Psychiatric outcome following paediatric intensive care unit (PICU) admission: a cohort study

Mediators of Initial Acute and Later Posttraumatic Stress in Youth in a PICU

OBJECTIVES

Youth in a PICU and their parents may experience initial symptoms of acute stress disorder and later symptoms of posttraumatic stress disorder. The objective of this study was to examine potential mediators of these conditions, including youth anxiety, depression, negative affect, and hospital fear, as well as parent anxiety and depression

DESIGN

This study involved a short longitudinal design that encompassed initial assessments in a PICU setting and later assessments 4-7 weeks after discharge.

SETTING

Youth and their parents completed dependent measures in the hospital and at follow-up at the youth's home or an outpatient clinic setting.

PATIENTS

Fifty youth aged 9-17 yrs were admitted to a PICU for respiratory illness/asthma (30.0%), trauma (26.0%), surgery and after surgery recovery (20.0%), infections/viral illness (8.0%), neurologic disorder (6.0%), or other (10.0%). Parents (n = 50) were also assessed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Measures were utilized for youth anxiety, acute stress, depression, negative affect, posttraumatic stress, and hospital fear, as well as parent anxiety, acute stress, depression, and posttraumatic stress. Some youth (26%) and parents (24%) had substantial posttraumatic stress disorder symptoms develop. Youth acute stress disorder symptoms in the PICU predicted later youth posttraumatic stress disorder symptoms, parent acute stress disorder symptoms in the PICU predicted later parent posttraumatic stress disorder symptoms, and youth acute stress disorder symptoms in the PICU predicted later parent posttraumatic stress disorder symptoms. Youth anxiety, negative affect, and hospital fear mediated initial youth acute stress disorder symptoms and later youth posttraumatic stress disorder symptoms.

CONCLUSIONS

Youth in a pediatric intensive care unit are at increased risk for posttraumatic stress disorder and should be screened for acute stress disorder.

Health-related quality of life following pediatric critical illness

PURPOSE

The aims of this focused review of the literature on children surviving critical illness were to (1) determine whether health-related quality of life (HRQL) represents a clinically meaningful outcome measure for children surviving critical illness and (2) evaluate the HRQL measures implemented in pediatric critical care studies to date.

METHODS

This was a focused review of the literature from 1980 to 2015 based on a search of EMBASE/PubMed, MEDLINE and PsycInfo assessing trends and determinants of HRQL outcomes in children surviving critical illness. We also evaluated the psychometric properties of the HRQL instruments used in the studies identified by examining each measure's reported reliability, validity and sensitivity to clinical change.

RESULTS

The literature search identified 253 pediatric articles for potential inclusion in the review, among which data from 78 studies were ultimately selected for inclusion. Of the 22 measures utilized in the studies reviewed, only four demonstrated excellent psychometric properties for use in pediatric critical care trials. Trends in HRQL identified in the studies reviewed suggest significant ongoing morbidity for children surviving critical illness. Key determinants of poor HRQL outcomes include reason for PICU admission (sepsis, meningoencephalitis, trauma), antecedents (chronic comorbid conditions), treatments received (prolonged cardiopulmonary resuscitation, long-stay patients, invasive technology), psychological outcomes (post-traumatic stress disorder, parent anxiety/depression) and social and environmental characteristics (low socioeconomic status, parental education and functioning).

CONCLUSIONS

Validated pediatric HRQL instruments are now available. Significant impact on HRQL has been demonstrated in acute and acute on chronic critical illness. Future pediatric critical care interventional trials should include both mortality as well as long-term HRQL measurements to truly ascertain the full impact of critical illness in children.

Ethics of drug research in the pediatric intensive care unit

Critical illness and treatment modalities change pharmacokinetics and pharmacodynamics of medications used in critically ill children, in addition to age-related changes in drug disposition and effect. Hence, to ensure effective and safe drug therapy, research in this population is urgently needed. However, conducting research in the vulnerable population of the pediatric intensive care unit (PICU) presents with ethical challenges. This article addresses the main ethical issues specific to drug research in these critically ill children and proposes several solutions. The extraordinary environment of the PICU raises specific challenges to the design and conduct of research. The need for proxy consent of parents (or legal guardians) and the stress-inducing physical environment may threaten informed consent. The informed consent process is challenging because emergency research reduces or even eliminates the time to seek consent. Moreover, parental anxiety may impede adequate understanding and generate misconceptions. Alternative forms of consent have been developed taking into account the unpredictable reality of the acute critical care environment. As with any research in children, the burden and risk should be minimized. Recent developments in sample collection and analysis as well as pharmacokinetic analysis should be considered in the design of studies. Despite the difficulties inherent to drug research in critically ill children, methods are available to conduct ethically sound research resulting in relevant and generalizable data. This should motivate the PICU community to commit to drug research to ultimately provide the right drug at the right dose for every individual child.

Children's psychological and behavioral responses following pediatric intensive care unit hospitalization: the caring intensively study

BACKGROUND

Pediatric intensive care unit (PICU) hospitalization places children at increased risk of persistent psychological and behavioral difficulties following discharge. Despite tremendous advances in medical technology and treatment regimes, approximately 25% of children demonstrate negative psychological and behavioral outcomes within the first year post-discharge. It is imperative that a broader array of risk factors and outcome indicators be explored in examining long-term psychological morbidity to identify areas for future health promotion and clinical intervention. This study aims to examine psychological and behavioral responses in children aged 3 to 12 years over a three year period following PICU hospitalization, and compare them to children who have undergone ear, nose and/or throat (ENT) day surgery.

METHODS/DESIGN

This mixed-methods prospective cohort study will enrol 220 children aged 3 to 12 years during PICU hospitalization (study group, n = 110) and ENT day surgery hospitalization (comparison group, n = 110). Participants will be recruited from 3 Canadian pediatric hospitals, and followed for 3 years with data collection points at 6 weeks, 6 months, 1 year, 2 years and 3 years post-discharge. Psychological and behavioral characteristics of the child, and parent anxiety and parenting stress, will be assessed prior to hospital discharge, and again at each of the 5 subsequent time points, using standardized measures. Psychological and behavioral response scores for both groups will be compared at each follow-up time point. Multivariate regression analysis will be used to adjust for demographic and clinical variables at baseline. To explore baseline factors predictive of poor psychological and behavioral scores at 3 years among PICU patients, correlation analysis and multivariate linear regression will be used. A subgroup of 40 parents of study group children will be interviewed at years 1 and 3 post-discharge to explore their perceptions of the impact of PICU hospitalization on their children and enhance our understanding of findings generated from standardized measures in the larger cohort study. An interpretive descriptive approach will guide qualitative data collection and analysis.

DISCUSSION

This study aims to generate new information regarding the magnitude and duration of psychological and behavioral disturbances among children admitted to PICUs, potentially leading to remedial or preventive interventions.

Predictors of parent post-traumatic stress symptoms after child hospitalization on general pediatric wards: a prospective cohort study

OBJECTIVE

The aim of this study was to identify predictors of parental post-traumatic stress symptoms following child hospitalization.

METHODS

In this prospective cohort study, a sample of 107 parents completed questionnaires during their child's hospitalization on pediatric (non-intensive care) wards and again three months after discharge. Eligible parents had a child expected to be hospitalized for three or more nights. Standardized questionnaires were used to assess parent distress during the child's hospitalization, parent coping strategies and resources, and symptoms of post-traumatic stress after the hospitalization. Correlations and multiple regressions were used to determine whether parent distress during hospitalization and coping strategies and resources predicted post-traumatic stress symptoms three months after the child's discharge, while controlling for relevant covariates.

