The increasing prevalence of posttraumatic stress disorder (PTSD), especially during and after COVID-19, is a major public health crisis in the U.S., with a 16-25% prevalence of PTSD in youth (Murata et al., 2021). PTSD is associated with increased neurovascular inflammation, suicidality, adulthood mental health disorders, and major adverse life events (Ahmadi et al., 2020; Ahmadi et al., 2018). There has been a significant increase in the prevalence of PTSD and emergency room visits due to PTSD-related suicidality (Ahmadi et al., 2022; O'Rourke et al., 2023). Increased rates of suicidality in youth have been documented, escalating from 14.1% in 2016 to 30.5% in 2021, the peak of the COVID-19 pandemic in California, for example (Lund et al., 2023). Childhood PTSD and related suicidality are a significant public health problem with serious health consequences to children, with an estimated public health cost of $103 billion annually (Ahmadi et al., 2018; Dolan & Mace, 2006; Gill et al., 2017; Oliveira et al., 2019). The lack of grief-enhanced trauma-informed early screening for PTSD and prolonged grief disorder (PGD) resulted in many individuals with PTSD going undiagnosed and not receiving early interventions.
With funding as a Substance Abuse and Mental Health Services Administration (SAMHSA) National Child Traumatic Stress Initiative (NCTSI) Category III clinical service grantee, seven hundred youth with suicidality (age 13±2 years old, 60% female) - admitted to the Olive View UCLA Psychiatry Emergency Room (PER) between September 2021 to December 2022 - received linguistically/culturally competent grief-enhanced trauma-informed clinical evaluation, a 35% increase from the number expected during this period.
Youth with PTSD and/or PGD, and their caregivers received brief grief-enhanced trauma-informed intervention at the psychiatry emergency room at PER as a part of NCTSI project. They completed the UCLA PTSD Reaction Index for DSM-5 (R.I.), the UCLA Trauma Reminder Inventory (TRI), the Prolonged Grief Disorder Checklist (PGDC), and clinical interviews. Based on the youth's severity of PTSD symptoms and the severity of functional impairment, they stratified their treatment to one of three: 1) protective – for mild symptoms, 2) resilient – for moderate symptoms - or 3) restorative – for severe symptoms. Youths with moderate to severe symptoms and their families received a Family Intervention for Suicide Prevention (FISP) and a Reminder Focused Positive Psychiatry Intervention (RFPP). RFPP, a developmentally age-appropriate reminder-focused trauma/loss-informed and safety prevention intervention, consists of components addressing trauma/loss reminders and avoidance, negative cognition, safety planning, and distress tolerance skillsets for adolescents with PTSD and their families.
The prevalence of youth with PTSD and PGD was 70% and 39% in youth admitted to the psychiatry emergency room with suicidality, respectively. This constitutes 40% with COVID-19-related PTSD, of whom 90% also had PGD. Most of the youth with PTSD and PGD identified as Latinos (47%) and African Americans (26%), followed by White (24%) and other ethnicities.
The youth with PTSD and/or PGD (N=524, 75%) received RFPP and showed a significant reduction of RTR, with improved core symptoms and contracting for safety. Similarly, a significant decrease in Columbia-Suicide Severity Rating Scale (C-SSRS) scores from 4 at baseline to 1 on day two following RFPP was noted (p = 0.001). A rapid stabilization (2±0.5 days) and enhanced post-discharge follow-up of 100% were noticed. Furthermore, RFPP was associated with a significant increase in wellbeing, resilience, flexible thinking, improved coping skills, and parent-child interactions, compared to baseline (p < 0.05). At the 6-month follow-up, there were no readmissions for suicidality, and enrolled youth demonstrated reduced maladaptive grief and PTSD and PGD symptoms. The findings of this community study warrant a randomized clinical trial to further assess the long-term impact of grief-enhanced trauma-informed emergency department interventions of at risk youth with comorbid PTSD and suicidality.
The increase in the prevalence of psychiatry emergency room visits in at-risk youth, especially in those with PTSD, PGD, and suicidality, highlights the vital role of the psychiatry emergency room as the gateway for early identification, management and stabilization of at-risk youth, and connecting at-risk youth and their families to the mental health system (Asarnow, et al., 2017; Babeva, et al., 2016). The current study revealed a universal grief-enhanced trauma-informed clinical evaluation in a psychiatry emergency room has potential to accurately identify at-risk youth with PTSD and/or PGD, facilitate treatment stratifications, and enhance access to early brief grief-enhanced trauma-informed intervention for youth and their families in an emergency department setting. Furthermore, it reveals the promise of early grief-enhanced trauma-informed evaluations for PTSD, PGD, and suicidality, followed by tailored brief reminder-focused intervention with rapid stabilization of acute crisis, for the reduction of core PTSD, and PGD symptoms, lowering reactivity to trauma reminders and increase in contracting safety. It also shows associations with improvement in well-being, positive coping skills, parent-child interaction, and contracting safety skills by providing grief-enhanced trauma-informed RFPP to both youth and their caregivers. Finally, RFPP was associated with increased adherence to post-discharge follow-up appointments, sustained remission of PTSD and PGD, reduction of reactivity to trauma reminders, contracting safety, sustained reduced risk of suicide, and favorable clinical outcome.
