acute stress disorder and posttraumatic stress disorder in parents of injured children

Journal of Traumatic Stress, Vol. 22, No. 4, August 2009, pp. 294–302 ( C© 2009)

Acute Stress Disorder and Posttraumatic StressDisorder in Parents of Injured Children

Nancy Kassam-AdamsCenter for Injury Research and Prevention, Children’s Hospital of Philadelphia, Philadelphia, PA

Courtney Landau FleisherDepartment of Pediatrics, La Rabida Children’s Hospital and University of Chicago Pritzker Schoolof Medicine, Chicago IL

Flaura Koplin WinstonDivision of General Pediatrics, Department of Pediatrics, University of Pennsylvania School of Medicine,Philadelphia, PA

Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) were examined in 334 parents of childrenwith traffic-related injuries. In the first month after their child’s injury, 12% of parents had ASD and another25% had partial ASD. Among 251 parents assessed again approximately 6 months postinjury, 8% had PTSDand another 7% had partial PTSD. The ASD and PTSD severity were associated (r = .54), but ASD status wasnot a sensitive predictor of later PTSD. Independent predictors of ASD severity included prior trauma exposure,peritrauma exposure and perceptions of the child’s pain and life threat, and child ASD severity. Independentpredictors of PTSD severity included prior trauma exposure, parent ASD severity, and parent-rated child physicalhealth at follow-up.

Parents may develop acute stress disorder (ASD) or posttrau-matic stress disorder (PTSD) symptoms when children are exposedto trauma, and parent responses have consistently been found tobe associated with children’s posttrauma psychological recovery(Daviss et al., 2000; Meiser-Stedman, Yule, Dalgleish, Smith, &Glucksman, 2006). Parents’ own responses impact their percep-tions of child reactions (Kassam-Adams, Garcia-Espana, Miller, &Winston, 2006) and interact with children’s reactions (includingacute physiological responses) in determining the course of chil-dren’s psychological recovery after trauma (Nugent, Ostrowski,Christopher, & Delahanty, 2007).

Diagnostic criteria for ASD (assessed within one month oftrauma), and PTSD (at least one month’s duration of symptoms)both require symptoms of reexperiencing, avoidance, and hyper-arousal. Acute stress disorder additionally requires the presence ofdissociative symptoms. Only a few published studies have exam-ined prevalence or predictors of parental ASD after child trauma.Acute stress disorder rates ranged from 16% to 51% in parents ofchildren who were injured in traffic crashes (B. Bryant, Mayou,Wiggs, Ehlers, & Stores, 2004), admitted to the pediatric intensivecare unit (Balluffi et al., 2004) or neonatal intensive care unit (Shaw

This work was supported by a grant from the Maternal and Child Health Bureau (#R40 MC 00138).

Correspondence concerning this article should be addressed to: Nancy Kassam-Adams, Center for Injury Research and Prevention, Children’s Hospital of Philadelphia, 3535 Market Street, Suite1150, Philadelphia, PA 19104. E-mail: [email protected].

C© 2009 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20424

et al., 2006), or newly diagnosed with cancer (Patino-Fernandezet al., 2008). Predictors of parent ASD in these studies includedpreexisting individual factors such as parent trait anxiety (Patino-Fernandez et al., 2008); and peritrauma factors such as witnessinga child’s injury (B. Bryant et al., 2004), unexpected pediatric in-tensive care unit admission, and parental perception of life threatto the child (Balluffi et al., 2004). Objective measures of traumaseverity have not been associated with parental ASD.

