Medical Trauma
A look at what medical trauma is and how to help support children through planned procedures and recover better from emergency procedures.
Medical trauma is a very real experience for children who have had medical procedures, whether it be a once-off incident or an ongoing intervention. I have worked with several children over the years who have experienced varying degrees of medical trauma intensity. From car and motor bike accidents to machinery accidents to dog bites to being diagnosed and living with chronic medical conditions. Even a routine medical intervention such as an immunisation can be perceived as traumatic.
What is medical trauma?
The National Child Traumatic Stress Network (NCTSN) https://www.nctsn.org/ refers to medical trauma in children as paediatric medical traumatic stress and defines it as “A set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures and invasive or frightening treatment experiences.”
So, what does it look like when a child has experienced medical trauma? There is a continuum of symptoms which may present in different ways depending on the age of the child, the meaning they give to the medical intervention, and the support they receive before, during and after the intervention.
Hyperarousal symptoms (flight, fight response) could include increased aggression, heightened fears of things they were previously not afraid of, separation anxiety, increased “jumpiness” and general anxiety. They could have flashbacks or nightmares.
Hypo arousal symptoms (immobilisation response) could include avoidance; not wanting to talk about it at all, avoiding all possible reminders of the intervention or what caused the intervention to happen. They may become uncharacteristically cautious.
Sensory reminders (sights/smells/sounds) can be instant triggers to reexperiencing either the medical intervention or the incident that led to the medical intervention.
How can something that is meant to treat and heal be traumatic?
It depends on the perception of the child and their parents. Many parents have told me their feelings of guilt at having to help hold their child down whilst an injection is administered. It feels awful and conflictual to be your child’s protector and safe space AND in trying to help them, to hurt them.
Your child (and maybe you too) is scared and overwhelmed. The treatment itself may feel really painful and not feel healing at all. That’s very confusing for a child!
Pre-school children perceive pain as punishment and so may feel that they are in trouble. Imagine how it might impact a child of this age who doesn’t have the opportunity to process their experiences and who internalises “I did something wrong. I am bad.”?
For children of all ages, medical interventions can be very invasive and intrusive and have an impact on their sense of agency and confidence.
When children are feeling anxious, the sense of pain is heightened. “A child in an anxious state has increased sympathetic responses to pain stimulus that makes him or her even more aware of the pain signal.” (Arntz, Dreesen & Jong, 1994).
Medical trauma and caregivers
Did you notice in the definition of paediatric medical traumatic stress that it said “children and their families.” A child’s medical trauma sits with the parents too. In fact, it has been found that 20 to 30% of parents experience chronic stress after their child’s medical trauma. Parents who feel helpless in the face of the stress they and their child is experiencing can have heightened stress responses for a long time after the event is over, and even when their child is fully recovered.
It has been found that children’s anxiety in relation to medical procedures correlates highly with their parent’s anxiety (Hong-Gu He et al. 2015).
Planned vs. Emergency procedures
Medical interventions happen in one of two ways, either they are planned or they are emergencies.
When your child is going for a planned procedure, ensure that you get as much information as possible beforehand. Lisa Dion talks about “making the unknown, known.” When something is unknown to us, that can feel scary. When we make the unknown know, we prepare ourselves by forming a bit of a picture of what to expect.
In planned procedures make the unknown, known.
Talk to your doctor and ask for their help with giving your child age-appropriate and detailed information about what to expect. If your child is going for a tonsillectomy, ask the doctor to explain about what will happen before and after the procedure. Maybe ask for a picture of what tonsils look like, and where they are in the body. Make sure you and your child know what they will need to do to prepare eg: put on a hospital gown, not eating before the operation etc.. who will be allowed to be with them and where. It is important that the doctor (or parent) shares that it will likely feel sore in their throat after the tonsils come out. Don’t hide the pain from children, prepare them for it and give them an approximation. “The pain from having your tonsils out will feel like you have quite a sore throat. We will give you cool, soft things to eat.”
Don’t assume what children know; give as much information as possible and is still age appropriate.