RESULTS

Three months after the child's hospital discharge, 32.7% of parents (n=35) reported some degree of post-traumatic stress symptoms, and 21.5% (n=23) had elevated (≥34) scores consistent with a probable diagnosis of post-traumatic stress disorder. In the multivariable model, parent anxiety and uncertainty during hospitalization and use of negative coping strategies, such as denial, venting and self-blame, were associated with higher post-traumatic stress symptoms scores at three months post-discharge, even after controlling for the child's health status. Parental anxiety and depression during hospitalization moderated the relationship between negative coping strategies and post-traumatic stress symptoms.

CONCLUSIONS

More than one quarter of parents of children hospitalized on pediatric (non-intensive care) wards experienced significant post-traumatic stress symptoms after their child's discharge. Parents' hospital-related anxiety, uncertainty and use of negative coping strategies are potentially modifiable factors that most strongly influenced post-traumatic stress symptoms. Further research is urgently needed to test the effectiveness of different methods to provide psychological, emotional and instrumental support for parents, focusing on increasing parent coping resources and reducing distress during hospitalization.

A study of consent for participation in a non-therapeutic study in the pediatric intensive care population

OBJECTIVE

To document the legal guardian-related barriers to consent procurement, and their stated reasons for non-participation in a paediatric critical care research study.

STUDY DESIGN

A multicentre, prospective, cohort study.

PARTICIPANTS

Legal guardians of children who participated in a multicentre study on adrenal insufficiency in paediatric critical illness. Data were collected on all consent encounters in the main study.

METHODS

Screening data, reasons for consent not being obtained, paediatric risk of mortality (illness severity) scores and age were collected on all 1707 patients eligible for participation in the Adrenal Insufficiency Study.

RESULTS

The main barriers to approaching legal guardians for consent were lack of availability of the legal guardians (321/1707) and language barriers (84/1707). Legal guardians of 917 patients were approached with an overall consent rate of 42% (range 14-56% across the seven sites). 81% of the 528 legal guardians who declined consent provided an unsolicited reason for refusal. The three most commonly stated reasons were: being overwhelmed (117/429), not wanting anything else done to their child (63/429) and not wanting an additional medication (53/429). In addition, 14.2% cited research-related concerns as the reason for their non-participation.

CONCLUSIONS

Barriers to consent procurement in a non-therapeutic paediatric critical care study appear to occur at many levels with lack of availability of legal guardians, and legal guardians feeling overwhelmed, being the most commonly recorded reasons. Further research into the impact of these findings on the validity and generalisability of the results of such studies is necessary prior to the development and study of future consent models.

Parental symptoms of posttraumatic stress after pediatric extracorporeal membrane oxygenation*

OBJECTIVE

To investigate the prevalence of posttraumatic stress symptoms in parents of children who have been supported on extracorporeal membrane oxygenation and to explore associated factors.

DESIGN

Descriptive cross-sectional study.

SETTING

A specialist pediatric tertiary center in the United Kingdom.

SUBJECTS

Parents (n = 52) of children who had been supported with extracorporeal membrane oxygenation at least 6 months previously.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Self-reported questionnaires were completed measuring posttraumatic stress symptom, family functioning, depression, anxiety, and demographic variables. Approximately 20% of parents experienced posttraumatic stress symptoms at levels suggestive of a diagnosis of posttraumatic stress disorder, irrespective of the time that had elapsed since extracorporeal membrane oxygenation. Although having a child who had ongoing illness before extracorporeal membrane oxygenation was associated with avoidance posttraumatic stress symptoms, results suggest that other previously identified risk factors, such as gender and family functioning, may not be risk factors for posttraumatic stress symptom in this population.

CONCLUSIONS

A substantial number of parents in this population experience posttraumatic stress symptom. Psychological interventions may be targeted toward those whose child has had ongoing illness before extracorporeal membrane oxygenation.

Protocol for a longitudinal qualitative study: survivors of childhood critical illness exploring long-term psychosocial well-being and needs--The SCETCH Project

INTRODUCTION

Life-threatening critical illness affects over a quarter of a million children and adolescents (0-18 years old) annually in the USA and the UK. Death from critical illness is rare; however, survivors and their families can be exposed to a complex array of negative physical, psychological and social problems. Currently, within the literature, there is a distinct paucity of child and adolescent survivor self-reports, thus limiting our understanding of how survivors perceive this adversity and subsequently cope and grow in the long-term following their critical illness. This study aims to explore and understand psychosocial well-being and needs of critical illness survivors, 6-20 months post paediatric intensive care admission.

METHODS AND ANALYSIS

A longitudinal, qualitative approach will provide a platform for a holistic and contextualised exploration of outcomes and mechanisms at an individual level. Up to 80 participants, including 20 childhood critical illness survivors and 60 associated family members or health professionals/teachers, will be recruited. Three interviews, 7-9 weeks apart, will be conducted with critical illness survivors, allowing for the exploration of psychosocial well-being over time. A single interview will be conducted with the other participants enabling the exploration of contextual information and how psychosocial well-being may inter-relate between critical illness survivors and themselves. A 'tool box' of qualitative methods (semi-structured interviews, draw and tell, photo-elicitation, graphic-elicitation) will be used to collect data. Narrative analysis and pattern matching will be used to identify emergent themes across participants.

ETHICS AND DISSEMINATION

This study will provide an insight and understanding of participants' experiences and perspectives of surviving critical illness in the long term with specific relation to their psychosocial well-being. Multiple methods will be used to ensure that the findings are effectively disseminated to service users, clinicians, policy and academic audiences. The study has full ethical approval from the East Midlands Research Ethics Committee and has received National Health Service (NHS) governance clearance.

Psychosocial experiences of parents of infants with hypoplastic left heart syndrome in the PICU

OBJECTIVE

To evaluate the psychosocial status of mothers and fathers of infants with hypoplastic left heart syndrome while in the PICU.

DESIGN

A retrospective study combining interviews and psychometric testing of parents.

SETTING

Tertiary hospital PICU.

SUBJECTS

Twenty-nine parents (16 mothers and 13 fathers) of surviving children.

INTERVENTION

A semistructured face-to-face interview was conducted to explore parental experiences, and a Structured Clinical Interview for Diagnosis-Clinical Version (posttraumatic stress disorder module) was conducted to determine the possibility of an acute stress disorder or a posttraumatic stress disorder.

MEASUREMENT AND MAIN RESULTS

All parents reported multiple stresses which commenced with their infant's diagnosis and endured throughout their infant's time in PICU. The Structured Clinical Interview for Diagnosis revealed that acute stress disorder or posttraumatic stress disorder developed in 24 parents (83%). Of 18 parents whose infants were diagnosed with hypoplastic left heart syndrome in utero, eight of nine mothers (88%) and six of nine fathers (66%) had posttraumatic stress disorder. Of 11 parents whose infants were diagnosed with hypoplastic left heart syndrome postbirth, six of seven mothers had acute stress disorder and one mother had posttraumatic stress disorder, and of four fathers, two fathers had acute stress disorder and one father had posttraumatic stress disorder. The prevalence of parental stress-related disorder was not different between mothers and fathers (p = 0.85). Only five parents were free of traumatic stress-related illness. Parents also experienced losses. Many parents were marginalized from their infant's care by the environment of PICU. Fifty percent of mothers experienced difficulties with parental-infant bonding. Ten parents (34%) began the process of adaptation to their infant's hypoplastic left heart syndrome and were assisted by the support and sensitivity of staff or had discovered other resources.

