Which method of posttraumatic stress disorder classification best predicts psychosocial function in children with traumatic brain injury?

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

Involvement in litigation in children with PTSD following motor vehicle accident: Associations with emotional distress and treatment outcomes

OBJECTIVES

Litigation is common in the context of Post-traumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI), adding contradicting motivations to individuals' engagement in psychotherapeutic interventions. This study's main goal was to explore the relationship between litigation status and emotional distress among children with PTSD following motor vehicle accidents (MVAs). We also present preliminary findings from a pilot study on treatment efficacy for children with PTSD, with and without litigation.

METHODS

Participants included 76 children with PTSD following MVA and their main caregiving parent. The associations between litigation status (litigation involvement, litigation phase, and litigation's emotional impact) and children's global distress, PTSD, persistent post-concussion symptoms (PPCS), and sub-optimal effort, and parents' PTSD symptoms were assessed before and after intervention for PTSD. Comorbid mTBI was explored as a possible moderating factor.

RESULTS

Involvement in litigation was not related to children's and parents' pre-intervention distress, nor to the presence of mTBI or to children's effort. However, higher emotional impact of litigation on parents was associated with children's higher PPCS pre-intervention. A pilot study on intervention outcomes found an improvement both in children with and without litigation involvement. A greater decrease in PPCS following intervention was found in children of parents with higher emotional impact of litigation.

CONCLUSIONS

The emotional impact of litigation on parents should be considered while addressing children in litigation context. However, this study's preliminary findings suggest that children with litigation involvement may benefit from treatment, thus litigation should not serve solely as an exclusion criterion for psychological intervention. A larger study should further explore this issue.

Post-traumatic stress disorder attributed to traumatic brain injury in children - a systematic review

OBJECTIVE

To assess the proportion of pediatric patients who develop post-traumatic stress disorder (PTSD) attributed to traumatic brain injury (TBI).

METHODS

PubMed and Embase were searched from database inception until January 26, 2019. Two independent investigators screened titles, abstracts, and subsequently, full-text articles. Following this, the same investigators also extracted data relevant for the scope of this review.

RESULTS

Ten articles were included in this review. In these, six unique cohorts were described, with relative frequencies of PTSD attributed TBI ranging from 3.3% to 48.5%. Two studies also found that PTSD was more common in children after TBI compared to pediatric orthopedic controls. Study quality was determined as high or very high for all six included cohorts, although the studies differed considerably in terms of methodology.

CONCLUSIONS

Methodological variations confound comparisons of relative frequency assessments of PTSD attributed to TBI. However, PTSD is associated with considerable long-term disability and undetected PTSD in children should raise public concern. Thus, large scale, prospective studies are needed to ascertain the clinical course of PTSD attributed to TBI in children and adolescence.

Trajectories and Risk Factors for Post-Traumatic Stress Symptoms following Pediatric Concussion

A substantial minority of children experience post-traumatic stress symptoms (PTSS) following injury. Research indicates variation in the trajectory of PTSS following pediatric injury, but investigation of PTSS following concussion has assumed homogeneity. This study aimed to identify differential trajectories of PTSS following pediatric concussion and to investigate risk factors, including acute post-concussive symptoms (PCS), associated with these trajectories. A total of 120 children ages 8-18 years reported PTSS for 3 months following concussion diagnosis using the Child PTSD Symptom Scale, with a score of 16 or above indicating probable post-traumatic stress disorder diagnosis. Age, gender, injury mechanism, loss of consciousness, previous concussions, prior hospitalization, prior diagnosis of depression or anxiety, and acute PCS were assessed as risk factors. Data were analyzed using group-based trajectory modeling. Results revealed 16% of children had clinically significant PTSS 2 weeks post-concussion, declining to 10% at 1 month and 6% at 3 months post-injury. Group-based trajectory modeling identified three trajectories of PTSS post-concussion: "resilient" (70%); "recovering" (25%), in which children experienced elevated acute symptoms that declined over time; and "chronic symptomatology" (5%). Due to small size, the chronic group should be interpreted with caution. Higher acute PCS and prior diagnosis of depression or anxiety both significantly increased predicted probability of recovering trajectory group membership. These findings establish that most children are resilient to PTSS following concussion, but that PTSS do occur acutely in a substantial minority of children. The study indicates mental health factors, particularly PTSS, depression, and anxiety, should be considered integral to models of concussion management and treatment.

