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

Violent Injury as a Predictor of Subsequent Assault-Related Emergency Department Visits Among Adolescents

PURPOSE

To measure the risk of a subsequent assault-related emergency department (ED) visit in assault injured adolescents as compared to those who initially presented for non-assault related injuries.

METHODS

This was a historical cohort study of youth (ages 10-18 years) seen at two pediatric EDs between 2016 and 2019. Participants were included if their visit had an International Classification of Diseases-10 code for assaultive injury or accidental injury (motor vehicle collisions (MVC) and sports injuries). We calculated the rate of a subsequent ED visit for an assault-related injury, and then used survival analysis to compare time to subsequent ED visit with an assault-related injury between study and comparison groups.

RESULTS

A total of 6125 adolescents met inclusion criteria (Assault: n = 2782, 45.4%; MVC: n = 1834, 29.9%; Sports n = 1509, 24.6%). The overall rate per 100 person years of a subsequent assault-related ED visit was 5.6 (n = 344). Patients who initially presented with an assault-related injury had an increased adjusted relative risk (aRR) of return for a subsequent ED visit for an assault-related injury when compared to MVC patients (aRR 17.6 [95% CI: 9.6, 32.2]). Kaplan-Meier time to event analysis found that patients in the assault injury group have a higher probability of a subsequent ED visit for an assault-related injury compared to patients in the MVC injury group (adjusted hazard ratio (aHR): 17.7 [95% CI: 9.67, 32.42]).

CONCLUSIONS

Adolescents injured by assault are more likely to return to the ED for a subsequent assault-related injury compared to adolescents who initially present with non-assault-related injuries.

Pediatric Medical Traumatic Stress (PMTS) following Surgery in Childhood and Adolescence: a Systematic Review

The purpose of the present review was to systematically review, synthesize and quantify prevalence rates of subclinical and clinical psychological symptoms in children and adolescents who have undergone surgery. Systematic literature searches were conducted twofold in April 8, 2020 and March 7, 2021 in PsycInfo and PubMed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Manuscripts were screened against eligibility criteria and were included if they investigated psychological symptoms in children or adolescents (age between 1 to 21 years at the time of study) who were hospitalized for pediatric surgery. Means and standard deviations weighted by sample size were calculated. Eleven articles met inclusion criteria. The review revealed that a small but substantial number of children and adolescents are at an elevated risk for postoperative psychological symptoms and disorders. Up to 13% had symptoms consistent with a diagnosis of a posttraumatic stress disorder, 6% to 8% exhibited elevated symptoms of depression or anxiety, and about 25% showed internalizing and externalizing symptoms. This review provides preliminary evidence that children and adolescents experience significant psychological distress and posttraumatic stress symptoms after pediatric surgery. Apart from better training of clinicians, prevention, early psychological screening and psychosocial care in surgical wards of hospitals are recommended. Well-designed studies of high methodological quality are necessary to replicate existing findings and provide a broader base of evidence.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40653-021-00391-9.

Incidence, Trends, and Seasonality of Paediatric Injury-Related Emergency Department Presentations at a Large Level 1 Paediatric Trauma Centre in Australia