CONCLUSIONS

All parents of surviving infants with hypoplastic left heart syndrome in PICU, irrespective of timing of diagnosis, experienced numerous stresses and losses, and the majority exhibited clinical levels of traumatic stress. Receiving the diagnosis itself is very traumatic and is compounded by the environment of the PICU which alienates parents from their infants and interferes with parent-infant bonding. Parental adaptation to this situation can be assisted by staff.

Parental coping in the neonatal intensive care unit

Fifty-six mothers of premature infants who participated in a study to reduce symptoms of posttraumatic stress disorder (PTSD) completed the Brief COPE, a self-report inventory of coping mechanisms, the Stanford Acute Stress Reaction Questionnaire to assess acute stress disorder (ASD) and the Davidson Trauma Scale to assess PTSD. 18 % of mothers had baseline ASD while 30 % of mothers met the criteria for PTSD at the 1-month follow-up. Dysfunctional coping as measured by the Brief COPE was positively associated with elevated risk of PTSD in these mothers (RR = 1.09, 95 % CI 1.02-1.15; p = .008). Maternal education was positively associated with PTSD; each year increase in education was associated with a 17 % increase in the relative risk of PTSD at 1 month follow-up (RR = 1.17, 95 % CI 1.02-1.35; p = .03). Results suggest that dysfunctional coping is an important issue to consider in the development of PTSD in parents of premature infants.

Pediatric delirium: monitoring and management in the pediatric intensive care unit

This review article updates the pediatric medical community on the current literature regarding diagnosis and treatment of delirium in critically ill children. This information will be of value to pediatricians, intensivists, and anesthesiologists in developing delirium monitoring and management protocols in their pediatric critical care units.

Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children

OBJECTIVE

To assess short-term neuropsychological function and academic performance in school children following admission to intensive care and to explore the role of critical neurologic and systemic infection.

DESIGN

A prospective observational case-control study.

SETTING

Two PICUs.

SUBJECTS

A consecutive sample of 88 children aged 5-16 years (median age=10.00, interquartile range=6.00-13.00) who were admitted to intensive care between 2007 and 2010 with meningoencephalitis, septic illness, or other critical illnesses. They were assessed 3 to 6 months following discharge, and their performance was compared with that of 100 healthy controls. Patients were without prior neurologic or neurodevelopmental disorder.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data encompassing demographic and critical illness details were obtained, and children were assessed using tests of intellectual function, memory, and attention. Questionnaires addressing academic performance were returned by teachers. After adjusting for covariates, the children admitted to PICUs significantly underperformed on neuropsychological measures in comparison to healthy controls (p<0.02). Teachers deemed more children admitted to PICUs than controls as performing educationally worse and having problems with school work (ps=0.001), as well as performing below average on aspects of executive function and attention (ps<0.04). Analysis of the effect of illness type on outcome revealed that aspects of neuropsychological function, such as memory function, and teacher-rated academic performance were most reduced in children with meningoencephalitis and septic illness. In the PICU group, multivariable linear regression revealed that worse performance on a composite score of neuropsychologic impairment was more prevalent when children were younger, from a lower social class, and had experienced seizures during their admission (ps<0.02).

CONCLUSIONS

Admission to intensive care is followed by deficits in neuropsychologic performance and educational difficulties, with more severe difficulties noted following meningoencephalitis and septic illness. These results highlight the importance of future studies on cognition and educational outcome incorporating type of illness as a moderating factor.

Patterns of post-traumatic stress symptoms in families after paediatric intensive care

PURPOSE

To establish longitudinal rates of post-traumatic stress in a cohort of child-parent pairs; to determine associations with poorer outcome.

METHOD

This was a prospective longitudinal cohort study set in a 21-bed unit. In total 66 consecutive admissions aged 7-17 years were screened with one parent at 3 and 12 months post-discharge. Measures used were the Children's Revised Impact of Event Scale (CRIES-8) and the SPAN (short form of Davidson Trauma Scale).

RESULTS

In total 29 (44 %) child-parent pairs contained at least one member who scored above cut-off 12 months after discharge, with scores increasing over time for 18 parents and 26 children. At 3 months, 28 (42 %) parents and 20 (32 %) children scored above cut-off; at 12 months the rates were 18 (27 %) parents and 17 (26 %) children. Parents scoring above cut-off at 12 months were more likely to have had a child admitted non-electively (100 % vs. 77 %, p = 0.028); had higher 3-month anxiety scores (11.5 vs. 4.5, p = 0.001) and their children had higher post-traumatic stress scores at 3 months (14 vs. 8, p = 0.017). Children who scored above cut-off at 12 months had higher 3-month post-traumatic stress scores (18 vs. 7, p = 0.001) and higher Paediatric Index of Mortality (PIM) scores on admission (10 vs. 4, p = 0.037).

CONCLUSIONS

The findings that (a) nearly half of families were still experiencing significant symptoms of post-traumatic stress 12 months after discharge; (b) their distress was predicted more by subjective than by objective factors and (c) many experienced delayed reactions, indicate the need for longer-term monitoring and more support for families in this situation.

Posttraumatic stress disorder in children and their parents following admission to the pediatric intensive care unit: a review

OBJECTIVE

To evaluate posttraumatic stress disorder in children who have been admitted to the pediatric intensive care unit and their families.

DATA SOURCES

Studies were identified through PubMed, MEDLINE, and Ovid.

STUDY SELECTION

All descriptive, observational, and controlled studies with a focus on posttraumatic stress disorder and the pediatric intensive care unit were included.

DATA EXTRACTION AND DATA SYNTHESIS

Posttraumatic stress disorder rates in children following admission to the pediatric intensive care unit were between 5% and 28%, while rates of posttraumatic stress disorder symptoms were significantly higher, 35% to 62%. There have been inconsistencies noted across risk factors. Objective and subjective measurements of disease severity were intermittently positively associated with development of posttraumatic stress disorder. There was a positive relationship identified between the child's symptoms of posttraumatic stress disorder and their parents' symptoms.The biological mechanisms associated with the development of posttraumatic stress disorder in children admitted to the pediatric intensive care unit have yet to be explored. Studies in children following burn or other unintentional injury demonstrate potential relationships between adrenergic hormone levels and a diagnosis of posttraumatic stress disorder. Likewise genetic studies suggest the importance of the adrenergic system in this pathway.The rates of posttraumatic stress disorder in parents following their child's admission to the pediatric intensive care unit ranged between 10.5% and 21%, with symptom rates approaching 84%. It has been suggested that mothers are at increased risk for the development of posttraumatic stress disorder compared to fathers. Objective and subjective measures of disease severity yielded mixed findings with regard to the development of posttraumatic stress disorder. Protective parental factors may include education or the opportunity to discuss the parents' feelings during the admission.

CONCLUSIONS

Following admission to the pediatric intensive care unit, both children and their parents have high rates of trauma exposure, both personally and secondary exposure via other children and their families, and subsequently are reporting significant rates of posttraumatic stress disorder. To effectively treat our patients, we must recognize the signs of posttraumatic stress disorder and strive to mitigate the negative effects.

