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

Differentiated processing of emotional cues in adolescents and young adults with ICD-11 PTSD and complex PTSD after child abuse

BACKGROUND

The recent update of the International Classification of Diseases 11th revision (ICD-11) introduced the diagnosis of complex posttraumatic stress disorder (CPTSD) as a distinct entity from posttraumatic stress disorder (PTSD). Because psychophysiological alterations are a core diagnostic feature of PTSD and CPTSD, the aim of the current study was to examine potential distinctive patterns in cortical and cardiac responses to emotional words in adolescent and young adult patients with PTSD and CPTSD.

METHOD

Event-related potentials and heart rate responses were studied in 81 adolescent and young adult participants, of which 17 individuals were diagnosed with ICD-11 PTSD and 32 individuals with CPTSD, each after childhood sexual and/or physical abuse. Thirty-two individuals served as healthy controls. The paradigm consisted of a passive reading task with neutral, positive, physically threatening, and socially threatening words.

RESULTS

Differentiated early processing of emotional words was indicated by differences on P1 and left EPN components. Additionally, PTSD and CPTSD patients presented with specific patterns of heart rate responses to emotional words. In CPTSD patients, heart rate reactions to emotional words were more variable than in PTSD patients.

CONCLUSIONS

These findings provide early evidence of differentiated cortical and cardiac response patterns in adolescent and young adult patients with CPTSD and PTSD, supporting a nosological distinction between PTSD and complex PTSD. However, due to small and unequal sample sizes, findings presented in the current study are preliminary and require future research.

The association between physical complications following female genital cutting and the mental health of 12-year-old Gambian girls: A community-based cross-sectional study

BACKGROUND

Female genital cutting (FGC) involve an acute physical trauma that hold a potential risk for immediate and long-term complications and mental health problems. The aim of this study was to examine the prediction of depressive symptoms and psychological distress by the immediate and current physical complications following FGC. Further, to examine whether the age at which 12-year-old Gambian girls had undergone the procedure affected mental health outcomes.

METHOD

This cross-sectional study recruited 134 12-year-old girls from 23 public primary schools in The Gambia. We used a structured clinical interview to assess mental health and life satisfaction, including the Short Mood and Feeling Questionnaire (SMFQ), the Symptom check list (SCL-5) and Cantril's Ladder of Life Satisfaction. Each interview included questions about the cutting procedure, immediate- and current physical complications and the kind of help and care girls received following FGC.

RESULTS

Depressive symptoms were associated with immediate physical health complications in a multivariate regression model [RR = 1.08 (1.03, 1.12), p = .001], and with present urogenital problems [RR = 1.19 (1.09, 1.31), p < .001]. The girls that received medical help following immediate complications had a lower risk for depressive symptoms [RR = .73 (.55, .98), p = .04]. Psychological distress was only associated with immediate complications [RR = 1.04 (1.01, 1.07), p = .004]. No significant differences in mental health outcomes were found between girls who underwent FGC before the age of four in comparison to girls who underwent FGC after the age of four.

CONCLUSION

Our findings indicate that the immediate and long-term complications following FGC have implications for psychological health. Only a minimal number of girls received medical care when needed, and the dissemination of health education seems crucial in order to prevent adverse long-term physical and psychological health consequences.

Posttraumatic Stress in Children After Injury: The Role of Acute Pain and Opioid Medication Use

OBJECTIVES

After injury, many children experience posttraumatic stress symptoms (PTSS) that negatively impact recovery. Acute pain and PTSS share neurobiological pathways, and acute dosage of morphine has been linked to reduced PTSS in naturalistic studies. However, the complex interactions between pain, morphine and other opioid use, and PTSS have yet to be investigated in robust pediatric samples.This prospective, longitudinal study examined relationships between acute pain, opioid medications, and PTSS after pediatric injury.

METHODS

Ninety-six children aged 8 to 13 years (mean = 10.60, SD = 1.71), hospitalized for unintentional injury, completed assessments at baseline (T1) and 12 weeks (T2) later. Pain ratings and opioid administration data were obtained via chart review.

RESULTS

Structural equation modeling revealed that worst pain endorsed during hospitalization was positively associated with concurrent and later PTSS when controlling for evidence-based risk factors (ie, age, sex, prior trauma history, traumatic appraisals of injury event, heart rate). Neither opioid medications overall nor morphine specifically (milligram/kilogram/day) administered during hospitalization mediated the relationship between pain and T2 PTSS.

CONCLUSIONS

Pain during hospitalization may increase susceptibility for persistent PTSS above and beyond the influence of other empirical risk factors. Findings suggest that pain assessment may be a useful addition to pediatric PTSS screening tools and highlight the need for additional research on pharmacological secondary prevention approaches. Given that inadequate pain control and persistent PTSS each hinder recovery and long-term functioning, better understanding of interactions between acute pain and PTSS after injury is essential for improving screening, prevention, and early intervention efforts.

Trajectories of maternal symptoms of posttraumatic stress disorder predict long-term mental health of children following the Wenchuan earthquake in China: A 10-year follow-up study

BACKGROUND

Maternal psychopathology can be an important factor associated with psychological adjustment of children. However, there is limited research on long-term impacts of maternal posttraumatic stress disorder (PTSD) on children's mental health. This study examined how PTSD trajectories of women exposed to the 2008 Wenchuan earthquake in China predicted their children's mental health symptoms 10 years after the earthquake.

METHODS

410 dyads of mothers and their adolescent children who exposed to the Wenchuan earthquake were investigated at 12 and 18 months post-earthquake. While the mothers completed measures of earthquake exposure and PTSD symptoms, the children completed measures of earthquake exposure, PTSD, depression and anxiety symptoms. In the 10-year follow up, 257 out of the 410 children completed measures of PTSD, depression and anxiety symptoms. Data were analyzed using linear regression.

RESULTS

Four trajectories of maternal PTSD symptoms were identified: (a) chronic (9.5%); (b) resilient (66.3%); (c) delayed (7.6%); and (d) recovery (16.6%); More importantly, the findings demonstrated that children whose mothers experienced chronic PTSD reported higher level of PTSD and anxiety symptoms 10 years after the earthquake.

LIMITATIONS

Only two waves of maternal PTSD were collected, self-reported tools other than clinical reviews were used to collect data, and a significant proportion of participants did not respond at the 10-year follow-up.

CONCLUSIONS

This study identified maternal PTSD trajectories following the Wenchuan earthquake. Chronic PTSD symptoms in mothers were associated with increased risk of children's PTSD and anxiety 10 years after the earthquake.