This retrospective cohort study aimed to examine the characteristics, incidence, temporal trends, and seasonality of paediatric injury-related Emergency Department (ED) presentations at a large metropolitan paediatric hospital. It included children aged ≤15 years who presented to the ED at The Children’s Hospital at Westmead, Sydney Australia, with a principal diagnosis of injury during the ten-year period from 1 January 2010 to 31 December 2019. Descriptive statistics were used to describe the characteristics of the cohort and the distribution of ED presentations by mode of arrival, triage category, discharge status, injury diagnosis. Negative binomial regression was used to examine percentage change in annual incidence. Seasonality was examined with Seasonal and Trend decomposition using Loess (STL). There were 134,484 (59.7% male children) paediatric injury-related ED presentations during the ten-year period, of which 23,224 (17.3%) were admitted to hospital. Head injury accounted for more than one-quarter (26.8%) of ED presentations. The average annual increase in incidence was more pronounced during the first five years (5.6% [95%CI 4.1% to 7.1%]) than in the last five years (0.8% [95%CI 0.2% to 1.5%]). The monthly incidence of ED presentations had a bimodal distribution with peaks during autumn (March–May) and spring (October–November) seasons. The mean number of ED presentations per day was higher on weekends (40.8 ± 0.3) than weekdays (35.3 ± 0.8). During 2010 to 2019, there was a significant increase in the annual incidence of injury-related ED presentations for children aged ≤15 years, with head injury accounting for more than one-quarter of the ED presentations. The incidence of paediatric injury-related ED presentations was higher during autumn and spring seasons and at weekends. These data will inform health resource planning and priority-setting and advocacy for child injury prevention strategies in Australia.

Feasibility of PTSD risk identification in pediatric trauma patients using PsySTART: A pilot study

BACKGROUND

Trauma patients undergo a standardized history and physical, however identification of mental health risk factors is not typically included. We aimed to assess the feasibility of using a modified version of Psychological Simple Triage and Rapid Treatment (PsySTART) to identify post-traumatic stress disorder (PTSD) risk factors in pediatric trauma patients. We hypothesized that PsySTART could identify risk factors and be integrated into the electronic medical record (EMR).

METHODS

Trauma patients 10-17 years old at a level II pediatric trauma center from 2014 to 2015 were screened. PsySTART was used on a pilot cohort to determine if risk factors were present. PsySTART was then integrated into an automated EMR workflow and completion rates were evaluated.

RESULTS

PsySTART was completed in a pilot cohort of 63 patients with the following findings: 33.3% (n = 21) with 1 risk factor, 22.2% (n = 14) with 2 risk factors, and 19.1% (n = 12) with ≥3 risk factors. The most commonly identified risk factor was, "felt or expressed extreme fear or panic" (n = 27, 43.0%). After EMR integration, PsySTART was successfully completed with automatic consults in 156 of 198 patients (78.8%).

CONCLUSIONS

PsySTART identified risk factors in pediatric trauma patients. EMR integration was feasible and led to proactive psychological management and intervention.

LEVEL OF EVIDENCE

IV.

Screening of Acute Traumatic Stress Disorder and Posttraumatic Stress Disorder in Pediatric Trauma Patients: A Pilot Study

BACKGROUND

Children who experience traumatic physical injuries are at risk of developing acute stress disorder and posttraumatic stress disorder (PTSD). Early identification and treatment of these high-risk children can lead to improved mental health outcomes in this population.

OBJECTIVE

This study assesses the feasibility of a study protocol that compares 3 screening tools for identifying patients at a high risk of later development of acute stress disorder or PTSD among pediatric trauma patients.

METHODS

This pilot study compared 3 questionnaires used as screening tools for predictors of later development of PTSD in a convenience sample of pediatric trauma patients aged 7-17 years. Patients were randomized to one of 3 screening tools. Families were contacted at 30, 60, and 90-120 days postinjury to complete the Child Report of Post-Traumatic Symptoms questionnaire. The sensitivity and negative predictive value of the screening tools were compared for the diagnosis of PTSD defined using the Child Report of Post-Traumatic Symptoms questionnaire.

RESULTS

Of the 263 patients identified for possible enrollment, 52 patients met full inclusion criteria and agreed to participate. Only 29 (55.7%) patients completed at least one follow-up questionnaire. The prevalence of acute stress disorder and PTSD in our population was 41% (95% CI [24, 61]) and 31% (95% CI [15, 51]), respectively.

CONCLUSIONS

In this pilot study, we sought to determine the utility of the 3 commonly used screening instruments for measuring traumatic stress symptoms in pediatric trauma patients to predict the diagnosis of acute stress disorder or PTSD. Limitations include the use of the Child Report of Post-Traumatic Symptoms screening tool as the gold standard for calculating test characteristics and lack of 24/7 enrollment capabilities. As such, a significant portion of patients were discharged prior to our teams' engagement for enrollment.

