Depression, acute stress and behavioral risk factors in violently injured adolescents

Validation of Patient-Reported Outcome Measurement Information System for Detection of Posttraumatic Stress in Children and Adolescents Following Procedures for Acute Orthopaedic Trauma

OBJECTIVES

The efficiency and validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were determined for pediatric orthopaedic trauma patients with posttraumatic stress disorder (PTSD) symptoms in a clinic setting.

METHODS

DESIGN

Prospective cohort study.

SETTING

Single-institution, Level I trauma center.

PATIENT SELECTION CRITERIA

All consecutive children aged 8-18 years undergoing procedures or surgery for orthopaedic trauma.

OUTCOME MEASURES AND COMPARISONS

The convergent, divergent, and discriminant validity of the PROMIS Anger and Anxiety computerized adaptive tests (CATs) were evaluated and compared with the previously validated Child PTSD Symptom Scale (CPSS). The efficiency in time to completion of the outcome measures was compared between the CPSS and PROMIS surveys. Cutoffs for increased likelihood of PTSD were established for the PROMIS questionnaires.

RESULTS

A total of 233 subjects were included in this study (mean age 13.1 years with SD 2.8 years, 71% male). The majority (51%) of injuries were related to sports, and most (60%) involved the upper extremity. Of those included, 41 patients had high levels of PTSD symptoms on the CPSS (18%; 95% CI, 13.1-23.2%). The CPSS took 182 (interquartile range [IQR] 141-228) seconds versus 52 (IQR 36-84) and 52 (IQR 36-70) seconds for PROMIS Anger and Anxiety CATs, respectively. Convergent validity showed patient scores on both PROMIS instruments significantly correlated with CPSS scores (Anger: P < 0.001, r = 0.51; Anxiety: P < 0.001, r = 0.41). Neither PROMIS score correlated with University of California Los Angeles Activity Score (Anger: r = -0.26; Anxiety: r = -0.22), a functional outcome measure, demonstrating divergent validity. Both PROMIS instruments sufficiently discriminated across PTSD risk groups (Anger P < 0.001; Anxiety P < 0.001). A score of at least 53 on PROMIS Anger or at least 48 on PROMIS Anxiety indicated an increased likelihood of PTSD risk.

CONCLUSIONS

PROMIS Anger and Anxiety CATs are efficient and valid for evaluating posttraumatic stress in children following orthopaedic trauma procedures.

LEVEL OF EVIDENCE

Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

[Prevalence and predictors of post-traumatic stress disorder in road traffic accidents]

Introduction

trauma-related disorders following a road accident have both a health and an economic impact.

Methods

we conducted a prospective study to determine the prevalence of these disorders, and to identify risk factors in subjects victims of road accidents and hospitalized in the Department of Orthopedic Surgery and Traumatology of the University Hospital Center of Sfax-Tunisia.

Results

a total of sixty-ten subjects were included in this study. The prevalence of acute stress disorder was 37.1% and was associated with female sex, low educational level, previous medical and surgical history, passivity during the accident, severity of injuries and the presence of anxious and depressive symptoms. Post-traumatic stress disorder was observed in 40% of subjects and was associated with urban residential environment, passivity during the accident and anxious and depressive symptoms. Low scores for functional coping strategies and high scores for dysfunctional coping strategies were significantly associated with both disorders. Low educational level, urban residential environment, high levels of anxiety and depression, and denial coping strategy appear to be independent risk factors for acute stress and post-traumatic stress disorder.

Conclusion

It is therefore important to determine the profile of people at greater risk of post-traumatic stress disorder, to enable early diagnosis in victims of road accidents.

The Incidence of Posttraumatic Stress Symptoms in Children

OBJECTIVE

To determine the incidence of posttraumatic stress disorder (PTSD) symptoms and risk factors for their development in children and adolescents undergoing orthopaedic surgery for trauma.

DESIGN

Prospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS

Children (8 to 18), undergoing surgery for orthopaedic trauma.

INTERVENTION

Upper and lower extremity surgery for orthopaedic trauma.

MAIN OUTCOME MEASUREMENTS

PTSD symptoms at postoperative follow-up as determined by the Child PTSD Symptom Scale (CPSS).

RESULTS

A total of 176 children with an average age at surgery of 13 years (8 to 18.8 years) participated in the study. Twenty-six subjects had high levels of PTSD symptoms (15%; 95% CI = 10.0 to 21.1%). Univariable and multivariable analyses determined that female sex (OR 2.63, 95% CI = 1.06 to 6.67, P = 0.04), older age at surgery (OR 1.25, 95% CI = 1.04 to 1.51, P = 0.02), and undergoing a previous surgery (OR 2.86, 95% CI = 1.06 to 7.73, P = 0.04) were all associated with increased PTSD risk.

CONCLUSIONS

Children and adolescents experience a high level of PTSD symptoms (15%) after surgery for orthopaedic trauma. Clinicians should be aware of PTSD symptoms in children and adolescents after surgery for orthopaedic injuries and use comprehensive screening to facilitate timely intervention and treatment.

LEVEL OF EVIDENCE

II.