Evaluation and comparison of parental needs, stressors, and coping strategies in a pediatric intensive care unit

OBJECTIVE

To evaluate and compare the needs, stressors, and coping strategies of mothers and fathers in a pediatric intensive care unit, and to advance the development of the COMPASS questionnaire for examining parent experiences.

DESIGN

Prospective cohort study using a modified version of a pilot questionnaire, incorporating a series of 58 questions based on a visual analog scale in three categories of needs, stressors, and coping strategies.

SETTING

Tertiary pediatric intensive care unit, Southampton University Hospitals, Southampton, UK.

SUBJECTS

A total of 182 parents (91 mothers and 91 fathers) of children admitted to the pediatric intensive care unit.

INTERVENTIONS

Collection and analysis of needs, stressors, and coping strategies scores.

MEASUREMENTS AND MAIN RESULTS

Both parents identified the need for honest, open, timely, and understandable information, with access to their child as paramount. Parents found feelings of uncertainty and helplessness to be particularly stressful. The main coping strategies employed by parents were related to trust, assurance, and believing in positive outcomes. The particular needs and stressors of mothers and fathers were found to be similar. There were, however, some statistically significant differences in stressors: mothers had higher stress scores regarding how their child looked, not being able to care for them, witnessing procedures, and on leaving their child as compared with fathers. There were no statistically significant differences in coping mechanisms between the sexes.

CONCLUSIONS

Acute parental experiences can be documented using the COMPASS questionnaire. This study highlights the principal needs, stressors, and coping strategies of parents of children in the pediatric intensive care unit. The experiences of mothers and fathers are similar, but we identify some differences in stressors between the sexes.

Family-centred care in the paediatric intensive care unit

AIM

The aim was to assess emotional support given to mothers of children in intensive care units (ICUs) and make recommendations to nurse managers regarding family-centred nursing care in paediatric ICUs in South Africa.

BACKGROUND

Family-centred care is an essential component of paediatric care. Nurse managers should enhance implementation and sustainability to ensure quality care.

METHODS

A quantitative descriptive research design was used. Structured interviews using questionnaires were conducted with 62 mothers whose children were nursed in ICUs in Bloemfontein.

FINDINGS

Fifteen stressors for mothers were identified and emotional support for mothers in ICU's was assessed and described. Analysis indicated that COPE (Creating Opportunities for Parent Empowerment) can be used within the South African context to enhance family-centred paediatric nursing care.

CONCLUSION

Competencies of nurse practitioners and other staff involved must be improved and the seriousness and importance of emotional support as part of family-centred care should be emphasized.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers should take responsibility for the training of staff in implementing COPE as a possible empowerment programme in Paediatric ICUs to ensure that emotional support is not neglected.

Delirium: an emerging frontier in the management of critically ill children

Delirium is a syndrome of acute brain dysfunction that commonly occurs in critically ill adults and most certainly is prevalent in critically ill children all over the world. The dearth of information about the incidence, prevalence, and severity of pediatric delirium stems from the simple fact that there have not been well-validated instruments for routine delirium diagnosis at the bedside. This article reviewed the emerging solutions to this problem, including description of a new pediatric tool called the pCAM-ICU. In adults, delirium is responsible for significant increases in both morbidity and mortality in critically ill patients. The advent of new tools for use in critically ill children will allow the epidemiology of this form of acute brain dysfunction to be studied adequately, will allow clinical management algorithms to be developed and implemented following testing, and will present the necessary incorporation of delirium as an outcome measure for future clinical trials in pediatric critical care medicine.

Measuring psychological outcomes following pediatric intensive care unit hospitalization: psychometric analysis of the Children's Critical Illness Impact Scale

OBJECTIVE

Critically ill children are at risk for psychological sequelae following pediatric intensive care unit hospitalization. This article reports on the psychometric testing of the first self-report measure of psychological distress for 6-12-yr-old children post-pediatric intensive care unit hospitalization: The Children's Critical Illness Impact Scale. This 23-item scale takes approximately 15 mins for children to complete.

DESIGN

Psychometric testing based on Classic Test Theory and guidelines for health measurement scale development.

SETTING

The pediatric intensive care units of four Canadian pediatric hospitals and the ear, nose, and throat clinic of one participating hospital.

PATIENTS

A total of 172 children (pediatric intensive care unit group, n = 84; ear, nose, and throat group, n = 88) aged 6-12 yrs and their parents.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We assessed the factor structure, internal consistency, and test-retest reliability of the Children's Critical Illness Impact Scale and conducted contrasted group comparisons and convergent and concurrent validation testing. Fit indices and internal consistency were best for a three-factor solution, suggesting three dimensions of psychological distress: 1) worries about getting sick again, 2) feeling things have changed, and 3) feeling anxious and fearful about hospitalization. As expected, Children's Critical Illness Impact Scale scores were positively correlated with child anxiety and medical fear scores. The ear, nose, and throat group scores were higher than expected. Higher Children's Critical Illness Impact Scale scores in older children may reflect a better understanding of the situation and its complexity and meaning, and younger children's tendency to provide more positive self-evaluation.

CONCLUSIONS

The Children's Critical Illness Impact Scale is a promising new self-report measure of psychological distress with demonstrated reliability and validation testing in 6-12-yr-old children post-pediatric intensive care unit hospitalization. This new measure has potential to advance the evidence base for pediatric intensive care unit and post-pediatric intensive care unit health promotion interventions.

The experience of hospital-related fears of 4- to 6-year-old children

BACKGROUND

There is little information available on a 4- to 6-year-old child's subjective experience of hospital-related fears, even though the data collected from parents and hospital staff indicate that hospitalization is an anxiety-producing experience for young children.

METHODS

A qualitative method was chosen using a purposive sample of 90 children. The data were gathered via semi-structured interview from 2004 to 2006. The data were analysed using the structure of Colaizzi's Method of Phenomenological Analysis.

RESULTS

The essential fears were fears related to nursing interventions and pain, to the separation from parents and being left alone, to the lack of information, and to instruments and equipment. Children expressed their fears verbally or through their actions. The meaning of hospital-related fear formed four main clusters: insecurity, injury, helplessness, and rejection.

CONCLUSIONS

For young children, an experience of hospital-related might be so traumatic that it influences the well-being of the child. The fear may damage the sense of security felt by the children, and weaken the child's willingness to trust health-care professionals. The children often expressed their fear in a contradictory manner or denied it. Children need the help of adults to express their hospital-related fears, including the objects of these fears.

Parental presence and visiting policies in Italian pediatric intensive care units: a national survey

OBJECTIVE

To investigate parental presence and visiting policies in Italian pediatric intensive care units (PICUs).

DESIGN

: Descriptive survey.

SETTING

All 34 Italian PICUs.

PATIENTS

Patients were not involved in this work.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A questionnaire was sent to the unit heads. Response rate was 100%. Median daily visiting time for parents was 300 mins; for other visitors, it was 120 mins. Twelve percent of PICUs had unrestricted policies; 59% did not allow the constant presence of a parent, even during the day. Visits from other relatives and from nonfamily were not permitted in 35% and 88% of units, respectively. Policies were not modified for a dying patient in 6% of PICUs. Children's visits were not allowed in 76% of units. Cardiac surgical PICUs were more likely to have restrictive visiting hours. Parents were permitted to be present at the bedside during ordinary nursing procedures, invasive procedures or cardiopulmonary resuscitation in 62%, 3%, and 9% of PICUs, respectively. No waiting room was provided in 32% of PICUs. Gowning procedures were compulsory for visitors in 94% of units. In 48% of PICUs, a formal process of revising visiting policies was ongoing. On patient admission, 77% of PICUs provided the family with informative material on the unit. Phone information on the patient was given frequently (often/always, 70% of PICUs).

