This study investigated trauma symptom trajectories of children 2-16 years old following admission to pediatric intensive care and identified factors that predicted a child's trauma symptom ...trajectory.
Prospective longitudinal design.
Two tertiary care PICUs in Brisbane, Qld, Australia.
Children 2-16 years old admitted to PICU for longer than 8 hours.
Maternal reported child posttraumatic stress symptoms (n = 272) on the Trauma Symptom Checklist for Young Children were used to assess posttraumatic stress symptoms up to 12 months post admission. Semiparametric group-based trajectory analyses were completed to identify patterns over time. Age, gender, length of stay, premorbid functioning, maternal perceived threat to life, and maternal acute distress were assessed as potential risk factors. Three likely trajectory groups were identified. The majority of children were resilient (83.8%); however, a significant minority experienced chronic symptoms (12.9%) or elevated stress symptoms which resolved quickly (3.3%). After controlling for other variables, maternal report of premorbid internalizing behavior significantly predicted both chronic (odds ratio, 6.3) and recovery (odds ratio, 38.0) trajectories. Maternal acute distress significantly predicted child chronic symptom trajectories (odds ratio, 5.2).
Children with elevated trauma symptoms postintensive care need timely and effective intervention. The majority of children with high levels of acute symptoms will continue to have chronic, ongoing posttraumatic stress symptoms. In addition, acute maternal distress and preexisting internalizing child behavior predict ongoing psychologic distress after discharge from the PICU. Screening in the acute period post-PICU admission may identify children likely to experience ongoing chronic posttraumatic distress symptoms and enable targeted treatment of children at risk. This is the first study to examine symptom trajectories in children following pediatric intensive care admission and includes a sample of very young children.
Objective
Early childhood is a high-risk period for exposure to traumatic medical events due to injury/illness. It is also one of the most important and vulnerable periods due to rapid development in ...neurobiological systems, attachment relationships, cognitive and linguistic capacities, and emotion regulation. The aim of this topical review is to evaluate empirical literature on the psychological impact of medical trauma during early childhood (0–6 years) to inform models of clinical care for assessing, preventing, and treating traumatic stress following injury/illness.
Methods
Topical review of empirical and theoretical literature on pediatric medical traumatic stress (PMTS) during early childhood.
Results
There are important developmental factors that influence how infants and young children perceive and respond to medical events. The emerging literature indicates that up to 30% of young children experience PMTS within the first month of an acute illness/injury and between 3% and 10% develop posttraumatic stress disorder. However, significant knowledge gaps remain in our understanding of psychological outcomes for infants and young children, identification of risk-factors and availability of evidence-based interventions for medical trauma following illness.
Conclusions
This topical review on medical trauma during early childhood provides: (a) definitions of key medical trauma terminology, (b) discussion of important developmental considerations, (c) summary of the empirical literature on psychological outcomes, risk factors, and interventions, (d) introduction to a stepped-model-of-care framework to guide clinical practice, and (e) summary of limitations and directions for future research.
Objective Group-based trajectory modeling was used to identify patterns of posttraumatic stress symptom (PTSS) in children 6–16 years following accidental injury. The aims were to: (a) identify ...probable groups of children following distinct trajectories, and (b) identify risk factors affecting the probability of group membership. Method Children's Impact of Events Scale (n = 190) was used to assess PTSS up to 2 years post injury. Age, gender, type of injury, and preinjury behavior were assessed as risk factors. Results Three distinct trajectory groups were identified: resilient (57%), elevated stress symptoms which recovered quickly (33%), and chronic (10%). Younger children were more likely to be in the recovery group. Those with serious injuries were more likely to be in the chronic group. Preinjury child behavior problems were predictive of recovery and high chronic symptoms. Conclusion Identification of distinct PTSS trajectory groups has implications for understanding the course and treatment of PTSS in children.