Translating Violence Prevention Programs from Research to Practice: SafERteens Implementation in an Urban Emergency Department

BACKGROUND

Youth violence is a leading cause of adolescent mortality, underscoring the need to integrate evidence-based violence prevention programs into routine emergency department (ED) care.

OBJECTIVES

To examine the translation of the SafERteens program into clinical care.

METHODS

Hospital staff provided input on implementation facilitators/barriers to inform toolkit development. Implementation was piloted in a four-arm effectiveness-implementation trial, with youth (ages 14-18 years) screening positive for past 3-month aggression randomized to either SafERteens (delivered remotely or in-person) or enhanced usual care (EUC; remote or in-person), with follow-up at post-test and 3 months. During maintenance, ED staff continued in-person SafERteens delivery and external facilitation was provided. Outcomes were measured using the RE-AIM implementation framework.

RESULTS

SafERteens completion rates were 77.6% (52/67) for remote and 49.1% (27/55) for in-person delivery. In addition to high acceptability ratings (e.g., helpfulness), post-test data demonstrated increased self-efficacy to avoid fighting among patients receiving remote (incidence rate ratio [IRR] 1.22, 95% confidence interval [CI] 1.09-1.36) and in-person (IRR 1.23, 95% CI 1.12-1.36) SafERteens, as well as decreased pro-violence attitudes among patients receiving remote (IRR 0.83, 95% CI 0.75-0.91) and in-person (IRR 0.87, 95% CI 0.77-0.99) SafERteens when compared with their respective EUC groups. At 3 months, youth receiving remote SafERteens reported less non-partner aggression (IRR 0.52, 95% CI 0.31-0.87, Cohen's d -0.39) and violence consequences (IRR 0.47, 95% CI 0.22-1.00, Cohen's d -0.49) compared with remote EUC; no differences were noted for in-person SafERteens delivery. Barriers to implementation maintenance included limited staff availability and a lack of reimbursement codes.

CONCLUSIONS

Implementing behavioral interventions such as SafERteens into routine ED care is feasible using remote delivery. Policymakers should consider reimbursement for violence prevention services to sustain long-term implementation.

Daily patterns of substance use and violence among a high-risk urban emerging adult sample: Results from the Flint Youth Injury Study

OBJECTIVE

Interpersonal violence is a significant public health problem, with substance use a key risk factor. Intensive longitudinal methods (ILMs) provide data on daily patterns/relationships between substance use and violence, informing prevention. Prior daily research has not focused on these relationships among urban minority samples.

METHODS

Within an RCT comparing ILM assessment/schedule methods, 162-participants completed daily IVR (n = 81) or SMS (n = 81) assessments measuring 19 substance use and violence (partner/non-partner) behaviors daily for 90-days. GLMMs characterized between- and within-person predictors of daily violence.

RESULTS

Participants [48.7%-female; age = 24.4; 62.3%-African-American; 66.7%-public assistance] completed an average of 46.5 daily reports [SD = 26.7]. Across 90-days, alcohol was characterized by episodic weekend use (average = 10 days-of-use, 34.4% drinking-days involved binge-drinking), while marijuana use was continuous (average = 27 days-of-use; 1.7 times/day), with no weekend differences. Among 118-violent conflicts, 52.5% occurred on weekends; 57.6% were with non-partners/peers; 61.0% involved perpetration/57.6% victimization; and 52.5% involved severe violence. For violence conflicts, 27.1% were preceded by alcohol/22.9% preceded by drug use. Between-person predictors of daily violence included retaliatory attitudes (AOR = 3.2) and anxiety (AOR = 1.1). Within-person predictors included weekends (AOR = 1.6), binge drinking (AOR = 1.9), non-medical prescription opioid use (AOR = 3.5) and illicit drug use (AOR = 8.1).

CONCLUSION

Among a high-risk urban minority sample, we found that higher baseline retaliatory attitudes and anxiety, as well as same-day binge drinking, non-medical prescription opioid use, and illicit drug use were associated with daily violence, likely reflecting both pharmacological and socio-contextual factors. Addressing substance use and retaliatory violence with tailored prevention efforts may aid in decreasing negative interpersonal violence outcomes.

Development of an international data repository and research resource: the Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive

Background: Studies that identify children after acute trauma and prospectively track risk/protective factors and trauma responses over time are resource-intensive; small sample sizes often limit power and generalizability. The Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive was created to facilitate more robust integrative cross-study data analyses. Objectives: To (a) describe creation of this research resource, including harmonization of key variables; (b) describe key study- and participant-level variables; and (c) examine retention to follow-up across studies. Methods: For the first 30 studies in the Archive, we described study-level (design factors, retention rates) and participant-level (demographic, event, traumatic stress) variables. We used Chi square or ANOVA to examine study- and participant-level variables potentially associated with retention. Results: These 30 prospective studies (N per study = 50 to 568; overall N = 5499) conducted by 15 research teams in 5 countries enrolled children exposed to injury (46%), disaster (24%), violence (13%), traffic accidents (10%), or other acute events. Participants were school-age or adolescent (97%), 60% were male, and approximately half were of minority ethnicity. Using harmonized data from 22 measures, 24% reported significant traumatic stress ≥1 month post-event. Other commonly assessed outcomes included depression (19 studies), internalizing/externalizing symptoms (19), and parent mental health (19). Studies involved 2 to 5 research assessments; 80% of participants were retained for ≥2 assessments. At the study level, greater retention was associated with more planned assessments. At the participant level, adolescents, minority youth, and those of lower socioeconomic status had lower retention rates. Conclusion: This project demonstrates the feasibility and value of bringing together traumatic stress research data and making it available for re-use. As an ongoing research resource, the Archive can promote 'FAIR' data practices and facilitate integrated analyses to advance understanding of child traumatic stress.

