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Surgical procedures and pediatric medical traumatic stress (PMTS) syndrome: Assessment and future directions
Surgical Procedures and Pediatric Medical Traumatic Stress (PMTS) Syndrome: Assessment and Future Directions Amichai Ben Ari, Tuvia Peri, Daniella Margalit, Esti Galili-Weisstub, Raphael Udassin, Fortu Benarroch PII: DOI: Reference:
S0022-3468(17)30667-X doi: 10.1016/j.jpedsurg.2017.10.043 YJPSU 58373
To appear in:
Journal of Pediatric Surgery
Received date: Revised date: Accepted date:
9 June 2017 7 September 2017 7 October 2017
Please cite this article as: Ari Amichai Ben, Peri Tuvia, Margalit Daniella, GaliliWeisstub Esti, Udassin Raphael, Benarroch Fortu, Surgical Procedures and Pediatric Medical Traumatic Stress (PMTS) Syndrome: Assessment and Future Directions, Journal of Pediatric Surgery (2017), doi: 10.1016/j.jpedsurg.2017.10.043
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ACCEPTED MANUSCRIPT Surgical Procedures and Pediatric Medical Traumatic Stress (PMTS) Syndrome: Assessment and Future Directions
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Amichai Ben Ari, MAa,b Tuvia Peri, PhDd
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Daniella Margalit, PhDa
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Esti Galili-Weisstub, MDa Raphael Udassin, MDc Fortu Benarroch, MDb
Department of Behavioral Sciences, Ariel University, Israel
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Herman Dana Division of Child and Adolescent Psychiatry, Hadassah-Hebrew University
Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Medical Center, Jerusalem, Israel
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Bar-Ilan University, Israel
Corresponding author: Amichai Ben Ari, Ben Zakai 36/8, Jerusalem, Israel. Phone: 00972-29978901; Fax: 00972-2-5324844; [email protected]
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ACCEPTED MANUSCRIPT Abstract Introduction
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Surgical procedures involve traumatic stress. Children may develop chronic psychological
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distress and dysfunction after surgery, with consequent reluctance to comply with medical follow-up care. A literature review of this topic shows that it has been under-studied. Our
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study aims to assess the frequency and characteristics of symptoms of persistent psychological distress in children following surgery, which have not been documented
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before, in order to promote its awareness and its early identification. Methods
Parents of 79 children (aged 1–6) that were hospitalized in a pediatric surgical ward, comprising a representative sample, completed three validated questionnaires assessing their
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children’s psychological symptoms 3–5 months after the hospitalization.
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Results
A significant portion of children suffer from psychological distress 3–5 months after
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hospitalization. Moreover, 10.39% of the children exhibited symptoms of PTSD, and 28.6% of parents reported that the child’s distress causes dysfunction. Additionally, our findings emphasize the parents’ concerns regarding the child’s behavior, function, and health
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following hospitalization. Conclusion
Since a significant prevalence of hospitalization-related traumatic stress is documented, the awareness to it has to be improved, in order to reduce its frequency and increase adherence to medical follow-up care. Type of study Prognosis study (level of evidence – 1). Keywords:
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Pediatric Medical Traumatic Stress (PMTS), PTSD, pediatric surgery, screening, risk factors.
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ACCEPTED MANUSCRIPT 1. Introduction Disease and injury followed by admission to a pediatric surgical ward introduce children and their families to a medical environment in which they may experience fear, uncertainty,
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helplessness, painful surgical interventions, and even life-threatening situations [1]. These
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elements are significant emotional stressors and thus the medical event, which includes the diagnosis and the intervention during hospitalization, may fit the definition of a traumatic event that is a prerequisite for Post-Traumatic Stress Disorder (PTSD) diagnosis.
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An acute traumatic-stress reaction to the hospitalization is frequent [2], but most children recover spontaneously. Nevertheless 25%–30% of them will develop chronic post-
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traumatic symptoms affecting the course of their physical recovery and overall function [3], and 10%–20% meet the criteria for PTSD outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) [3]. The remaining 5%–20% are children who do not meet the full diagnostic criteria for PTSD but still have significant emotional distress and/or significantly disrupted functioning which persist for a long time after the
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hospitalization. In order to capture the unique aspects of a condition caused by a medical event, the term Pediatric Medical Traumatic Stress (PMTS) has been used. PMTS is
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characterized by an array of physical and emotional symptoms such as hyper-arousal, avoidance, and re-experience of the event, which have developed due to a major illness or
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medical intervention that involved a threat to the child’s health and an intrusive, painful, and alarming medical care [1].
Since this field has not received enough attention to date in the area of pediatric
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surgery, it is important to review here the existing literature, in order to understand the background in which our study was planned. We will then present our data, which aim is to document, for the first time in the literature, the prevalence of PMTS in pediatric surgery. 1.1. Literature Review 1.1.1. PMTS Prevalence in Children A summary of studies that report prevalence of post-traumatic stress symptoms in children following a medical procedure is presented in Table 1. A comparison of the studies is difficult since many different outcome measures are used. Studies on children who have been hospitalized have found that 16%–28% of children report a decline in quality of life and emotional difficulties following their hospitalization [4–7]. PTSD rates among children who underwent cardiac or transplant surgical interventions ranged between 12%–16% [8, 9]. Among children with cancer, PTSD rates of 5%–10% and Post-Traumatic Stress Syndrome
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ACCEPTED MANUSCRIPT rates of 17%–21% have been reported [10]. Reports about post-traumatic stress among children following hospitalization in general surgery were not found in our literature search. 1.1.2. Compliance with Medical Care
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Compliance with medical care affects treatment outcomes, and has been associated with
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various health indicators. In a review of 25 articles [11], it was found that the level of compliance with medical care among patients who suffer from anxiety and depression is three times smaller than that of the normal population. Furthermore, a study of 19 children
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who underwent liver transplant found a high positive correlation between avoidance patterns (one of the main symptoms of post-traumatic stress) and lack of medical compliance,
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suggesting that children may associate medication-taking with their traumatic experiences, and thus try to avoid it [12]. Another study [1] found that among children with cancer a high level of PMTS reduces the probability of consistently arriving to follow-up medical treatments. Future studies are warranted on the relationship between PMTS and lack of medical compliance.
