The Impact of Unintentional Pediatric Trauma:

A Review of Pain, Acute Stress, and

Posttraumatic Stress
Jeffrey I. Gold, PhD
Alexis J. Kant, BA
Seok Hyeon Kim, MD, PhD

This article reviews current research on acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) resulting from
pediatric simple (i.e., single, unpredictable, and unintentional) physical injury and how pain may act as both a trigger and a
coexisting symptom. Although several studies have explored predictors of ASD and PTSD, as well as the relationship between
these conditions in adults, there is less research on ASD and PTSD in children and adolescents. This review highlights the
importance of early detection of pain and acute stress symptoms resulting from pediatric unintentional physical injury in the
hopes of preventing long-term negative outcomes, such as the potential development of PTSD and associated academic, social,
and psychological problems.
2008 Elsevier Inc. All rights reserved.

EDIATRIC UNINTENTIONAL PHYSICAL

injuries continue to be the leading cause of
morbidity and mortality in children aged 1 year in
the United States. According to the National Center
for Health Statistics (2006), 34.3% of all deaths for
children aged 14 years and 39.0% of all deaths for
children aged 514 years resulted from unintentional injury in 2004. The National Trauma Data
Bank annual report of 2006 found that, on that
year in the United States, 12.1% of patients with
trauma were aged 014 years and 9.3% were aged
1519 years (American College of Surgeons,
2006). For children and adolescents, the majority
of patients with trauma were male: b 1 year, 60.4%;
14 years, 59.3%; 59 years, 61.7%; 1014 years,
70.2%; 1519 years, 70.8%. The most common
mechanism of injury for infants (b 1 year; 41.3%)
and children (14 years, 35.6%; 59 years, 34.0%)
is a fall. Motor vehicle traffic accidents are the
leading cause of injury for the remaining age
groups: 1014 years, 31.2%; 1519 years, 49.9%
(American College of Surgeons, 2006).
Although children and adolescents may face
numerous other types of physical traumas, including physical and sexual assault, the purpose of the
current article is to review unintentional physical
injuries. Stoddard and Saxe (2001) distinguished
between two main categories of injury: simple and

Journal of Pediatric Nursing, Vol 23, No 2 (April), 2008

complex. Simple injury refers to a single unpredictable event that causes bodily damage and is
minimally related to factors within the child and the
social environment. Complex injuries occur in the
context of preexisting problems, including familial,
community, and societal instability (Stoddard &
Saxe, 2001). The interaction between pain, complex injury, and the development of posttraumatic
stress disorder (PTSD) is beyond this article's
scope; therefore, the remainder of this review will
focus on simple injury, as defined above.
When a trauma requiring medical intervention
occurs, both the physical and the psychological

From the Department of Anesthesiology Critical Care

Medicine, Children's Hospital Los Angeles, Los Angeles, CA,
Keck School of Medicine, University of Southern California, Los
Angeles, CA, and Department of Neuropsychiatry and Institute
of Mental Health, Hanyang University College of Medicine,
Seoul, South Korea.
Corresponding author. Jeffrey I. Gold, PhD, Comfort, Pain
Management, and Palliative Care Program, Department of
Anesthesiology Critical Care Medicine, Children's Hospital Los
Angeles, 4650 Sunset Boulevard, MS No. 12, Los Angeles, CA
90027-6062. E-mail: jgold@chla.usc.edu.
0882-5963/$ - see front matter
2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.pedn.2007.08.005

81

82

integrity of the child are threatened (KassamAdams, 2006). Psychological sequelae of acute
physical trauma, including acute stress disorder
(ASD) and PTSD, have been described following
fractures, spinal cord injuries, and burns; psychological symptoms occur regardless of injury
severity (Abdullah et al., 1994; Anderson & Schutt,
1980; Pillemer & Michlei, 1988). In a study
conducted at a Level I trauma center in Philadelphia, 25% of pediatric patients and 15% of their
parents experienced PTSD symptoms following a
traffic injury (de Vries et al., 1999). As these studies
suggest, pediatric populations may be prone to
psychological problems such as ASD and PTSD
following unintentional injuries. It is estimated that
1 million American children develop some form of
PTSD (acute, chronic, or delayed onset) every year
(Schreier, Ladakakos, Morabito, Chapman, &
Knudson, 2005).
A 10-year literature review conducted by
Stoddard and Saxe (2001) regarding pediatric
physical injuries found that psychiatric epidemiological data are nearly absent in this area of
research, except for a few relatively small studies.
As noted in this review, there continues to be an
absence of data detailing outcomes associated with
pediatric physical injury. This article provides a
current review of the research on pediatric ASD
and PTSD due to traumatic simple injury, focusing
on the mechanism of pain and how it may
contribute to the development of acute and
posttraumatic stress reactions. Although pain has
not been included as a symptom or as part of the
diagnostic criteria for acute or posttraumatic stress,
the authors propose that pain may operate as both
a trigger (i.e., reminder) and a coexisting symptom. Pain has been defined as an unpleasant
sensory and emotional experience associated with
actual or potential tissue damage or has been
described in terms of such damage (Merskey &
Bogduk, 1994). To fully appreciate the complex
nature of pain, however, we turn to the American
Pain Society's definition: Chronic pain in
children is the result of a dynamic integration of
biological processes, psychological factors, and
sociocultural context considered within a developmental trajectory (Bursch et al., 2001). Pain
has traditionally been viewed as an outcome
associated with injury but not necessarily associated with the development of an ongoing anxiety
disorder such as ASD or PTSD. However, pain
associated with traumatic injury may act as a
reminder of the traumatic event, which may

GOLD, KANT, AND KIM

further reinforce memories associated with the

trauma. This review will also explore the relationship between initial ASD symptoms and the later
development of PTSD, underscoring the importance of early detection of pain and ASD symptoms in injury victims.
Articles included in this review were chosen
based on their relevance to acute stress, PTSD, and
pain associated with acute/simple unintentional
injury in children. Articles highlighting complex
PTSD (i.e., childhood physical or sexual abuse)
were excluded to avoid additional confounds that
were beyond the scope of the current review.
Electronic database searches (i.e., PubMed, MEDLINE, and PsycINFO) were conducted using the
following keywords: pediatric pain and unintentional injury, ASD or PTSD and pediatric unintentional injury, pediatric ASD and PTSD, and pain
and pediatric injury. The current review is comprehensive given the search terms and the recent
literature addressing pediatric pain and the development of ASD or PTSD.
ASD AND PTSD