Latent classes of DSM-5 acute stress disorder symptoms in children after single-incident trauma: findings from an international data archive

Background: After a potentially traumatic event (PTE), children often show symptoms of acute stress disorder (ASD), which may evolve into posttraumatic stress (PTS) disorder. A growing body of literature has employed latent class analysis (LCA) to disentangle the complex structure underlying PTS symptomatology, distinguishing between homogeneous subgroups based on PTS presentations. So far, little is known about subgroups or classes of ASD reactions in trauma-exposed children. Objective: Our study aimed to identify latent classes of ASD symptoms in children exposed to a single-incident PTE and to identify predictors of class membership (gender, age, cultural background, parental education, trauma type, and trauma history). Method: A sample of 2287 children and adolescents (5-18 years) was derived from the Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive, an international archive including studies from the USA, UK, Australia, and Switzerland. LCA was used to determine distinct subgroups based on ASD symptoms. Predictors of class membership were examined using a three-step approach. Results: Our LCA yielded a three-class solution: low (42%), intermediate (43%) and high (15%) ASD symptom severity that differed in terms of impairment and number of endorsed ASD symptoms. Compared to the low symptoms class, children in the intermediate or high severity class were more likely to be of female gender, be younger of age, have parents who had not completed secondary education, and be exposed to a road traffic accident or interpersonal violence (vs. an unintentional injury). Conclusions: These findings provide new information on children at risk for ASD after single-incident trauma, based on a unique set of international data. Classifying children based on latent symptom profiles helps to identify target groups for prevention and intervention after exposure to a PTE.

A technology-augmented intervention to prevent peer violence and depressive symptoms among at-risk emergency department adolescents: Protocol for a randomized control trial

BACKGROUND

Peer violence and depressive symptoms are increasingly prevalent among adolescents, and for many, use the emergency department (ED) as their primary source of healthcare. Brief in-person interventions and longitudinal text-message-based interventions are feasible, acceptable, and may be effective in reducing peer violence and depressive symptoms when delivered in the ED setting. This paper presents the study design and protocol for an in-ED brief intervention (BI) and text messaging program (Text).

METHODS

This study will be conducted in a pediatric ED which serves over 50,000 pediatric patients per year. Recruitment of study participants began in August 2018 and anticipated to continue until October 2021. The study will enroll 800 adolescents (ages13-17) presenting to the ED for any reason who self-report past-year physical peer violence and past-two week mild-to-moderate depressive symptoms. The study will use a factorial randomized trial to test both overall intervention efficacy and determine the optimal combination of intervention components. A full 2 × 2 factorial design randomizes patients at baseline to 1) BI or no BI; and 2) Text or no Text. Peer violence and depressive symptoms improvements will be measured at 2, 4, and 8 months through self-report and medical record review.

DISCUSSION

This study has important implications for the progress of the greater field of mobile health interventions, as well as for adolescent violence and depression prevention in general. This proposal has high clinical and public health significance with high potential scalability, acceptability, and impact.

Prevalence of post-traumatic stress disorder, acute stress disorder and depression following violence related injury treated at the emergency department: a systematic review

BACKGROUND

In order to gain insight into the health impact of violence related injury, the psychological consequences should be taken into account. There has been uncertainty regarding the prevalence of posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and depression among patients with violence related injury. An overview of prevalence rates may inform our understanding of both prognosis and recovery for these patients. Therefore, we aim to provide an overview of the published literature reporting the prevalence rates and trajectories of PTSD, ASD, and depression following violence related injury, and to assess the quality of the studies included.

METHODS

A systematic review was conducted in order to provide an overview of the published literature reporting the prevalence of PTSD, ASD and depression following violence related injury treated at the emergency department or hospital. The EMBASE, MEDLINE, Cochrane Central, PubMed, and PsycINFO databases were searched systematically. The quality of the included studies was assessed.

RESULTS

We included sixteen studies reporting the prevalence rates of PTSD, ASD, or depression. Clear prevalence trajectories could not be identified because the range of prevalence rates was diverse at each time point. Heterogeneity resulting from the use of different diagnostic instruments limited comparability. The included studies were susceptible to bias due to low response rates and loss to follow-up.

CONCLUSIONS

The differences in diagnostic instruments limited comparability of the prevalence rates. Therefore, clear prevalence trajectories could not be identified. Study participation and loss to follow-up require more attention in future studies. Uniformity in diagnostic procedures is needed in order to draw general conclusions on the prevalence of PTSD, ASD, and depression following violence related injury.

Acute stress and subsequent health outcomes: A systematic review

OBJECTIVE

To systematically review the relationship between acute posttraumatic stress symptoms (<1 month) and subsequent physical and mental health outcomes other than posttraumatic stress disorder (PTSD).