The Association Between Acute Pain and Posttraumatic Stress Symptoms in Children and Adolescents 3 Months After Accidental Injury

Previous research suggests that acute pain is a risk factor for later posttraumatic stress symptoms (PTSS). In a prospective cohort study, we examined the association between acute pain from accidental injury and PTSS in children and adolescents, taking into account factors potentially related to pain or posttraumatic stress. Participants were 135 children and adolescents, 8-18 years old. We measured the worst experienced pain since the accident took place with a visual analogue scale. Three months after the accident, posttraumatic stress was assessed with a self-report measure. We found a positive association between acute pain and posttraumatic stress. The amount of pain was negatively associated with injury severity in girls and positively associated with the presence of an extremity fracture in boys. In children who reported severe pain, this pain was significantly associated with PTSS and may account for around 10% of the variance in the severity of PTSS. Although the experience of pain is subjective, our study indicates that severe pain is associated with the severity of later PTSS. Timely management of pain according to acute pain protocols in all phases and disciplines after accidental injury is therefore recommended.

Sleep disturbances and internalizing behavior problems following pediatric traumatic injury

OBJECTIVE

This prospective longitudinal study investigated sleep disturbance (SD) and internalizing problems after traumatic injury, including traumatic brain injury (TBI) or extracranial/bodily injury (EI) in children and adolescents, relative to typically developing (TD) children. We also examined longitudinal relations between SD and internalizing problems postinjury.

METHOD

Participants (N = 87) ages 8-15 included youth with TBI, EI, and TD children. Injury groups were recruited from a Level 1 trauma center after sustaining vehicle-related injuries. Parent-reported SD and internalizing problems were assessed at preinjury/baseline, and 6 and 12 months postinjury. Linear mixed models evaluated the relation of group and time of assessment on outcomes.

RESULTS

Controlling for age, the combined traumatic injury group experienced significantly higher postinjury levels of SD (p = .042) and internalizing problems (p = .024) than TD children; however, TBI and EI injury groups did not differ from each other. Injury severity was positively associated with SD in the EI group only, but in both groups SD was associated with additional postinjury sequelae, including fatigue and externalizing behavior problems. Internalizing problems predicted subsequent development of SD but not vice versa. The relation between injury and SD 1 year later was consistent with mediation by internalizing problems at 6 months postinjury.

CONCLUSIONS

Children with both types of traumatic injury demonstrated higher SD and internalizing problems than healthy children. Internalizing problems occurring either prior to or following pediatric injury may be a risk factor for posttraumatic SD. Consequently, internalizing problems may be a promising target of intervention to improve both SD and related adjustment concerns. (PsycINFO Database Record

Lifelong consequences of brain injuries during development: From risk to resilience

Traumatic brain injuries in children represent a major public health issue and even relatively mild injuries can have lifelong consequences. However, the outcomes from these injuries are highly heterogeneous, with most individuals recovering fully, but a substantial subset experiencing prolonged or permanent disabilities across a number of domains. Moreover, brain injuries predispose individuals to other kinds of neuropsychiatric and somatic illnesses. Critically, the severity of the injury only partially predicts subsequent outcomes, thus other factors must be involved. In this review, we discuss the psychological, social, neuroendocrine, and autonomic processes that are disrupted following traumatic brain injury during development, and consider the mechanisms the mediate risk or resilience after traumatic brain injury in this vulnerable population.

Cardiac reactions to emotional words in adolescents and young adults with PTSD after child abuse

Post-traumatic stress disorder (PTSD) is associated with alterations in cardiac reactivity to threat cues. Meta-analyses have summarized that adults with PTSD have increased heart rates in response to trauma-related stimuli. However, the opposite effect (i.e., cardiac hyporeactivity) has recently been reported in subgroups of PTSD patients. In children and adolescents with PTSD, reports of cardiac alterations are rare and ambiguous. So far, most studies in adolescents and young adults are restricted to victims of accidents, even though PTSD is highly prevalent in victims of child maltreatment. The present study aimed at investigating cardiac reactions in adolescents and young adults with PTSD after child abuse. Cardiac responses to standardized emotional words were studied in 39 adolescent and young adult PTSD patients after childhood sexual and/or physical abuse as compared to 39 healthy control subjects (age range: 15-20 years). The experimental paradigm consisted of a passive reading task with neutral, positive, physically threatening, and socially threatening (swear) words. Results showed that cardiac reactions to negative stimuli, particularly physically threatening stimuli, were less pronounced in PTSD patients than in controls. Moreover, cardiac reactions in response to socially threatening words were less variable in the PTSD group. No differences between and within groups were present in reaction to neutral or positive stimuli. Findings suggest that a physiologically blunted subtype of PTSD may already manifest during adolescence and young adulthood. Moreover, the results of the present study emphasize the relevance of individual trauma history for physiological reactions.

Test Accuracy of the Screening Tool for Early Predictors of Post-traumatic Stress Disorder for Post-injury Mental Health in a Managed-Medicaid Population

OBJECTIVE

To determine the Screening Tool for Early Predictors of Post-Traumatic Stress Disorder (STEPP) test accuracy in identifying children with new mental health diagnoses and psychotropic medications prescribed within 12 months after unintentional injuries in a managed-Medicaid population.

STUDY DESIGN

We conducted a secondary analysis of a retrospective cohort that investigated mental health diagnoses and psychotropic medications pre- and post-injury in children ≤18 years of age treated at a pediatric trauma center from 2005 to 2015 (n = 2208). For this study, we analyzed children with STEPP scores from their injury admission (n = 85). For children without previous mental health diagnoses or psychotropic prescriptions, we calculated the sensitivity, specificity, and positive and negative predictive values for the child and parent STEPP.

RESULTS

Of 78 children without previous diagnoses, 12 had post-injury mental health diagnoses. Of 68 children without previous psychotropic medication use, 10 had psychotropic medications prescribed. The child STEPP sensitivity was 8.3% for mental health diagnoses (95% CI 0.2, 38.5) and 10% for psychotropic medications (95% CI 0.3, 44.5). The child STEPP specificity was 77.3% for mental health diagnoses (95% CI 65.3, 86.7) and 75.9% for psychotropic medication (95% CI 62.8, 86.1).

CONCLUSIONS

We found that the STEPP performed poorly in identifying children who received new mental health diagnoses and new psychotropic medications following injury.