Evaluating Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Posttraumatic Stress Disorder Diagnostic Criteria in Older Children and Adolescents

OBJECTIVES

Few studies have assessed how the diagnostic criteria for posttraumatic stress disorder (PTSD) apply to older children and adolescents. With the introduction of a new, developmentally sensitive set of criteria for very young children (age 6 years and younger) in Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), this raises new questions about the validity of the criteria for older children and adolescents. The current study investigated how diagnostic changes in DSM-5 impact diagnosis rates in 7-18-year olds.

METHODS

PTSD, impairment, and comorbid psychopathology were assessed in 135 trauma-exposed, treatment-seeking participants. Children (ages 7-12) were examined separately from adolescents (ages 13-18) to assess for potential developmental differences.

RESULTS

A significantly higher proportion of 7-12-year-old children met criteria for DSM-5 diagnosis (53%) compared to Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) (37%). However, among 13-18-year-old adolescents, the proportions diagnosed with DSM-5 (73%) and DSM-IV (74%) did not differ. Participants who met criteria for DSM-5 only (17%) did not differ from those diagnosed with DSM-IV in terms impairment or comorbidity. Using the newly accepted age 6 years and younger criteria resulted in a significantly higher proportion of 7-12-year-old (but not 13-18-year olds) children meeting criteria compared to DSM-IV or DSM-5. However, these children showed less impairment and comorbidity than those diagnosed with DSM-IV.

CONCLUSION

These findings suggest that DSM-5 criteria may be more developmentally sensitive than DSM-IV criteria, and may lead to higher prevalence rates of PTSD for 7-12-year-old children, but not for adolescents. Using the very young children criteria for 7-12-year-old children may further increase prevalence, but capture children with less severe psychopathology.

A Critical Review for Developing Accurate and Dynamic Predictive Models Using Machine Learning Methods in Medicine and Health Care

Recently, Artificial Intelligence (AI) has been used widely in medicine and health care sector. In machine learning, the classification or prediction is a major field of AI. Today, the study of existing predictive models based on machine learning methods is extremely active. Doctors need accurate predictions for the outcomes of their patients' diseases. In addition, for accurate predictions, timing is another significant factor that influences treatment decisions. In this paper, existing predictive models in medicine and health care have critically reviewed. Furthermore, the most famous machine learning methods have explained, and the confusion between a statistical approach and machine learning has clarified. A review of related literature reveals that the predictions of existing predictive models differ even when the same dataset is used. Therefore, existing predictive models are essential, and current methods must be improved.

Feasibility of a screening program for at-risk children following accidental injury

Screening is recommended as a simple method for identifying those who should be monitored for risk following trauma. Effective methods for implementing large-scale screening programs are yet to be established. This study tested the feasibility and utility of a screening program with hospitalized youth exposed to injury in 3 Australian hospitals. Eligible families (N = 1,134) were contacted and 546 children (48.0%) screened for risk of posttraumatic stress disorder (PTSD) at 1-2 weeks postinjury. There were 95 (17.4%) children whose screen result was at risk. A rescreening phase was introduced during the study, with 68 children completing the rescreen at 4-6 weeks postinjury, and 26 (38.2% of those rescreened) still at risk. Of those initially screened, 29 (5.3%) completed diagnostic assessments, 21 (3.8%) were diagnosed with partial or full PTSD, and 17 (3.1%) commenced treatment. Screening was successful at identifying and reaching children with PTSD, but the response rate was lower than expected, which limited the utility of the program. The addition of a rescreening phase demonstrated that not all at-risk children required intervention. These findings replicate previous studies that have shown natural remission in PTSD symptoms and highlight the potential for rescreening as part of a watchful waiting approach.