METHODS

A systematic search of electronic databases (PubMed, PsycINFO, CINAHL, and Web of Science) was conducted to identify longitudinal studies examining the link between acute posttraumatic stress and physical and mental health. Inclusion criteria required assessment of acute posttraumatic stress (<1 month post-event) and at least one follow-up assessment of a physical or mental health outcome (not PTSD).

RESULTS

1,051 articles were screened; 22 met inclusion criteria. Fourteen studies examined physical health outcomes and 12 examined non-PTSD mental health outcomes. Early psychological responses to trauma were associated with a variety of short- (<1 year) and long- (≥1 year) term physical and mental health outcomes. Physical health outcomes included poor general physical health, increased pain and disability, lower quality of life, and higher risk of all-cause mortality. Significant psychological outcomes included more cumulative psychiatric disorders, depression, and anxiety. Significant psychosocial outcomes included increased family conflict.

CONCLUSIONS

Methodologically rigorous longitudinal studies support the utility of measuring acute psychological responses to traumatic events as they may be an important marker of preventable trauma-related morbidity and mortality that warrants long-term monitoring and/or early intervention.

Prevalence of acute stress disorder among road traffic accident survivors: a meta-analysis

BACKGROUND

Road traffic accident (RTA), an unexpected traumatic event, may not only lead to death and serious physical injuries, but also could put survivors at an increased risk for a wide range of psychiatric disorders, particularly acute stress disorder (ASD). Early assessment of trauma-related psychological responses is important because acute trauma responses in the early post-traumatic period are among the robust predictors of long-term mental health problems. However, estimates of the prevalence of ASD among RTA survivors varied considerably across studies. Therefore, this meta-analysis aimed to identify the pooled prevalence of ASD among RTA survivors.

METHODS

A systematic literature search in the databases of PubMed, PsycINFO, PsycARTICLES, Embase and Web of Science was performed from their inception dates to December 2017. Subject headings were used to identify relevant articles, and the search strategy was adjusted across databases. Heterogeneity across studies was evaluated by Cochran's χ² test and quantified by the I² statistic. Subgroup analyses were performed to identify the pooled prevalence in relation to the country of study, instrument used to identify ASD, age, gender and traumatic brain injury. When significant heterogeneity was observed, the influence of some potential moderators was explored using meta-regression analyses.

RESULTS

Thirteen eligible studies conducted in 8 countries were included. A total of 2989 RTA survivors were assessed, of which 287 were identified with ASD. The overall heterogeneity was high across studies (I²=96.8%, P < 0.001), and the pooled prevalence of ASD among RTA survivors was 15.81% (95% confidence interval: 8.27-25.14%). Subgroup analyses indicated that the prevalence of ASD among RTA survivors differed significantly with regard to the country of study, instrument used to identify ASD, age and gender (P < 0.05). Meta-regression analyses showed that mean age of participants and quality assessment score were significant moderators for heterogeneity (P < 0.05).

CONCLUSIONS

Nearly one-sixth of RTA survivors suffer from ASD, indicating the need for regular assessment of early trauma responses among RTA survivors, as well as the importance of implementing early psychological interventions.

A Comprehensive Prevention Approach to Reducing Assault Offenses and Assault Injuries among Youth

Since 2011, the CDC-funded Michigan Youth Violence Prevention Center (MI-YVPC), working with community partners, has implemented a comprehensive prevention approach to reducing youth violence in Flint, MI, based on public health principles. MI-YVPC employed an intervention strategy that capitalizes on existing community resources and application of evidence-based programs using a social-ecological approach to change. We evaluated the combined effect of six programs in reducing assaults and injury among 10-24 year olds in the intervention area relative to a matched comparison community. We used generalized linear mixed models to examine change in the intervention area counts of reported assault offenses and assault injury presentation relative to the comparison area over a period 6 years prior- and 30 months post-intervention. Results indicated that youth victimization and assault injuries fell in the intervention area subsequent to the initiation of the interventions and that these reductions were sustained over time. Our evaluation demonstrated that a comprehensive multi-level approach can be effective for reducing youth violence and injury.

Efficacy of a Universal Brief Intervention for Violence Among Urban Emergency Department Youth

BACKGROUND

Violent injury is the leading cause of death among urban youth. Emergency department (ED) visits represent an opportunity to deliver a brief intervention (BI) to reduce violence among youth seeking medical care in high-risk communities.

OBJECTIVE

The objective was to determine the efficacy of a universally applied BI addressing violence behaviors among youth presenting to an urban ED.

METHODS

ED youth (14 to 20 years old) seeking medical or injury-related care in a Level I ED (October 2011-March 2015) and screening positive for a home address within the intervention or comparison neighborhood of a larger youth violence project were enrolled in this quasi-experimental study. Based on home address, participants were assigned to receive either the 30-minute therapist-delivered BI (Project Sync) or a resource brochure (enhanced usual care [EUC] condition). The Project Sync BI combined motivational interviewing and cognitive skills training, including a review of participant goals, tailored feedback, decisional balance exercises, role-playing exercises, and linkage to community resources. Participants completed validated survey measures at baseline and a 2-month follow-up assessment. Main outcome measures included self-report of physical victimization, aggression, and self-efficacy to avoid fighting. Poisson and zero-inflated Poisson regression analyses analyzed the effects of the BI, compared to the EUC condition, on primary outcomes.