Parental PTSD in association with child trauma exposure hasbeen more widely researched. Studies have employed a wide rangeof follow-up time points, and PTSD rates have ranged from 4%to 40%. Parent PTSD symptoms have been documented after dis-asters or terrorist attacks (Jones, Ribbe, Cunningham, & Weddle,2002; Koplewicz, 2002; Stuber et al., 2002), but the most prolificliterature in this area concerns parents’ traumatic stress in associa-tion with pediatric medical events, including cancer (Kazak et al.,1998; Manne, Du Hamel, Gallelli, Sorgen, & Redd, 1998), burns(Hall et al., 2006), injury (B. Bryant et al., 2004; DeVries et al.,1999), intensive care admission (Balluffi et al., 2004; Bronner,Knoester, Bos, Last, & Grootenhuis, 2008), organ transplanta-tion (Young et al., 2003), asthma (Kean, Kelsay, Wamboldt, &

294

ASD and PTSD in Parents of Injured Children 295

Wamboldt, 2006), and diabetes (Landolt, Vollrath, Laimbacher,Gnehm, & Sennhauser, 2005).

Predictors of parental PTSD have included preexisting indi-vidual factors such as parent pretrauma psychological adjustment(Kazak et al., 1998; Manne et al., 2002, 2004), peritrauma factorssuch as parents’ direct exposure to child trauma (involvement in thesame car crash, witnessing painful medical procedures; B. Bryantet al., 2004; Landolt, Vollrath, Ribi, Gnehm, & Sennhauser, 2003),and parent appraisal of life threat or medical severity (Balluffi et al.,2004; Kazak et al., 1998; Landolt et al., 2003; Manne et al., 2004;Rizzone, Stoddard, Murphy, & Kruger, 1994; Young et al., 2003).Parental PTSD has also been associated with aspects of the post-trauma experience: child PTSD severity (Hall et al., 2006), poorerchild physical recovery and health status (Young et al., 2003), andthe presence of persistent trauma-related stressors (Balluffi et al.,2004; Young et al., 2003). Results are inconsistent regarding therole of family structure and family conflict, parent ethnicity, andparent age.

The ability of the ASD diagnosis to predict a later PTSD diag-nosis has been a topic of much recent interest. To our knowledge,only one study to date (Balluffi et al., 2004) has prospectively ex-amined diagnostic criteria for both ASD and PTSD in parents oftrauma-exposed children, and the relationship between these dis-orders over time. Balluffi et al. (2004) found that ASD and PTSDseverity were associated; ASD had moderate sensitivity (.64) as apredictor of later PTSD. These findings were consistent with otheradult prospective studies in suggesting that current ASD diagnos-tic criteria may not be optimal for PTSD prediction (Brewin,Andrews, Rose, & Kirk, 1999; R. Bryant, Guthrie, Moulds, &Harvey, 2000; Harvey & Bryant, 1998).

The current study was undertaken in the context of a largerstudy of the psychosocial impact of traffic-related childhood in-juries. In the United States, road traffic injuries account for 15%of all nonfatal injuries, and 32% of injuries requiring hospitaladmission, in children age 5 to 17 (National Center for InjuryPrevention and Control, n.d.). (As a comparison, violent injuriesmake up 5% of nonfatal injuries and 4% of injury admissions). Itis important to understand the impact on children and families ofthis relatively common type of unintentional injury.

This prospective study addresses gaps in the literature con-cerning parental responses to acute child trauma by prospectivelyexamining in a large sample of parents of injured children: (a) ratesof self-reported ASD and PTSD, (b) the relationship between ASDand PTSD, and (c) pre-, peri- and posttrauma predictors of ASDand of PTSD.

M E T H O D

ParticipantsWe enrolled one parent per child from a consecutive cohort ofchildren (age 5–17) hospitalized at a Level I Pediatric Trauma

Center, for injuries sustained as a pedestrian, bicyclist, or motorvehicle passenger. Exclusion criteria were lack of English languageproficiency, physical or cognitive limitations that precluded inter-view participation, or living more than a 2-hour travel distancefrom the hospital. To be eligible, parents had to live with the in-dex child and have (or share) primary responsibility for the child’scare. To minimize family burden from research participation, onlyone parent per child was enrolled. Interviewers spoke to the firstavailable parent who met inclusion criteria. Parents were asked forwritten consent for participation, in accordance with an institu-tional review board-approved protocol. Detailed study methodshave been reported elsewhere (Kassam-Adams & Winston, 2004).Preexisting and peritrauma factors, as well as ASD symptoms wereassessed within one month of injury (T1); PTSD symptoms andpostinjury factors were assessed at least 3 months after injury (T2).At each assessment point, child and parent were interviewed sepa-rately in the family’s home, and parents completed questionnaires.Interviewers conducting assessments at T2 were not aware of theASD status of parents at T1.