Graph theory analysis of DTI tractography in children with traumatic injury

OBJECTIVE

To evaluate brai structural connectivity in children with traumatic injury (TI) following a motor vehicle accident using graph theory analysis of DTI tractography data.

METHODS

DTI scans were acquired on a 3 T Philips scanner from children aged 8-15 years approximately 2 months post-injury. The TI group consisted of children with traumatic brain injury (TBI; n = 44) or extracranial injury (EI; n = 23). Healthy control children (n = 36) were included as an age-matched comparison group. A graph theory approach was applied to DTI tractography data to investigate injury-related differences in connectivity network characteristics. Group differences in structural connectivity evidenced by graph metrics including efficiency, strength, and modularity were assessed using the multi-threshold permutation correction (MTPC) and network-based statistic (NBS) methods.

RESULTS

At the global network level, global efficiency and mean network strength were lower, and modularity was higher, in the TBI than in the control group. Similarly, strength was lower and modularity higher when comparing the EI to the control group. At the vertex level, nodal efficiency, vertex strength, and average shortest path length were different between all pairwise comparisons of the three groups. Both nodal efficiency and vertex strength were higher in the control than in the EI group, which in turn were higher than in the TBI group. The opposite between-group relationships were seen with path length. These between-group differences were distributed throughout the brain, in both hemispheres. NBS analysis resulted in a cluster of 22 regions and 21 edges with significantly lower connectivity in the TBI group compared to controls. This cluster predominantly involves the frontal lobe and subcortical gray matter structures in both hemispheres.

CONCLUSIONS

Graph theory analysis of DTI tractography showed diffuse differences in structural brain network connectivity in children 2 months post-TI. Network differences were consistent with lower network integration and higher segregation in the injured groups compared to healthy controls. Findings suggest that inclusion of trauma-exposed comparison groups in studies of TBI outcome is warranted to better characterize the indirect effect of stress on brain networks.

Role of dopamine D3 receptor in alleviating behavioural deficits in animal models of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a complicated psychiatric disorder, which occurs after exposure to a traumatic event. The main clinical manifestation of PTSD includes fear and stress dysregulation. In both animals and humans, dysregulation of dopamine function appears to be related to conditioned fear responses. Previous studies show that the dopamine D3 receptor (D3R) is involved in schizophrenia, autism, and substance use disorders and is related to emotional disorders. However, few studies have investigated the role of the D3R in the pathogenesis and aetiology of PTSD. In the current study, we have reported that D3R knockout (D3R^-/-) mice displayed decreased freezing time of contextual fearing and anxiolytic effects following training sessions consisting of exposure to inescapable electric foot-shocks. Similarly, highly selective blockade of D3Rs by YQA14, a novel D3R antagonist, significantly ameliorated freezing and anxiogenic-like behaviours in the single-prolonged stress (SPS) model of PTSD in rats. And more, YQA14 selectively alleviated the symptoms of PTSD in WT mice but not in D3R^-/- mice. In summary, this study demonstrates the anti-PTSD effects of blockade or knockout of the D3R, suggesting that the D3R might play an important role in the pathogenesis and aetiology of PTSD, and might be a potential target for the clinical management of PTSD.

Using High-Risk Adolescents' Voices to Develop a Comprehensible Cognitive Behavioral Therapy-Based Text-Message Program

At-risk adolescents' comprehension of, and preferences for, the content of a text-message (SMS) delivered, cognitive behavioral therapy (CBT)-based depression prevention intervention was investigated using two qualitative studies. Adolescents with depressive symptoms and a history of peer violence were recruited from an urban emergency department. Forty-one participants completed semi-structured qualitative interviews. Thematic analysis using deductive and inductive codes were used to capture a priori and emerging themes. Five major themes were identified: CBT-based messages resonated with at-risk adolescents; high levels of peer violence, comorbid symptoms, and prior exposure to the mental health system were variables affecting preferred content; participants endorsed emotional regulation messages, but found mindfulness content difficult to understand via SMS; cognitive awareness and restructuring content was most acceptable when framed by self-efficacy content; adolescent participants generated applicable CBT content in their own voices. Overall, CBT-informed content was able to be distilled into 160-character text messages without losing its comprehensibility.

Statistical analysis of factors affecting re-operative times in paediatric patients with scar deformity after deep second-degree burn injury

Deep second-degree burn injuries pose a challenge for treating scar deformity in developing paediatric patients. Some patients underwent several re-operations during their development. There was no literature reporting which factors affect re-operative times. In this article, we intend to analyse possible influential factors that are responsible for re-operative times in paediatric patients with scar deformity after deep second-degree burn injuries. From 2010 to 2016, 177 paediatric cases with a history of deep second-degree burn injury who underwent re-operation once, twice, and equal to or more than thrice were recruited to this study, with age ranging from 0 to 18 years. The following factors were analysed: age, gender, size of scar, method for reconstruction, location, postoperative anti-scar treatment, preschool group, school group, combined deformity, and combined method for reconstruction. One-way ANOVA and multi-way ANOVA analysis were used as statistical tools to analyse the above factors and re-operative times. There were 83 male cases and 94 female cases, with an average age of 7.47 years. Statistical significance was achieved for the size of scar (P = 0.000), operation method (P = 0.001), and combined deformity (P = 0.026) under 1-way ANOVA in different re-operative times. The operation methods for the head and neck area (P < 0.05) and the lower extremities (P < 0.05) are critical factors for multi-factor variance analysis in different re-operative times. Multivariate logistic regression analysis also demonstrated that the size of scar was an independent risk factor for the number of operations. Combined operative method was a protective risk factor for the number of operations. There was no statistical significance obtained for other factors. Size of scar, operation method, and combined operation method are the risk factors for re-operative times, while operation methods for the head and neck area and lower extremities are the critical factors for re-operative times. We can use the combined method to resolve scar-related problems in order to reduce re-operative times.

Parental Factors Associated with Child Post-traumatic Stress Following Injury: A Consideration of Intervention Targets

Post-traumatic stress disorder (PTSD) symptoms are relatively common following pediatric traumatic injury and are related to poor long-term child outcomes. However, due to concerns regarding the efficacy of early child preventive interventions, and difficulty intervening with injured and medicated children soon after the event, it is not feasible to provide early psychological interventions to children exposed to traumatic injury. Parental PTSD symptoms and reactions to the child's traumatic injury impact child outcomes and provide potential targets for early intervention to reduce child symptom development without involving the child. The authors conducted a review of the literature using Psycinfo and Pubmed research databases (publication years = 1990-2017) and identified 65 published studies relevant to the topic of the review. The present review considers parent factors [parenting styles, parental post-traumatic pathology (PTS), adaptive and maladaptive coping strategies, and communication regarding the traumatic injury] and their impact on child PTS. We focus specifically on factors amenable to intervention. We further review moderators of these relationships (e.g., child age and gender, parent gender) and conclude that it is unlikely that a one-size-fits-all approach to treatment will be successful. Rather, it is necessary to consider the age and gender of parent child dyads in designing and providing targeted interventions to families following the traumatic injury of a child.