Definition of ASD and PTSD

ASD and PTSD are anxiety disorders that can
result when a person experiences, witnesses, or is
confronted by an event involving actual or
threatened death or serious injury to oneself or
others, or if a person's physical integrity is
threatened (American Psychiatric Association,
1994). Events linked with the development of
ASD or PTSD include interpersonal violence with
or without direct victimization (e.g., physical or
sexual abuse, torture), severe motor vehicle accidents (MVAs), war exposure, being kidnapped or
taken hostage, terrorist attack, incarceration as a
prisoner of war or in a concentration camp, natural
or man-made disasters, community violence, or
being diagnosed with a life-threatening illnesses
(e.g., cancer). The American Psychiatric Association notes that the individual's response to this event
must involve intense fear, helplessness, or horror.
According to its criteria, an individual meets a
diagnosis of ASD if symptoms appear within 2 days
and persist for no longer than 4 weeks, whereas
those meeting the diagnosis of PTSD must have
experienced symptoms for N 30 days.
Once the traumatic event and the individual's
response had been established, the diagnosis of
ASD or PTSD based on Diagnostic and Statistical

PAIN, ASD, AND PTSD

Manual of Mental Disorders, Fourth Edition

(DSM-IV) criteria for adults requires a minimum
of one of five criterion items of reexperiencing,
three of seven items reflecting avoidance and
numbing characteristics, and two of five items
demonstrating hyperarousal symptoms. Additional
information regarding declines in function is
necessary to meet full criteria for PTSD.
Few investigations have focused on the incidence
of ASD and PTSD following acute physical injury
in children (de Vries et al., 1999; Kassam-Adams,
2006; Stoddard & Saxe, 2001). Furthermore, little
is known about the normal range of acute
psychological responses in children in the immediate aftermath of unintentional traumatic injury,
making identification of adverse child responses
extremely difficult. This article will first review the
most recent studies pertaining to manifestations,
developmental differences, and predictors of pediatric ASD and PTSD. It will follow with an overview
of how pain relates to the two diagnoses, both in
adults and in children, and conclude with some
clinical recommendations.

Clinical Manifestations of Pediatric

ASD and PTSD
Until recently, DSM-IV criteria for children and
adolescents had been shaped by adult clinical
manifestations of ASD and PTSD. However,
many children do not develop the full array of
DSM-IV-specified ASD and PTSD symptoms after
the most severe traumatic incidents, although they
experience significant distress and functional
impairment (Schreier et al., 2005). Recent studies
have reported that younger children tend to display
a broader range of mood, anxiety, and behavioral
symptoms, whereas the psychiatric sequelae (e.g.,
depression and anxiety disorders) of adolescents
may closely resemble those of adults (Steinberg &
Avenevoli, 2000; Yule, 2001).
According to the DSM-IV, trauma symptom
expression in children is often associated with a
complex array of verbal and behavioral symptoms.
Their behavior may appear agitated or disorganized, and the traumatic event may be
reexperienced through recurrent and intrusive
recollections of the event (i.e., thoughts about the
trauma popping into their minds). Often, this is
seen through repetitive play in which themes or
aspects of the trauma are depicted, such as
repetitively smashing a toy bus into a doll or
drawing the same image over and over again. As
observed in adults, children may avoid stimuli

83

associated with the trauma or may experience

emotional numbing, a state in which a person has
difficulty expressing emotion and feels detached
from the outside world and from one's previous
lifestyle (American Psychiatric Association, 1994).
Children may also experience increased arousal
(such as difficulty sleeping), irritability, enuresis
(Eidlitz-Markus, Shuper, & Amir, 2000), or difficulty concentrating. The impact of these symptoms
can result in declines in daily psychological,
social, cognitive, physical, and sleep functioning.
Notably, both children and adults can present with
some symptoms associated with ASD or PTSD
but lack sufficient symptoms to warrant a formal
diagnosis; this is referred to as subsyndromal ASD
or partial PTSD.
Winston et al. (2002) investigated the range and
type of ASD symptoms in children aged 517 years
and their parents after a traffic accident left the child
injured. Eighty-eight percent of children and 83%
of parents met criteria for at least one symptom (i.e.,
dissociation, reexperiencing, avoidance, or arousal)
associated with the injury. Winston et al. identified
dissociation as the most commonly reported
symptom. These results led them to suggest that
most pediatric victims of traumatic injury will
display some ASD symptoms, prompting the need
for families to be educated that their child's
symptoms are likely to resolve. However,
Winston et al. noted that referral for psychological
care may be necessary if the child's symptoms
persist for N 1 month or are particularly distressing
in their intensity.
Daviss et al. (2000) examined 48 children aged
717 years and their parents during the child's
hospitalization for physical injury and at 1-month
follow-up. More than 90% of the children studied
met Criterion A (a qualifying traumatic event) for
PTSD diagnosis. At 1-month follow-up, 12.5% of
the participants qualified for full PTSD, and 16.7%
qualified for subsyndromal (partial) PTSD. In
another study, partial PTSD was reported in
47.5% of children after acute traumatic injury
(Aaron, Zaglud, & Emergy, 1999). Schreier et al.
(2005) further investigated symptom characteristics
in children and adolescents with unintentional
injuries using the UCLA Posttraumatic Stress
Disorder Reaction Index to determine partial
PTSD and using DSM-IV criteria to evaluate full
PTSD. Sixty-nine percent of children were found to
have at least mild PTSD symptoms at baseline
(57% at 1 month, 59% at 6 months, and 38% at
18 months). By contrast, 43% of the patients met

84

the diagnostic criteria for full PSTD at 1 month,

with approximately 30% meeting full criteria at
6 and 18 months postinjury.
As these studies suggest, although a full PTSD
diagnosis may not be applicable for many children
following traumatic injury, subsyndromal or partial
PTSD is a common occurrence. Children who meet
the diagnostic criteria for two or three PTSD
symptom clusters demonstrate functional impairments equivalent to those in children who meet full
diagnostic criteria for PTSD (Carrion, Weems, Ray,
& Reiss, 2002); therefore, clinicians must shift their
attention from diagnosis to the patients' symptom
severity. Identifying emotional, behavioral, and
sleep disruptions is critical during clinical assessment and intervention.