For a planned procedure, give time to sit with your child as often as they need to, to talk about what to expect. If they have questions you can’t answer, write them down and try to get the answer for them. Normalise all the emotions they may bring up; excitement at missing school! Fear of the pain, uncertainty, curiosity, anxiety and whatever else they bring up. Don’t suggest emotions to them “You must be feeling anxious” because maybe they’re not! Rather, ask what they’re feeling or thinking about the procedure and follow their cues.
But what happens when there is an emergency? An accident happens, your child breaks their arm, they are in immense pain and they have to go for emergency surgery. There is little or no time to prepare. At this point as a parent, you are likely as dysregulated and stressed as your child (if not more so), and so things feel pretty tough.
Create as much physical and emotional safety as possible.
As far as possible, simply be there. Ensure that at least one parent, or significant, beloved adult, is with the child at all times as far as possible. This can create a sense of safety in the midst of any chaos, unless the parent is not coping/hysterical with their own anxiety in which case it would be best to have an adult known to the child and who is able to create safety for the child.
I remember once when my children were about 7 and 6 they were on a playdate and their friend just about chopped his finger off. His mom rushed him (along with my kids) to the emergency room. She went through with him to get his finger seen to, and my kids were with their friend’s older sister in the waiting room. I arrived to find my two children white-faced and fearful. In an emergency, sometimes children simply have to wait for a safe adult to be able to be present, the difference when they arrive is immediate relief!
After an emergency procedure, being there when they wake up is really important. They may have forgotten what happened and be faced with a flood of overwhelming memories. They may feel disoriented and really scared. Go gently and quietly. Offer gentle reassurance, your presence is often more than enough.
In these situations, you can often spend a lot of time on your phone updating people. When your child is awake, they need your full attention particularly in the immediate aftermath of the events/surgery. Get someone else to give updates and switch your phone off to be fully present with your child particularly in this period of time.
It is interesting that in some research I read it said that it has been found that children’s post-operation pain is often not well managed. I’m not sure why this is, perhaps because many children seem to have a high pain-threshold? Or maybe because they can’t articulate their pain as clearly as adults and so they may “act out” in their pain and they are labelled as naughty rather than the pain being recognised as pain. Whatever the reason, don’t be afraid to be an advocate for your child’s pain management.
After a medical emergency, give time for physical healing to take place and then start to assess your child’s emotional well-being. Your child may not remember how they got into the hospital, gently help to tell the story of how they got there when it seems they may be ready to hear it.
After about a month of healing if they don’t seem to be themselves and you’re recognising some of the symptoms of dysregulation as mentioned above, then seek professional help. They simply need some assistance making meaning of the very scary set of experiences that have just happened to their body. And likely as their parent, you do too!
Be led by your child.
Sometimes we are asked or want to tell the story of the traumatic event repeatedly to others. I highly recommend doing so when your child is not present. The repeated telling of the story in their presence when they have not chosen to tell or hear it, can enforce a re-experiencing of the worst parts of the story for them, flooding them with intense, scary emotions.
It is very different when they choose to tell the story for themselves, at their pace and when they are ready. Even the youngest child who is able to talk knows intuitively when they are ready to process a part of the story. You can let them know you are willing to talk about anything at any time, and they get to choose when that is.
Remember always that individual perception of events in an individual's life is what leads to the psychological symptoms that result after the events. It may be surprising and even confounding to deal with a child who has all but changed in personality in a short space of time.
Stay close, listen, and get help for yourself and them when needed.
Continue to have grace for yourself as a parent. Particulary in medical emergencies so much can come at you so fast that it's hard to know which way is up, let alone be able to be emotionally present to your child. Recovery takes so much time. Take all the time you need.
References
The Effectiveness of Therapeutic Play Intervention in Reducing Perioperative Anxiety, Negative Behaviors, and Postoperative Pain in Children Undergoing Elective Surgery: A Systematic Review by Hong-GuHe, LixiaZhu, Sally Wai Chi Chan, Piyanee Klainin-Yobas, and Wenru Wang. 2015.
Play Therapy Treatment of Pediatric Medical Trauma: A Retrospective Case Study of a Preschool Child. Margaret G. Locatelli. 2020.