Over a 28-month period, 334 parents were enrolled and com-pleted a T1 interview. This represents 59% of 567 eligible fami-lies: 101 (18%) refused participation, and 132 (23%) could notbe contacted or could not complete the T1 assessment within onemonth. Participants and nonparticipants did not differ in race /ethnicity or child age, gender, or injury severity. Two hundredfifty-one (75%) completed a T2 interview and are included in thecurrent analyses of PTSD outcome. Parents completing T2 didnot differ from those completing only T1 with regard to childage, gender, injury severity, or T1 parent ASD. However, fewerfathers than mothers (46% vs. 78%), χ2 (1, N = 334) = 17.29,p < .001, and fewer Black parents than parents of other ethnici-ties (69% vs. 83%), χ2 (1, N = 334) = 9.39, p < .01, completedfollow-up. To ensure optimal retention, the study team made mul-tiple attempts to arrange follow-up. Mean time to T2 assessmentwas 6.5 months postinjury, and time lag to follow-up was notassociated with PTSD severity (r = .02, ns).

MeasuresInformation on demographics, injury diagnoses, Injury SeverityScore (Association for the Advancement of Automotive Medicine,1990; Baker, O’Neill, & Haddon, 1974), and length and type ofhospital admission was abstracted from medical records and thehospital trauma registry, and injury diagnoses were coded accord-ing to standard methods (Aharonson-Daniel, Boyko, Ziv, Avitzour,& Peleg, 2003; Baker et al., 1974; Barell et al., 2002). Medianneighborhood income was derived from 2000 U.S. Census datafor each participant’s postal zip code (U.S. Bureau of the Census).

Parent ASD was assessed with the Stanford Acute Stress Re-action Questionnaire (Cardena, Koopman, Classen, Waelde, &Spiegel, 2000), scored to yield a total ASD symptom severity scoreand to determine the presence of parent ASD (meeting symptom

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

296 Kassam-Adams, Fleisher, and Winston

criteria according to the Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition (DSM-IV; American Psychiatric Associa-tion, 1994) or “partial ASD” (meeting all criteria except for dissoci-ation symptoms). The Child Acute Stress Questionnaire (Winstonet al., 2002), based on a student version of the Stanford Acute StressReaction Questionnaire (Seagraves, Cardena, Classen, Koopman,& Spiegel, 1994), assessed child self-reported ASD severity.

Parent PTSD was assessed with the PTSD Checklist (Weathers& Ford, 1996), scored to yield a total PTSD symptom severityscore and to determine the presence of parent PTSD (meetingDSM-IV symptom criteria) or partial PTSD (defined as at leastone severe symptom in each symptom category plus reported im-pairment from these symptoms). Child PTSD for children age5–7 was evaluated using the Posttraumatic Symptom Inventoryfor Children (Eisen & Carlson, 1997). Children age 8–17 were as-sessed with the Clinician-Administered PTSD Scale for Childrenand Adolescents (CAPS-CA; Newman & Kaloupek, 1996). Forthe current analyses each Posttraumatic Symptom Inventory forChildren or CAPS-CA interview was scored for the presence of atleast partial PTSD.

At T1, parents reported on their own and their child’s prior ex-posure to 15 types of potentially traumatic events via the TraumaticEvents Screening Inventory (National Center for PTSD, 1996).At T2, parents reported on child interim exposure (since the indexinjury) to the same set of events. Prior trauma and interim traumawere each scored as a count (0–15) of types of traumatic eventsexperienced.