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1.1.3. PMTS Risk Factors
Identification of risk factors for the development of PMTS is important in order to understand
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PMTS determinants, to enable early diagnosis of children who are at high risk for psychological difficulties, and to apply timely interventions. Studies of children who were
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hospitalized have identified several risk factors, as follows. 1.1.3.1. Level of Anxiety during Hospitalization Multiple studies have found that children who reported anxiety and extreme distress during
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hospitalization were at high risk of developing post-traumatic stress a few months after the hospitalization [13, 14]. One important indicator for assessing anxiety and arousal levels is heart rate, which is usually assessed in routine procedures upon hospital admission and enables a prospective examination. Several studies have found that the heart rate on the first day of hospitalization correlates with a higher rate of post-traumatic symptoms following a few months [15–17]. 1.1.3.2. Perceived Hazard during Hospitalization Children often perceive hospitalization as a frightening and life-threatening experience. One study found that a majority of children who survived a major illness recalled a near-death experience at 6-month follow-up when in fact fewer than 10% of them were in a lifethreatening situation [18]. Similarly, a study of 102 children at 3 months following hospitalization, found that 32% of them recalled hospitalization as a life-threatening experience even though that was not actually the case [5]. Indeed, in a review of 28 studies 5
ACCEPTED MANUSCRIPT on psychological outcomes following hospitalization [19], it was found that children recall many aspects of hospitalization accurately but amplify perceptions of danger and life threat, which engenders anxiety. This review found that the child’s perception and interpretation of
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the disease and hospitalization experience had a significant impact on behavioral and
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emotional outcomes. In a study of 226 children at one year following discharge, 22.1% reported a decline in emotional status due to specific fears relating to the hospitalization experience [6].
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Anxiety during hospitalization is related to the perception of life threat, and has been found to predict the child’s level of distress a few months after hospital discharge. For
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example, it has been found that children who experienced anxiety believing that they are going to die during hospitalization subsequently showed more post-traumatic symptoms than those who did not have such beliefs [13]. Similarly, in a meta-analysis of 14 studies on accidental trauma [20], the child’s perception of life threat was a potent, consistent predictor of post-traumatic stress development.
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Children’s anxiety has been inversely associated with their level of cognitive understanding [21]. The child’s cognitive understanding is related to the development of
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abstract thinking and to understanding cause-effect relations; sometimes a childlike, egocentric thinking style may lead to an incorrect interpretation of the event and to elevated
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anxiety levels (e.g. a child who thinks that getting an injection means a declining medical status). Accordingly, younger children are in need of more careful explanations, adapted to their developmental level [1].
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1.1.3.3. The Experience of Lack of Control In a study utilizing a small sample, children who were discharged from intensive care had higher levels of lack of control in comparison to children who were discharged from regular hospitalization, and lack of control was associated with a feeling of helplessness [22]. Others have found that an intense experience of lack of control may explain the development of medical fear (including anxiety symptoms and avoidance of medical checkups and care) [23]. Lack of control was found to be a mediating factor shared by all other risk factors (age, severity of illness, and the level of exposure to intrusive interventions) [23]. The above findings suggest a possible correlation between the child’s experience of lack of control during hospitalization and PMTS. 1.1.3.4. Parental Anxiety A child’s hospitalization may comprise a traumatic event for parents. A study of 272 children hospitalized in intensive care and their families, found that 33% of parents reported 6
ACCEPTED MANUSCRIPT symptoms meeting ASD criteria during hospitalization, and that at 4-month follow-up, 6.6% of parents met criteria for PTSD. Also, the duration and extent of the parents’ initial response during hospitalization and their subjective perception of the extent of the danger to the child’s
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life were predictors of child PTSD development [24]. Indeed, the parents’ emotional reaction
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may affect the emotional coping of their children. A study of children with cancer found that stress and distress experienced by one of the parents predict the development of posttraumatic distress in the child at 6- to 8-month follow-up [25]. Additionally, a positive
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correlation was found between the level of ASD symptoms in children with burns and that of their parents [26]. Similar findings were found in studies of children hospitalized due to
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injury or illness. In one study, the level of maternal anxiety in the first hours following hospitalization was a significant predictor of negative behavioral symptoms in children aged 2–7 at 6 months following discharge [27]. Others have found a positive association between post-traumatic symptoms among parents and their children [20]. However, another study found no associations between post-traumatic symptoms in parents and adolescents [28]. This
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discrepancy may be due to the stronger effect of parental symptoms of stress and distress on children in comparison to adolescents.
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1.1.3.5. History of Previous Psychopathology It has been found that the child’s psychological function pre-hospitalization and history of
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psychopathology are associated with increased risk for developing chronic post-traumatic stress due to injury or hospitalization [29]. A study of children with cancer found that having a high level of anxiety and psychological difficulties pre-hospitalization predicted post-
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traumatic stress [30]. Nonetheless, others have found no associations between psychological background and distress following hospitalization [31]. This study, however, examined referrals to mental health services rather than direct measures of psychopathology, which may limit its representativeness. 1.1.3.6. History of Traumatic Events Regarding trauma history, a single study found that children who were previously exposed to a traumatic event had a lesser tendency to develop post-hospitalization symptoms in comparison to other children [32]. It may be that the traumatic event can, under special conditions, have a strengthening effect, if experienced as an event that can be overcome. However, widely based evidence on general trauma supports the opposite conclusion. Indeed, previous experience of a traumatic event was found to be a risk factor for developing PTSD among children who were hospitalized at an intensive care unit [19]. Similarly, large number of stressful events prior to experiencing a burn were found to predict subsequent ASD 7
ACCEPTED MANUSCRIPT development [26]. The researchers suggested that children’s self-image served as a mediator so that the past experience of stressors negatively affects the child’s self-image and vulnerability, which in turn increases the risk for post-traumatic stress [26]. Most often
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traumatic events involve experiences of helplessness, increase vulnerability, and are a risk
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factor for developing post-traumatic symptoms in the event of future trauma exposure [17]. 1.1.3.7. Family Function and Support
Family dysfunction is a main risk factor for PMTS. The level of family and social support
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among children with cancer has been found to be inversely associated with the emergence of post-traumatic symptoms [33]. Others have found that a high level of family conflicts is
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associated with the development of post-traumatic symptoms following hospitalization [34]. The same study found that children in achievement-oriented families with low levels of emotional expression tend to develop post-traumatic symptoms following hospitalization [34].