Developmental Differences in Manifestations

of Pediatric ASD and PTSD
Developmental differences in pediatric physical
injury have yet to be fully explored in the literature.
However, Schwarz and Kowalski (1991) studied
children aged 514 years following a school
shooting and found that avoidance symptoms were
more common in younger children, whereas older
children reported more symptoms of reexperiencing
and arousal. Although older children and adults
appear to suffer from greater distress when faced
with specific traumatic reminders, younger children
seem more likely to experience spontaneous intrusive memories and thoughts. The authors suggest
that flashbacks and physiological arousal (e.g.,
being easily startled) symptomatology might
increase with age, whereas intrusive thoughts are
more likely to be experienced by younger children.
Similarly, adolescents (7th and 10th graders)
who were in shelters during threatened missile
attacks in the Persian Gulf War used more
emotion-focused coping strategies, such as avoidance and distraction, than problem-focused strategies (Weisenberg, Schwarzwald, Waysman,
Solomon, & Klingman, 1993). The opposite was
true for younger children (5th graders). Using
study-developed self-report coping behavior and
emotional reaction measures, Weisenberg et al.
expressed that adolescents who focused on emotional coping involving elements of denial demonstrated less postwar reactions. These findings were
similar to the work of Cohen and Lazarus (1973),
which demonstrated that there are times when
avoidance is a highly effective coping strategy.
Although there are identified developmental
differences with regard to traumatic responses,

GOLD, KANT, AND KIM

other intervening indices such as coping have also

been shown to impact on the expression of stress
reactions (Cohen & Lazarus, 1973).

Predictors of ASD and PTSD Development

Several studies have examined factors related to
the development of ASD and PTSD in children and
adolescents, such as demographic variables (e.g.,
age and gender), prior psychopathology, injury
severity, and physiological factors (e.g., heart rate
and physiological arousal). One study of 401
adolescents aged 1219 years demonstrated that
female gender, perceived threat to life, and violencerelated mechanism of injury were predictive of
ASD, as measured by the Impact of Events Scale
Revised (Holbrook et al., 2005a). Within the same
study population, Holbrook et al. (2005b) offered
support for injury-related factors (i.e., perceived
threat to life, death of a family member at the scene,
lack of control over injury event, and violencerelated injury) and demographic variables (i.e.,
female gender, older age, low socioeconomic status,
drug and alcohol abuse, and other behavioral
problems) predicting PTSD risk at 618 months
postinjury. In a study of 48 children aged 717 years
who were hospitalized for physical injury, Daviss et
al. (2000) demonstrated that a diagnosis of full
PTSD was associated with a higher level of prior
psychopathology, greater parental acute distress,
and higher rates of prior sexual abuse, as compared
with partial or no PTSD. Similarly, PTSD symptomatology correlated with prior psychopathology
and traumatization, parental distress, and the child's
acute distress. In a later study of 101 adolescent and
adult trauma survivors aged 1465 years, Zatzick
et al. (2002) identified the following set of factors as
significant predictors of increased PTSD symptomatology 1 year postinjury: female gender, higher
PTSD symptom levels in surgical wards, numerous
prior traumas, and stimulant intoxication on admission. According to the authors, the severity of PTSD
symptoms while in the surgical ward was the
strongest and most parsimonious predictor of
PTSD symptoms in this study sample in the course
of the year postinjury. In contrast to other studies
(Holbrook et al., 2005a,b), injury type and severity,
pre-event functioning, age, and demographic characteristics such as income and education were not
significant predictors of PTSD symptom development. In light of the conflicting findings, future
research is needed to further elucidate the demographic and injury-related variables associated with
ASD and PTSD development.

PAIN, ASD, AND PTSD

Recent studies examining pediatric physical

injury have also targeted physiological outcomes
as predictors of PTSD. After examining the
relationship between acute heart rate around the
time of injury and the development of PTSD in
children following a traffic-related physical injury,
researchers reported that the group of children who
developed partial or full PTSD had a higher mean
heart rate at emergency department triage than
children who did not go on to develop PTSD
6 months postinjury (Kassam-Adams, GarciaEspaa, Fein, & Winston, 2005). Likewise, a
study of 82 children aged 818 years demonstrated
that heart rate during emergency medical service
transport to a trauma center and during the first
20 minutes of hospitalization significantly correlated with PTSD symptoms presenting at 6-week
follow-up, even when controlling for demographic
variables and depressive symptoms (Nugent,
Christopher, & Delahanty, 2006). This finding
gained additional support in a study by Saxe,
Stoddard, et al. (2005), where path analyses
revealed that heart rate, body image, and the
parent's acute stress symptoms were directly related
to the development of ASD symptoms in children
with burns approximately 10 days postinjury and
accounted for 41% of its variance. These studies
suggest a relationship between physical injury and
acute physiological arousal (as measured by heart
rate) and later development of ASD and PTSD.
Additional studies have investigated whether
epinephrine and cortisol, two hormones released
by the hypothalamicpituitaryadrenal axis in
response to stress, predict PTSD development
(Pitman, 1989). In a study of child trauma victims
aged 818 years, baseline urinary cortisol levels
significantly correlated with subsequent PTSD
symptoms 6 weeks postinjury (r = .31) (Delahanty,
Nugent, Christopher, & Walsh, 2005). After
removing the variance associated with demographic
information and depressive symptoms, urinary
cortisol and epinephrine levels predicted 710%
of the variance in PTSD symptoms. Gender
analyses revealed that the relationship between
urinary hormone levels and PTSD was particularly
strong in boys but was not significant among
girlsa surprising finding that should be examined
in future research.

Relationship Between ASD Symptoms and

Development of PTSD
Since ASD was first recognized as a disorder,
there have been numerous studies on the relation-