The T1 interview assessed the parent’s subjective sense of lifethreat to their child (“At any time during the accident or in thehospital, did you think your child might die?”), and the extentof the parent’s exposure to the incident in which the child wasinjured. Parent exposure was coded as direct (physically involvedin the crash, or eyewitness to the crash in which the child wasinjured) or indirect (not present when the child was injured).

At T1 and T2, parents rated their child’s worst pain since theinjury, using the Colored Analogue Scale (McGrath et al., 1996),a visual analogue pain measure scored on a continuous scale from1 to 10. Parents completed the 18-item physical health subscale ofthe Child Health Questionnaire (Landgraf, Abetz, & Ware, 1996)at T2 to assess the child’s physical recovery from injury.

Data AnalysisDescriptive analyses summarized sample characteristics and theproportion (with 95% confidence interval) of parents reportingASD and PTSD symptoms. We compared ASD and PTSD ratesin parents with direct versus indirect exposure to the injury event,by means of chi square analyses. The association between ASD andPTSD was assessed via correlations (Spearman’s rho, two-tailed)between continuous severity scores, and calculation of the sen-sitivity, specificity, positive predictive value (PPV), and negativepredictive value (NPV) of ASD status (and specific ASD symp-

tom criteria) as predictors of PTSD status. Demographics, priortrauma, peritrauma factors, and posttrauma factors were exam-ined as predictors of ASD or of PTSD using hierarchical multipleregression, entering groups of variables according to theoreticalrelevance. Finally, in exploratory analyses, a path model integrat-ing results of both regression models was evaluated. Analyses wereconducted using SPSS 16.0 and (for path analyses) AMOS 7.0.

R E S U L T SParent and child demographics and characteristics of the child’sinjury are presented in Table 1. Children were 5–17 years old(M = 9.7, SD = 3.2). Injury Severity Score ranged from 1 to 38;Mdn = 5. The length of the child’s hospital stay ranged from 1 to35 days; Mdn = 2 days. Ninety-nine of the children (30%) wereadmitted to the intensive care unit. Sixty-four parents (19%) haddirect exposure to the injury event (they were either in the crash

Table 1. Demographic and Child Injury Characteristics(N = 334)

n %

Parent relationship to childFather 33 10Mother 273 82Other female guardian 28 8

Race/ethnicityBlack 185 55White 133 40Other race/ethnicity 16 5

Child age5–7 years 101 308–11 years 160 4812–17 years 73 22

Child genderMale 237 71Female 97 29

Circumstances of child injuryPedestrian struck by vehicle 127 38Motor vehicle passenger in crash 57 17Bicyclist struck by vehicle 62 19Bicycle fall 88 26

Nature of child injurya

Contusion/superficial injury 199 60Fracture 183 55Internal organ 144 43Open wound 104 31Sprain/strain or dislocation 14 4Amputation 2 1

aChildren can have multiple injuries, thus percentages do not sum to 100%.



Table 2. Number of Parents Meeting DSM-IV Criteria for ASD orPTSD Symptoms

ASD (n = 334) PTSD (n = 251)

n % 95% CI n % 95% CI

Dissociation 66 20 16–24Reexperiencing 191 57 52–63 82 33 27–39Avoidance 161 48 43–54 23 9 6–13Arousal 243 73 68–78 58 23 18–29Meet partial symptom criteriaa 84 25 21–30 18 7 4–11Meet all symptom criteria 41 12 9–16 19 8 5–12

Note. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV;American Psychiatric Association, 1994); ASD = acute stress disorder; PTSD = posttraumaticstress disorder.aPartial symptom criteria: Partial ASD defined as meeting all symptom criteria for acute stressdisorder, except dissociation; partial PTSD defined as having at least one severe symptom in eachcategory (reexperiencing, avoidance, and arousal) plus impairment from these symptoms.

in which their child was injured or were eyewitnesses). Thirteenof these parents were injured themselves.

