then step two is looking at the actual symptoms on the 12 item checklist and determining how severe it is based upon the number of symptoms and impairment in functioning. And then in addition to referring them to trauma-focused cognitive behavioral therapy if needed you think about what is the one thing the most important thing you can do at that visit to try to help the family. Jumping back a little bit to thinking about who do we screen? I did some work down in South Florida in Parkland after the Marjorie Stoneman Douglas school shooting. And one of the things that we recommended at that time was universal screening in the community who was exposed to the trauma. So I'm wondering, in addition to screening at well visits in a typical pediatric population in kids 11 and up, are there any other subpopulations where you might think about using this tool?

Dr. Brooks Keshin:

Certainly trauma screening, is very well integrated within any of our kind of quote unquote mental health visits. And I think you could make an argument that there's certain sick visits especially a lot of somatic complaints where if you were to be including trauma screening as part of that would be well worth your while. And at the same time, you mentioned the shooting also as we're recording this, you have a hurricane headed towards Florida So I think, when we're talking about shootings, when we're talking about natural disasters it is reasonable for pediatric clinics to say, Hey, for the next month, We're just gonna add kind of one question about exposure is there anything about x that you would like us to address during your visit today? Some invitation to recognize that we've all been through this. And we don't have to focus on it because, if Jimmy's got an ear infection and that's what you wanna talk about, that's great but to open that door I would envision like if you got your regular intake paperwork there would just be a question are you concerned that your child's been adversely impacted by the hurricane? I would still be doing the trauma screener as part of the pre-work paperwork.

Dr. Elise Fallucco:

And briefly, I want to go back to this idea that PTSD can really look like anxiety or depression or even ADHD. Post-traumatic stress can manifest as. Poor concentration and poor sleep and

Dr. Brooks Keshin:

hyperactivity, hyper reactivity,

Dr. Elise Fallucco:

so in primary care when you're assessing somebody for symptoms of adhd using the vanderbilt or the Connors do you also have them do the post-traumatic stress screening at that appointment?

Dr. Brooks Keshin:

Our six to 10 year olds, yes, our parents are doing the 6 to 10 year old parent report version of the screen, It is really hard to tell the difference between A D H D and trauma when trauma and traumatic stress are present if trauma's present, but not a lot of traumatic stress. That's probably a D H D. If it's a D H D symptoms and not trauma, it's probably a D H D. But in the context of traumatic stress, it is really challenging. You can't tell by just starting a stimulant and seeing if there's any response. Most kids will have a little bit of response. So we started a stimulant, and now school seems to be a little better. That's the story of lots of kids who have trauma, who actually went down that A D H D pathway. It's not to say that kids can't have a D H D and traumatic stress. But at the same time, if we have access to trauma specific assessment and then trauma specific treatment resources, working with families where it could be one or the other, trying to do a stepwise approach. Let's get started with trauma treatment. Let's continue to follow. And if trauma symptoms improve and A D H D symptoms persist, that really supports the overall diagnosis of A D H D. If as trauma symptoms improve A D H D symptoms also improve, that helps for the diagnostic clarification that, really a lot of what we were seeing would've been better explained by a traumatic stress construct. Hard to get some families to buy him, some families like, and for very Understandable reasons want to go for a quick fix type of approach. But I think most families, if they realize that we're not abandoning them, we're not saying no, we're just saying let's take a stepwise approach and explaining the rationale behind it. Most families will actually buy into that.

Dr. Elise Fallucco:

Have you had any experiences with parents or caregivers being upset about being screened with trauma?

Dr. Brooks Keshin:

we really haven't in primary care, like it's been generally very well accepted. Not a lot of pushback at all from parents. The fact that it can be just no and move on that's still the majority of all of our screens.

Dr. Elise Fallucco:

Do you have a easy way that pediatricians across the country could find out who in their community practices trauma-focused C B T, or who has been trained in it?

Dr. Brooks Keshin:

There, there are several different ways that one can go about doing it. There's a T F C B T website where people can be listed as being certified. And the certification is not just going to a couple hour training, like it's multiple days and then year, a year of consultation. The family based way is that if they say they're going to someone who does trauma treatment you can, I think ask a family well. Tell me a little what's going on in therapy. Families might say I know that they're gonna do a narrative or they're gonna have our kid tell a story as part of working through the trauma. So something like that, that identifies core piece of TF C B T, which is the trauma narrative, would be a great clue. And then lastly, and I would say this is true of really any evidence-based trauma therapy. If they're already seeing a therapist and you're not sure whether they're seeing the right therapist or not asking a parent, so what's your involvement? In the treatment if they are four years old or 14 years old, or 17 years old, the parents should be connecting with a therapist on a regular basis, being apprised of what's going on. The therapist should be teaching the parents about the different skills that we're having the kid teach the parent some of the skills. The parental role in really good evidence-based trauma treatment is not a passive role. So if they're describing something where they literally drive up, the car doesn't even stop. They're just rolling as the kid pops out and then they go run some errands when they come back to the clinic an hour later to pick up the kid. That's not good.

Dr. Elise Fallucco:

What is one thing that you wish all pediatric clinicians knew or did to address traumatic stress in kids

Dr. Brooks Keshin:

Screen for it. When you start screening, you see how many positives you have in your clinic. The piece that I do think is helpful to understand it's actually in planning the response ahead of time. So it's the screening, but it's really, it's in preparing for the different responses that you get and realizing that when you prepare, then it becomes pretty straightforward

Dr. Elise Fallucco:

So to wrap up some of our PsychEd4Peds pearls pearls about post-traumatic stress in kids would be one about 10% of kids in primary care present with post-traumatic stress And can look like they're doing just fine Or look like they have anxiety, depression, or ADHD. Number two. You recommend screening at all? Well, visits 11 and up for post-traumatic stress as well as in kids with ADHD, depression, or anxiety, somatic complaints or known trauma. Finally, number three, make sure to assess kids who screen positive for safety. Refer those who need it to trauma-focused cognitive behavioral therapy and try to address one of the symptoms, possibly sleep in the visit we'll have all of the information about your screening tool and about the care process model that you developed in Utah on our websites. Psyched4Peds.com thank you so much for all the work that you're doing with these kids and with these families. And I know that you're uncovering so many kids who have been experiencing traumatic stress, you're able to identify them early and get them appropriate intervention and hopefully prevent them from developing additional impairment in functioning at school, at home, everywhere. And thank you for joining us at Psyched4Peds.

Dr. Brooks Keshin:

Thanks. Thanks for having me. Great to be with you.

Dr. Elise Fallucco:

And to our friends and colleagues, if you found this episode helpful, please share it with a friend. And we'd love to hear from you. Visit us on our website. Psyched4Peds.Com, leave us a message and tell us what you want to hear about. Thanks so much for joining us see you next time