85

ship between ASD and PTSD in adults, revealing

that 6383% of those patients diagnosed with ASD
develop PTSD (Brewin, Andrews, Rose, & Kirk,
1999; Bryant & Harvey, 1998; Classen, Koopman,
Hales, & Spiegel, 1998; Difede et al., 2002; Harvey
& Bryant, 1998). An increasing number of studies
have demonstrated that specific acute stress reactions, such as dissociation and intrusion, are strong
predictors of later PTSD development (Koopman,
Classen, & Spiegel, 1994; Rothbaum, Foa, Riggs,
Murdoch, & Walsh, 1992; Shalev, Peri, Canetti, &
Schreiber, 1996). Research has also shown that
other early acute stress symptoms (e.g., arousal and
reexperiencing) appear predictive of PTSD development (Creamer, O'Donnell, & Pattison, 2004;
Mellman, David, Bustamante, Fins, & Esposito,
2001; Wittmann, Moergeli, & Schnyder, 2006).
Being one of the few studies to date to have
evaluated the relationship between ASD and PTSD
in children, Kassam-Adams and Winston (2004)
examined the utility of ASD as a predictor of PTSD
among youth aged 817 years following a traffic
accident. ASD was measured in 243 children within
1 month of injury using the Child Acute Stress
Questionnaire (Winston et al., 2002), whereas
PTSD was assessed in 177 children 3 months
after injury using the Clinician-Administered PTSD
Scale for Children and Adolescents (Newman &
Ribbe, 1996). Based on the outcomes of these
measures, ASD and PTSD symptom severity scores
were positively associated (r = .56, p b .0005).
Among the children who completed both assessments, 14% of those with ASD and 9% of those with
subthreshold (i.e., not meeting full criteria) ASD
went on to develop PTSD. Although the sensitivity
was low for distinguishing PTSD from ASD in
children and adolescents, the authors note that ASD
sensitivity, as a predictor of PTSD, was far lower in
this sample of injured children (0.20) than in
published studies of injured adults (0.390.64)
(Brewin et al., 1999; Bryant, Guthrie, Moulds, &
Harvey, 2000; Bryant & Harvey, 1998; Harvey &
Bryant, 1998; Michaels et al., 1998).
RELATIONSHIP OF PAIN TO
ASD AND PTSD

Adults: Pain, ASD, and PTSD

Evidence has supported the relationship between
pain resulting from traumatic physical injury and
the development of ASD and PTSD in adults. One
study examined 323 adult accident victims and

86

assessed numerous accident- and ASD-related

variables (Fuglsang, Moergeli, Hepp-Beg, &
Schnyder, 2002). They found three constellations
summing nine variables, including two objective
accident-related variables (traffic accident and
admission to the intensive care unit), two pretrauma
and trait variables (psychiatric disorder and sense of
coherence), and five accident- and recovery-related
cognitions (pain, sense of death threat, appraisal of
accident severity, preventability of the accident by
others, and appraisal of coping ability regarding
physical recovery). Together, these variables
accounted for 38% of the variance in the ASD
symptom level. These authors reported that pain
made a highly significant contribution to their
overall predictive model. However, they cited that
pretrauma and trait characteristics, in addition to
accident- and recovery-related cognitions and pain,
together accounted for most of the risk associated
with the development of ASD. Fuglsang et al.
hypothesized that pain associated with an accident
may be a powerful trigger for reexperiencing
symptoms, thus reminding patients of their trauma.
These findings provide support for the usefulness of
pain management strategies in the prevention of
ASD and PTSD.
Adult studies have also demonstrated that pain
can act as a traumatic stimulus following whiplash
injuries, where pain was associated with acute
posttraumatic psychological responses (Drottning,
Staff, Levin, & Malt, 1995); traffic accidents, where
pain was related to the incidence of PTSD (Kuch,
Cox, & Evans, 1996); and MVAs, where decreased
pain severity was a significant predictor of reduced
PTSD symptomatology (Fedoroff, Taylor, Asmundson, & Koch, 2000). Although these studies have
laid a foundation for understanding the role of
pain as a trigger of ASD or PTSD, future studies
need to evaluate this relationship in greater depth.
Pain can also serve as a coexisting symptom of
PTSD. Clinical practice and research suggest a high
incidence of pain and PTSD, and highlight the
negative impact of their coexistence. High rates of
PTSD have been reported in patients referred for
psychological treatment following an MVA (Hickling & Blanchard, 1992; Hickling, Blanchard,
Silverman, & Schwartz, 1992). Research indicated
that rates of PTSD in patients for which pain is
secondary to an MVA ranged from 30% to 50%
(Chibnall & Duckro, 1994; Hickling et al., 1992;
Taylor & Koch, 1995). These studies begin to
provide support for the association between pain
and the development of PTSD. Whether pain is a

GOLD, KANT, AND KIM

reminder, a trigger, or part of the physiological

response associated with hyperarousal is yet to be
determined. Further research investigating the role
of pain and the later development of ASD or PTSD
is needed.

Children and Adolescents: Pain and ASD

There is even less research on the relationship
between ASD and pain in children and adolescents.
In a study of children aged 718 years who were
hospitalized with one or more injuries, Saxe, Miller,
et al. (2005) identified four risk factors of ASD
development: level of family stress, caregiver
stress, child's experience with pain, and child's
age. On a scale of 075, children in this study
suffered from a mean injury score of 8.9 7, and
27.7% of the participants met DSM-IV criteria for
ASD during their hospitalization. The investigators
advised further exploration of these risk factors to
develop interventions designed to prevent the longterm negative effects of trauma, such as the
development of PTSD.
Acute and posttraumatic stress responses in
infants and toddlers, although dramatically different
from those in children and adolescents, are
equally valuable in understanding the relationship
between pain and stress responses. Stoddard et al.
(2006) studied 72 infants and toddlers (aged 12
48 months) with burn injuries and revealed several
associations between physiological and psychological outcomes during hospitalization and at
1-month follow-up. Notably, the child's pain rating
24 hours postinjury was related to reduced
vocalizations 1 month after hospitalization. There
emerged a number of other significant outcomes,
including reduced spontaneous smiling at 1 month,
among children who were described as more
irritable in the hospital, who had nightmares,
who were perceived by their parents to think
continually about the burn, and who demonstrated
symptoms consistent with arousal based on the
Diagnostic Interview for Children and Adolescents
(a structured clinical interview on the child's
posttraumatic stress symptoms completed by parents) during their hospitalization. Additionally,
children who were described as upset by reminders
of the burn demonstrated reduced vocalizations
at 1-month follow-up. Finally, the higher the
infant's heart rate at 24 hours and 7 days postinjury,
the less the infant was found to spontaneously
smile 1 month later. These findings imply that
increased pain intensity and physiological arousal
(i.e., heart rate) may be associated with a greater

PAIN, ASD, AND PTSD

incidence of psychological distress in the infant

trauma victim.