The Kids Are Alright: Outcome of a Safety Programme for Addressing Childhood Injury in Australia

Globally, injuries are the leading cause of death and represent the highest burden of ongoing disease amongst children 1–16 years of age. Increasingly, prevention programmes are recognising a growing need for intervention strategies that target children. The purpose of this study was to determine the efficacy of the SeeMore Safety Programme, designed to teach children (4–6 years of age) how to make conscious decisions about their own capabilities related to safety and how to manage risk. This retrospective study examined de-identified pre- and post-programme data from a sample of 1027 4 to 6-year-old pre-school children over the four-year period who participated in the SeeMore Safety Programme. Results show a significant improvement in each of the post-test scores and when compared to the pre-test scores (p < 0.001). Children from rural areas, as well as those from areas of greater disadvantage, also showed significant improvement in their pre- and post-test scores (p < 0.001). Overall, the findings highlight that the SeeMore Safety Programme over the four-year period demonstrates an increase in the children’s capacity to recognise and identify danger and safety amongst all children, offering great promise for reducing the burden of injury on children, their families and society.

Post-traumatic stress disorder of children with traffic accidents and their parents in Japan

BACKGROUND

Children who survive traffic accidents, and their parents, may develop post-traumatic stress disorder (PTSD) or related symptoms (depression or anxiety), which can hinder the children's development and the parents' ability to provide effective care. In Japan, the PTSD incidence rate following traffic accidents and its related factors remain unclarified.

METHOD

Participants were 79 children and 104 parents. The children were aged 3-18 years when injured. From August-December 2015, participants completed a self-reported questionnaire survey that comprised the 15-item Post-traumatic Stress Symptoms for Children and the Japanese version of the Impact of Event Scale-Revised. The children's Injury Severity Score (ISS) was also obtained from their medical records. Correlations, analyses of variance, and multiple regression analyses were conducted.

RESULTS

Among the children and the parents, 10.2% and 22.1% were deemed to be at high risk of PTSD, respectively. Their stress scores were significantly positively correlated with each other and negatively correlated with children's age at the time of the accident. Parents who witnessed their children's accidents and those whose children were hospitalized were more stressed. Neither the children's nor the parents' risk for PTSD was associated with the ISS and the amount of time since the accident.

CONCLUSIONS

A system that simultaneously works with children and parents, to support both parties' psychological recovery is required. To ensure psychological care post-injury, it is necessary to evaluate PTSD risk, regardless of injury severity. Implementing preventive and early interventions can prove more valuable than awaiting natural recovery.

Long-Term Posttraumatic Stress Following Accidental Injury in Children and Adolescents: Results of a 2-4-Year Follow-Up Study

In this study, we determined the long-term prevalence of posttraumatic stress disorder (PTSD) in children and adolescents after accidental injury and gained insight into factors that may be associated with the occurrence of PTSD. In a prospective longitudinal study, we assessed diagnosed PTSD and clinically significant self-reported posttraumatic stress symptoms (PTSS) in 90 children (11–22 years of age, 60% boys), 2–4 years after their accident (mean number of months 32.9, SD 6.6). The outcome was compared to the first assessment 3 months after the accident in 147 children, 8–18 years of age. The prevalence of PTSD was 11.6% at first assessment and 11.4% at follow-up. Children with PTSD or PTSS reported significantly more permanent physical impairment than children without. Children who completed psychotherapy had no symptoms or low levels of symptoms at follow-up. Given the long-term prevalence of PTSD in children following accidents, we recommend systematic monitoring of injured children. The role of possible associated factors in long-term PTSS needs further study.

