Symptoms and responses to critical incidents in paramedics who have experienced childhood abuse and neglect Robert G Maunder, 1,2 Janice Halpern, 1,2 Brian Schwartz, 2,3 Maria Gurevich 4 ABSTRACT Background Mental and physical symptoms are common in paramedics, which may relate to high work stress, including critical incidents. As previous trauma is a risk factor for psychological symptoms after exposure to critical incidents, the prevalence of childhood experiences with abuse and neglect and paramedics’ adaptation to critical incidents may be important. Methods 635 paramedics were surveyed regarding childhood experiences of physical, sexual or emotional abuse as well an index critical incident from the past, acute stress responses to that event and current mental and physical symptoms. A comparison group of 159 female hospital-based healthcare workers completed the same survey of childhood abuse and neglect in a separate study. Results 232 paramedics (36.5%) responded. Among these, physical, sexual or emotional childhood abuse was reported by 38.4%. Female paramedics reported significantly more emotional and physical abuse and neglect than female hospital workers. Paramedics who reported childhood abuse or neglect more frequently experienced signs of acute stress immediately following the index critical incident and for the following 2 weeks. Childhood abuse and neglect were associated with significantly higher scores for depressive symptoms, physical symptoms and burnout, and a higher prevalence of ‘cases’ scoring above thresholds of clinical significance. Conclusion Childhood abuse may be more common in paramedics than in other healthcare workers, at least in women. Childhood abuse and neglect is associated with acute stress responses to critical incidents and to current physical and mental symptoms. These results are based on a low response rate and may not be generalisable. Paramedics face many stressors in their work including critical incidents, which range from highly public mass disasters 1 to less sensational events that provoke distressing feelings because of their personal meaning. 2 Relative to the general working population, ambulance workers experience elevated rates of standardised mortality and of early retirement for medical reasons, as well as more frequent accidental injury and musculoskeletal symptoms. 3 Mental health concerns among ambulance workers are common, including an incidence of posttraumatic stress disorder symp- toms greater than 20%, and high rates of anxiety and other psychopathology, 3 which are thought to be partly due to the chronic effects of exposure to critical incident stress. 1 In addition to the cost of these symptoms to individuals, the conditions that contribute to stress may also make recruitment and retention of professionals more difficult and may affect patient outcomes. Not all paramedics are equally affected. Identi- fying the determinants of paramedics’ resilience or vulnerability to critical incidents may lead to better individual health, and in turn enhance patiente provider interaction and quality of care. Although not enough is known about the individual differ- ences that contribute to stress and resilience, emergency personnel who are prone to dissociation after a critical incident are at higher risk of long- term sequelae, 1 and personality characteristics such as neuroticism may also contribute. 4 Importantly, a leading cause of the propensity to dissociation is previous experience with severe trauma, especially childhood abuse. 5 Similarly, previous trauma expe- rience is a marker of posttraumatic stress disorder risk after exposure to a traumatic event. 6 While the experience of childhood abuse or neglect is a plausible risk factor for adverse consequences of work stress among paramedics, there is no infor- mation available about its prevalence or relation- ship with response to critical incidents or current symptoms. The experience of childhood abuse and neglect is common in the general population, 7 8 but has received little study in healthcare workers, 9e12 and we have found no reports of this prevalence in police, paramedics or firefighters. The purpose of this study is to determine the prevalence of child- hood abuse and neglect in a sample of paramedics, and whether the experience of childhood abuse and neglect is associated with paramedics’ responses to critical incidents and with current physical and psychiatric symptoms. METHODS Participants and procedure Paramedics study Paramedics and supervisors in a large urban emer- gency medical services (EMS) organisation completed a survey. Recruitment has been described previ- ously. 13 Participants were recruited from attendees of a mandatory continuing education programme. Paramedics who were on leave were informed of the study by mail. Subjects chose a paper or iden- tical web-based survey. The study was approved by a hospital research ethics board. Of approximately 1000 paramedics working for the EMS organisation, 635 signed a consent form and received the survey, and 243 (38.3%) partly or fully completed it over the following 8 months. 1 Department of Psychiatry, Mount Sinai Hospital, Toronto, Ontario, Canada 2 University of Toronto, Toronto, Ontario, Canada 3 Sunnybrook-Osler Centre for Prehospital Care, Toronto, Ontario, Canada 4 Department of Psychology, Ryerson University, Toronto, Ontario, Canada Correspondence to Dr Robert G Maunder, Department of Psychiatry, Mount Sinai Hospital and University of Toronto, 600 University Avenue, Toronto, ON M5G 1X5, Canada; rmaunder@mtsinai.on.ca Accepted 5 February 2011 Maunder RG, Halpern J, Schwartz B, et al. Emerg Med J (2011). doi:10.1136/emj.2010.099838 1 of 6 Original article EMJ Online First, published on March 21, 2011 as 10.1136/emj.2010.099838 Copyright Article author (or their employer) 2011. 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