Gender Differences in Posttraumatic Stress Symptoms Among Participants of a Violence Intervention Program at a Pediatric Hospital: A Pilot Study

Hospital-based violence intervention programs (HVIPs) have emerged as a strategy to address posttraumatic stress (PTS) symptoms among violently injured patients and their families. HVIP research, however, has focused on males and little guidance exists about how HVIPs could be tailored to meet gender-specific needs. We analyzed pediatric HVIP data to assess gender differences in prevalence and type of PTS symptoms. Girls reported more PTS symptoms than boys (6.96 vs 5.21, P = .027), particularly hyperarousal symptoms (4.00 vs 2.82, P = .002) such as feeling upset by reminders of the event (88.9% vs 48.3%, P = .005). Gender-focused research represents a priority area for HVIPs.

Plasma Lipidomic Profiling in a Military Population of Mild Traumatic Brain Injury and Post-Traumatic Stress Disorder with Apolipoprotein E ɛ4-Dependent Effect

In the military population, there is high comorbidity between mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) due to the inherent risk of psychological trauma associated with combat. These disorders present with long-term neurological dysfunction and remain difficult to diagnose due to their comorbidity and overlapping clinical presentation. Therefore, we performed cross-sectional analysis of blood samples from demographically matched soldiers (total, n = 120) with mTBI, PTSD, and mTBI+PTSD and those who were considered cognitively and psychologically normal. Soldiers were genotyped for apolipoprotein E (APOE) ɛ4, and phospholipids (PL) were examined using liquid chromatography/mass spectrometry analysis. We observed significantly lower levels of several major PL classes in TBI, PTSD, and TBI+PTSD, compared with controls. PTSD severity analysis revealed that significant PL decreases were primarily restricted to the moderate-to-severe PTSD group. An examination of the degree of unsaturation showed that monounsaturated fatty acid-containing phosphatidylcholine (PC) and phosphatidylinositol (PI) species were lower in the TBI and TBI+PTSD groups. However, these PLs were unaltered among PTSD subjects, compared with controls. Similarly, ether PC (ePC) levels were lower in PTSD and TBI+PTSD subjects, relative to controls. Ratios of arachidonic acid (AA) to docosahexaenoic acid (DHA)-containing species were significantly decreased within PC and phosphatidylethanolamine (PE) classes. APOE ɛ4 (+) subjects exhibited higher PL levels than their APOE ɛ4 (-) counterparts within the same diagnostic groups. These findings suggest that PL profiles, together with APOE genotyping, could potentially aid to differentiate diagnosis of mTBI and PTSD and warrant further validation. In conclusion, PL profiling may facilitate clinical diagnosis of mTBI and PTSD currently hindered by comorbid pathology and overlapping symptomology of these two conditions.

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.

Scar Management in the Pediatric and Adolescent Populations

For most children and adolescents who have developed symptomatic scars, cosmetic concerns are only a portion of the motivation that drives them and their caregivers to obtain treatment. In addition to the potential for cosmetic disfigurement, scars may be associated with a number of physical comorbidities including hypertrichosis, dyshidrosis, tenderness/pain, pruritus, dysesthesias, and functional impairments such as contractures, all of which may be compounded by psychosocial factors. Although a plethora of options for treating scars exists, specific management guidelines for the pediatric and adolescent populations do not, and evidence must be extrapolated from adult studies. New modalities such as the scar team approach, autologous fat transfer, and ablative fractional laser resurfacing suggest a promising future for children who suffer symptomatically from their scars. In this state-of-the-art review, we summarize cutting-edge scar treatment strategies as they relate to the pediatric and adolescent populations.

Physical injury and posttraumatic stress reactions. A study of the survivors of the 2011 shooting massacre on Utøya Island, Norway

OBJECTIVE

The objective of the study was to investigate the relationship between physical injury (no, moderate and severe) and posttraumatic stress reactions (PTSR) at 4-5 months after the attack in survivors of the terror attack at Utøya Island, Norway, 22 July 2011, adjusting for sociodemographic, psychosocial and trauma-related factors.

METHODS

Overall, 325 young survivors (47% women, mean age 19.4 years) were interviewed 4-5 months (T1) and 14-15 months (T2) after the attack. Variables concerning physical injury, PTSR (UCLA PTSD-RI scale, 0-4), peritraumatic exposure, sociodemographic and psychosocial backgrounds were measured. To evaluate the role of injury, multiple linear regression analyses were conducted.

RESULTS

The physically injured (n=60) reported higher levels of PTSR than did the non-injured. The difference was statistically significant between the moderately injured (n=37, mean 1.9) and the non-injured (n=265, mean 1.5). No significant differences were found between the moderately and the severely (n=23, mean 1.8) injured. Higher levels of peritraumatic events, peritraumatic reactions and loss of close, female sex and non-Norwegian ethnicity were significantly related to higher levels of PTSR in the full regression model.

CONCLUSION

Physical injury was associated with higher PTSR after the terror attack. Moderately injured survivors may, as those severely injured, exhibit high levels of PTSR, and this should be taken into account when targeting early psychosocial health care after terror.

Systematic Review: A Reevaluation and Update of the Integrative (Trajectory) Model of Pediatric Medical Traumatic Stress

OBJECTIVE

The objective of this systematic review is to reevaluate and update the Integrative Model of Pediatric Medical Traumatic Stress (PMTS; Kazak et al., 2006), which provides a conceptual framework for traumatic stress responses across pediatric illnesses and injuries.

METHODS

Using established systematic review guidelines, we searched PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and PubMed (producing 216 PMTS papers published since 2005), extracted findings for review, and organized and interpreted findings within the Integrative Model framework.

RESULTS

Recent PMTS research has included additional pediatric populations, used advanced longitudinal modeling techniques, clarified relations between parent and child PMTS, and considered effects of PMTS on health outcomes. Results support and extend the model's five assumptions, and suggest a sixth assumption related to health outcomes and PMTS.