Children and Adolescents: Pain and PTSD

Research on pain and PTSD in pediatric injury is
scarce. Recently, Saxe, Stoddard, et al. (2005)
identified two conceptual pathways for the development of PTSD for patients with pediatric burns.
They documented that one pathway was mediated
by separation anxiety ( = .68) and that another
pathway was mediated by dissociative responses
( = .26). The magnitude of the trauma, as measured by the size of the burn, was not directly
related to PTSD but exerted its influence indirectly
through both pathways. Pain ( = .50) also exerted
its influences indirectly through separation anxiety,
but not through dissociation, demonstrating the
complex interaction between family influences,
pain, and the development of PTSD.
Several reports lend further support to the
relationship between pain and later PTSD development by describing how aggressive pharmacological pain management at the time of initial
hospitalization can reduce the likelihood of PTSD
development. Saxe, Stoddard et al. (2001) investigated the relationship between the dose of morphine administered during a child's hospitalization
for an acute burn and the course of PTSD symptoms
in the 6-month period following discharge from the
hospital. Children receiving higher doses of
morphine had a greater reduction in PTSD
symptoms after 6 months. The authors suggested
that acute treatment of pain with morphine could
also prevent PTSD.
Additionally, a case report demonstrated that a
child who received 6 mg/kg morphine in the
emergency department following an acute unintentional physical injury showed a clinically significant decrease in heart rate compared to another
youth with a similar injury profile who received
3 mg/kg (Gold, Carson, Kant, Joseph, & Mahour,
2005). The authors speculate that therapeutic
dosing of acute pain medicine might ameliorate
physiological arousal associated with pain and
trauma, which may contribute to the development
of postinjury stress symptoms.
CLINICAL RECOMMENDATIONS
Although investigators have separately identified
the predictive role of physiological indices, acute
physiological reactivity (e.g., hyperarousal), acute
pain, and ASD in the development of PTSD, this

87

article emphasizes their complex interplay. Identifying relationships between these variables will
inform and enhance medical and psychological
care for children and adolescents following traumatic physical injury. This section will highlight
recommendations for early identification of,
and intervention for, acute and posttraumatic
stress symptoms while incorporating the authors'
suggestions for the detection and treatment of
pain symptomatology.
Regarding the psychiatric assessment of ASD
and PTSD in children, many researchers have
emphasized the importance of an approach that
includes subsyndromal types versus full ASD or
PTSD diagnosis alone (Aaron et al., 1999; Carrion
et al., 2002; Schreier et al., 2005). If clinicians use a
symptom-based model, rather than only identifying
patients with full ASD or PTSD, more children
suffering from psychological sequelae associated
with physical injury will be evaluated and treated.
Ultimately, the goal for clinicians is to understand
the full continuum of stress reactions and to provide
sufficient interventions to avoid future psychological disability for undiagnosed psychopathology,
thereby reducing the costs and resources required to
address PTSD. In a clinical setting, the benefits of
evaluating subsyndromal stress reactions and
providing appropriate interventions far outweigh
the risks of not providing treatment.
During formal clinical research assessments,
investigators have noted that children tend to report
significantly more stress reactions than their parents
for weeks after the accident (Dyb, Holen, Braenne,
Indredavik, & Aarseth, 2003). Although a multiinformant modality of data collection is usually a
good methodological consideration, it may be
preferable clinically to obtain injury-related stress
symptoms directly from the child instead of the
child's caregiver. A good clinical assessment of
acute or posttraumatic stress reactions starts with
first acknowledging that pediatric traumatic injury
has psychological components.
Given the noted associations between pain, ASD,
and PTSD, clinicians conducting diagnostic assessments of child and adolescent victims of traumatic
injury should assess for all related symptoms. If
there is reason to believe that a history of trauma or
pain exists, several well-validated self-report questionnaires and diagnostic interviews for ASD and
PTSD, most of which are listed on the National
Center for PTSD, U.S. Department of Veterans
Affairs (2007) Web site (http://www.ncptsd.va.gov/
ncmain/assessment/), are available for use. Of

88

GOLD, KANT, AND KIM

particular interest to pediatric nurses is a 12-item

measure that can be administered at an injured
patient's bedside, the Screening Tool for Early
Predictors of PTSD (STEPP) (Winston, KassamAdams, Garcia-Espaa, Ittenbach, & Cnaan, 2003).
This measure, which was developed to help
improve the delivery of emergency medical services to injured patients through triaging, demonstrates high sensitivity and specificity for the
prediction of PTSD in injured children. A sample
of nurses reported that the measure was easy to use,
that it was of appropriate length for use in the
emergency department, that parents and children
seemed comfortable being asked such questions,
and that they felt comfortable asking the questions
(Ward-Begnoche et al., 2006). In addition, a
comprehensive pain assessment should be conducted to assess pain intensity, location, frequency,
quality, and events that both exacerbate or alleviate
the pain symptom(s). Further exploration of pain
and its association with the injury or its relationship
to stress reactions as a trigger or as a coexisting
symptom is recommended and will ultimately
guide interventions.
As for psychological interventions, some medicalsurgical settings currently attempt to treat the
child's injury-related pain, anxiety, and other
mental health issues by offering preparation for
postinjury procedures, patient participation, cognitivebehavioral therapies, relaxation, and hypnosis
(Caffo & Belaise, 2003). Winston et al. (2002)
recommended the following for health care providers dealing with traumatic traffic-related injury in
children and adolescents:
1. Routinely call the family 12 weeks after a
traffic injury to ask about behavioral symptoms and family function;
2. Make use of the ongoing clinicianpatient
relationship to explore symptom presence,
intensity, and any functional impairment in
the injured child (a brief office visit with the
child and parents could serve this purpose);
3. Be sure to explore the effect that the child's
injury has had on the family (remember that
parents also experience posttraumatic stress
symptoms after pediatric traffic-related injuries, and these symptoms may limit the
parents' ability to support the child);
4. Provide supportive care and give families the
opportunity to discuss the accident and their
current feelings (but do not force families to
talk about the accident); and

5. Pay particular attention to the parents of child

pedestrians who are struck by motor vehicles
(these parents experience posttraumatic symptoms more commonly than parents of children
in other traffic accidents).
Recently, some studies have suggested that
administration of morphine or glucocorticoid
during acute exposure to trauma (e.g., septic
shock, cardiac surgery, and acute burn) could
prevent PTSD or, at the very least, reduce PTSD
symptom severity (Saxe, Stoddard, et al., 2001;
Schelling, Roozendaal, & De Quervain, 2004). A
recent publication by Ratcliff et al. (2006) noted
an almost 25% decrease in the diagnosis of ASD
since the Shriners Hospitals for Children (Galveston, TX) instituted a pain protocol in 1992. During
the period of 19931994, 28.9% of pediatric burn
victims were treated with benzodiazepines for
background anxiety, and 12.1% of the victims
were diagnosed with ASD. The percentage of
patients treated with benzodiazepines steadily
increased over time, whereas the percentage of
patients diagnosed with ASD decreased: 59.8%
and 9.2% in 1998; and 71.3% and 8.7% in 2001,
respectively. Future investigations examining the
use of early psychopharmacological intervention
following unintentional traumatic physical injury
may lead to improved treatment for accidentrelated pain and anxiety.
Although a growing body of evidence on the
lingering impact of traumatic stress stemming from
interpersonal or intrapersonal violence (i.e., physical or sexual abuse) has encouraged clinicians to
seek more immediate and appropriate interventions,
empirical models of acute and posttraumatic stress
resulting from simple traumatic injury, particularly
in children and adolescents, have yet to be
explored. Clinicians and investigators alike need
to increase their awareness of the psychological
symptoms associated with simple traumatic injury
to evaluate and provide treatment during the
immediate postinjury period.
CONCLUSIONS
This article is the first comprehensive review of
the proposed interaction of acute stress reactions,
PTSD, and the role of pain as it pertains to pediatric
unintentional physical injury. In addition to presenting the current literature on the relationship
between ASD and PTSD, the authors have discussed the role of pain in triggering the deleterious