RESULTS

A total of 409 eligible youth (82% participation) were enrolled and assigned to receive either the BI (n = 263) or the EUC condition (n = 146). Two-month follow-up was 91% (n = 373). There were no significant baseline differences between study conditions. Among the entire sample, mean (±SD) age was 17.7 (±1.9) years, 60% were female, 93% were African American, and 79% reported receipt of public assistance. Of participants, 9% presented for a violent injury, 9% reported recent firearm carriage, 20% reported recent alcohol use, and 39% reported recent marijuana use. Compared with the EUC group, participants in the therapist BI group showed self-reported reductions in frequency of violent aggression (therapist, -46.8%; EUC, -36.9%; incident rate ratio [IRR] = 0.87; 95% confidence interval [CI] = 0.76 to 0.99) and increased self-efficacy for avoiding fighting (therapist, +7.2%; EUC, -1.3%; IRR = 1.09; 95% CI = 1.02 to 1.15). No significant changes were noted for victimization.

CONCLUSIONS

Among youth seeking ED care in a high-risk community, a brief, universally applied BI shows promise in increased self-efficacy for avoiding fighting and a decrease in the frequency of violent aggression.

PTSD, cyberbullying and peer violence: prevalence and correlates among adolescent emergency department patients

OBJECTIVE

Posttraumatic stress disorder (PTSD) is often underdiagnosed and undertreated among adolescents. The objective of this analysis was to describe the prevalence and correlates of symptoms consistent with PTSD among adolescents presenting to an urban emergency department (ED).

METHODS

A cross-sectional survey of adolescents aged 13-17 years presenting to the ED for any reason was conducted between August 2013 and March 2014. Validated self-report measures were used to measure mental health symptoms, violence exposure and risky behaviors. Multivariate logistic regression analysis was performed to determine adjusted differences in associations between symptoms consistent with PTSD and predicted correlates.

RESULTS

Of 353 adolescents, 23.2% reported current symptoms consistent with PTSD, 13.9% had moderate or higher depressive symptoms and 11.3% reported past-year suicidal ideation. Adolescents commonly reported physical peer violence (46.5%), cyberbullying (46.7%) and exposure to community violence (58.9%). On multivariate logistic regression, physical peer violence, cyberbullying victimization, exposure to community violence, female gender and alcohol or other drug use positively correlated with symptoms consistent with PTSD.

CONCLUSIONS

Among adolescents presenting to the ED for any reason, symptoms consistent with PTSD, depressive symptoms, physical peer violence, cyberbullying and community violence exposure are common and interrelated. Greater attention to PTSD, both disorder and symptom levels, and its cooccurring risk factors is needed.

The Youth Nonfatal Violent Injury Review Panel: An Innovative Model to Inform Policy and Systems Change

Among young people in the United States, nonfatal violent injuries outnumber fatal violent injuries by 171 to 1. The Child Fatality Review Team (CFRT) is a well-established model for informing injury prevention planning. The CFRT's restricted focus on fatal injuries, however, limits its ability to identify opportunities to prevent violent reinjury and address issues unique to nonfatal violent injuries. We adapted the CFRT model to develop and implement a Youth Nonfatal Violent Injury Review Panel. We convened representatives from 23 agencies (e.g., police, housing, and education) quarterly to share administrative information and confidentially discuss cases of nonfatal violent injury. In this article, we describe the panel model and present preliminary data on participants' perceptions of the process. Although outcomes research is needed to evaluate its impacts, the Youth Nonfatal Violent Injury Review Panel offers an innovative, promising, and replicable model for interagency collaboration to prevent youth violence and its effects.

Traumatic Stress, Depression, and Recovery: Child and Parent Responses After Emergency Medical Care for Unintentional Injury

OBJECTIVE

To assess psychological symptoms in injured children (aged 8-17 years) and their parents after emergency department (ED) care to examine the relationship between posttraumatic stress and depression symptoms, co-occurrence of symptoms within families, and the relationship of these symptoms to parent-reported overall recovery.

METHODS

Children and parents (n = 263 child-parent dyads) were enrolled during ED treatment for unintentional injury. Approximately 5 months later, children and parents (n = 178 dyads) completed standardized measures of posttraumatic stress and depression symptoms and parents reported on child overall recovery.

RESULTS

Follow-up assessments found significant posttraumatic stress symptoms in 15% of children and 5% of parents, significant depression symptoms in 13% of children and 16% of parents, and problematic overall recovery in 17% of children. For both children and parents, posttraumatic stress and depression symptom severity were strongly associated. Child and parent symptoms were only modestly associated with each other, and there were few families in which both child and parent had significant posttraumatic stress or depression. Parent symptoms, but not child symptoms, were inversely associated with children's overall recovery.

CONCLUSIONS

For about 1 in 6 children and parents, unintentional injury treated in the ED can be associated with negative psychological sequelae and suboptimal recovery. Within families, child and parent responses may differ; their relative association with overall recovery deserves additional research. To promote emotional recovery, ED clinicians should be aware of the potential psychological impact of unintentional injury, provide timely evidence-based anticipatory guidance, and communicate these concerns to primary care clinicians.