CONCLUSIONS

Based on new evidence, the renamed Integrative Trajectory Model includes phases corresponding with medical events, adds family-centered trajectories, reaffirms a competency-based framework, and suggests updated assessment and intervention implications.

Young people's experiences with scoliosis surgery: a survey of pain, nausea, and global satisfaction

BACKGROUND

Scoliosis surgery is one of the most extensive elective surgical processes performed on young people. Although there is a great store of knowledge of surgical techniques, patients' experiences of going through surgery have not been extensively studied.

PURPOSE

The aim of this study is to describe how a cohort of young people and their parents retrospectively rate postoperative pain and nausea and describe their experiences of scoliosis surgery.

METHODS

In a retrospective cohort study, 87 young people aged 8-25 years with scoliosis who underwent corrective surgery from 2004 to 2007 were invited to complete a questionnaire, as were their parents. The semistructured questionnaire dealt with experiences of pain, nausea, and global satisfaction pre- and posthospitalization, assessed by visual analogue scales. The free text commentaries were analyzed using qualitative content analysis.

RESULTS

A total of 51 patients (59%) and 65 parents (75%) answered the questionnaires. Out of the completed questionnaires, 41 had idiopathic, 23 neuromuscular, and 6 other types of scoliosis. Postoperative patient-rated pain was severe 7.3 (median, interquartile range 5-8.4, visual analogue scale 0-10 cm), and the severe pain lasted for 5 (median, 2.7-7.0) days. Nausea was rated to a median of 5 (1.1-7.3) and lasted for a median of 3 (1-5.2) days. Global satisfaction was rated to a median of 3.2 (1.5-5.2). Postoperative pain was the most prominent issue, and present pain was found in 51% of respondents. Nausea and loss of appetite were common during the entire hospital stay. Waiting for the nurses' assistance, lack of control, and technical failures with the analgesia equipment caused discomfort. Parents experienced a lack of confidence in the nurses and felt helpless to support their child or relieve the child's suffering.

CONCLUSION

Young people who underwent scoliosis surgery reported severe postoperative pain and nausea during the hospitalization period and persistent and recent onset pain after discharge, although they did not indicate global dissatisfaction with the hospital stay.

Psychophysiological characteristics of pediatric posttraumatic stress disorder during script-driven traumatic imagery

BACKGROUND

Psychophysiological alterations such as elevated baseline levels and hyperresponsivity in cardiac, electrodermal, and facial muscle activity have been observed in adults with posttraumatic stress disorder (PTSD). There are only few, inconclusive studies investigating psychophysiological responses in children and adolescents with PTSD.

OBJECTIVE

This cross-sectional study sought to examine if autonomic variables, facial electromyography (EMG), and self-reported anxiety at baseline, while listening to neutral and idiosyncratic trauma scripts, differ between minors with a trauma history and PTSD, and a traumatized control (TC) group without PTSD. A better understanding of psychophysiological reactions in trauma-exposed children and adolescents could improve differential assessment and treatment decisions.

METHOD

PTSD was assessed using the Clinician Administered PTSD Scale for Children and Adolescents in 6- to 17-year-old trauma-exposed children, resulting in a group with PTSD according to DSM-IV (n=16) and a TC group without PTSD (n=18). Facial EMG, (para-)sympathetic measures (heart rate, electrodermal activity, respiratory sinus arrhythmia), and self-reported anxiety were measured during 5-min baseline, 3-min neutral script, and 3-min idiosyncratic trauma script. Baseline, reactivity (trauma minus baseline), and script contrast (trauma minus neutral) were analyzed by multivariate analyses of variance.

RESULTS

Children and adolescents with PTSD reported more anxiety compared to TC for baseline, reactivity, and script contrast (ps<0.021, ds>0.59), and showed elevated corrugator supercilii muscle activity for script contrast (p<0.05, d=0.79). No group differences emerged for sympathetic or parasympathetic measures.

CONCLUSIONS

Children and adolescents with PTSD experienced elevated anxiety at baseline and elevated anxiety and facial corrugator muscle response to an idiosyncratic trauma narrative. Autonomic hyperreactivity, typical for adult PTSD samples, did not figure prominently.

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.

Factors related with unintentional injuries in children with newly diagnosed attention-deficit/hyperactivity disorder

The aim of the present study was to investigate the factors associated with unintentional injury in children newly diagnosed with attention-deficit/hyperactivity disorder (ADHD). One thousand four hundred and thirty children between the ages of 6 and 18 who were diagnosed with ADHD for the first time in child psychiatry outpatient clinics were included in the present study. The socio-demographic information of the children, their developmental histories, chronic physical health conditions, comorbid psychiatric disorders, and information obtained via the Turgay DSM-IV-based Child and Adolescent Disorders Screening and Rating Scale were examined retrospectively. It was determined that 12.8% of the children (n = 183) experienced unintentional injury. It was established that age, male gender, disruptive behavioural problems, and low education levels among mothers were predictive of unintentional injuries. The results of the present study suggest that behavioural problems accompanying ADHD and comorbid psychiatric disorders are important in terms of unintentional injuries.

The relationship between behavioural problems in preschool children and parental distress after a paediatric burn event

This study examines mother- and father-rated emotional and behaviour problems in and worries about 0- to 5-year-old children at 3 and 12 months after a burn event and the relation with parental distress. Mothers (n = 150) and fathers (n = 125) representing 155 children participated in this study. Child emotional and behaviour problems and parental worries about the child were assessed with the Child Behavior Checklist at both time points. Parents' level of acute subjective distress was assessed within the first month after the burn event with the Impact of Event Scale. Mothers and fathers held comparable views of their child's emotional and behaviour problems, which were generally within the normal limits. Parents' own acute stress reactions were significantly related to parent-rated child behaviour problems at 3 and 12 months postburn. A substantial part of mothers' and fathers' worries about the child concerned physical and emotional aspects of the burn trauma, and potential future social problems. Parents with high acute stress scores more often reported burn-related concerns about their child at 3 and 12 months postburn. Health-care professionals should be informed that parents' distress in the subacute phase of their child's burn event may be related to subsequent worries about their child and to (parent-observed) child emotional and behaviour problems. The authors recommend a family perspective, with particular attention for the interplay between parents' distress and parent-reported child behaviour problems and worries, in each phase of paediatric burn care.

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.