PAIN, ASD, AND PTSD

89

effects of trauma. This article concludes with

clinical recommendations for early assessment,
reassessment, and pharmacological and psychological interventions.
Physical injury continues to be the primary
reason for trauma care and surgery in pediatric
hospitals across the country; however, emergent
pediatric care is often remiss of consistent
psychological evaluation and treatment. Although
children have been shown to have adequate
physical recovery, the psychological effects of
trauma can be extensive and devastating. Of
particular interest is the dynamic role of acute
pain, physiological reactivity linked to hyperarousal, and the triggering nature of pain symptoms and physiology. Some studies have
demonstrated the role of early pain intervention
and the potential long-lasting benefit for physical
and psychological healing. Yet health care professionals in pediatric settings continue to place the
majority of focus on the physical nature of trauma
in lieu of the potential psychological effects.
Additionally, health care professionals outside
the mental health field may not be properly
educated on ASD and PTSD and their connection
to traumatic injury. Urgent attention to the
ongoing evaluation of pain symptoms and the
psychological responses to traumatic injury will
improve both acute and long-term health outcomes
for these children and their families. In particular,
attention to the expression of stress symptoms,
instead of diagnosis alone, will assist in identifying these health concerns.

The scientific community has identified some

long-term consequences of untreated stress symptoms and pathological pain: numerous functional
disabilities (neurobiologic and endocrine) (Ehlert,
Gaab, & Heinrichs, 2001; Marshall & Garakani,
2002), cortical changes (Chae et al., 2004), selfmedicating effects (Kuhne, Nohner, & Baraga,
1986), sleep disturbances (Lavie, 2001), and other
comorbid psychiatric conditions (Licanin & Redzic,
2002). Although pathological pain and stress
responses have been separately associated with
numerous negative health outcomes, few investigators have empirically examined their combined
impact on daily functioning in children and their
families. Children facing traumatic stress during
critical periods of central nervous system development, who have less psychological resources to
cope with the stress, may face a greater frequency
and severity of functional disabilities.
In closing, future studies investigating pediatric
physical injury would benefit from early identification of pain and its role in the development of acute
stress and later PTSD. Furthermore, the triggering
role of pain physiology, hyperarousal, and physiological indices (e.g., increased epinephrine and
cortisol) of acute stress and PTSD require further
empirical investigation. As many children may not
have the verbal or emotional maturity needed to
identify the potentially catastrophic effects of
traumatic injury and ongoing pain signaling,
caregivers and health care providers must routinely
assess for acute and posttraumatic stress symptoms
following these injuries.

REFERENCES
Aaron, J., Zaglud, H., & Emergy, R. (1999). Posttraumatic
stress in children following acute physical injury. Journal of
Pediatric Psychology, 24, 335343.
Abdullah, H., Blakeney, P., Hunt, R., Broemling, L., Phillips,
L., Herndon, D. N., et al. (1994). Visible scars and self-esteem
in pediatric patients with burns. Journal of Burn Care &
Rehabilitation, 15, 164168.
American College of Surgeons (2006). National Trauma Data
Bank annual report (Version 6.0). Chicago, IL: American
College of Surgeons.
American Psychiatric Association (1994). Diagnostic and
statistical manual of mental disorders (DSM-IV), 4th ed.
Washington, DC: American Psychiatric Association.
Anderson, J. M., & Schutt, A. H. (1980). Spinal injury in
children: A review of 56 cases seen from 1950 through 1978.
Mayo Clinic Proceedings, 55, 499504.
Brewin, C. R., Andrews, B., Rose, S., & Kirk, M. (1999).
Acute stress disorder and posttraumatic stress disorder in
victims of violent crime. American Journal of Psychiatry, 156,
360366.
Bryant, R. A., Guthrie, R. M., Moulds, M. L., & Harvey, A. G.
(2000). A prospective study of psychophysiological arousal,

acute stress disorder, and posttraumatic stress disorder. Journal

of Abnormal Psychology, 109, 341344.
Bryant, R. A., & Harvey, A. G. (1998). Relationship between
acute stress disorder and posttraumatic stress disorder following
mild traumatic brain injury. American Journal of Psychiatry,
155, 625662.
Bursch, B., Collier, J., Joseph, M., Kuttner, L., McGrath, P.,
Sethna, N., et al. (2001). Pediatric chronic pain. American Pain
Society Bulletin, 11, 11.
Caffo, E., & Belaise, C. (2003). Psychological aspects
of traumatic injury in children and adolescents. Child
and Adolescent Psychiatric Clinics of North America, 12,
493535.
Carrion, V. G., Weems, C. F., Ray, R., & Reiss, A. L. (2002).
Toward an empirical definition of pediatric PTSD: The
phenomenology of PTSD symptoms in youth. Journal of the
American Academy of Child and Adolescent Psychiatry, 41,
166173.
Chae, J. H., Jeong, J., Peterson, B. S., Kim, D. J., Bahk, W. M.,
Jun, T. Y., et al. (2004). Dimensional complexity of the EEG in
patients with posttraumatic stress disorder. Psychiatry Research,
131, 7989.