Applying a traumatic stress approach to understanding PCS following pediatric mild TBI

Pediatric traumatic brain injury is a significant public health concern affecting hundreds of thousands of children each year. The majority of children who sustain traumatic brain injuries are classified as having a mild traumatic brain injury, and a subset of these children go on to experience persistent physical, cognitive, and emotional symptoms. These symptoms, known as postconcussive symptoms, can endure for months and even years after injury. The outcomes of mild traumatic brain injury are variable and not well understood for a small percentage of children who experience persistent symptoms. The current article explores the potential influence of children's posttraumatic stress symptoms on persistent postconcussive symptoms. Despite the high incidence of posttraumatic stress symptoms after pediatric accidental injury, they have not yet been identified as an important factor for consideration in the understanding of pediatric postconcussive outcomes. The article will review the literature on posttraumatic stress and postconcussive symptoms after pediatric injury and consider neurobiological and cognitive factors to propose a model explaining a pathway through which posttraumatic stress reactions may serve as the mechanism for the expression and maintenance of postconcussive symptoms after mild traumatic brain injury. The clinical implications for the proposed relationship between posttraumatic stress symptoms and postconcussive symptoms are considered prior to the conclusion of the article, which acknowledges limitations in the current literature and provides suggestions for future research.

The diagnosis of posttraumatic stress disorder in school-aged children and adolescents following pediatric intensive care unit admission

OBJECTIVES

This study explored the diagnosis of posttraumatic stress disorder (PTSD) in children and adolescents following pediatric intensive care unit (PICU) admission. Specifically, the study aimed to describe the presentation and prevalence of PTSD symptoms 6 months postdischarge, explore the validity of the DSM-IV PTSD algorithm and alternative PTSD algorithm (PTSD-AA) in school-aged children and adolescents, and examine the diagnostic utility of Criterion C3 (inability to recall aspects of a trauma) in this cohort.

METHODS

Participants were 59 children aged 6-16, admitted to PICU for at least 8 hours. PTSD was assessed via diagnostic interview (Children's PTSD Inventory) 6 months following PICU discharge.

RESULTS

The PTSD-AA was found to provide the most valid measure of PTSD at 6 months. Removing Criterion C3 improved the validity of Criterion C.

CONCLUSIONS

This study supports the use of the PTSD-AA excluding Criterion C3 for identifying highly traumatized children and adolescents following PICU admission.

Posttraumatic stress disorder in early childhood: classification and diagnostic issues

The 0-3 diagnostic classification of infant mental health, on the basis of DSM-IV-R, describes posttraumatic stress disorder (PTSD) as a pattern of symptoms that may be shown by children who have experienced a single traumatic event, a series of connected traumatic events, or chronic, enduring stress situations. This definition, related to young children, needs the consideration of several factors to understand the child's symptoms, organize the diagnostic process, and realize clinical interventions. In this sense, the clinician must appreciate the classification criteria of PTSD in early childhood in the context of the child's age, temperament, and developmental level. This report presents a review of the research in the domain of the PTSD in early childhood with particular attention to the developmental considerations to define critical diagnostic criteria, specifically organized on the child characteristics, competences, and needs. Along this line, it will describe two proposed modifications of the diagnostic classification in childhood: the Post Traumatic Stress Disorder Alternative Algorithm (PTSD-AA) and the definition of developmental trauma disorder (DTD).