This study aimed to identify predictors, especially cognitive predictors, of posttraumatic stress symptoms (PTSS) and posttraumatic stress disorder (PTSD) in children 6 months after Paediatric ...Intensive Care Unit (PICU) admission. Participants were 55 children aged 6–16, admitted to PICU for at least 8 h. Medical data were collected from patient charts. Cognitive variables (peri-trauma affect, cognitive processing and trauma memory) were assessed by interview and self-report questionnaires 2–4 weeks and 6 months following PICU admission. Acute PTSS at 2–4 weeks were assessed by self-report questionnaire and PTSD at 6 months was assessed by clinical interview. Receiving ketamine in PICU was the only non-cognitive variable associated with PTSS at 6 months. Peri-trauma affect, cognitive processing, and trauma memory significantly and independently accounted for 21% of the variance in PTSS at 6 months even after controlling for acute PTSS (and ketamine). A mediation analysis showed that peri-trauma affect indirectly influenced PTSS at 6 months through its effect on cognitive processing. Conclusions: Cognitive variables significantly contribute to PTSS in children, following PICU admission. Peri-trauma affect influenced PTSS only via disrupted cognitive processing. Prevention or early intervention strategies aimed at helping children develop a complete, contextual trauma narrative may be effective in reducing persistent posttraumatic stress responses in children following PICU.
Objective Trajectory analyses were used to empirically differentiate patterns of posttraumatic stress symptoms in parents following child accidental injury and explore the relationship between parent ...and child recovery patterns. Method Parent (n = 189) self-reported symptoms from acute to 2 years post accident were examined to (1) identify distinct parent symptom trajectories; (2) identify risk factors; and (3) explore the patterns of children and parents together. Results Analysis revealed three distinct symptom trajectory groups for parents: resilient (78%); clinical level acute symptoms that declined to below clinical level by 6 months (recovery 8%); and chronic subclinical (14%). Children of resilient parents were most likely to be resilient. Half of the children of parents with chronic subclinical trajectories were likely to have chronic trajectories. Conclusion Clinicians cannot rely only on clinical level symptoms in parents to identify high risk families but include families where the parent has subclinical level symptoms.
The authors examined the relationship between maternal depression, paternal psychopathology, and adolescent diagnostic outcomes in a community sample of 522 Australian families. They also examined ...whether chronic family stress, father's expressed emotion, and parents' marital satisfaction mediated the relationship between parental psychopathology and adolescent outcomes. Mother's education, child's gender, and family income were covaried in all analyses. Results revealed that maternal depression and paternal depression had an additive effect on youth externalizing disorders. In addition, maternal depression interacted with both paternal depression and paternal substance abuse in predicting youth depression but not youth nondepressive disorders. Chronic family stress and father's expressed emotion appeared to mediate the relationship between parental psychopathology and youth depression.
This study aimed to explore children's experiences and memories of the pediatric intensive care unit (PICU) and identify the relative importance of premorbid, trauma, and cognitive/affective ...variables associated with acute posttraumatic stress symptoms (PTSS). Participants were 95 children aged 6-16 years admitted to the PICU and their parents. Children completed questionnaires and an interview assessing PTSS, peritrauma affect, and their memory of the admission 3 weeks following discharge. Medical data were extracted from patient charts. Premorbid and demographic data were provided by parent questionnaire. Most children remembered some aspects of their admission. Younger age, admission for traumatic injury (rather than non-injury-related reasons), and cognitive/affective factors including confusion, peritrauma panic, and sensory memory quality were associated with acute PTSS. Age and traumatic injury accounted for 18% of the variance in PTSS (p < .01). The addition of cognitive/affective variables increased the explained variance to 38% (p < .001). Child age did not moderate the effect of cognitive/affective variables on PTSS. This study demonstrates that objective indicators of disease severity do not adequately explain the high prevalence of PTSS in children following PICU admission. It also suggests that subjective, cognitive factors such as the way children process and remember a PICU admission are very important in the onset of PTSS.