90

Chibnall, J. T., & Duckro, P. N. (1994). Post-traumatic stress

disorder and motor vehicle accidents. Headache, 34, 357361.
Classen, C., Koopman, C., Hales, R., & Spiegel, D. (1998).
Acute stress disorder as a predictor of posttraumatic stress
symptoms. American Journal of Psychiatry, 155, 620624.
Cohen, F., & Lazarus, R. S. (1973). Active coping processes,
coping dispositions, and recovery from surgery. Psychosomatic
Medicine, 35, 375389.
Creamer, M., O'Donnell, M. L., & Pattison, P. (2004). The
relationship between acute stress disorder and posttraumatic
stress disorder in severely injured trauma survivors. Behaviour
Research and Therapy, 42, 315328.
Daviss, W. B., Mooney, D., Racusin, R., Ford, J. D.,
Fleischer, A., & McHugo, G. J (2000). Predicting posttraumatic
stress after hospitalization for pediatric injury. Journal of the
American Academy of Child and Adolescent Psychiatry, 39,
576583.
de Vries, A. P., Kassam-Adams, N., Cnaan, A., ShermanSlate, E., Gallagher, P. R., & Winston, F. K. (1999). Looking
beyond the physical injury: Posttraumatic stress disorder in
children and parents after pediatric traffic injury. Pediatrics, 104,
12931299.
Delahanty, D. L., Nugent, N. R., Christopher, N. C., &
Walsh, M. (2005). Initial urinary epinephrine and cortisol
levels predict acute PTSD symptoms in child trauma victims.
Psychoneuroendocrinology, 30, 121128.
Difede, J., Ptacek, J. T., Roberts, J., Barocas, D., Rives, W.,
Apfeldorf, W., et al. (2002). Acute stress disorder after burn
injury: A predictor of posttraumatic stress disorder? Psychosomatic Medicine, 64, 826834.
Drottning, M., Staff, P. H., Levin, L., & Malt, U. F. (1995).
Acute emotional response to common whiplash predicts
subsequent pain complaints: A prospective study of 107 subjects
sustaining whiplash injury. Nordic Journal of Psychiatry, 49,
293299.
Dyb, G., Holen, A., Braenne, K., Indredavik, M. S., &
Aarseth, J. (2003). Parentchild discrepancy in reporting
children's post-traumatic stress reactions after a traffic accident.
Nordic Journal of Psychiatry, 57, 339344.
Ehlert, U., Gaab, J., & Heinrichs, M. (2001). Psychoneuroendocrinological contributions to the etiology of depression,
posttraumatic stress disorder, and stress-related bodily disorders:
The role of the hypothalamuspituitaryadrenal axis. Biological
Psychology, 57, 141152.
Eidlitz-Markus, T., Shuper, A., & Amir, J. (2000). Secondary
enuresis: Post-traumatic stress disorder in children after car
accidents. Israel Medical Association Journal, 2, 135137.
Fedoroff, I. C., Taylor, S., Asmundson, G. J. G., & Koch, W. J.
(2000). Cognitive factors in traumatic stress reactions: Predicting
PTSD symptoms from anxiety sensitivity and beliefs about
harmful events. Behavioral and Cognitive Psychotherapy, 28,
515.
Fuglsang, A. K., Moergeli, H., Hepp-Beg, S., & Schnyder, U.
(2002). Who develops acute stress disorder after accidental
injuries? Psychotherapy and Psychosomatics, 71, 214222.
Gold, J. I., Carson, M. C., Kant, A., Joseph, M. H., & Mahour,
G. H. (2005). Pain and acute stress reaction in pediatric physical
injury. Journal of Pain, 6, S72.
Harvey, A. G., & Bryant, R. A. (1998). The relationship
between acute stress disorder and posttraumatic stress
disorder: A prospective evaluation of motor vehicle accident
survivors. Journal of Consulting and Clinical Psychology,
66, 507512.
Hickling, E. J., & Blanchard, E. B. (1992). Post-traumatic
stress disorder and motor vehicle accidents. Journal of Anxiety
Disorders, 6, 285291.
Hickling, E. J., Blanchard, E. B., Silverman, D. J., &
Schwartz, S. P. (1992). Motor vehicle accidents, headaches,
and post-traumatic stress disorder: Assessment findings in a
consecutive series. Headache, 32, 147151.

GOLD, KANT, AND KIM

Holbrook, T. L., Hoyt, D. B., Coimbra, R., Potenza, B., Sise,

M., & Anderson, J. P. (2005). High rates of acute stress disorder
impact quality-of-life outcomes in injured adolescents: Mechanism and gender predict acute stress disorder risk. Journal of
Trauma, 59, 11261130.
Holbrook, T. L., Hoyt, D. B., Coimbra, R., Potenza, B., Sise,
M., & Anderson, J. P. (2005). Long-term posttraumatic stress
disorder persists after major trauma in adolescents: New data on
risk factors and functional outcome. Journal of Trauma, 58,
769771.
Kassam-Adams, N. (2006). Introduction to the special
issue: Posttraumatic stress related to pediatric illness and injury.
Journal of Pediatric Psychology, 31, 337342.
Kassam-Adams, N., Garcia-Espaa, J. F., Fein, J. A., &
Winston, F. K. (2005). Heart rate and posttraumatic stress
in injured children. Archives of General Psychiatry, 62,
335340.
Kassam-Adams, N., & Winston, F. K. (2004). Predicting child
PTSD: The relationship between acute stress disorder and PTSD
in injured children. Journal of the American Academy of Child
and Adolescent Psychiatry, 43, 403411.
Koopman, C., Classen, C., & Spiegel, D. (1994). Predictors of
posttraumatic stress symptoms among survivors of the Oakland/
Berkeley, Calif., firestorm. American Journal of Psychiatry,
151, 888894.
Kuch, K., Cox, B. J., & Evans, R. J. (1996). Posttraumatic
stress disorder and motor vehicle accidents: A multidisciplinary
overview. Canadian Journal of Psychiatry, 41, 429434.
Kuhne, A., Nohner, W., & Baraga, E. (1986). Efficacy of
chemical dependency treatment as a function of combat in
Vietnam. Journal of Substance Abuse and Treatment, 3,
191194.
Lavie, P. (2001). Sleep disturbances in the wake of traumatic
events. New England Journal of Medicine, 345, 18251832.
Licanin, I., & Redzic, A. (2002). Posttraumatic stress disorder
(PTSD) and co-morbidity. Bosnian Journal of Basic Medical
Sciences, 2, 5761.
Marshall, R. D., & Garakani, A. (2002). Psychobiology of the
acute stress response and its relationship to the psychobiology of
post-traumatic stress disorder. Psychiatric Clinics of North
America, 25, 385395.
Mellman, T. A., David, D., Bustamante, V., Fins, A. I., &
Esposito, K. (2001). Predictors of post-traumatic stress disorder
following severe injury. Depression and Anxiety, 14, 226231.
Merskey, H., & Bogduk, N. (1994). Classification of chronic
pain. Seattle: International Association for the Study of Pain
Press.
Michaels, A. J., Michaels, C. E., Moon, C. H., Zimmerman,
M. A., Peterson, C., & Rodriguez, J. L. (1998). Psychosocial
factors limit outcomes after trauma. Journal of Trauma, 44,
644648.
National Center for Health Statistics (2006). Health, United
States, 2006 with chartbook on trends in the health of Americans.
(Hyattsville, MD).
National Center for PTSD, U.S. Department of Veterans
Affairs (2007). Assessment. retrieved on April 26, 2007, from
http://www.ncptsd.va.gov/ncmain/assessment/.
Newman, E., & Ribbe, D. (1996). Psychometric review of
the clinician-administered PTSD scale for children. In B. H.
Stamm (Ed.), Measurement of stress, trauma and adaptation
(pp. 106114). Lutherville, MD: Sidran Press.
Nugent, N. R., Christopher, N. C., & Delahanty, D. L. (2006).
Emergency medical service and in-hospital vital signs as
predictors of subsequent PTSD symptom severity in pediatric
injury patients. Journal of Child Psychology and Psychiatry, 47,
919926.
Pillemer, F., & Michlei, L. (1988). Psychological considerations in youth sports. Clinics in Sports Medicine, 7, 679689.
Pitman, R. K. (1989). Post-traumatic stress disorder, hormones, and memory. Biological Psychology, 26, 221223.