1.1.3.8. Medical Intervention and Hospitalization Characteristics
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Intrusive medical interventions are a significant predictor of post-traumatic stress in children following hospitalization [19, 32]. Severity of disease or injury as well as exposure to
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medical interventions were found to be positively associated with the experience of fear, lack of control, and post-traumatic symptoms at 6 month following hospitalization [19]. Also, the
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level of noise in the department was a significant predictor of emotional distress among children [19]. Another study found a relationship between duration of intensive care hospitalization and the severity of post-traumatic symptoms among children who have had
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heart surgery [8]. Moreover, experiencing and treating pain during hospitalization have been associated with subsequent chronic stress. For example, it has been found that administering morphine to children aged 1–4 after burn experience reduces the level of post-traumatic symptoms at 3- and 6-month follow-up [35], suggesting that early pain treatment may contribute to reducing mental stress risks. 1.1.4. PMTS Awareness A study of 287 pediatricians found that PMTS awareness is low: only 7% believed that children could develop psychological symptoms due to hospitalization, and only 11% were familiar with methods to assess such symptoms [36]. Also, it was found that due to insufficient awareness, the identification of emotional distress often occurs only once the difficulties had become more severe. Late identification hinders the possibility of early intervention, which has been proven to be effective in children [1]. One of the factors explaining the low PMTS awareness is that the treatment during acute hospitalization is 8
ACCEPTED MANUSCRIPT focused on the physical status of the child [37], and not enough attention is paid to the psychological consequences of the situation. Despite growing awareness to the emotional and mental outcomes of medical care among medical professionals in recent years [17], this
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awareness is often unsatisfactory [19], as some children do not receive the proper preparation
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prior to surgery or other medical procedures and consequently develop emotional distress. Another important reason for this lack of awareness is the misconception (which is unfortunately still very common, even among some health professionals) about infants and
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young children not being candidates for post-traumatic stress since “they do not understand” the experience. Widely based evidence has established that traumatic experiences have a
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significant effect on very young infants and that they can have even more devastating and longer lasting effects than on older children [38]. 1.1.5. Preventive Interventions
According to the Pediatric Psychosocial Preventative Health Model [1], the first stage of preventive interventions in children who are exposed to medical trauma involves providing
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them with information regarding the expected emotional response to treatment, thus normalizing their feelings. Moreover, the American Academy of Pediatrics Committee
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recommends allowing parents to be present during medical procedures, because their support has been associated with lower PMTS rates in children [3]. Additionally, it was found that
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providing relevant information to parents via leaflets increases awareness and the probability of early PMTS identification [3]. Providing safe maximal sedative treatment during the initial care increases the probability of arriving to subsequent treatments and reduces PMTS [3, 26].
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One study described and tested a 3-sessions intervention plan focusing on identifying parental perceptions regarding the disease, coping with it, and processing it. This plan has been found effective in reducing PMTS symptoms among children with cancer [1]. These findings suggest that preventive interventions can be effective, but we are not aware of any similar data concerning pediatric surgery. Once PMTS symptoms have developed and persist, they can be treated using Trauma-Focused Cognitive-Behavioral Treatment (TFCBT) that includes the provision of psycho-educational information, acquisition of emotional regulation, family communication skills, and narrative and emotional processing of trauma. These components of TFCBT have been found effective in treating children who experienced medical trauma and in hindering the development of chronic PTSD [3]. This literature review emphasizes the importance of improving the awareness to PMTS, in order to promote its prevention, its early identification, and its treatment. As a first 9
ACCEPTED MANUSCRIPT step towards this goal, the aim of the following study is to assess the frequency and characteristics of PMTS in children following hospitalization in a pediatric surgery ward. 2. Methods and Procedure
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2.1. Objective
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To assess the frequency and characteristics of psychological symptoms persisting 3 months after hospitalization in a pediatric surgery ward. 2.2. Methods
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2.2.1. Study Procedure
The study was approved by the Institutional Reviewing Board of the Medical Center.
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Participants were recruited consequentially from a list of all the patients hospitalized in the pediatric surgery ward of the Hadassah-Hebrew University Medical Center in Jerusalem between 1 June 2015 and 1 January 2016, sorted according to their date of admittance. All the Hebrew-speaking parents were approached. Eighteen patients )18% of the sample) declined to participate; their age averaged 4.9 years (σ=2.3) and their average period of hospitalization
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was 5.1 days (σ=9.3). The remaining parents of 79 children compose the final study sample. After signing an Informed Consent form, the parents were contacted three to five months
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following discharge and answered questionnaires via telephone. The telephone conversations were conducted by one of the authors, who is a licensed rehabilitational psychologist, and
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each lasted for one hour on average. 2.2.2. Participants
Seventy-nine children (65% boys) participated in the study, aged 1–6 years old, the average
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being 4.5 (σ=2.8). Half of the participants (50%) were hospitalized for minor surgery, 32% for other kinds of surgery, 15% were hospitalized without surgery, and 3% were treated for burns. The surgical procedures captured were in urology (32%), orthopedics (11%), ENT (10%), dermatology (10%), gastroenterology (10%), nephrology (10%), neurology (3%), cardiology (3%), ophthalmology (2%), combined (3%), and other (6%). The period of hospitalization ranged from a few hours to 90 days, averaging 5.6 days (σ=12.1). For 57% the hospitalization was elective. Furthermore, 58.3% of the children were hospitalized without receiving prior preparation. Regarding the education of the parents, 51.6% had a bachelor’s degree, 39.8% secondary education, and 8.6% a master’s degree. As for their level of religiosity, 35.8% were either highly religious or Haredi Jews, 35.8% religious, 18.9% secular, and 9.5% Masortim (neither strictly observant nor secular). Concerning their marital status, 94.6% were married, while only 5.4% were divorced or separated. Furthermore, regarding their financial 10
ACCEPTED MANUSCRIPT situation, 61.5% were in no economic distress, 28.1% had some financial troubles, and 10.4% were in difficult financial straits. Not all of the participants completed all of the questionnaires: 77 parents completed
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the PTSDSSI and PCASS questionnaires, while 76 parents answered the CBCL. There was
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no overlap among the parents who did not complete the different questionnaires. 2.3. Measures 2.3.1. Demographic Questionnaire
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This questionnaire includes: age and gender of the child; reason of hospitalization; gender of the parent who answered the questionnaire; religious denomination; and the parent’s level of
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education. Information regarding hospitalization characteristics and medical intervention was taken from the hospital’s medical records.