CONCLUSIONS

In Italian PICUs, there is a marked tendency to apply restrictive visiting policies, not to allow parents 24-hr access at bedside, and to limit the presence of parents during procedures and cardiopulmonary resuscitation. A revision of current policies has begun, signaling a readiness for change.

Anxiety in medically ill children/adolescents

Anxiety disorders are thought to be one of the most common psychiatric diagnoses in children/adolescents. Chronic medical illness is a significant risk factor for the development of an anxiety disorder, and the prevalence rate of anxiety disorders among youths with chronic medical illnesses is higher compared to their healthy counterparts. Anxiety disorders may develop secondary to predisposing biological mechanisms related to a child's specific medical illness, as a response to being ill or in the hospital, a threatening environment, as a result of other genetic and psychological factors, or as a combination of all these factors. Additionally, exposure to physical pain early in one's life and/or frequent painful medical procedures are correlated with fear and anxiety during subsequent procedures and treatments, and may lead to medical nonadherence and other comorbidities. Anxiety disorders can have serious consequences in children/adolescents with chronic and/or life-limiting medical illnesses. Therefore, proper identification and treatment of anxiety disorders is necessary and may improve not only psychiatric symptoms but also physical symptoms. Behavioral and cognitive methods as well as psychotropic medications are used to treat anxiety disorders in pediatric patients. We will review current treatments for anxiety in children/adolescents with medical illnesses and propose future research directions.

Psychiatric morbidity in pediatric critical illness survivors: a comprehensive review of the literature

OBJECTIVES

To review the prevalence of psychiatric syndromes in pediatric critical illness survivors as well as to summarize data on vulnerabilities and pediatric intensive care unit exposures that may increase risk of developing these syndromes.

DATA SOURCES

MEDLINE (1966-2009), the Cochrane Library (2009, issue 3), and PsycINFO (1967-2009) as of August 9, 2009.

STUDY SELECTION

Case-control, cross-sectional, prospective cohort and retrospective cohort studies as well as randomized controlled trials.

MAIN EXPOSURES

Hospitalization for the treatment of a critical illness.

MAIN OUTCOME MEASURES

Assessments of psychiatric symptoms/disorders at least once after discharge.

RESULTS

Seventeen studies were eligible. The most commonly assessed psychiatric disorders were posttraumatic stress disorder and major depression. The point prevalence of clinically significant posttraumatic stress disorder symptoms ranged from 10% to 28% (5 studies). The point prevalence of clinically significant depressive symptoms ranged from 7% to 13% (2 studies). Preillness psychiatric and/or developmental problems and parental psychopathology were associated with vulnerability to psychiatric morbidity. Neither age nor sex of a child consistently increased vulnerability to postillness psychopathology. Exposure to increased severity of medical illness and pediatric intensive care unit service-delivery characteristics (eg, invasive procedures) were predictors of psychiatric illness in some but not all studies. Early postillness psychiatric symptoms were predictors of later psychiatric morbidity.

CONCLUSIONS

Psychiatric morbidity appears to be a substantial problem for pediatric critical illness survivors. Future research should include more in-depth assessment of post-critical illness depressive, anxiety, and psychotic symptoms, validate existing psychiatric instruments, and clarify how vulnerability factors, pediatric intensive care unit service-delivery characteristics, and severity of critical illnesses are associated with subsequent psychopathology.

Do parents benefit from the offer of a follow-up appointment after their child's admission to intensive care?: an exploratory randomised controlled trial

OBJECTIVE

The study aim was to evaluate the psychological impact on parents of the provision of a paediatric intensive care follow-up clinic.

DESIGN

Exploratory randomised controlled trial. Families were allocated to intervention (follow-up clinic appointment two months after discharge) or control (no appointment) condition.

SETTING

An eight-bed Paediatric Intensive Care Unit (PICU) in an inner city teaching hospital.

MEASUREMENTS

Parents' baseline stress was assessed using the Parental Stressor Scale: PICU. Post-traumatic stress, anxiety and depression were assessed at five months using the Impact of Event Scale and the Hospital Anxiety and Depression Scale.

RESULTS

Only 18/72 families (25%) in the intervention group chose to attend the clinic. Outcome data were provided by 55/82 parents in the intervention group and 50/72 in the control group. Although no significant differences were found between the groups as a whole, parents with higher baseline stress reported lower rates of post-traumatic stress (n=8/32(25%) vs. n=13/23(57%), p=0.018) and depression (n=6/32(19%) vs. n=12/23(52%), p=0.009) at five months if they had been offered an appointment than if they had not.

CONCLUSIONS

Whilst these results do not justify routine follow-up for all, they suggest that, for the most traumatised parents, rates of long-term distress could be reduced by this intervention.

Coping strategies for hospital-related fears in pre-school-aged children

AIM

The aim of this study was to describe the child-reported coping strategies for hospital-related fears in 4-6-year-old children.

METHOD

The data were collected by semi-structured interviews of 4-6-year-old volunteering children (n= 82) in Finland. Thirty-four children were interviewed in hospital, and 48 in kindergarten. The children were chosen through a purposive sampling method, in which volunteers were asked to take part in the study. The data were analysed with quantitative and qualitative methods.

RESULTS

The most frequent child-reported coping strategies were: the presence of parents and other family members (81/517, 15.7%), the help of the hospital personnel (58/517, 11.2%), positive images and humour (57/517, 11%), play (57/517, 11%) and the child's own safety toy (45/517, 8.7%). The children interviewed in hospital mentioned significantly more often play (P= 0.000) as their coping strategy than children interviewed in a kindergarten. Children interviewed in kindergarten expressed significantly more often the presence of parents (P= 0.032) and the help of the doctor (P= 0.012) as their coping strategy than the children interviewed in the hospital.

CONCLUSIONS

The results showed that children have many coping strategies, especially ones in which the children themselves play an active role. Besides, the traditional methods for alleviating fear, children need possibilities to use coping methods in which they have an active role giving them a feeling of some control over the hospital environment and medical procedures.

Course and predictors of posttraumatic stress disorder in parents after pediatric intensive care treatment of their child

OBJECTIVE

To study posttraumatic stress disorder (PTSD) in parents after unexpected pediatric intensive care unit (PICU) treatment of their child and to identify risk factors for its development.

METHOD

Parents completed PTSD questionnaires 3 and 9 months (N = 190) after PICU treatment. Risk factors included pretrauma data, medical data, social demographics and posttraumatic stress responses at 3 months.

RESULTS

In total, 30.3% of parents met criteria for subclinical PTSD and 12.6% for clinical PTSD at 3 months. Clinical PTSD prevalence rates did not change over time. At 9 months, 10.5% of parents still met criteria for PTSD. Number of earlier stressful life events, earlier psychosocial care and posttraumatic stress responses at 3 months predicted persistent subclinical and clinical PTSD.

CONCLUSIONS

PICU admission is a stressful event associated with persistent parental PTSD. Assessment of risk factors can facilitate detection of persistent PTSD for early intervention.