One hundred twenty-five parents (37%) met criteria for partialor full ASD at T1, and 37 parents (15%) met criteria for partialor full PTSD at T2. Table 2 presents the proportion of parentsmeeting criteria for each symptom category, partial, or full ASDand PTSD.

Relationship Between ASD and PTSDThe ASD and PTSD severity scores were moderately associated(r = .54; p < .001). Acute stress disorder status was associatedwith the likelihood of developing full PTSD: 32% (n = 9) ofthose with ASD, 10% (n = 6) of those with partial ASD, and3% (n = 4) of those without ASD went on to meet all symptomcriteria for PTSD, χ2 (2, N = 251) = 30.51, p < .001. Table 3shows the sensitivity, specificity, PPV, and NPV for prediction

Table 3. Prediction of PTSD from ASD Symptom Criteria inParents of Injured Children (N = 251)

Sensitivity Specificity PPV NPV

Dissociation (≥ 3 symptoms) .58 .89 .31 .96Dissociation (≥ 1 symptom) .90 .59 .15 .99Reexperiencing .90 .46 .12 .98Avoidance .79 .57 .13 .97Arousal .95 .30 .10 .99ASD .47 .92 .32 .96ASD or Partial ASDa .79 .68 .17 .98

Note. PTSD = Posttraumatic stress disorder; ASD = acute stress disorder; PPV = positivepredictive value; NPV = negative predictive value.aPartial ASD defined as meeting all symptom criteria for acute stress disorder, exceptdissociation.

of parent PTSD based on ASD, partial ASD, or ASD symptomcategories. Acute stress disorder was not a sensitive predictor ofPTSD. Utilizing a standard of “at least partial ASD” improvedsensitivity substantially, but reduced specificity.

Predictors of ASD and PTSDParents with direct exposure to the injury event were more likely tomeet symptom criteria for ASD than those with indirect exposure(20% vs. 10%), χ2 (1, N = 334) = 4.74, p < .05. Parent directversus indirect exposure to the injury event was not associatedwith later PTSD outcome (11% vs. 7% met symptom criteria forPTSD; χ2 < 1.)

Table 4 presents bivariate correlations among variables. Weexamined multicollinearity indicators among variables to be in-cluded in regression models; all were well within acceptable limits.In two separate hierarchical multiple regression models, sets of



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Table 5. Predictors of ASD and PTSD in Parents Following Child Injury

ASD (n = 289) PTSD (n = 173)

Step Variables R2 �R2 Final β R2 �R2 Final β

1 Preexisting factors .15 .15∗∗∗ .18 .18∗∗∗

Parent gender (Female) .06 .00Parent race (Black) .09 .06Median neighborhood income .01 −.09Child prior trauma (# events) .17∗∗ −.03Parent prior trauma (# events) .19∗∗ .14∗

2 Peritrauma characteristics .28 .13∗∗∗ .31 .13∗∗∗

Parent direct exposure (Yes) .10∗ .05Child Injury Severity Score .10 .04Perceived life threat to child (Yes) .21∗∗∗ .07Child pain at T1 .19∗∗∗ −.05

3 Child acute distress 0.33 0.05∗∗∗ 0.31 0.01Child ASD severity .24∗∗∗ −.06

4 Parent acute distress 0.47 0.16∗∗∗

Parent ASD severity .38∗∗∗

5 Child physical recovery 0.53 0.07∗∗∗

Child pain at T2 .03Child’s physical health at T2 −.33∗∗∗

6 Postinjury psychosocial factors 0.54 0.00Interim trauma (# events) .05Child has partial/full PTSD −.02

Note. ASD = acute stress disorder; PTSD = posttraumatic stress disorder.∗ p < .05. ∗∗ p < .01. ∗∗∗ p < .001.

predictors that were hypothesized to play a role in the develop-ment of parent ASD or PTSD were entered in the following or-der: (1) preexisting factors—parent demographic characteristics,prior parent trauma exposure, prior child trauma exposure; (2)Peritrauma characteristics—child injury severity, parent direct vs.indirect exposure, parent-reported child pain and life threat atT1; (3) Child acute distress—child ASD severity at T1; (4) Par-ent acute distress—parent ASD severity at T1; (5) Child physicalrecovery—parent-reported child pain and child physical health atT2; (6) Postinjury psychosocial factors—new traumatic events ex-perienced after the index injury, child PTSD outcome at T2. Sets1–3 were examined as predictors of ASD, and sets 1–6 as predictorsof PTSD. Table 5 presents the results of these regression analyses(beta weights presented are for the final ASD and PTSD modelswith all sets of predictors entered).