2.3.2. Achenbach’s Child Behavior Checklist (CBCL)
A self-report questionnaire filled out by parents of children aged 1.5–5 years, used in many studies in order to assess emotional and behavioral problems among children. It yields a
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General (total) scale, two sub-scales (Internalizing and Externalizing Problems) and refers to seven domains—emotional reactivity, anxiety/depression, somatic problems, avoidance,
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sleeping problems, attention, and aggressive behavior—through 100 items with an amount of agreement of 0–2 on a Likert scale [39]. Internal consistency estimates range from a= 0.89
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for internalizing scale and a=0.91 for externalizing scale [39]. In the current study, internal consistency for internalization scale yielded a=0.94 and a=0.92 for externalization scales. 2.3.3. Assessment of PTSD Symptoms
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It is difficult to assess symptoms of PTSD in infants and preverbal children. We have to rely on parents’ reports, who can find it difficult to be accurate and consistent in the interpretation and the description of their child’s behavior. That is why we opted to use two different questionnaires targeting the same symptoms. The integration of the results from these two questionnaires can help make the assessment more accurate. 2.3.3.1. The Post-Traumatic Stress Disorder Semi-Structured Interview (PTSDSSI) A parent-report questionnaire assessing symptoms of PTSD among children aged 1–6. It is concerned with the child’s response during and after the traumatic event and with developmental changes, and includes 29 items with an amount of agreement of 1–3 on a Likert scale. The internal reliability of this measure is 0.87, and a correlation of 0.66 has been found between the results of this measure and the severity and number of symptoms found in a clinical interview several months later [40]. Internal reliability in the current study yielded a=0.91. 11
ACCEPTED MANUSCRIPT 2.3.3.2. The Preschool Children’s Assessment of Stress Scale (PCASS) A parent-report questionnaire assessing symptoms of PTSD among children aged 1–6. This measure is concerned with symptoms of anxiety, fear, sleep difficulties, mood changes, and
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developmental regression, and includes 29 items with an amount of agreement of 1–5 on a
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Likert scale. The internal reliability of this measure is 0.89 [41]. In the current study, internal reliability yielded a= 0.96. 3. Results
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In the CBCL’s General Scale, 4% of children were in the borderline range and 11% in the clinical range. The results in the subscales show that the most prevalent symptoms are in the
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Internalizing category, where 20% of the children were in the clinical range. The domains in which the symptoms were more frequent were Emotional Reactivity, Anxiety/Depression, and Attention.
The PTSDSSI questionnaire, assessing the frequency of PTSD symptoms, shows that 55.7% of the children have significant symptoms of re-experiencing, 30.4% have significant
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symptoms of avoidance and 32.9% have significant symptoms of hyperarousal. In addition, 28.6% of parents reported that the child’s distress causes dysfunction and adjustment
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difficulties.
In the PCASS questionnaire, responding to the question “Since the surgery, how
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concerned are you about the following domains?” 15.6% of the parents reported that they are very concerned about the child’s separation difficulties. For example, 18.4% reported that the child is more protective of family members (item 1), and 28.9% reported that since the
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hospitalization the child clings more to family members (item 2). Moreover, 19.5% of parents reported being concerned about the child’s mood, and 26% reported being very concerned about the child’s fears since the surgery. For example, 17.1% reported that since the hospitalization the child is more afraid of objects, places, and specific people (item 8); 22.1% reported that since the hospitalization the child reacts with fright or panic to sudden changes (item 9); 23.4% reported that the child asks too many questions about what will happen during the day (item 10); and 22.1% reported that since the hospitalization the child’s games consistently revolve around one scary or dangerous subject (item 11). Additionally, 20.8% were very concerned about the child’s health. Furthermore, many parents reported considerable concern about the child’s state after the surgery in the domains of separation difficulties, mood, fears, and health. The parents’ reports show a significant rise (p=.000, T(76)=4.291) between their perceptions of the child’s state after the surgery (SD=0.59, M=1.36) and those before it (SD=0.34, M=1.13). 12
ACCEPTED MANUSCRIPT All three measures used in this study assess the same dependent variable (PMTS). The assessment of the dependent variable by the three measures points to convergent validity. As seen in Table 2, a high correlation has been found among the three questionnaires, indicating
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consistency at the individual patient level across the three tools.
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4. Discussion and Conclusions
This is the first study documenting the prevalence of PMTS among a representative sample of children hospitalized in a pediatric surgery ward. Our findings help improve understanding of
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an under-researched field, as they indicate that a significant portion of children aged 1–6 suffer from psychological difficulties 3–5 months after hospitalization or surgery. The data
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collected from the CBCL shows that many participants suffered from emotional distress following their hospitalization. The responses to the PTSDSSI questionnaire, moreover, indicate that 10.39% of the children exhibit symptoms of PTSD, and that 28.6% of parents reported that the child’s distress causes dysfunction and adjustment difficulties. Furthermore, the findings of the PCASS questionnaire emphasize the parents’ concerns regarding the
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child’s behavior, function, and health following hospitalization, with a significant rise between the parents’ reports of their conception of the child’s state before the surgery and
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after it. 4.1. Conclusions
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Our findings emphasize the fact that a significant portion of children experience posttraumatic symptoms following surgical procedures, which may persist beyond several weeks and inflict functional and psychological difficulties. It is important to increase awareness to
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this issue among medical staff in hospitals in order to decrease hospitalization-related trauma, thus preventing emotional distress and increasing compliance with medical follow-up care. The evidence-based recommendations in this field include providing guidance to the child and parents about the expected response to the medical treatment in order to minimize the experience of lack of control and death anxiety. In addition, safe maximal sedative treatment is recommended, as well as enabling parents to be present during medical procedures and support their child. In case of indications of mental distress, TFCBT strategies may be useful. Also, family factors should be considered when evaluating psychological symptoms and designing intervention programs. Currently, the low awareness among medical professionals to the field of medical trauma limits the possibility of conducting preventive interventions. Also, due to lack of awareness among parents, children who suffer from psychological distress following hospitalization are often not referred to treatment. In order to promote the incorporation of 13
ACCEPTED MANUSCRIPT this issue into routine procedures in pediatric surgery departments and intensive care units, a small group of high-risk children should be identified for a focused use of limited public resources. To that aim, we are conducting a study to develop a validated screening instrument
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designed to detect risk factors for PMTS that would enable early intervention and in some
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cases prevention.
