Link for Injured Kids A Patient-Centered Program of Psychological First Aid After Trauma Marizen Ramirez, MPH, PhD,* Maisha Toussaint, MPH,* Briana Woods, PhD,† Karisa Harland, MPH, PhD,* Kristel Wetjen, BSN, RN,‡ Tammy Wilgenbusch, PhD,§ Graeme Pitcher, MD,‡ and Charles Jennissen, MDk Objective: Injury, the most common type of pediatric trauma, can lead to a number of adverse psychosocial outcomes, including posttraumatic stress disorder. Currently, few evidence-based parent programs exist to support children hospitalized after a traumatic injury. Using methods in evaluation and intervention research, we completed a formative research study to de- velop a new program of psychological first aid, Link for Injured Kids, aimed to educate parents in supporting their children after a severe traumatic injury. Methods: Using qualitative methods, we held focus groups with par- ents and pediatric trauma providers of children hospitalized at a Level I Children's Hospital because of an injury in 2012. We asked focus group participants to describe reactions to trauma and review drafts of our inter- vention materials. Results: Health professionals and caregivers reported a broad spectrum of emotional responses by their children or patients; however, difficulties were experienced during recovery at home and upon returning to school. All parents and health professionals recommended that interventions be of- fered to parents either in the emergency department or close to discharge among admissions. Conclusions: Results from this study strongly indicate a need for posttrauma interventions, particularly in rural settings, to support families of children to address the psychosocial outcomes in the aftermath of an in- jury. Findings presented here describe the process of intervention develop- ment that responds to the needs of an affected population. Key Words: trauma, injury, psychological first aid, mental health, adolescents (Pediatr Emer Care 2015;00: 00–00) U nintentional injury is the most common type of trauma expe- rienced by children annually, leading to more than 11,000 deaths and more than 280,000 hospital admissions in the United States. 1 Exposure to a variety of traumatic injuries such as traffic crashes or falls may trigger a number of chronic psychological conditions, of which posttraumatic stress disorder (PTSD) is the most prominent. 2–4 Prevalence of PTSD symptoms among injured youth ranges from 13% to 32%, depending on the time of assessment. 5 Many injured trauma patients do not immediately display symptoms of distress while in the hospital setting. Hence, a sub- stantial proportion of injured children with adjustment disorders are undiagnosed, do not seek treatment, and are not referred to psychosocial services. 6 In rural areas, families of traumatized chil- dren face additional challenges in the availability and acceptability of mental health resources. 7,8 Rural hospitals lack standardized protocols for identifying and referring at-risk traumatized children to mental health services. 9 Moreover, acceptability of psycholog- ical services is lower in rural than in urban settings because of in- creased stigma and decreased anonymity. 8 One program that may assist children after trauma is Listen Protect Connect—Model & Teach (LPC), a form of psychological first aid originally developed by school psychologists and social workers to support children after various types of crises, particu- larly natural disasters and violence. 10–12 Analogous to physical first aid, psychological first aid “uses interpersonal skills provided by individuals to respond to the psychological consequences of (trauma). ” 11 The steps of LPC are to listen without judgment, pro- tect by helping a child feel safe, connect children with others, model positive behavior, and teach about expected reactions. In a quasi-experiment of 20 students with stressful life experiences including traumatic injury and illness, a modified version of LPC was associated with reduced symptoms of PTSD and depres- sion as well as increased school connectedness and coping. 12 With these promising results, our team conducted transla- tional research to adapt elements of LPC for the posttrauma care of hospitalized children. We called this new program, Link for Injured Kids, a 2-step skill-based program of psychological first aid developed using a patient-centered approach and parents/ guardians as potential interventionists. The 2 steps, links 1 and 2, were created based on a parent- based intervention in the area of teen driving 13,14 and our pilot study on LPC. 12 According to our pilot work, when parents and nurses reported 2 key skills—communication and screening— were valued most in their interactions with traumatized children. Link 1 involves communicating with a child by using open- ended questions and reflections, 2 types of motivational inter- viewing skills that help increase empathy and create a calm and safe place for traumatized children to share feelings. Link 2 in- volves linking children with family, friends, and other supports. As part of link 2, parents are taught how to screen for stress using the Kessler-6 Screener (2002), a simple 6-question scale that asks children to rate how sad, nervous, restless or fidgeting, hopeless, frustrated, or worthless a child might feel in the past 2 weeks. This helps the parent understand current levels of distress to assist in decisions for seeking additional psychosocial support. For this current study, we used formative research methods to create the new link program and identify procedures for future im- plementation and testing of the program for children with severe injuries admitted into a hospital setting. Similar methods have been used to inform the development of interventions in previous studies. 15–18 Focus groups with parents/guardians and health care From the *University of Iowa Injury Prevention Research Center, Department of Occupational and Environmental Health; †Department of Community Be- havioral Health, University of Iowa College of Public Health; ‡Department of Surgery, University of Iowa Hospitals and Clinics; §Department of Pediatric Psychology, University of Iowa Children's Hospital; and kDepartment of Emer- gency Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA. Disclosure: The authors declare no conflict of interest. The findings and conclusions in this journal article are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Reprints: Marizen Ramirez, MPH, PhD, Department of Occupational and Environmental Health, Rm S318, University of Iowa College of Public Health, Iowa City, IA 52242 (e‐mail: marizen-ramirez@uiowa.edu). This work was supported by the University of Iowa Prevention Research Center, Centers for Disease Control and Prevention (1-U48DP001902-01). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161 ORIGINAL ARTICLE Pediatric Emergency Care • Volume 00, Number 00, Month 2015 www.pec-online.com 1 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.