Indicated and selective preventive interventions

Exposure to traumatic events places children at risk for developing distressing, significant emotional reactions such as posttraumatic stress symptoms (PTSS). These reactions also affect long-term functional outcomes. Research on identified and potential risk factors for the development of significant, persistent PTSS is under way. Evidence for preventive interventions is in its infancy but progressing. Family-centered interventions comprising education about emotional reactions to traumatic events and focusing on communication between children and parents show promising results. Only morphine has shown sufficient evidence as a pharmacologic intervention in children. Additional research is necessary to support the establishment of gold-standard preventive practices.

Health-related quality of life in children and adolescents following traumatic injury: a review

This paper comprehensively reviews the published literature investigating health-related quality of life (HRQOL) following general traumatic injury in individuals between birth and 18 years. Studies were not considered if they primarily compared medical treatment options, evaluated physical function but not other aspects of HRQOL, or focused on non-traumatic wounds. Specific injury types (e.g., burn injury) were also not included. A total of 16 studies met criteria. Participants were age 1-18 years, with 12 studies considering children 5 years of age or older. Males were overrepresented. Injury severity averaged mostly in the moderate range. HRQOL deficits were noted in injured samples in all studies except the two with the longest time to follow-up (6-11 years). Some improvement was seen 6 months to 2 years after injury. Factors associated with HRQOL deficits were investigated, with acute and posttraumatic stress disorder symptoms showing the strongest relationship. Research to date in this area is impressive, particularly the number of studies using prospective longitudinal investigations and validated measures. Challenges remain regarding methodologic differences, assessment of preinjury status, retention of participants, and management of missing data. Suggested future directions include extension of follow-up duration, utilization of pediatric self-report when possible, inclusion of younger children, and development of intervention programs.

Pharmacological secondary prevention of PTSD in youth: challenges and opportunities for advancement

Child and adolescent posttraumatic stress disorder (PTSD) is associated with an increased risk for a number of deleterious mental and physical health outcomes that if untreated may persist throughout the life course. Efficacious interventions applied soon after trauma exposure have the potential to reduce or prevent the development of PTSD symptoms and their associated impact on behavior and physical health. We review extant research related to treatment-modifiable peritraumatic predictors of pediatric PTSD, which have informed an emerging field of pharmacologic secondary prevention (i.e., occurring shortly following trauma exposure) of PTSD. Challenges and opportunities for early posttrauma PTSD prevention are described. Finally, we offer new models for biologically informed integration of pharmacologic and psychosocial secondary prevention intervention strategies for children and adolescents.

Prevalence of post-traumatic stress disorder among children and adolescents who survive road traffic crashes: a systematic review of the international literature

While road traffic crashes are known to have a significant impact in terms of deaths and hospitalisations, quantifying the burden of psychological sequelae is more challenging. This systematic review critically evaluates published studies designed to estimate the prevalence of post-traumatic stress disorder among children and adolescents who have survived a road crash. Most studies have focused on injured school-aged children and adolescents, and estimate the occurrence of this condition to be between 12% and 46% in the first 4 months following crash involvement and between 13% and 25% 4-12 months following the crash. The relatively high prevalence of post-traumatic stress disorder following one of the commonest causes of injury underscores the need for greater vigilance and active management to mitigate the adverse consequences on the health and development of young crash survivors. The findings also emphasise the important role that child health professionals must play in promoting strategies that prevent road traffic crashes.

Posttraumatic stress disorder: shifting toward a developmental framework

This article reviews the current classification of posttraumatic stress disorder and its limitations when applied to youth. Distinctions are made between single-event and multiple-event traumas. Diagnosis, neurobiology, treatment development, and treatment outcomes are presented. A summary of current empirical interventions is provided. The authors present implications for future research and for clinical practice.

Differences in posttraumatic stress reactions between witnesses and direct victims of motor vehicle accidents

The present study describes posttraumatic stress reactions in young witnesses of motor vehicle accidents (MVAs). This study investigated (a) whether witnesses of MVAs report fewer trauma symptoms than direct victims, but more than adolescents who were never exposed to an MVA; and (b) whether individual differences in sex, negative appraisal, avoidant coping, and social support account for variability in trauma symptoms beyond status as a witness as compared to a victim. Self-report data came from a community-based sample of 3,007 adolescents with an average age of 14.6 years and comprising 53% boys. Compared to direct victims of an MVA in which someone was injured, witnesses of MVAs with injury reported significantly less internalizing symptoms, such as symptoms of posttraumatic stress (d = 0.25), fear (d = 0.21), and depression (d = 0.17). Compared to adolescents who were never exposed to an MVA with injury, witnesses reported significantly more externalizing symptoms (d = 0.24). In multiple regression analyses the significant difference between witnesses and victims disappeared when sex, other stressful events, appraisals, and coping were added to the model. These findings suggest that adolescent witnesses, as well as direct victims, may be at risk for posttraumatic reactions.

Predictors of parental posttraumatic stress disorder symptoms in the year after adolescent traumatic injury

OBJECTIVES

Parental posttraumatic stress disorder (PTSD) is common after pediatric traumatic injury and may negatively impact parental functioning and quality of life during this key period of the child's early postinjury recovery. This study aimed to evaluate the course and predictors of PTSD in parents during the year after an adolescent traumatic injury.

METHODS

This prospective cohort study included a population-based sample of 99 parent-adolescent dyads. Assessment was through structured interview administration of standardized measures. Interviews were conducted within 30 days of injury and 2, 5, and 12 months after injury. Mixed model regression was used to evaluate variables potentially associated with repeated measures of parental PTSD symptoms at the follow-up time points.

RESULTS

Twenty-three percent of parents met symptomatic criteria for PTSD at the first postinjury evaluation, as did 15% at 2 months, 7% at 5 months, and 6% at 12 months after the injury. The percentage of parents meeting symptomatic PTSD criteria decreased significantly between the 2-month and 12-month evaluations. Mixed-model regression analyses revealed greater PTSD symptoms within 30 days of injury and a greater number of postinjury parental traumatic and/or stressful life events as significant predictors of parental PTSD. Adolescent factors did not affect the risk of parental PTSD.

CONCLUSIONS

A substantial subgroup of parents demonstrate high PTSD symptom levels during the course of the year after an adolescent injury. Given that early modifiable risk factors can be identified, future investigations focusing on screening and intervention are warranted.