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ACCEPTED MANUSCRIPT References 1. Kazak AE, Kassam-Adams N, Schneider S, Zelikovsky N, Alderfer MA, Rourke M. An
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integrative model of pediatric medical traumatic stress. J Pediatr Psychol 2006; 31: 343–55. 2. Judge D, Nadel S, Vergnaud S, Garralda EM. Psychiatric adjustment following
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meningococcal disease treated on a PICU. Intensive Care Med 2002; 28: 648–50. 3. Forgey M, Bursch B. Assessment and management of pediatric iatrogenic medical trauma.
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Curr Psychiatry Rep 2013; 15: 1–9.
4. Rennick JE, Johnston CC, Dougherty G, Platt R, Ritchie JA. Children’s psychological responses after critical illness and exposure to invasive technology. J Dev Behav Pediatr 2002; 23: 133–44.
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5. Colville G, Kerry S, Pierce C. Children's factual and delusional memories of intensive
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care. Am J Respir Crit Care Med 2008; 177: 976–82. 6. Gemke R, Bonsel GJ, Van Vught A. Long-term survival and state of health after paediatric
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intensive care. Arch Dis Child 1995; 73: 196–201.
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7. Taylor A, Butt W, Ciardulli M. The functional outcome and quality of life of children after admission to an intensive care unit. Intensive Care Med 2003; 29: 795–800. 8. Connolly D, McClowry S, Hayman L, Mahony L, Artman M. Posttraumatic stress disorder in children after cardiac surgery. J Pediatr 2004; 144: 480–4. 9. Mintzer LL, Stuber ML, Seacord D, Castaneda M, Mesrkhani V, Glover D. Traumatic stress symptoms in adolescent organ transplant recipients. Pediatrics 2005; 115: 1640–4. 10. Kazak AE, Alderfer M, Rourke MT, Simms S, Streisand R, Grossman JR. Posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in families of adolescent childhood cancer survivors. J Pediatr Psychol 2004; 29: 211–9. 11. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance 15
ACCEPTED MANUSCRIPT with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000; 160: 2101–7.
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12. Shemesh E, Lurie S, Stuber ML, Emre S, Patel Y, Vohra P, et al. A pilot study of
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posttraumatic stress and nonadherence in pediatric liver transplant recipients. Pediatrics 2000; 105: e29.
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13. Winston FK, Kassam-Adams N, Garcia-España F, Ittenbach R, Cnaan A. Screening for risk of persistent posttraumatic stress in injured children and their parents. JAMA 2003; 290:
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643–9.
14. Kassam-Adams N, Garcia-Espana JF, Fein JA, Winston FK. Heart rate and posttraumatic stress in injured children. Arch Gen Psychiatry 2005; 62: 335–40. 15. Bryant RA, Salmon K, Sinclair E, Davidson P. Heart rate as a predictor of posttraumatic
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stress disorder in children. Gen Hosp Psychiatry 2007; 29: 66–8.
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16. Olsson KA, Kenardy JA, De Young AC, Spence SH. Predicting children's post-traumatic stress symptoms following hospitalization for accidental injury: Combining the Child Trauma
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Screening Questionnaire and heart rate. J Anxiety Disord 2008; 22: 1447–53.
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17. Rennick JE, McHarg LF, Dell’Api M, Johnston CC, Stevens B. Developing the Children’s Critical Illness Impact Scale: Capturing stories from children, parents, and staff. Pediatr Crit Care Med 2008; 9: 252–60. 18. Morse M, Castillo P, Venecia D, Milstein J, Tyler DC. Childhood near-death experiences. Am J Dis Child 1986; 140: 1110–4. 19. Rennick JE, Rashotte J. Psychological outcomes in children following pediatric intensive care unit hospitalization: a systematic review of the research. J Child Health Care 2009; 13: 128–49. 20. Cox CM, Kenardy JA, Hendrikz JK. A meta-analysis of risk factors that predict psychopathology following accidental trauma. J Spec Pediatr Nurs 2008; 13: 98–110.
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ACCEPTED MANUSCRIPT 21. Tichy A, Braam C, Meyer T, Rattan N. Stressors in pediatric intensive care units. Pediatr Nurs 1987; 14: 40–2.
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22. Rees G, Gledhill J, Garralda ME, Nadel S. Psychiatric outcome following paediatric
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intensive care unit (PICU) admission: a cohort study. Intensive Care Med 2004; 30: 1607–14. 23. Pai AL, Patiño-Fernández AM, McSherry M, Beele D, Alderfer MA, Reilly AT, et al.
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The Psychosocial Assessment Tool (PAT2. 0): psychometric properties of a screener for psychosocial distress in families of children newly diagnosed with cancer. J Pediatr Psychol
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2008; 33: 50–62.
24. Balluffi A, Kassam-Adams N, Kazak A, Tucker M, Dominguez T, Helfaer M. Traumatic stress in parents of children admitted to the pediatric intensive care unit. Pediatr Crit Care Med 2004; 5: 547–53.
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25. Best M, Streisand R, Catania L, Kazak AE. Parental distress during pediatric leukemia and posttraumatic stress symptoms (PTSS) after treatment ends. J Pediatr Psychol 2001; 26:
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299–307.