Psychiatric morbidity and functional impairments in survivors of burns, traumatic injuries, and ICU stays for other critical illnesses: a review of the literature

Severe burns, traumatic injuries and other critical illnesses are a substantial source of morbidity in the United States. As more patients survive these conditions, there has been increasing interest in psychiatric and functional outcomes of these individuals. In this article, we reviewed the literature on the prevalence of psychiatric conditions, with particular emphasis on posttraumatic stress disorder (PTSD) and depression, as well as functional impairments, in adult and pediatric survivors of burns, trauma and intensive care unit stays for other critical illnesses. We found that PTSD and depressive symptoms are quite prevalent in these patient groups. We also examined potential risk factors for psychiatric morbidity and impaired function in all three patient groups, and conclude that patient-specific and acute care factors, in addition to early post-acute care psychiatric symptoms, may convey risk for subsequent psychopathology and diminished function. Finally, we discussed limitations in the literature as well as possible directions for future research, particularly in clarifying risk factors for psychiatric disorders as well as potential preventative and treatment interventions that may improve outcomes.

Parental anxiety and medical comprehension within 24 hrs of a child's admission to the pediatric intensive care unit*

OBJECTIVE

Admission of a child to the pediatric intensive care unit (PICU) can create high-parental anxiety. The authors examined the factors that contribute to parental anxiety and the effect of parental anxiety on comprehension of medical information within 24 hrs of a child's admission to the PICU. The physician's recognition of parental anxiety related to their child's hospitalization was also evaluated.

DESIGN

Prospective cohort study with a convenience sample of primary caregivers of critically ill children.

SETTING

Twenty-bed PICU at an urban tertiary children's hospital.

SUBJECTS

The primary caregivers of 35 children with Pediatric Risk of Mortality III scores >or=7 admitted to the PICU as well as PICU fellows.

INTERVENTIONS

Parental anxiety was assessed with the State-Trait Anxiety Inventory, a validated tool used to measure both the temporary (State) and long-standing (Trait) anxiety in adults. Comprehension of medical information was assessed by an open-ended questionnaire. Physician assessment of parental anxiety was measured by multiple-choice questionnaire.

MEASUREMENTS AND MAIN RESULTS

Of the 34 parents completing the State-Trait Anxiety Inventory, 21 (62%) had State Anxiety that was significantly higher than a validated sample of patients with generalized anxiety disorder. The child's need for mechanical ventilation was the only significant predictor of high-parental State Anxiety (p = .03). Among the 28 parents completing the questionnaire of comprehension of medical information, 26 (93%) demonstrated excellent or fair comprehension. Physicians had generally low recognition of parental anxiety but were significantly more likely to rate a parent's anxiety as high if the child was on mechanical ventilation.

CONCLUSION

Parental anxiety is high following a child's admission to the PICU. Physicians failed to recognize high-parental anxiety in nearly one third of the parents. Despite the high anxiety associated with a child's admission to the PICU, parents seem to understand their children's medical issues within the first 24 hrs.

A pilot study on peritraumatic dissociation and coping styles as risk factors for posttraumatic stress, anxiety and depression in parents after their child's unexpected admission to a Pediatric Intensive Care Unit

AIM

To study the prevalence of posttraumatic stress disorder (PTSD), anxiety and depression in parents three months after pediatric intensive care treatment of their child and examine if peritraumatic dissocation and coping styles are related to these mental health problems.

METHODS

This is a prospective cohort study and included parents of children unexpectedly admitted to the Pediatric Intensive Care Unit (PICU) from January 2006 to March 2007. At three months follow-up parents completed PTSD (n = 115), anxiety and depression (n = 128) questionnaires. Immediately after discharge, parents completed peritraumatic dissocation and coping questionnaires. Linear regression models with generalized estimating equations examined risk factors for mental health problems.

RESULTS

Over 10% of the parents were likely to meet criteria for PTSD and almost one quarter for subclinical PTSD. Respectively 15% to 23% of the parents reported clinically significant levels of depression and anxiety. Peritraumatic dissocation was most strongly associated with PTSD, anxiety as well as depression. Avoidance coping was primarily associated with PTSD.

CONCLUSION

A significant number of parents have mental health problems three months after unexpected PICU treatment of their child. Improving detection and raise awareness of mental health problems is important to minimize the negative effect of these problems on parents' well-being.

Delirium: an emerging frontier in the management of critically ill children

The objectives of this article are (1) to introduce pediatric delirium and provide understanding of acute brain dysfunction with its classification and clinical presentations (2) to understand how delirium is diagnosed and discuss current modes of delirium diagnosis in the critically ill adult population and translation to pediatrics (3) to understand the prevalence and prognostic significance of delirium in the adult and pediatric critically ill population (4) to discuss the pathophysiology of delirium as currently understood, and (5) to provide general management guidelines for delirium.

Psychological outcomes in children following pediatric intensive care unit hospitalization: a systematic review of the research

A systematic review of published research on children's psychological outcomes following Pediatric Intensive Care Unit (PICU) hospitalization was conducted. Of the 275 papers published between 1970 and April 2008 which were identified using keywords, reference lists and one author's collections, a total of 28 papers met the inclusion criteria for this review. The papers fell into four categories based on the focus of the research: (1) children's PICU perceptions and recall; (2) children's psychological outcomes, broadly defined; (3) post-traumatic stress responses; and (4) general health status and quality of life. The findings suggest that PICU hospitalization can result in negative psychological sequelae in children, which can manifest themselves up to one year post-discharge. While a small number of studies have attempted to identify predictors of psychological outcome, this work remains in its infancy. The importance of the child's interpretation of the illness experience in influencing subsequent behavioral and emotional responses is highlighted.

Outcomes of meningococcal disease in adolescence: prospective, matched-cohort study

OBJECTIVE

We examined the physical, cognitive, educational, social, and psychological outcomes of invasive meningococcal disease in adolescence, as well as demographic and disease factors associated with outcomes.

METHODS

A population-based, matched-cohort study was performed. A total of 101 gender- and age-matched case-control pairs (15-19 years of age at the time of disease; 46% male) from 6 regions of England underwent follow-up evaluations 18 to 36 months after invasive meningococcal disease. Educational, social, and vocational function, mental health, social support, self-efficacy, and quality-of-life data were collected by using standardized questionnaires and neuropsychological tests.

RESULTS

Fifty-seven percent of case subjects (n = 58) had major physical sequelae. Survivors had greater depressive symptoms, greater fatigue, less social support, greater reduction in quality of life, and lower educational attainment compared with control subjects. Survivors with serogroup C disease had greater physical sequelae than did those with serogroup B disease. Greater cognitive deficits were associated with younger age at diagnosis. Only 53 of 101 case subjects reported any medical follow-up care after invasive meningococcal disease.

CONCLUSIONS

Survivors of invasive meningococcal disease in adolescence have a disturbing series of deficits, including poorer physical and mental health, quality of life, and educational achievement. Serogroup C is associated with poorer outcomes. Invasive meningococcal disease attributable to serogroup B disease remains a major cause of morbidity and death among adolescents. Medical care is poor after discharge from the hospital. Routine follow-up care of adolescent survivors may prevent or ameliorate physical and psychosocial morbidity after invasive meningococcal disease.

The impact on parents of a child's admission to intensive care: integration of qualitative findings from a cross-sectional study

OBJECTIVES

In this study, parents were asked which aspects of their experience of having a child in intensive care had caused them the most distress and how they continued to be affected by these experiences.

