Better predictors are needed for posttraumatic stress disorder in children
Unlike in adults, acute stress disorder is not a sensitive predictor of PTSD in children
Philadelphia -- Clinicians seeking to predict which acutely traumatized children are in need of more extensive follow-up should not rely solely on assessment of acute stress disorder (ASD) as a diagnostic tool. Research at The Children's Hospital of Philadelphia found that only one in five children who developed posttraumatic stress disorder (PTSD) would have been identified during the immediate post-trauma period using only ASD diagnostic criteria. The study appears in the April issue of the Journal of the American Academy of Child and Adolescent Psychiatry.
"Based on previous findings that have found a strong connection between ASD and future PTSD in adults, we set out to demonstrate sensitivity and specificity in predicting child PTSD among children with significant ASD symptoms," said lead author Nancy Kassam-Adams, Ph.D., associate director of behavioral research, TraumaLink at Children's Hospital. "Only when we used symptom subsets like dissociation or arousal did we find sensitive predictors for PTSD."
The study population included 243 children admitted to The Children's Hospital of Philadelphia for traffic-related injuries between July 1999 and October 2001. The children had been injured in a traffic crash in which the child was a motor vehicle passenger, a pedestrian or a bicyclist. The researchers assessed ASD symptoms within one month of the injury in 243 children. They assessed PTSD at least three months after the injury in 177 of the 243 children assessed previously.
Acute stress disorder is a group of symptoms and reactions that may occur within the first month after a traumatic experience. ASD symptoms include re-experiencing the trauma (unwanted and upsetting thoughts or memories), avoiding reminders of the trauma, hyperarousal (jumpiness), and dissociation (emotional numbing, feelings of unreality).
Post-traumatic stress disorder (PTSD) is diagnosed when the re-experiencing, avoidance and hyperarousal symptoms persist for a long time (at least one month) and begin to impair the individual's everyday functioning. Prior research indicates that even children with minor injuries from a traffic crash are at risk for developing PTSD, says Dr. Kassam-Adams.
The Children's Hospital researchers found that acute stress symptoms were common within the first month after injury. Among the 243 injured children, eight percent met criteria for ASD; another 14 percent reported all symptoms except dissociation, and 21 percent, regardless of diagnosis, reported impairment in their functioning from acute stress symptoms.
In the 177 children evaluated three months or more after the injury, six percent met criteria for PTSD, while another 11 percent reported moderate to severe symptoms in each category of PTSD and impairment from these symptoms.
However, of the children who went on to develop PTSD, only 20 percent had met the full criteria for ASD within a month after their injury. Even when diagnoses of subsyndromal ASD (meeting all ASD criteria except dissociation) were added to those of full ASD, 60 percent of the children who later developed PTSD would not have been predicted by ASD diagnoses.
"More research is needed to provide the best criteria for predicting PTSD in children," said Flaura K. Winston, M.D., Ph.D., study co-author and director of TraumaLink at The Children's Hospital of Philadelphia. "This study confirms previous research that a substantial subset of injured children are affected by traumatic stress disorders--about one-fifth of the children in our study."
In the meanwhile, Dr. Kassam-Adams and her colleagues are developing practical tip sheets and parent handouts to help health care professionals who take care of injured children provide appropriate assistance and information to children and families. These materials are available from the Center for Pediatric Traumatic Stress at Children's Hospital of Philadelphia: email@example.com.
Recommendations for health care professionals treating a recently injured child include:
1. Ask child and parents about the injury, their reactions and how they are coping.
2. Help your patient and his/her parents understand common acute stress reactions, by sharing basic information about the range of normal emotional reactions. A key message is that some acute distress is common, and that most children and parents will recover well.
3. Offer parents anticipatory guidance, such as:
- Talk with your child and listen to his/her thoughts and feelings
- Help your child get back to normal activities (as much as possible given the injury).
- Use your support system, and remember to get support for yourself as well as your child.
4. Listen for any distressing traumatic stress reactions or interference with day-to-day activities. Keep in mind that some factors (such as prior traumatic experiences) put children at higher risk for persistent distress.
5. If acute stress appears to be impairing your patient's day-to-day functioning or multiple risk factors are present, schedule a follow-up visit to monitor the child's reactions more closely and consider referral to a mental health professional for further evaluation and support.
Source: Eurekalert & othersLast reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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