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26. Saxe G, Stoddard F, Chawla N, Lopez CG, Hall E, Sheridan R, et al. Risk factors for
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acute stress disorder in children with burns. J Trauma Dissociation 2005; 6: 37–49. 27. Small L, Melnyk BM. Early predictors of post-hospital adjustment problems in critically ill young children. Res Nurs Health 2006; 29: 622–35. 28. Zatzick DF, Jurkovich GJ, Fan M-Y, Grossman D, Russo J, Katon W, et al. Association between posttraumatic stress and depressive symptoms and functional outcomes in adolescents followed up longitudinally after injury hospitalization. Arch Pediatr Adolesc Med 2008; 162: 642–8. 29. Brosbe MS, Hoefling K, Faust J. Predicting posttraumatic stress following pediatric injury: a systematic review. J Pediatr Psychol 2011; 36: 718–29. 30. Manne S, DuHamel K, Ostroff J, Parsons S, Martini DR, Williams SE, et al. Anxiety, depressive, and posttraumatic stress disorders among mothers of pediatric survivors of 17
ACCEPTED MANUSCRIPT hematopoietic stem cell transplantation. Pediatrics 2004; 113: 1700–8. 31. Meiser-Stedman R, Dalgleish T, Smith P, Yule W, Glucksman E. Diagnostic,
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in children and adolescents. J Abnorm Psychol 2007; 116: 63–79.
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demographic, memory quality, and cognitive variables associated with acute stress disorder
32. Keppel-Benson JM, Ollendick TH, Benson MJ. Post-traumatic stress in children
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following motor vehicle accidents. J Child Psychol Psyc 2002; 43: 203–12.
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33. Young GS, Mintzer LL, Seacord D, Castañeda M, Mesrkhani V, Stuber ML. Symptoms of posttraumatic stress disorder in parents of transplant recipients: incidence, severity, and related factors. Pediatrics 2003; 111: e725–e31.
34. Schreier H, Ladakakos C, Morabito D, Chapman L, Knudson MM. Posttraumatic stress symptoms in children after mild to moderate pediatric trauma: a longitudinal examination of
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Crit Care 2005; 58: 353–63.
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symptom prevalence, correlates, and parent-child symptom reporting. J Trauma Injury Infect
35. Stoddard Jr FJ, Sorrentino EA, Ceranoglu TA, Saxe G, Murphy JM, Drake JE, et al.
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Preliminary evidence for the effects of morphine on posttraumatic stress disorder symptoms
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in one- to four-year-olds with burns. J Burn Care Res 2009; 30: 836–43. 36. Ziegler MF, Greenwald MH, DeGuzman MA, Simon HK. Posttraumatic stress responses in children: Awareness and practice among a sample of pediatric emergency care providers. Pediatrics 2005; 115: 1261–7. 37. Marcin JP, Pollack MM. Review of the methodologies and applications of scoring systems in neonatal and pediatric intensive care. Pediatr Crit Care Med 2000; 1: 20–7. 38. Chu AT, Lieberman AF. Clinical implications of traumatic stress from birth to age five. Annu Rev Clin Psychol 2010; 6: 469–94. 39. Achenbach TM, Edelbrock C. Manual for the Child's Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: Queen City Printers; 1983.
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ACCEPTED MANUSCRIPT 40. Scheeringa MS, Zeanah CH. PTSD semi-structured interview and observational record for infants and young children. New Orleans: Department of Psychiatry and Neurology,
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Tulane University Health Sciences Center; 1994.
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41. Laor N, Wolmer L, Mayes LC, Golomb A, Silverberg DS, Weizman R, et al. Israeli preschoolers under Scud missile attacks: A developmental perspective on risk-modifying
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factors. Arch Gen Psychiatry 1996; 53: 416–23.
42. Jones S, Rantell K, Stevens K, Colwell B, Ratcliffe JR, Holland P, et al. Outcome at 6
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months after admission for pediatric intensive care: a report of a national study of pediatric
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intensive care units in the United Kingdom. Pediatrics 2006; 118: 2101–8.
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ACCEPTED MANUSCRIPT Table 1: Summary of Findings on Pediatric Medical Traumatic Stress (PMTS) Prevalence Objective
Sample
Design and Data
Findings
Authors
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Collection
Describing
39 UK children Exploratory study.
et al.
memories and
who were
Interviewing children
children met PTSD criteria.
(2008)
mental well-
hospitalized in
and parents,
There was no association
being of
intensive care.
administering PTSD
between self-reports of
children
measures at 2-months
children and parents. There
following
following discharge.
was no association between
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intensive care
(2004)
hospitalization. Children who reported delusional
when compared to those who reported actual memories.
43 English
Pre-post design
At pre-surgery, no child met
speaking US
without a control
PTSD criteria. At post-
response to
children with
group. Assessed by the surgery, 12% of the children
heart surgery
no cognitive
Raven test (cognitive
and identifying
impairment
assessment),
its moderators.
aged 5–10,
temperament
who
questionnaire, and
underwent
diagnostic PTSD
heart surgery.
interview.
children’s
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et al.
age, gender, or duration of
higher level of symptoms
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Connolly Studying
level of symptoms, child’s
(imagined) memories had a
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hospitalization.
Twenty-three percent of
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Colville
developed PTSD.
Gemke
Evaluating
226 Swiss
Prospective design.
Twenty-two percent of
et al.
survival ability
parents to
Measurements:
parents reported that their
(1995)
and health status children aged 1 severity of disease at 1
child showed more
at 1-year
month to 16
year post-discharge
emotional difficulties and
following
years who
(by measure of
experienced durable fears.
20
ACCEPTED MANUSCRIPT were
Pediatric Mortality
According to parental
discharge.
hospitalized in
Risk), general medical
reports, 72.6% of children
intensive care
status 1 year post-
experienced no medical
due to non-
discharge (Multi
status exacerbation when
trauma
attribute Health Status
reasons.
Classification).
hospitalization.
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intensive care
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compared to pre-
Evaluating the
1455 UK
Prospective design.