Although there is some information available regarding the utility of the Children's Revised Impact of Event Scale (CRIES) in screening for posttraumatic stress disorder (PTSD), data are scarce and ...limited to studies sampling children predominantly injured in road traffic accidents. This study investigated the utility of 2 versions, the CRIES‐8 and CRIES‐13, in identifying those children meeting criteria for PTSD following admission to a pediatric intensive care unit (PICU). The Children's PTSD Inventory (CPTSDI), a diagnostic interview, and the CRIES‐13 were administered to 55 children, aged 6–16 years, 6 months following admission to the PICU. Of the 55, 14 (25%) met criteria on the CPTSDI. Cutoff scores of 14.5 on the CRIES‐8 and 22.5 on the CRIES‐13 maximized sensitivity and specificity and correctly classified 78%–86% of children. Both cutoff scores were lower than those reported in other samples. The CRIES‐13 appeared to offer greater utility than the CRIES‐8, also in contrast to previous findings. Methodological or sampling differences may account for the discrepancy with prior studies. The proposed cutoffs are recommended specifically for use with PICU patients and replication and further validation of the CRIES with other samples is warranted.
To assess the effect of an intensive care unit (ICU) diary versus no ICU diary on patients, and their caregivers or families, during the patient's recovery from admission to an ICU.
Systematic review ...of randomized controlled trials (RCTs) and clinical controlled trials.
CENTRAL, MEDLINE, CINAHL, EMBASE, PsycINFO, PILOT; Web of Science Conference Proceedings, clinical trial registries and reference lists of identified trials.
Studies evaluated the effectiveness of patient diaries, when compared to no ICU diary, for patients or family members to promote recovery after admission to ICU were included. Outcome measures for describing recovery from ICU included the risk of post-traumatic stress disorder (PTSD), anxiety, depression and post-traumatic stress symptomatology, health-related quality of life and costs. We used standard methodological approaches as expected by The Cochrane Collaboration. Two review authors independently reviewed titles for inclusion, extracted data and undertook risk of bias according to pre-specified criteria.
We identified three eligible studies; two describing ICU patients (N=358), and one describing relatives of ICU patients (N=30). No study adequately reported on risk of PTSD as described using a clinical interview, family or caregiver anxiety or depression, health-related quality of life or costs. Within a single study there was no clear evidence of a difference in risk for developing anxiety (RR 0.29, 95% CI 0.07–1.19) or depression (RR 0.38, 95% CI 0.12–1.19) in participants who received ICU diaries, in comparison to those that did not receive a patient diary. Within a single study there was no evidence of difference in median post-traumatic stress symptomatology scores (diaries 24, SD 11.6; no diary 24, SD 11.6) and delusional ICU memory recall (RR 1.04, 95% CI 0.84–1.28) between the patients recovering from ICU admission who received patient diaries, and those who did not. One study reported reduced post-traumatic stress symptomatology in family members of patients recovering from admission to ICU who received patient diaries (median 19; range 14–28), in comparison to no diary (median 28; range 14–38).
Currently there is minimal evidence from RCTs of the benefits or harms of patient diaries for patients and their caregivers or family members. A small study has described their potential to reduce post-traumatic stress symptomatology in family members. However, there is currently inadequate evidence to support their effectiveness in improving psychological recovery after critical illness for patients and their family members.
This study explored the diagnosis of posttraumatic stress disorder (PTSD) in children and adolescents following pediatric intensive care unit (PICU) admission. Specifically, the study aimed to ...describe the presentation and prevalence of PTSD symptoms 6 months postdischarge, explore the validity of the DSM-IV PTSD algorithm and alternative PTSD algorithm (PTSD-AA) in school-aged children and adolescents, and examine the diagnostic utility of Criterion C3 (inability to recall aspects of a trauma) in this cohort.
Participants were 59 children aged 6-16, admitted to PICU for at least 8 hours. PTSD was assessed via diagnostic interview (Children's PTSD Inventory) 6 months following PICU discharge.
The PTSD-AA was found to provide the most valid measure of PTSD at 6 months. Removing Criterion C3 improved the validity of Criterion C.
This study supports the use of the PTSD-AA excluding Criterion C3 for identifying highly traumatized children and adolescents following PICU admission.
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