A 10-year review of child injury hospitalisations, health outcomes and treatment costs in Australia

BACKGROUND

Childhood injury is a leading cause of hospitalisation, yet there has been no comprehensive examination of child injury and survival over time in Australia. To examine the characteristics, temporal trend and survival for children who were hospitalised as a result of injury in Australia.

METHOD

A retrospective examination of linked hospitalisation and mortality data for injured children aged 16 years or less during 1 July 2001 to 30 June 2012. Negative binomial regression examined change in injury hospitalisation trends. Cox proportional hazard regression examined the association of risk factors on 30-day survival.

RESULTS

There were 6 86 409 injury hospitalisations, with an age-standardised rate of 1489 per 1 00 000 population (95% CI 1485.3 to 1492.4) in Australia. Child injury hospitalisation rates did not change over the 10-year period. For every severely injured child, there are at least 13 children hospitalised with minor or moderate injuries. The total cost of child injury hospitalisations was $A2.1 billion (annually $A212 million). Falls (38.4%) were the most common injury mechanism. Factors associated with a higher risk of 30-day mortality were: child was aged ≤10 years, higher injury severity, head injury, injured in a transport incident or following drowning and submersion or other threats to breathing, during self-harm and usual residence was regional/remote Australia.

CONCLUSIONS

Childhood injury hospitalisation rates have not reduced in 10 years. Children's patterns of injury change with age, and priorities for injury prevention alter according to developmental stages. The development of a national multisectorial childhood injury monitoring and prevention strategy in Australia is long overdue.

Road casualties in work-related and private contexts: occupational medical impact. Results from the ESPARR cohort

BACKGROUND

Road accidents may impact victims' physical and/or mental health and socio-occupational life, notably including return to work.

OBJECTIVES

To assess whether the occupational medical consequences sustained by subjects injured in road accidents occurring in a work-related context differ from those associated with private accidents.

METHODS

778 adults who were in work or occupational training at the time of their accident were included. Two groups were distinguished: 354 (45.5%) injured in road accidents occurring in a work-related context (commuting or on duty) and 424 (54.5%) injured in a private accident. The groups were compared on medical and occupational factors assessed on prospective follow-up at 6 months and 1 and 3 years. Multivariate analysis explored for factors associated at 6 months and 1 year with sick leave following the accident and duration of sick leave.

RESULTS

There were no significant differences between groups for demographic data apart from a slightly higher injury severity in private accidents (32.5% of private accidents with MAIS3+(Maximum Abbreviated Injury Scale greater or equal to 3) vs. 23.7% for work-related accidents, p = 0.007). Victims of work-related accidents were more often on sick leave (OR = 1.8; 95% CI, 1.1-2.9). Although the length of sick leave is higher for work-related accidents that for private accidents, multivariate analysis showed that the injury severity and the post-traumatic stress disorder (PTSD) are significant factors to explain the time to return to work. There were no significant differences according to occupational impact during follow-up, notably including sick-leave duration, number of victims returning to work within 3 years and number of victims out of work due to incapacity.

CONCLUSIONS

In the ESPARR (follow-up study of a road-accident population in the Rhône administrative county: Etude de Suivi d'une Population d'Accidentés de la Route dans le Rhône) cohort, the fact that a road accident occurred in a work-related context did not affect the occupational consequences.

Associations between severity of anxiety and clinical and biological features of major affective disorders

Patients with major affective disorders (MAFD) with comorbid anxiety show a greater functional impairment than those without anxiety. The aim of this study is to delineate the associations between severity of anxiety in MAFD, namely bipolar disorder (BD) and major depression (MDD), and MAFD characteristics and serum high-density lipoprotein (HDL)-cholesterol levels. Recruited were 82 participants with anxiety disoders and 83 without anxiety disoders, including 101 MAFD patients and 51 healthy controls. We used the Hamilton Anxiety Rating Scale (HAM-A) to measure severity of anxiety and made the diagnoses of posttraumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), panic disorder (PD), generalized anxiety disorder (GAD) and phobias. The HAM-A score is significantly predicted by higher number of depressive episodes, GAD and phobias, childhood trauma, tobacco use disorder, metabolic syndrome and lowered HDL-cholesterol. Increased HAM-A scores are, independently from severity of depression, associated with lowered quality of life, increased disabilities and suicidal ideation. Lithium treatment significantly lowers HAM-A scores. It is concluded that severity of anxiety significantly worsens the phenomenology of MAFD. Therefore, treatments of MAFD should target increased severity of anxiety and its risk factors including low HDL-cholesterol, metabolic syndrome, childhood trauma and tobacco use disorder.