PAIN, ASD, AND PTSD

Ratcliff, S. L., Brown, A., Rosenberg, L., Rosenberg, M.,

Robert, R. S., Cuervo, L. J., et al. (2006). The effectiveness of a
pain and anxiety protocol to treat the acute pediatric burn patient.
Burns, 32, 554562.
Rothbaum, B. O., Foa, E. B., Riggs, D. S., Murdock, T., &
Walsh, W. (1992). A prospective examination of post-traumatic
stress disorder in rape victims. Journal of Traumatic Stress, 5,
455475.
Saxe, G., Stoddard, F., Chawla, N., Lopez, C. G., Hall, E.,
Sheridan, R., et al. (2005). Risk factors for acute stress disorder
in children with burns. Journal of Trauma and Dissociation, 6,
3749.
Saxe, G., Stoddard, F, Courtney, D, Cunningham, K, Chawla,
N, Sheridan, R, et al. (2001). Relationship between acute
morphine and the course of PTSD in children with burns.
Journal of the American Academy of Child and Adolescent
Psychiatry, 40, 915921.
Saxe, G. N., Miller, A., Bartholomew, D., Hall, E., Lopez, C.,
Kaplow, J, et al. (2005). Incidence of and risk factors for acute
stress disorder in children with injuries. Journal of Trauma, 59,
946953.
Saxe, G. N., Stoddard, F., Hall, E., Chawla, N., Lopez, C.,
Sheridan, R., et al. (2005). Pathways to PTSD: Part I. Children
with burns. American Journal of Psychiatry, 162, 12991304.
Schelling, G, Roozendaal, B, & De Quervain, D. J (2004). Can
posttraumatic stress disorder be prevented with glucocorticoids?
Annals of the New York Academy of Sciences, 1032, 158166.
Schreier, H., Ladakakos, C., Morabito, D., Chapman, L., &
Knudson, M. M. (2005). Posttraumatic stress symptoms in
children after mild to moderate pediatric trauma: A longitudinal
examination of symptom prevalence, correlates, and parent
child symptom reporting. Journal of Trauma, 58, 353363.
Schwarz, E. D, & Kowalski, J. M (1991). Malignant
memories: PTSD in children and adults after a school shooting.
Journal of the American Academy of Child and Adolescent
Psychiatry, 30, 936944.
Shalev, A. Y., Peri, T., Canetti, L., & Schreiber, S. (1996).
Predictors of PTSD in injured trauma survivors: A prospective
study. American Journal of Psychiatry, 153, 219225.
Steinberg, L., & Avenevoli, S. (2000). The role of context in
the development of psychopathology: A conceptual framework

91

and some speculative prepositions. Child Development, 71,

6674.
Stoddard, F. J, Ronfeldt, H, Kagan, J, Drake, J. E, Snidman, N,
Murphy, J. M, et al. (2006). Young burned children: The course
of acute stress and physiological and behavioral responses.
American Journal of Psychiatry, 163, 10841090.
Stoddard, F. J., & Saxe, G. (2001). Ten-year research review
of physical injuries. Journal of the American Academy of Child
and Adolescent Psychiatry, 40, 11281145.
Taylor, S., & Koch, W. J. (1995). Anxiety disorders due to
motor vehicle accidents: Nature and treatment. Clinical Psychology Review, 15, 721738.
Ward-Begnoche, W. L., Aitken, M. E, Liggin, R, Mullins, S.
H, Kassam-Adams, N., Marks, A., et al. (2006). Emergency
department screening for risk for post-traumatic stress disorder
among injured children. Injury Prevention, 12, 323326.
Weisenberg, M., Schwarzwald, J., Waysman, M., Solomon,
Z., & Klingman, A. (1993). Coping of school-age children in the
sealed room during scud missile bombardment and postwar
stress reactions. Journal of Consulting and Clinical Psychology,
61, 462467.
Winston, F. K., Kassam-Adams, N., Garcia-Espaa, F.,
Ittenbach, R., & Cnaan, A. (2003). Screening for risk of
persistent posttraumatic stress in injured children and their
parents. Journal of the American Medical Association, 290,
643649.
Winston, F., Kassam-Adams, N, Vivarelli-O'Neill, C, Ford, J,
Newman, E, Baxt, C, et al. (2002). Acute stress disorder
symptoms in children and their parents after pediatric traffic
injury. Pediatrics, 109, e90.
Wittmann, L., Moergeli, H., & Schnyder, U. (2006). Low
predictive power of peritraumatic dissociation for PTSD
symptoms in accident survivors. Journal of Traumatic Stress,
19, 639651.
Yule, W. (2001). Posttraumatic stress disorder in the general
population and in children. Journal of Clinical Psychiatry, 62,
2328.
Zatzick, D. F., Kang, S. M., Muller, H. G., Russo, J. E.,
Rivara, F. P., Katon, W., et al. (2002). Predicting posttraumatic
distress in hospitalized trauma survivors with acute injuries.
American Journal of Psychiatry, 159, 941946.