As sets 1–3 were entered into the model, each step added signifi-cantly to the prediction of ASD severity. The final model explained33% of the variance in parent ASD severity and included thefollowing independent predictors: child and parent prior traumaexposure, parent direct exposure to the injury incident, parent sub-jective sense of life threat to the child, parent report of child pain,and child ASD severity.

As sets 1–6 were entered into the model, preexisting factors(Step 1), peritrauma characteristics (Step 2), parent acute distress(Step 4), and the child’s physical recovery (Step 5) added sig-nificantly to the prediction of PTSD severity. Several variablesrepresenting preexisting and peritrauma factors (race, parent priortrauma, child acute pain, parent’s sense of life threat to the child)emerged as independent predictors of parent PTSD severity, butwhen parent ASD severity entered the equation in Step 4, it becamethe only significant independent predictor in the model. The finalmodel explained 54% of the variance in parent PTSD severity,and included the following independent predictors: parent priortrauma exposure, parent ASD severity, and child physical healthat follow-up (inversely associated).

In exploratory analyses to better understand and integrateresults of the ASD and PTSD regression models, signifi-cant predictors from both final regression models were en-tered into a single path model that combined ASD andPTSD prediction. Fit statistics for this initial model indicatedroom for improvement (χ2/df = 161.88/27 = 5.99, N = 334;RMSEA = .122; CFI = .65). Based on further examination of bi-variate correlations and consideration of potential substantive rela-tionships among child physical health and parent/child traumatic



Figure 1. Path model for parent acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) derived from significant predictorsin the regression models for ASD and PTSD.

stress responses, paths were added to the model. Adding pathsfrom T1 child variables (pain and ASD) to child physical health atT2 improved model fit (χ2/df = 81.14/24 = 3.38, N = 334; RM-SEA = .085; CFI = .85). Adding another path from parent ASDto child physical health produced a model (Figure 1) that fit thedata well (χ2/df = 43.63/23 = 1.90, N = 334; RMSEA = .052;CFI = .95).

D I S C U S S I O NThese results suggest that many parents experience distressing post-traumatic stress reactions when their child is exposed to an acutetraumatic event. One in three parents in the current study expe-rienced significant acute posttraumatic stress reactions and aboutone in six had persistent posttraumatic distress (at least partialPTSD) when assessed an average of 6 months later. Acute stressdisorder and PTSD symptoms were observed in parents regardlessof whether they had direct personal exposure to the event in whichtheir child was injured. The study also provides prospective dataregarding predictors of acute and longer-term traumatic stress inparents. Prior trauma exposure was a predictor of both ASD andPTSD severity, peritrauma factors (direct exposure, perceived lifethreat and pain, child acute stress) predicted parent ASD severity,and parent acute distress and poorer post-trauma child physicalhealth (as rated by parents) predicted parent PTSD severity.

The observed rate of ASD (12%) among parents in this samplewas comparable to prior studies of parents of injured children (B.Bryant et al., 2004; Landolt et al., 2003), or adults who werethemselves injured (Brewin et al., 1999; R. Bryant et al., 2000; R.Bryant & Harvey, 1998; Harvey & Bryant, 1998; Michaels et al.,1998), but markedly lower than prior studies of parents whosechildren were admitted to intensive care or newly diagnosed withcancer (Balluffi et al., 2004; Patino-Fernandez et al., 2008; Shawet al., 2006). The proportion of parents (8%) meeting diagnosticcriteria for PTSD in this sample is consistent with past studies ofparents of injured children with similar follow-up times (B. Bryantet al., 2004; DeVries et al., 1999). For these parents, ASD statusalone was not a sensitive predictor of PTSD, with sensitivity andspecificity generally comparable to that found in studies of injuredadults.