Health burden of serious road injuries in the Netherlands

BACKGROUND

The consequences of injuries in terms of disabilities and health burden are relevant for policy making. This article provides an overview of the current knowledge on this topic and discusses the health burden of serious road injuries in The Netherlands.

METHODS

The overview of current knowledge on disabilities following a road crash is based on a literature review. The health burden of serious road injuries is quantified in terms of years lived with disability (YLD), by combining incidence data from the Dutch hospital discharge register with information about temporary and lifelong disability.

RESULTS

Literature shows that road traffic injuries can have a major impact on victims' physical and psychological well-being and functioning. Reported proportions of people with disability vary between 11 and 80% depending on the type of casualties, time elapsed since the crash, and the health impacts considered. Together, all casualties involving serious injuries in The Netherlands in 2009 account for about 38,000 YLD, compared to 25,000 years of life lost (YLL) of fatalities. Ninety percent of the burden of injury is due to lifelong consequences that are experienced by 20% of all those seriously injured in road accidents. Lower leg injuries and head injuries represent a high share in the total burden of injury as have cyclists that are injured in a crash without a motorized vehicle. Pedestrians and powered 2-wheeler users show the highest burden of injury per casualty.

CONCLUSION

Given their major impacts and contribution to health burden, road policy making should also be aimed at reducing the number of serious road injuries and limiting the resulting health impacts.

Screening for post-traumatic stress disorder after injury in the pediatric emergency department--a systematic review protocol

BACKGROUND

Pediatric injury is highly prevalent and has significant impact both physically and emotionally. The majority of pediatric injuries are treated in emergency departments (EDs), where treatment of physical injuries is the main focus. In addition to physical trauma, children often experience significant psychological trauma, and the development of acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) is common. The consequences of failing to recognize and treat children with ASD and PTSD are significant and extend into adulthood. Currently, screening guidelines to identify children at risk for developing these stress disorders are not evident in the pediatric emergency setting. The goal of this systematic review is to summarize evidence on the psychometric properties, diagnostic accuracy, and clinical utility of screening tools that identify or predict PTSD secondary to physical injury in children. Specific research objectives are to: (1) identify, describe, and critically evaluate instruments available to screen for PTSD in children; (2) review and synthesize the test-performance characteristics of these tools; and (3) describe the clinical utility of these tools with focus on ED suitability.

METHODS

Computerized databases including MEDLINE, EMBASE, CINAHL, ISI Web of Science and PsycINFO will be searched in addition to conference proceedings, textbooks, and contact with experts. Search terms will include MeSH headings (post-traumatic stress or acute stress), (pediatric or children) and diagnosis. All articles will be screened by title/abstract and articles identified as potentially relevant will be retrieved in full text and assessed by two independent reviewers. Quality assessment will be determined using the QUADAS-2 tool. Screening tool characteristics, including type of instrument, number of items, administration time and training administrators level, will be extracted as well as gold standard diagnostic reference properties and any quantitative diagnostic data (specificity, positive and negative likelihood/odds ratios) where appropriate.

DISCUSSION

Identifying screening tools to recognize children at risk of developing stress disorders following trauma is essential in guiding early treatment and minimizing long-term sequelae of childhood stress disorders. This review aims to identify such screening tools in efforts to improve routine stress disorder screening in the pediatric ED setting.

TRIALS REGISTRATION

PROSPERO registration: CRD42013004893.