RESEARCH METHODOLOGY

Semi-structured interviews held with 32 mothers and 18 fathers of children admitted to a paediatric intensive care unit 8 months earlier, were audiotaped, transcribed and subjected to a thematic analysis.

SETTING

The setting was an eight-bed paediatric intensive care unit in an inner city teaching hospital.

RESULTS

Significant themes included the vividness of parents' memories of admission; the intensity of distress associated with times of transition and the lasting impact of their experience, in terms both of the ongoing need to protect their child and in relation to their priorities in life. Fathers reported different coping strategies, spent less time on the unit and were less likely than mothers to report fearing that their child would die.

CONCLUSIONS

Parents report significant and persisting distress. Further research is needed on how best to support them acutely and in the longer term.

The psychologic impact on children of admission to intensive care

There is growing literature on the psychologic impact on parents and families of having a child on the pediatric intensive care unit (PICU), but less is known about the child's experience. In this article the relevant literature is explored and illustrated with examples from the author's research. Recurring themes are the persistence of distress in a significant minority of children and the association between parental anxiety and child's psychologic symptoms. The evidence on the extent of children's factual and delusional memories relating to PICU is also examined. Finally, the implications of the current state of knowledge for future research and for clinical work are discussed.

Posttraumatic stress disorder (PTSD) in children after paediatric intensive care treatment compared to children who survived a major fire disaster

BACKGROUND

The goals were to determine the presence of posttraumatic stress disorder (PTSD) in children after paediatric intensive care treatment, to identify risk factors for PTSD, and to compare this data with data from a major fire disaster in the Netherlands.

METHODS

Children completed the Dutch Children's Responses to Trauma Inventory at three and nine months after discharge from the paediatric intensive care unit (PICU). Comparison data were available from 355 children survivors who completed the same questionnaire 10 months after a major fire disaster.

RESULTS

Thirty-six children aged eight to 17 years completed questionnaires at three month follow-up, nine month follow-up, or both. More than one third (34.5%) of the children had subclinical PTSD, while 13.8% were likely to meet criteria for PTSD. Maternal PTSD was the strongest predictor for child PTSD. There were no significant differences in (subclinical) PTSD symptoms either over time or compared to symptoms of survivors from the fire disaster.

CONCLUSION

This study shows that a considerable number of children have persistent PTSD after PICU treatment. Prevention of PTSD is important to minimize the profound adverse effects that PTSD can have on children's well-being and future development.

Developing the Children's Critical Illness Impact Scale: capturing stories from children, parents, and staff

OBJECTIVE

With the evolution of pediatric critical care medicine has come an awareness of the ethical imperative of healthcare professionals to attend to the psychological sequelae of technologically intensive care. Recent attempts to measure psychological outcomes in these children have been limited. The purpose of this study was to develop a measure of posthospitalization distress, the Children's Critical Illness Impact Scale (CCIIS), for children aged 6-12 yrs following pediatric intensive care unit hospitalization.

DESIGN

A measurement development study consisting of two phases: 1) item generation and scale formatting; and 2) item reduction and scale revisions. Items were generated following thematic analysis of qualitative data from focus groups and individual interviews with children, parents, and healthcare professionals. Children reviewed items for interpretability and importance and assessed scaling technique and item presentation; healthcare professionals further evaluated item relevance.

SETTING

The pediatric intensive care units of three quaternary care, Canadian pediatric teaching hospitals.

PATIENTS

Phase 1 included 18 children, 22 parents, and 12 healthcare professionals (n = 52). Phase 2 included eight children and four healthcare professionals (n = 12).

MEASUREMENTS AND MAIN RESULTS

Five key domains were identified in the thematic analyses: worries, fears, friends and family, sense of self, and behaviors. Thirty-six items were initially generated, and subsequent item reduction resulted in 23 items that were retained on the final scale. Items were generally rated extremely relevant and were judged to capture the content area (content validity index = 0.87). The CCIIS was easily understood, and the scaling format worked well. Older children preferred written items, while younger children will require a modified, pictorial version.

CONCLUSIONS

The CCIIS is a new self-report measure with demonstrated content validity and specific relevance for young school-aged children following pediatric intensive care unit hospitalization. Valid, accessible, and developmentally appropriate measures are essential to identify high-risk children and, ultimately, promote healthy growth and development.

Neuropsychological function in children following admission to paediatric intensive care: a pilot investigation

OBJECTIVE

Little is known about neuropsychological status following acute severe paediatric illness. This pilot study explored the effects on memory function of severe acute paediatric illness and associations between memory functioning and psychiatric sequelae.

DESIGN AND SETTING

Case control study of children after paediatric intensive care unit (PICU) discharge and healthy volunteers.

PATIENTS AND PARTICIPANTS

16 PICU discharged children comprised of 11 boys and 5 girls (mean age 9.44 +/- 2.85 years) tested a mean of 4.8 +/- 1.4 months following hospital discharge, and 16 age- and sex-matched controls.

MEASUREMENTS AND RESULTS

Visual-spatial memory and attention were assessed using the CANTAB battery (visual memory) and verbal memory with the Children Memory Scale; Intelligence Quotient was tested using the Wechsler Abbreviated Scale of Intelligence. Emotional and behavioural function was measured with the Strengths and Difficulties Questionnaire and Impact of Event Scales. Children admitted to PICU displayed statistically poorer performance on tests of spatial memory (spatial working memory) sustained attention (rapid visual information) and verbal memory (word pairs learning and delayed recognition). Septic illness was specifically associated with poorer pattern recognition memory on the CANTAB. There were significant correlations in the PICU group between cognitive functioning and emotional/behaviour scores.

CONCLUSIONS

Our results suggest impaired memory and attention in children following acute severe paediatric illness, a specific deficit in children with septic illness and links between memory anomalies and emotional/behavioural problems. The findings and their clinical significance require replication and clarification in a larger sample.

Quality of life in children three and nine months after discharge from a paediatric intensive care unit: a prospective cohort study

BACKGROUND

Improved survival in children with critical illnesses has led to new disease patterns. As a consequence evaluation of the well being of survivors of Pediatric Intensive Care Units (PICU) has become important. Outcome assessment should therefore consist of evaluation of morbidity, functional health and Health Related Quality of Life (HRQoL). Awareness of HRQoL consequences and physical sequelae could lead to changes in support during the acute phase and thereafter. The aim of this study was to evaluate HRQoL in PICU survivors.

METHODS

Prospective follow-up study three and nine months after discharge from a 14-bed tertiary PICU. Eighty-one of 142 eligible, previously healthy children were included from December 2002 through October 2005. HRQoL was assessed with the TNO-AZL Preschool Children Quality of Life Questionnaire (TAPQOL-PF) for children aged 1 to 6 years of age, the TNO-AZL Children's Quality of Life Questionnaire Parent Form (TACQOL-PF) for children aged 6 to 12 years of age, and the TNO-AZL Children's Quality of Life Questionnaire Child Form (TACQOL-CF) for children aged 8 to 15 years of age. The studied patients were compared with age appropriate normative data using non-parametric tests and effect sizes.