Twenty-six percent of
al.
mental status of
children who
Administration of
children showed mild
(2006)
children
were
general medical-
emotional difficulties, 5%
following
hospitalized in
mental questionnaire
showed medium emotional
intensive care
intensive care.
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Jones et
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hospitalization.
at 6-month post-
difficulties, and 2% showed
discharge.
severe emotional difficulties. Most (67%) children showed no change in medical-mental status.
Evaluating
150 children
PTSD questionnaires
Posttraumatic stress
al.
posttraumatic
who had
were administered
development was reported
(2004)
symptoms
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Kazak et
cancer between after discharge.
by 43.7% of mothers,
the ages of 10–
Assessments: SCID,
35.3% of fathers, and
who recovered
19, and their
IES-R, PTSD-RI.
17.6% of children. PTSD
from cancer.
parents.
criteria were met by 13.7%
Follow-up took
of mothers, 9.6% of fathers,
place 1–10
and 8% of children.
AC
CE
among children
years postrecovery.
Rennick
Comparing
120 Canadian
Prospective study.
An increase in the level of
et al.
psychological
children who
Predictors: child’s age,
intrusive interventions
(2002)
response of
speak English
severity of disease,
predicted an increase in
children
or French, aged rating of intrusive
psychological distress. The
hospitalized in
6–17, who
procedures,
former as well as younger
intensive care to
were
psychological
age predicted increase in
those of children hospitalized for evaluation at 6-week
medical fear in children.
hospitalized in
Increase in disease severity
a minimum of
and 6-month
21
ACCEPTED MANUSCRIPT following discharge.
and younger age predicted a
departments and
Instruments: Children
decline in child’s sense of
identifying
Impact of Events
control. Child’s age was
response-
Scale; Children
significantly and inversely
associated
Medical Fears Scale;
factors.
Child Health Locus of
associated with severity of
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Control Scale,
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general pediatric 24 hours.
intrusive interventions.
SC
Behavioral Changes Questionnaire. Assessing
727 Australian
al.
function and
children aged
(2003)
quality of life in
0–29 who were phone interview with
of life (12.4% mild, 2.6%
children
hospitalized as
child or parents at 2-,
high, 1.4% very high).
following
children in
3-, and 6-years
There was an interaction
intensive care
intensive care.
following
between level of reports and
hospitalization.
time of measurements
Assessments included
among the groups.
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study that included
the Glasgow scale (function) and the Health state utility (quality of life).
AC
CE
PT
hospitalization.
Prospective follow-up
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Taylor et
22
Of the parents, 16.4% reported a decline in quality
ACCEPTED MANUSCRIPT Table 2: Consistency across the Tools PTSDSSI
PCASS
CBCL
1
.576**
.540**
T
Pearson Correlation Sig. (2-tailed)
.000
.000
77
77
1
.688**
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PTSDSSI
77
Pearson Correlation
.576**
Sig. (2-tailed)
.000
N
77
77
77
Pearson Correlation
.540**
.688**
1
Sig. (2-tailed)
.000
.000
76
76
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CBCL
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PCASS
SC
N
N
.000
AC
CE
PT
** Correlation is significant at the 0.01 level (2-tailed).
23
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S0022-3468(17)30667-X doi: 10.1016/j.jpedsurg.2017.10.043 YJPSU 58373
To appear in:
Journal of Pediatric Surgery
Received date: Revised date: Accepted date:
9 June 2017 7 September 2017 7 October 2017
Please cite this article as: Ari Amichai Ben, Peri Tuvia, Margalit Daniella, GaliliWeisstub Esti, Udassin Raphael, Benarroch Fortu, Surgical Procedures and Pediatric Medical Traumatic Stress (PMTS) Syndrome: Assessment and Future Directions, Journal of Pediatric Surgery (2017), doi: 10.1016/j.jpedsurg.2017.10.043
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Surgical Procedures and Pediatric Medical Traumatic Stress (PMTS) Syndrome: Assessment and Future Directions
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Amichai Ben Ari, MAa,b Tuvia Peri, PhDd
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Daniella Margalit, PhDa
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Esti Galili-Weisstub, MDa Raphael Udassin, MDc Fortu Benarroch, MDb
Department of Behavioral Sciences, Ariel University, Israel
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a
b
Herman Dana Division of Child and Adolescent Psychiatry, Hadassah-Hebrew University
Department of Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
d
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c
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Medical Center, Jerusalem, Israel
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Bar-Ilan University, Israel
Corresponding author: Amichai Ben Ari, Ben Zakai 36/8, Jerusalem, Israel. Phone: 00972-29978901; Fax: 00972-2-5324844; [email protected]
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ACCEPTED MANUSCRIPT Abstract Introduction
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Surgical procedures involve traumatic stress. Children may develop chronic psychological
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distress and dysfunction after surgery, with consequent reluctance to comply with medical follow-up care. A literature review of this topic shows that it has been under-studied. Our
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study aims to assess the frequency and characteristics of symptoms of persistent psychological distress in children following surgery, which have not been documented
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before, in order to promote its awareness and its early identification. Methods
Parents of 79 children (aged 1–6) that were hospitalized in a pediatric surgical ward, comprising a representative sample, completed three validated questionnaires assessing their
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children’s psychological symptoms 3–5 months after the hospitalization.
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Results
A significant portion of children suffer from psychological distress 3–5 months after
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hospitalization. Moreover, 10.39% of the children exhibited symptoms of PTSD, and 28.6% of parents reported that the child’s distress causes dysfunction. Additionally, our findings emphasize the parents’ concerns regarding the child’s behavior, function, and health
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following hospitalization. Conclusion
Since a significant prevalence of hospitalization-related traumatic stress is documented, the awareness to it has to be improved, in order to reduce its frequency and increase adherence to medical follow-up care. Type of study Prognosis study (level of evidence – 1). Keywords:
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Pediatric Medical Traumatic Stress (PMTS), PTSD, pediatric surgery, screening, risk factors.