Understanding the service needs of assault-injured, drug-using youth presenting for care in an urban Emergency Department

BACKGROUND

Violence is a leading cause of injury among youth 15-24years and is frequently associated with drug use. To inform optimal violence interventions, it is critical to understand the baseline characteristics and intent to retaliate of drug-using, assault-injured (AI) youth in the Emergency Department (ED) setting, where care for violent injury commonly occurs.

METHODS

At an urban ED, AI youth ages 14-24 endorsing any past six-month substance use (n=350), and a proportionally-sampled substance-using comparison group (CG) presenting for non-assault-related care (n=250), were recruited and completed a baseline assessment (82% participation). Medical chart review was also conducted. Conditional logistic regression was performed to examine correlates associated with AI.

RESULTS

Over half (57%) of all youth met the criteria for drug and/or alcohol use disorder, with only 9% receiving prior treatment. Among the AI group, 1 in 4 intended to retaliate, of which 49% had firearm access. From bivariate analyses, AI youth had poorer mental health, greater substance use, and were more likely to report prior ED visits for assault or psychiatric evaluation. Based on multivariable modeling, AI youth had greater odds of being on probation/parole (AOR=2.26; CI=1.28, 3.90) and having PTSD (AOR=1.88; CI=1.01, 3.50) than the CG.

CONCLUSIONS

AI youth may have unmet needs for substance use and mental health treatment, including PTSD. These characteristics along with the risk of retaliation, increased ED service utilization, low utilization of other health care venues, and firearm access highlight the need for interventions that initiate at the time of ED visit.

Evaluating predictive screening for children's post-injury mental health: New data and a replication

BACKGROUND

Recommended approaches for secondary prevention of posttrauma mental health difficulties in children require empirically sound predictive screening to determine which children require more intensive monitoring or targeted intervention. Although there are several promising screening tools for injured children, none has emerged as the gold standard, and little replication data are available regarding their performance.

OBJECTIVE

To evaluate a predictive screening protocol for risk of later posttraumatic stress (PTS) and depression outcomes and address a crucial lack of replication studies by examining performance of two previously published screening tools (Screening Tool for Early Predictors of PTSD [STEPP] and Child Trauma Screening Questionnaire [CTSQ]).

METHOD

The study enrolled 290 children hospitalized after acute injury. A three-part screening protocol, including acute PTS and depression symptoms and other empirically derived risk factors, was administered in hospital as part of a stepped care study. PTS and depression symptoms and health-related quality of life (HRQoL) were assessed 6 months post-injury.

Acute stress, depression, and anxiety symptoms among English and Spanish speaking children with recent trauma exposure

A growing literature suggests the clinical importance of acute stress disorder symptoms in youth following potentially traumatic events. A multisite sample of English and Spanish speaking children and adolescents (N = 479) between the ages of 8-17, along with their caregivers completed interviews and self-report questionnaires between 2 days and 1 month following the event. The results indicate that children with greater total acute stress symptoms reported greater depressive (r = .41, p < .01) and anxiety symptoms (r = .53, p < .01). Examining specific acute stress subscales, reexperiencing was correlated with anxiety (r = .47, p < .01) and arousal was correlated with depression (r = .50, p < .01) and anxiety (r = .55, p < .01). Age was inversely associated with total acute stress symptoms (r = -.24, p < .01), reexperiencing (r = -.17, p < .01), avoidance (r = -.27, p < .01), and arousal (r = -.19, p < .01) and gender was related to total anxiety symptoms (Spearman's ρ = .17, p < .01). The current study supports the importance of screening acute stress symptoms and other mental health outcomes following a potentially traumatic event in children and adolescents. Early screening may enable clinicians to identify and acutely intervene to support children's psychological and physical recovery.

The psychological sequelae of violent injury in a pediatric intervention

PURPOSE

Pediatric trauma centers have unique potential to prevent violent injury and its psychological sequelae. Hospital-based violence intervention programs (HVIPs) are proliferating across the U.S., but little is known about the psychological needs of pediatric patients who participate in them. The purpose of this study was to describe the prevalence of symptoms of posttraumatic stress and exposure to community violence among pediatric HVIP participants.

METHODS

We conducted a cross-sectional analysis of psychosocial needs assessment data that were collected for 48 participants. The Child Trauma Screening Questionnaire (CTSQ) and modified Survey of Children's Exposure to Community Violence were used to assess primary outcomes.

RESULTS

The sample was 62.5% male and had a mean age of 14.5 years. Twenty-three percent reported previously sustaining a violent injury resulting in medical care, and 47.8% had witnessed a shooting. The majority (66.0%) had a CTSQ score at/above the threshold for probable PTSD diagnosis. The mean CTSQ score was 5.9 and hyperarousal (3.3) symptoms were more common than re-experiencing symptoms (2.6).

CONCLUSION

Pediatric HVIPs and trauma centers should consider integrating PTSD screening and trauma-focused psychoeducation into the practice and protocols. Future research should evaluate the impacts of these interventions.