RESULTS

Thirty-one and 27 children, and 55 and 50 parents completed questionnaires respectively three and nine months after discharge. In 1-6 year old children parents reported more lung problems (3 and 9 months), worse liveliness (9 months) and better appetite and problem behaviour (3 months); in 6-12 year old children parents reported worse motor functioning (3 months); and 12-15 year old adolescents reported worse motor functioning (3 months). Large effect sizes indicating clinical significant differences in HRQoL with healthy control subjects were found on more domains.

CONCLUSION

In this small group of PICU survivors differences in HRQoL with the normative population exist three and nine months after discharge. Calculated effect sizes were smaller nine months after discharge. These changes suggest that HRQoL improves over time. More research is necessary but we believe that HRQoL assessment should be incorporated in follow-up programs of PICU survivors.

Follow-up after paediatric intensive care treatment: parental posttraumatic stress

AIM

To study the prevalence of posttraumatic stress in parents after an acute admission to a paediatric intensive care unit (PICU) and to determine risk factors for the development of posttraumatic stress.

METHODS

Parents completed posttraumatic stress questionnaires three months after their child's discharge. This questionnaire measures both symptoms of posttraumatic stress disorder (PTSD) and enables determination of the full psychiatric diagnosis of PTSD. Medical and demographic data concerning their child were gathered from physical evaluations three months after discharge. Of 250 eligible families, 144 (57.6%) participated in this study. The questionnaires were completed by 140 mothers and 107 fathers.

RESULTS

More than three-quarters of the parents experienced persistent symptoms of PTSD. In 21 mothers (15.0%) and 10 fathers (9.3%), the full psychiatric diagnosis of PTSD was determined. In six families, both parents had PTSD. Furthermore, a significant positive correlation was found between symptoms of PTSD of the mothers and the fathers. No obvious medical risk factors could be distinguished.

CONCLUSION

The unexpected admission of a child to a PICU is a stressful event associated with parental posttraumatic stress. Treatment should not end after discharge. Follow-up care is warranted and research should be focused on prevention of these symptoms.

Children's factual and delusional memories of intensive care

RATIONALE

Delusional memories are significantly associated with post-traumatic stress in adult patients after intensive care.

OBJECTIVES

In this study, we attempted to establish whether this relationship was found in children. We also examined the association between factual memory and distress.

METHODS

One hundred two consecutive children, aged between 7 and 17 years, were interviewed about their pediatric intensive care unit (PICU) experience 3 months after discharge from a PICU. Principal measures were the ICU Memory Tool (a checklist of intensive care memories) and an abbreviated version of the Impact of Event Scale (a screen for post-traumatic stress disorder).

MEASUREMENTS AND MAIN RESULTS

In total, 64 of 102 (63%) children reported at least one factual memory of their admission and 33 of 102 (32%) reported delusional memories, including disturbing hallucinations. Traumatic brain injury was negatively associated with factual memory (odds ratio, 0.23; 95% confidence interval [CI], 0.09-0.58; P = 0.002). Longer duration of opiates/benzodiazepines was associated with delusional memory (odds ratio, 4.98; 95% CI, 1.3-20.0; P = 0.023). Post-traumatic stress scores were higher in children reporting delusional memories (adjusted difference, 3.0; 95% CI, 0.06-5.9; P = 0.045) when illness severity and emergency status were controlled for. Factual memory was not significantly associated with post-traumatic stress.

CONCLUSIONS

This study indicates that delusional memories are reported by almost one-third of children and are associated both with the duration of opiates/benzodiazepines and risk of post-traumatic stress. More research is needed on the presence of delusional memories and associated risk factors in children receiving intensive care treatment.

Psychobiology of posttraumatic stress disorder in pediatric injury patients: A review of the literature

Research suggests that about a quarter to a third of children with traffic-related injuries develop posttraumatic stress disorder (PTSD). Early symptoms of PTSD have been found to predict poor mental and physical outcome in studies of medically injured children. However, these symptoms are rarely recognized by physicians who provide emergency care for these children. In addition, there is insufficient knowledge about predictors of posttraumatic stress symptoms in this specific pediatric population. Early identification of those children at particular risk is needed to target preventive interventions appropriately. After some introducing remarks on the classification and the nature of posttraumatic stress reactions, current research findings on psychological and biological correlates of PTSD in pediatric injury patients are presented. The particular focus in this paper is on the neurobiological mechanisms that influence psychological responses to extreme stress and the development of PTSD. Continued study of the psychobiology of trauma and PTSD in pediatric injury patients, both in terms of neurobiology and treatment is needed.

Psychological impact of trauma on developing children and youth

All too often, children and adolescents are exposed to traumatic events that lead to physical injury in many cases, psychological perturbation in most cases, and enduring psychological reactions, notably posttraumatic stress disorder, in a minority of individuals. This sequence of events can affect later development, learning, emotions, and behavior. In the process of caring for the physical injury, it is important for the primary care practitioner (PCP) to correctly interpret these presentations and anticipate the need for specific assessments, immediate intervention, referral, and follow-up. This report provides the foundation for such actions on the part of the PCP.

Outcome of paediatric intensive care survivors

The development of paediatric intensive care has contributed to the improved survival of critically ill children. Physical and psychological sequelae and consequences for quality of life (QoL) in survivors might be significant, as has been determined in adult intensive care unit (ICU) survivors. Awareness of sequelae due to the original illness and its treatment may result in changes in treatment and support during and after the acute phase. To determine the current knowledge on physical and psychological sequelae and the quality of life in survivors of paediatric intensive care, we undertook a computerised comprehensive search of online databases for studies reporting sequelae in survivors of paediatric intensive care. Studies reporting sequelae in paediatric survivors of cardiothoracic surgery and trauma were excluded, as were studies reporting only mortality. All other studies reporting aspects of physical and psychological sequelae were analysed. Twenty-seven studies consisting of 3,444 survivors met the selection criteria. Distinct physical and psychological sequelae in patients have been determined and seemed to interfere with quality of life. Psychological sequelae in parents seem to be common. Small numbers, methodological limitations and quantitative and qualitative heterogeneity hamper the interpretation of data. We conclude that paediatric intensive care survivors and their parents have physical and psychological sequelae affecting quality of life. Further well-designed prospective studies evaluating sequelae of the original illness and its treatment are warranted.

Psychiatric adjustment in the year after meningococcal disease in childhood

OBJECTIVE

To assess psychiatric status after meningococcal disease.

METHOD

Cohort study of 66 children (34 boys, 32 girls) ages 4 to 17 years admitted to pediatric hospitals with meningococcal disease. The main outcome measure was psychiatric disorder (1-year period and point prevalence on the Schedule for Affective Disorders and Schizophrenia for School-Age Children interview for children 6 years or older; point prevalence in younger children on the Behavior Screening Questionnaire).

RESULTS

During the course of the year after discharge from hospital, psychiatric disorders were identified in 23 of 40 (57%) children ages 6 years or older. The most common primary disorders were depressive, oppositional defiant, and anxiety disorders. At the time of 12-month follow-up, psychiatric disorders were present in 13 of 40 (32%) of those ages 6 or older and in 7 of 26 (26%) under 6 years old. Two children had a diagnosis of posttraumatic stress disorder. Logistic regression analysis showed that global meningococcal illness severity score, clinical shock on admission, and impairing premorbid emotional and behavioral problems in the child were independent predictors of psychiatric disorder at 12-month follow-up.

CONCLUSIONS

Psychiatric disorders are common in the year after meningococcal disease. Especially at risk are children who are severely medically ill and those with more impairing premorbid emotional and behavioral problems.