Prior investigations have identified a range of factors that mayinfluence or predict parental traumatic stress after child trauma,including preexisting individual or family factors and character-istics of the traumatic event and of the postevent environment.Among preexisting factors, the current study points most stronglyto trauma history. Parents who have themselves experienced moreprior traumatic events appear to be at increased risk for bothacute and longer-term traumatic stress when their child experi-ences a trauma. Like the few prior studies of parent acute re-sponses, we found peritrauma factors (such as direct exposure



or parent-appraised life threat) to be important predictors. Thisstudy additionally identifies parent appraisals of child pain as a per-itrauma risk factor for parent ASD. Although peritrauma factorswere clearly associated with acute traumatic stress symptoms, theyappeared to play a lesser role in maintaining ongoing traumaticstress responses.

There is a small but growing literature on the association be-tween child traumatic stress symptoms and physical health andfunctioning (Holbrook et al., 2005; Seng, Graham-Bermann,Clark, McCarthy, & Ronis, 2005). This literature has largely fo-cused on these phenomena within individuals, but it is possiblethat family members’ trauma responses and physical health maybe mutually influencing over time. A few past studies have foundparent PTSD symptoms to be associated with child health statusas rated by parents (Young et al., 2003) or by health care providers(Farley et al., 2007; Landolt et al., 2003). The current findings areconsistent with this, and also suggest that parent traumatic stresssymptoms may both shape and be shaped by parent appraisals ofchild health.

Studies of parent responses to child trauma provide a windowto understand traumatic stress after events that are indirectly ex-perienced (e.g., learning of their occurrence to a loved one) incontrast with directly experienced events. Consistent with severalpast studies (B. Bryant et al., 2004; Landolt et al., 2003), wefound that direct exposure to child injury placed a parent at riskfor more severe early traumatic stress symptoms, but we did notfind that direct exposure conferred increased risk for longer-termtraumatic stress. Anecdotally, it seems clear that even indirect expo-sure to events that injure or threaten one’s child can be traumaticfor parents. Parents in the current study were asked to describethe “worst part” of their child’s injury for them. Although thosewho were physically present often mentioned aspects of this ex-perience (“Getting the kids out of the car—I thought the carwas on fire,” “Seeing him lying on the ground, barely breathing,blood, scrapes”), many who had not been present still described in-tense fear and helplessness upon learning about their child’s injury(“Being away and my child was hurt and I couldn’t get to him fastenough—feeling helpless to be there for him,” “Having to drive tothe emergency room not knowing how serious his injuries were”)and some reported having intrusive images of the event they hadnot witnessed.

Because this study included only traffic-related injuries, cautionis required in generalizing from these results to parental responsesafter other types of childhood trauma. In particular, events involv-ing intentional violence may differ in important respects from theunintentional injury events that were the focus of this study. Inclu-sion of just one parent per child precluded the possibility of exam-ining interparental differences. Future studies might include morethan one parent as well as other family members, and assess parents’appraisals of child traumatic stress and physical health at multipletime points to help illuminate family processes of adaptation andrecovery after a child is exposed to a potentially traumatic event.

Clinicians treating trauma-exposed children have a valuableopportunity to attend to the needs of parents as well, both to reduceparents’ own distress and to promote parents’ optimal assistance totheir children. Given the important role for parent responses thathas been suggested by prior investigations (Kassam-Adams et al.,2006; Nugent et al., 2007), intervention development for childtraumatic stress should incorporate an understanding of parentaltraumatic stress.

R E F E R E N C E SAmerican Psychiatric Association. (1994). Diagnostic and statistical manual of

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