This work highlights the importance of grief-enhanced-trauma-informed clinical evaluation and the dual role management of youth at risk for PTSD and PGD and their families in underserved communities, addressing the disproportionately higher rate of suicidality and vulnerability in such populations. Enhancing access to early, brief, preventive, grief-enhanced and trauma-informed interventions in emergency department settings has potential to enchance the wellbeing and clinical outcome of youth with PTSD and PGD, and their families.
Child Trauma Special Interest Group of ISTSS
The increasing prevalence of traumatic stress disorder in youth, especially since the COVID-19 pandemic, is a major public health crisis. The ISTSS Child Trauma Special Interest Group (SIG) includes diverse members who provide grief-enhanced trauma-informed services globally in various settings (private practice, universities, clinics, hospitals, research laboratories, and outreach programs). The Child Trauma SIG members presented findings of their work at the 39th ISTSS Annual Meeting, which shows favorable outcomes for at-risk youth and their families with reducing core symptoms and improving wellbeing, social engagement, and parent-child interactions.
The Child Trauma SIG offers a forum for ISTSS members, associates, and affiliates to brainstorm, network, exchange updates in the field, and collaborate in novel approaches for disaster/trauma prevention, early assessment/intervention of youth at-risk for traumatic stress & and families in conjunction with other ISTSS members and organizations such as AACAP, NCTSN, etc. We look forward to expanding these scholarly works and welcoming all ISTSS members to join our SIG.
About the author
Dr. Naser Ahmadi, M.D., Ph.D., is Assistant Clinical Professor of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles School of Medicine.
References
Ahmadi, N., Chaudhry, S., Salam, T., Rodriguez, J., Kase, M., Olango, G., Molla, M., McCracken, J., & Pynoos, R. (2020). A Randomized Controlled Feasibility Trial of Reminder-Focused Positive Psychiatry in Adolescents With Comorbid Attention-Deficit/Hyperactivity Disorder and Posttraumatic Stress Disorder. Prim Care Companion CNS Disord, 22(5). https://doi.org/10.4088/PCC.19m02579
Ahmadi, N., Hajsadeghi, F., Nabavi, V., Olango, G., Molla, M., Budoff, M., Vaidya, N., Quintana, J., Pynoos, R., Hauser, P., & Yehuda, R. (2018). The Long-Term Clinical Outcome of Posttraumatic Stress Disorder With Impaired Coronary Distensibility. Psychosom Med, 80(3), 294-300. https://doi.org/10.1097/PSY.0000000000000565
Ahmadi, N., Pynoos, R., Leuchter, A., & Kopelowicz, A. (2022). Reminder-Focused Positive Psychiatry: Suicide Prevention Among Youths With Comorbid Posttraumatic Stress Disorder and Suicidality. Am J Psychother, 75(3), 114-121. https://doi.org/10.1176/appi.psychotherapy.20200061
Asarnow, J. R., Babeva, K. & Horstmann, E. (2017). The Emergency Department: Challenges and Opportunities for Suicide Prevention. Child Adolesc Psychiatr Clin N Am. , 26, 771-783.
Babeva, K., Hughes J. L., & Arsanow, J. (2016). Emergency Department Screening for Suicide and Mental Health Risk. Curr Psychiatry Rep, 18, 100.
Dolan, M. A., & Mace, S. E. (2006). Pediatric mental health emergencies in the emergency medical services system. American College of Emergency Physicians. Ann Emerg Med, 48(4), 484-486. https://doi.org/10.1016/j.annemergmed.2006.08.015
Gill, P. J., Saunders, N., Gandhi, S., Gonzalez, A., Kurdyak, P., Vigod, S., & Guttmann, A. (2017). Emergency Department as a First Contact for Mental Health Problems in Children and Youth. J Am Acad Child Adolesc Psychiatry, 56(6), 475-482 e474. https://doi.org/10.1016/j.jaac.2017.03.012
Lund, J. J., Tomsich, E., & Schleimer, J. P. (2023). Changes in suicide in California from 2017 to 2021: a population-based study. Inj. Epidemiol. 10, 19 (2023). https://doi.org/10.1186/s40621-023-00429-6.
Murata, S., Rezeppa, T., Thoma, B., Marengo, L., Krancevich, K., Chiyka, E., Hayes, B., Goodfriend, E., Deal, M., Zhong, Y., Brummit, B., Coury, T., Riston, S., Brent, D. A., & Melhem, N. M. (2021). The psychiatric sequelae of the COVID-19 pandemic in adolescents, adults, and health care workers. Depress Anxiety, 38(2), 233-246. https://doi.org/10.1002/da.23120
O'Rourke, M. C., Jamil, R. T., & Siddiqui, W. (2023). Washington State Suicide Prevention and Awareness. In StatPearls. https://www.ncbi.nlm.nih.gov/pubmed/33232071
Oliveira, J. E. S. L., Anderson, J. L., Bellolio, M. F., Campbell, R. L., Myers, L. A., Luke, A., & Jeffery, M. M. (2019). Pediatric emergency medical services in privately insured patients: A 10-year national claims analysis. Am J Emerg Med, 37(8), 1409-1415. https://doi.org/10.1016/j.ajem.2018.10.029