Boston Violence Intervention Advocacy Program: a qualitative study of client experiences and perceived effect

OBJECTIVES

This study intended to explore clients' experiences and provide a contextual basis for understanding their perceptions of the effectiveness of the Boston Medical Center (BMC) Violence Intervention Advocacy Program (VIAP).

METHODS

This was an exploratory, qualitative study conducted in an urban, Level I trauma center from July 1, 2011 to February 24, 2012. Emergency department (ED) patients older than 18 years with penetrating trauma, and who were enrolled in the VIAP, were eligible. Two trained, qualitative interviewers who were not part of the VIAP obtained consent and conducted in-depth, semistructured interviews. Interviews were audiotaped, transcribed, deidentified, coded, and analyzed. Thematic content analysis consistent with grounded theory was used to identify themes related to client experiences with VIAP, life circumstances, challenges to physical and emotional healing postinjury, services provided by VIAP, and perceptions of VIAP's effectiveness.

RESULTS

Twenty subjects were interviewed. Most were male, African American, and younger than 30 years of age, reflecting the overall program's clientele. Most subjects perceived their advocates as caring adults in their lives and cited aspects of the peer support model that helped establish trusting relationships. Major challenges to healing were fear and safety, trust, isolation as a coping mechanism, bitterness, and symptoms of posttraumatic stress disorder (PTSD). Every subject noted important services provided by VIAP advocates. Most subjects explicitly stated that they had positive experiences with the VIAP and perceived advocates' roles as a positive influence, providing client-centered advocacy, education, and support.

CONCLUSIONS

This study provides insight into the lives of 20 BMC VIAP clients and contextualizes their unique challenges. Participants described positive, life-changing behaviors on their journey to healing through connections to caring, supportive adults. Information gained from this study will help the VIAP to further support its clients. However, future research is needed to identify best practices for ED-based violence intervention programs and to measure community-wide efficacy in different settings.

Identifying youth at risk for difficulties following a traumatic event: pre-event factors are associated with acute symptomatology

This study examined factors related to children's acute symptoms following a potentially traumatic event (PTE) to more clearly identify domains that should be included in screenings of youth exposed to a PTE. In particular, the authors examined whether trauma category (i.e., sexual abuse/disclosure of abuse, intentionally perpetrated traumas other than sexual abuse, and unintentional traumas) was related to symptoms after controlling for other relevant factors. Participants were 112 youth presenting for clinical evaluation within a month of a PTE and their nonoffending caregivers. Using data from baseline assessments collected as part of a randomized controlled trial of a secondary prevention program, the following factors were tested in 3 hierarchical regression models: index PTE category, history of traumatic exposure, preindex event functioning, and parenting behaviors. Prior trauma exposure, preindex event functioning, and hostile parenting were uniquely related to children's symptoms in the acute posttraumatic period after controlling for time since the event and child age, but trauma category was not. Implications for identifying and referring children at high risk for poor outcomes in the early aftermath of a PTE are discussed. An exclusive focus on the event is insufficient and more comprehensive understanding of the child and family is required.

Correlates of depressive symptoms among at-risk youth presenting to the emergency department

OBJECTIVE

The study's objective was to identify correlates of depressive symptoms among at-risk youth in an urban emergency department (ED).

METHOD

A systematic sample of adolescents (ages 14-18) in the ED were recruited as part of a larger study. Participants reporting past-year alcohol use and peer aggression self-administered a survey assessing: demographics, depressive symptoms and risk/protective factors. Logistic regression identified factors associated with depressive symptoms.

RESULTS

Among 624 adolescents (88% response rate) meeting eligibility criteria, 22.8% (n=142) screened positive for depressive symptoms. In logistic regression, depressive symptoms were positively associated with female gender [odds ratio (OR): 2.84, 95% confidence interval (CI): 1.78-4.51], poor academic performance (OR: 1.57, 95% CI: 1.01-2.44), binge drinking (OR: 1.88, 95% CI: 1.21-2.91), community violence exposure (OR: 2.25, 95% CI: 1.59-3.18) and dating violence (OR: 2.14, 95% CI: 1.36-3.38) and were negatively associated with same-sex mentorship (OR: 0.52, 95% CI: 0.29-0.91) and older age (OR: 0.55, 95% CI 0.34-0.89). Including gender interaction terms did not significantly change findings.

CONCLUSIONS

Screening and intervention approaches for youth in the urban ED should address the co-occurrence of depressive symptoms with peer and dating violence, alcohol and nonmarijuana illicit drug use.

Burden of unmet mental health needs in assault-injured youths presenting to the emergency department

OBJECTIVES

To determine if there is a gap between behavioral symptoms and previously recognized mental health conditions in youth victims of peer assault injuries and to describe gender differences in psychological symptoms.

METHODS

A cross-sectional comparison of rates of previously diagnosed mental health conditions and clinical range behavioral symptoms as measured by the Child Behavior Checklist (CBCL) in 168 youths (range, 10-15 years old) presenting to the emergency department (ED) after an interpersonal assault injury. The Fisher exact test was used for comparisons.