Neuropsychological and neuroimaging findings in traumatic brain injury and post-traumatic stress disorder

Advances in imaging technology, coupled with military personnel returning home from Iraq and Afghanistan with traumatic brain injury (TBI) and/or post-traumatic stress disorder (PTSD), have increased interest in the neuropsychology and neurobiology of these two conditions. There has been a particular focus on differential diagnosis. This paper provides an overview of findings regarding the neuropsychological and neurobiological underpinnings of TBI and for PTSD. A specific focus is on assessment using neuropsychological measures and imaging techniques. Challenges associated with the assessment of individuals with one or both conditions are also discussed. Although use of neuropsychological and neuroimaging test results may assist with diagnosis and treatment planning, further work is needed to identify objective biomarkers for each condition. Such advances would be expected to facilitate differential diagnosis and implementation of best treatment practices.

The traumatic impact of motor vehicle accidents in high school students

OBJECTIVES

To obtain the year prevalence of nonfatal motor vehicle accidents (MVAs) in adolescents, to describe trauma symptoms (posttraumatic stress, depression, anxiety, dissociation), and to test a theoretical model of traumatic events.

METHODS

A community-based sample of 3,007 adolescents (mean age: 14.6 years) completed questionnaires regarding MVAs, appraisals, coping, support, and trauma symptoms.

RESULTS

Three percent of the adolescents reported being injured in a MVA during the past year. Of the adolescents who reported a MVA in their life (22.4%), 11.0% reported significant posttraumatic stress or other trauma symptoms. Structural equation modeling revealed that negative appraisals mediated the relation between trauma symptoms and MVA severity. Avoidant coping partially mediated the relation between appraisal and trauma symptoms. Social support was associated with less negative appraisals and with more avoidant coping.

CONCLUSIONS

Results suggest the need for a better registration of young traffic victims to optimize screening for psychological problems.

Predicting pediatric posttraumatic stress disorder after road traffic accidents: the role of parental psychopathology

This study examined prospectively the role of parental psychopathology among other predictors in the development and persistence of posttraumatic stress disorder (PTSD) in 57 hospitalized youths aged 7-18 years immediately after a road traffic accident and 1 and 6 months later. Self report questionnaires and semistructured diagnostic interviews were used in all 3 assessments. Neuroendocrine evaluation was performed at the initial assessment. Maternal PTSD symptomatology predicted the development of children's PTSD 1 month after the event, OR = 6.99, 95% CI [1.049, 45.725]; the persistence of PTSD 6 months later was predicted by the child's increased evening salivary cortisol concentrations within 24 hours of the accident, OR = 1.006, 95% CI [1.001, 1.011]. Evaluation of both biological and psychosocial predictors that increase the risk for later development and maintenance of PTSD is important for appropriate early prevention and treatment.

Association between traumatic injury and psychiatric disorders and medication prescription to youths aged 10-19

OBJECTIVE

Few clinical epidemiologic investigations have assessed whether youths exposed to a traumatic injury demonstrate elevations in the full spectrum of provider-recognized psychiatric disorders compared with unexposed, noninjured youths.

METHODS

In a population-based prospective cohort study, data for children and adolescents aged ten to 19 who were enrolled in the Group Health Cooperative health plan were screened for injury visits in the index year of 2001 (N=20,507). Psychiatric diagnoses, including anxiety and acute stress, depressive, substance use, and disruptive behavior disorders, given to these youths over the next three years (2002-2004) were documented, as were psychotropic medication prescriptions. Regression analyses assessed for an independent association between injury and psychiatric disorders and prescription of psychotropic medication.

RESULTS

In adjusted regression analyses, injury in the index year was independently associated with significantly increased odds of receiving a diagnosis of anxiety or acute stress (odds ratio [OR]=1.21, 95% confidence interval [CI]=1.02-1.44), depression (OR=1.30, CI=1.10-1.53), and a substance use disorder (OR=1.56, CI=1.21-2.00) and of receiving a psychotropic medication prescription (OR=1.37, CI=1.20-1.57). Youths with traumatic brain injuries also were significantly more likely to receive psychotropic medication prescriptions.

CONCLUSIONS

Traumatic injury was independently associated with an increased risk of receiving a full spectrum of anxiety, depressive, and substance use diagnoses among youths aged ten to 19. Population-based surveillance procedures that incorporate screening and stepped-care interventions targeting the spectrum of postinjury emotional disturbances have the potential to improve the quality of mental health care for youths treated in general medical settings.

The role of family phenomena in posttraumatic stress in youth

TOPIC

Youth face trauma that can cause posttraumatic stress (PTS).

PURPOSE

(1) To identify the family phenomena used in youth PTS research; and(2) to critically examine the research findings regarding the relationship between family phenomena and youth PTS.

SOURCES

Systematic literature review in PsycInfo, PILOTS, CINAHL, and MEDLINE. Twenty-six empirical articles met inclusion criteria.

CONCLUSION

Measurement of family phenomena included family functioning,support, environment, expressiveness, relationships, cohesion, communication, satisfaction, life events related to family, parental style of influence, and parental bonding. Few studies gave clear conceptualization of family or family phenomena. Empirical findings from the 26 studies indicate inconsistent empirical relationships between family phenomena and youth PTS, although a majority of the prospective studies support a relationship between family phenomena and youth PTS. Future directions for leadership by psychiatric nurses in this area of research and practice are recommended.

Family functioning and posttraumatic stress symptoms in youth and their parents after unintentional pediatric injury

This study examined the association between family functioning and the development of posttraumatic stress symptoms (PTSS) in youth and parents following an unintentional traumatic injury of a child. Fifty-one parent-child dyads completed questionnaires and a structured interview assessing PTSS and family functioning. Multiple regression analyses were applied to evaluate the contribution of family functioning to the development of PTSS after controlling for demographic characteristics and known predictors. Family functioning had both direct and moderating influences on the development of PTSS in parents. We were unable to demonstrate a systematic impact of family functioning on the development of PTSS in children from the same families.

Posttraumatic stress disorder in the pediatric trauma patient

Recent research has uncovered the prevalence of posttraumatic stress disorder (PTSD) after traumatic experiences in the pediatric population at an alarming rate. This review discusses new challenges in identifying children at risk for the development of PTSD, as well as understanding the unique aspects of this disorder found in the pediatric population. In addition to the characterization of pediatric PTSD, this review addresses current screening tools and treatment strategies used in childhood stress disorders.