Diagnosing PTSD in early childhood: an empirical assessment of four approaches

Prior studies have argued that the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria were insensitive for diagnosing posttraumatic stress disorder (PTSD) in young children. Four diagnostic criteria sets were examined in 284 3- to 6-year-old trauma-exposed children. The DSM-IV criteria resulted in significantly fewer cases (13%) compared to an alternative algorithm for young children (PTSD-AA, 45%), the proposed DSM-5 posttraumatic stress in preschool children (44%), and the DSM-5 criteria with 2 symptoms that are under consideration by the committee (DSM-5-UC, 49%). Using DSM-IV as the standard, the misclassification rate was 32% for PTSD-AA, 32% for DSM-5, and 37% for DSM-5-UC. The proposed criteria sets showed high agreement on the presence (100%), but low agreement on the absence (58-64%) of diagnoses. The misclassified cases were highly symptomatic, M = 7 or more symptoms, and functionally impaired, median = 2 domains impaired. The additional symptoms had little impact. Evidence for convergent validation for the proposed diagnoses was shown with elevations on comorbid disorders and Child Behavior Checklist Total scores compared to a control group (n = 46). When stratified by age (3-4 years and 5-6 years), diagnoses were still significantly elevated compared to controls. These findings lend support to a developmental subtype for PTSD.

PTSD in children and adolescents: toward an empirically based algorithma

In considering potential revisions for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V), describing developmental influences on symptomatic expression is a high priority. This review presents a number of options and preliminary recommendations to be considered for DSM-V. Research conducted in the past 15 years is reviewed that pertains to expressions of posttraumatic stress disorder (PTSD) symptoms in preschool and school age children and in adolescents. This research has attempted to determine the usefulness of the DSM-IV criteria for PTSD in children and adolescents. Based on the studies of preschool children, evidence supports two sets of suggestions: first, we suggest that developmental manifestations are warranted in A-D criteria of PTSD; and second, we suggest that a developmental preschool PTSD subtype is warranted that lowers the C threshold from three to one symptom. For school-age children and young adolescents, the evidence is more limited. Nevertheless, there is also evidence suggesting that modifications in PTSD criteria A-D, including fewer Cluster C symptoms, may facilitate accurate diagnosis in this age group.

Protocol for a randomised controlled trial of risk screening and early intervention comparing child- and family-focused cognitive-behavioural therapy for PTSD in children following accidental injury

BACKGROUND

Accidental injury represents the most common type of traumatic event to which a child or adolescent may be exposed, with a significant number of these children going on to experience posttraumatic stress disorder (PTSD). However, very little research has examined potential interventions for the treatment of PTSD in these children. The present trial aims to evaluate and compare child- and family-focused versions of a cognitive-behavioural early intervention for PTSD following accidental injury.

METHODS/DESIGN

The principal clinical question under investigation is the efficacy of an early, trauma-focused cognitive-behavioural intervention for the treatment of PTSD in children following accidental injury. Specifically, we compare the efficacy of two active treatments (child-focused and family-focused CBT) and a waitlist control (no therapy) to determine which is associated with greater reductions in psychological and health-related outcome measures over time. The primary outcome will be a reduction in trauma symptoms on a diagnostic interview in the active treatments compared to the waitlist control and greater reductions in the family-compared to the child-focused condition. In doing so, this project will also trial a method of stepped screening and assessment to determine those children requiring early intervention for PTSD following accidental injury.

DISCUSSION

The present trial will be one of the first controlled trials to examine a trauma-focused CBT, early intervention for children experiencing PTSD following accidental injury (as opposed to other types of traumatic events) and the first within a stepped care approach. In addition, it will provide the first evidence comparing the efficacy of child and family-focused interventions for this target group. Given the significant number of children and adolescents exposed to accidental injury, the successful implementation of this protocol has considerable implications. If efficacious, this early intervention will assist in reducing symptoms of traumatic stress as well as preventing chronic disorder and disability in children experiencing acute PTSD following accidental injury.

TRIAL REGISTRATION

Controlled-trials.com: ISRCTN79049138.