RESULTS

Mental health symptoms were common among assault-injured youths. More than half of the youths demonstrating clinical range symptoms on the attention problems or anxious/depressed scales of the CBCL had no prior diagnosis of these conditions. Girls were more likely than boys to exhibit clinical range aggressive behavior symptoms (odds ratio [OR], 3.61; 95% confidence interval [CI], 1.64-7.97). Aggressive behavior was associated with clinical range scores on the other problem scales of the CBCL.

CONCLUSIONS

After an ED visit for an assault-related injury, less than half of 10 to 15 year olds with significant symptoms of common mental conditions reported having a previously diagnosed disorder, reflecting a burden of unmet psychological needs. An ED visit for an assault injury provides an opportunity to screen for emotional/behavioral symptoms and to refer to appropriate follow-up mental health care.

Sex differences in characteristics of adolescents presenting to the emergency department with acute assault-related injury

OBJECTIVES

Adolescents with a history of peer assault are known to report high rates of other risky behaviors. The characteristics of adolescents seeking care in the ED for acute assault-related injury are less well established. This knowledge deficit is particularly noticeable for adolescent female victims of peer assault. This study's objectives were: 1) to characterize the demographics and risk behaviors of youths presenting to the emergency department (ED) with acute assault-related injury and 2) to compare assaulted youths' demographic characteristics, past experiences with violence, and other risk behaviors by sex.

METHODS

A systematic sample of adolescents (ages 14 to 18 years) presenting to an urban ED with acute assault-related injury (excluding dating violence, sexual assault, and child abuse) was recruited. Consenting participants self-administered a computerized survey about demographics, history of peer and dating aggression, and theoretical correlates of violence (e.g., alcohol and other drug use, depressive symptoms, weapon carriage). Multivariate logistic regression was performed to identify factors that were differentially associated with presentation to the ED for acute assault-related injury for females versus males.

RESULTS

Of 3,338 adolescents completing a screening survey during the 36-month study period, 197 had presented to the ED with acute assault-related injuries; seven of these were excluded from this study due to being victims of dating violence. Most (n = 179, 94.2%) of these 190 acutely assaulted participants were discharged home. The majority reported a history of past-year peer aggression (n = 160, 84.2%) and past-year violent injury (n = 106, 55.8%). Similar rates of past-year peer aggression, past-year violent injury, alcohol use, and weapon carriage were observed for adolescent males and females presenting with acute assault-related injury. Males and females also reported similar age, race, socioeconomic status, and education levels. Compared to males, females were less likely to report living with a parent (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.08 to 0.84) and were more likely to report depressive symptoms (OR = 2.59, 95% CI = 1.23 to 5.48) and past-year dating aggression (OR = 2.23, 95% CI = 1.04 to 4.82).

CONCLUSIONS

Male and female adolescents with acute assault-related injuries were very similar. Both reported extremely high rates of past year peer violence, assault-related injury, and substance use. The greater prevalence of some risk factors among adolescent females, such as depressive symptoms, dating aggression, and independent living status, should be further investigated.

Feasibility of an interactive voice response tool for adolescent assault victims

BACKGROUND

Assault-injured adolescents who are seen in the emergency department (ED) are difficult to follow prospectively using standard research techniques such as telephone calls or mailed questionnaires. Interactive voice response (IVR) is a novel technology that promotes active participation of subjects and allows automated data collection for prospective studies.

OBJECTIVES

The objective was to determine the feasibility of IVR technology for collecting prospective information from adolescents who were enrolled in an ED-based study of interpersonal violence.

METHODS

A convenience sample of assault-injured 12- to 19-year-olds presenting to an urban, tertiary care ED was enrolled prospectively. Each subject completed a brief questionnaire in the ED and then was randomly assigned to use the IVR system in differently timed schedules over a period of 8 weeks: weekly, biweekly, or monthly calls. Upon discharge, each subject received a gift card incentive and a magnetic calendar with his or her prospective call-in dates circled on it. Each time a subject contacted the toll-free number, he or she used the telephone's keypad to respond to computer-voice questions about retaliation and violence subsequent to the ED visit. Using Internet access, we added $5 to the gift card for each call and $10 if all scheduled calls were completed. The primary outcome was the rate of the first utilization of the IVR system. The numbers of completed calls made for each of the three call-in schedules were also compared.

RESULTS

Of the 95 subjects who consented to the follow-up portion of the study, 44.2% (95% confidence interval [CI] = 34.0% to 54.8%) completed at least one IVR call, and 13.7% (95% CI = 7.5% to 22.3%) made all of their scheduled calls. There were no significant differences among groups in the percentage of subjects calling at least once into the system or in the percentage of requested calls made. The enrolled subjects had a high level of exposure to violence. At baseline, 85.3% (95% CI = 76.5% to 91.7%) had heard gunshots fired, and 84.2% (95% CI = 75.3% to 90.9%) had seen someone being assaulted. Twenty-eight adolescents (29.5%, 95% CI = 20.6% to 39.7%) were reached for satisfaction interviews. All of those contacted found the IVR system easy to use and all but one would use it again.

CONCLUSIONS

Interactive voice response technology is a feasible means of follow-up among high-risk violently injured adolescents, and this relatively anonymous process allows for the collection of sensitive information. Further research is needed to determine the optimal timing of calls and cost-effectiveness in this population.