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

Controversy surrounds the classification of posttraumatic stress disorder (PTSD), particularly in children and adolescents with traumatic brain injury (TBI). In these populations, it is difficult to differentiate TBI-related organic memory loss from dissociative amnesia. Several alternative PTSD classification algorithms have been proposed for use with children. This paper investigates DSM-IV-TR and alternative PTSD classification algorithms, including and excluding the dissociative amnesia item, in terms of their ability to predict psychosocial function following pediatric TBI. A sample of 184 children aged 6-14 years were recruited following emergency department presentation and/or hospital admission for TBI. PTSD was assessed via semi-structured clinical interview (CAPS-CA) with the child at 3 months post-injury. Psychosocial function was assessed using the parent report CHQ-PF50. Two alternative classification algorithms, the PTSD-AA and 2 of 3 algorithms, reached statistical significance. While the inclusion of the dissociative amnesia item increased prevalence rates across algorithms, it generally resulted in weaker associations with psychosocial function. The PTSD-AA algorithm appears to have the strongest association with psychosocial function following TBI in children and adolescents. Removing the dissociative amnesia item from the diagnostic algorithm generally results in improved validity.

Adolescents' experience with scoliosis surgery: a qualitative study

This article reports a study of adolescents' narrated experiences of undergoing scoliosis surgery. Six adolescents were interviewed. Open and semistructured questions were asked, and a qualitative content analysis of the text was performed. The results are presented in three main categories followed by subcategories. The three main categories of experience were emotional, physical, and social. The emotional aspects that emerged were fear, nightmares, nervousness, and helplessness. These had a great impact on adolescents' well-being before, during, and after the hospital visit. The physical aspects were mobilization, scars, different hip levels, pain, nausea, appetite, and urinary catheter. These aspects caused much discomfort, mostly during the hospital visit. The social aspects were friends, power, coaching and comfort, and sports. Some of the social aspects had a strong negative impact on the adolescents' well-being mostly after the hospital visit. This study suggests that both before and long after the surgery adolescents have strong emotions that they should be better prepared and helped to manage. To optimize perioperative care an interdisciplinary, a holistic approach must be taken that incorporates the complexity and whole of the adolescent's experiences. The findings of this study suggest that perioperative care of adolescents during scoliosis surgery needs to be optimized. To improve patients' psychologic preparation before surgery pediatric nurses should learn more about the individual patient and make care plans from a holistic perspective. Follow-up after discharge should address emotional, social, and physical aspects of the adolescent's health.

The psychological impact of an adenoidectomy and adenotonsillectomy on young children

OBJECTIVE

Children react differently to surgeries. The purpose of this study is to examine the stress response in young children after an adenoidectomy and adenotonsillectomy, and whether child characteristics of behavioural and neurophysiological nature can predict this stress response.

METHODS

In this prospective cohort study 43 children, aged 2-7 years, scheduled for adenoidectomy or adenoitonsillectomy (response rate 43%) were recruited from the Ear, Nose and Throat Department of the Academic Medical Centre in Amsterdam, the Netherlands. Parents completed questionnaires about temperament 4 weeks before surgery, about behaviour and sleeping problems 4 weeks before and 6 weeks after surgery, and about posttraumatic stress symptoms 6 weeks after surgery. Neurophysiological measurements (cortisol and Respiratory Sinus Arrhythmia) were performed 4 weeks before, directly after and 6 weeks after surgery. Results were compared with a control group of healthy children. The data was analysed with paired t-tests and one-way repeated ANOVA.

RESULTS

Most children with an indication for an adenoidectomy and adenotonsillectomy had more behavioural and emotional problems before surgery then the control group. After surgery there was an improvement in behaviour and sleep, in respectively 75% and 68% of the children, especially in boys. Posttraumatic stress symptoms were rare. Emotional temperament was associated with more behavioural problems before surgery (r=0.53, P=0.02), after surgery (r=0.38, P<0.000), lower cortisol directly after surgery (r=-0.49, P=0.05) and lower Respiratory Sinus Arrhythmia at follow-up (r=-0.33, P=0.06). Other temperament styles and pre-surgery levels of Respiratory Sinus Arrhythmia and cortisol did not show associations with any behavioural or neurophysiological measures.

CONCLUSIONS

An adenoidectomy and adenotonsillectomy appear not to be stressful, but rather seems helpful for reducing pre-existing behavioural and emotional problems, possibly associated with the indication for surgery. For those children with an increase of behavioural and sleeping problems after surgery, this can only be partly explained by emotional temperament. There are indications that boys and girls react differently; boys tend to show a better behavioural and emotional improvement after an adenoidectomy and adenotonsillectomy. Other behavioural or neurophysiological child characteristics do not have a predictive value on the outcome.

A wait-list controlled pilot study of eye movement desensitization and reprocessing (EMDR) for children with post-traumatic stress disorder (PTSD) symptoms from motor vehicle accidents

The present study investigated the efficacy of four EMDR sessions in comparison to a six-week wait-list control condition in the treatment of 27 children (aged 6 to 12 years) suffering from persistent PTSD symptoms after a motor vehicle accident. An effect for EMDR was identified on primary outcome and process measures including the Child Post-Traumatic Stress-Reaction Index, clinician rated diagnostic criteria for PTSD, Subjective Units of Disturbance and Validity of Cognition scales. All participants initially met two or more PTSD criteria. After EMDR treatment, this decreased to 25% in the EMDR group but remained at 100% in the wait-list group. Parent ratings of their child's PTSD symptoms showed no improvement, nor did a range of non-trauma child self-report and parent-reported symptoms. Treatment gains were maintained at three and 12 month follow-up. These findings support the use of EMDR for treating symptoms of PTSD in children, although further replication and comparison studies are required.

The course of posttraumatic stress in children: examination of recovery trajectories following traumatic injury

OBJECTIVE

Group-based trajectory modeling was used to identify patterns of posttraumatic stress symptom (PTSS) in children 6-16 years following accidental injury. The aims were to: (a) identify probable groups of children following distinct trajectories, and (b) identify risk factors affecting the probability of group membership.

METHOD

Children's Impact of Events Scale (n = 190) was used to assess PTSS up to 2 years post injury. Age, gender, type of injury, and preinjury behavior were assessed as risk factors.

RESULTS

Three distinct trajectory groups were identified: resilient (57%), elevated stress symptoms which recovered quickly (33%), and chronic (10%). Younger children were more likely to be in the recovery group. Those with serious injuries were more likely to be in the chronic group. Preinjury child behavior problems were predictive of recovery and high chronic symptoms.

CONCLUSION

Identification of distinct PTSS trajectory groups has implications for understanding the course and treatment of PTSS in children.