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ACCEPTED MANUSCRIPT 1. Introduction Disease and injury followed by admission to a pediatric surgical ward introduce children and their families to a medical environment in which they may experience fear, uncertainty,
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helplessness, painful surgical interventions, and even life-threatening situations [1]. These
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elements are significant emotional stressors and thus the medical event, which includes the diagnosis and the intervention during hospitalization, may fit the definition of a traumatic event that is a prerequisite for Post-Traumatic Stress Disorder (PTSD) diagnosis.
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An acute traumatic-stress reaction to the hospitalization is frequent [2], but most children recover spontaneously. Nevertheless 25%–30% of them will develop chronic post-
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traumatic symptoms affecting the course of their physical recovery and overall function [3], and 10%–20% meet the criteria for PTSD outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) [3]. The remaining 5%–20% are children who do not meet the full diagnostic criteria for PTSD but still have significant emotional distress and/or significantly disrupted functioning which persist for a long time after the
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hospitalization. In order to capture the unique aspects of a condition caused by a medical event, the term Pediatric Medical Traumatic Stress (PMTS) has been used. PMTS is
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characterized by an array of physical and emotional symptoms such as hyper-arousal, avoidance, and re-experience of the event, which have developed due to a major illness or
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medical intervention that involved a threat to the child’s health and an intrusive, painful, and alarming medical care [1].
Since this field has not received enough attention to date in the area of pediatric
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surgery, it is important to review here the existing literature, in order to understand the background in which our study was planned. We will then present our data, which aim is to document, for the first time in the literature, the prevalence of PMTS in pediatric surgery. 1.1. Literature Review 1.1.1. PMTS Prevalence in Children A summary of studies that report prevalence of post-traumatic stress symptoms in children following a medical procedure is presented in Table 1. A comparison of the studies is difficult since many different outcome measures are used. Studies on children who have been hospitalized have found that 16%–28% of children report a decline in quality of life and emotional difficulties following their hospitalization [4–7]. PTSD rates among children who underwent cardiac or transplant surgical interventions ranged between 12%–16% [8, 9]. Among children with cancer, PTSD rates of 5%–10% and Post-Traumatic Stress Syndrome
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ACCEPTED MANUSCRIPT rates of 17%–21% have been reported [10]. Reports about post-traumatic stress among children following hospitalization in general surgery were not found in our literature search. 1.1.2. Compliance with Medical Care
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Compliance with medical care affects treatment outcomes, and has been associated with
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various health indicators. In a review of 25 articles [11], it was found that the level of compliance with medical care among patients who suffer from anxiety and depression is three times smaller than that of the normal population. Furthermore, a study of 19 children
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who underwent liver transplant found a high positive correlation between avoidance patterns (one of the main symptoms of post-traumatic stress) and lack of medical compliance,
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suggesting that children may associate medication-taking with their traumatic experiences, and thus try to avoid it [12]. Another study [1] found that among children with cancer a high level of PMTS reduces the probability of consistently arriving to follow-up medical treatments. Future studies are warranted on the relationship between PMTS and lack of medical compliance.
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1.1.3. PMTS Risk Factors
Identification of risk factors for the development of PMTS is important in order to understand
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PMTS determinants, to enable early diagnosis of children who are at high risk for psychological difficulties, and to apply timely interventions. Studies of children who were
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hospitalized have identified several risk factors, as follows. 1.1.3.1. Level of Anxiety during Hospitalization Multiple studies have found that children who reported anxiety and extreme distress during
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hospitalization were at high risk of developing post-traumatic stress a few months after the hospitalization [13, 14]. One important indicator for assessing anxiety and arousal levels is heart rate, which is usually assessed in routine procedures upon hospital admission and enables a prospective examination. Several studies have found that the heart rate on the first day of hospitalization correlates with a higher rate of post-traumatic symptoms following a few months [15–17]. 1.1.3.2. Perceived Hazard during Hospitalization Children often perceive hospitalization as a frightening and life-threatening experience. One study found that a majority of children who survived a major illness recalled a near-death experience at 6-month follow-up when in fact fewer than 10% of them were in a lifethreatening situation [18]. Similarly, a study of 102 children at 3 months following hospitalization, found that 32% of them recalled hospitalization as a life-threatening experience even though that was not actually the case [5]. Indeed, in a review of 28 studies 5
ACCEPTED MANUSCRIPT on psychological outcomes following hospitalization [19], it was found that children recall many aspects of hospitalization accurately but amplify perceptions of danger and life threat, which engenders anxiety. This review found that the child’s perception and interpretation of
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the disease and hospitalization experience had a significant impact on behavioral and
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emotional outcomes. In a study of 226 children at one year following discharge, 22.1% reported a decline in emotional status due to specific fears relating to the hospitalization experience [6].
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Anxiety during hospitalization is related to the perception of life threat, and has been found to predict the child’s level of distress a few months after hospital discharge. For
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example, it has been found that children who experienced anxiety believing that they are going to die during hospitalization subsequently showed more post-traumatic symptoms than those who did not have such beliefs [13]. Similarly, in a meta-analysis of 14 studies on accidental trauma [20], the child’s perception of life threat was a potent, consistent predictor of post-traumatic stress development.
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Children’s anxiety has been inversely associated with their level of cognitive understanding [21]. The child’s cognitive understanding is related to the development of
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abstract thinking and to understanding cause-effect relations; sometimes a childlike, egocentric thinking style may lead to an incorrect interpretation of the event and to elevated
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anxiety levels (e.g. a child who thinks that getting an injection means a declining medical status). Accordingly, younger children are in need of more careful explanations, adapted to their developmental level [1].
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1.1.3.3. The Experience of Lack of Control In a study utilizing a small sample, children who were discharged from intensive care had higher levels of lack of control in comparison to children who were discharged from regular hospitalization, and lack of control was associated with a feeling of helplessness [22]. Others have found that an intense experience of lack of control may explain the development of medical fear (including anxiety symptoms and avoidance of medical checkups and care) [23]. Lack of control was found to be a mediating factor shared by all other risk factors (age, severity of illness, and the level of exposure to intrusive interventions) [23]. The above findings suggest a possible correlation between the child’s experience of lack of control during hospitalization and PMTS. 1.1.3.4. Parental Anxiety A child’s hospitalization may comprise a traumatic event for parents. A study of 272 children hospitalized in intensive care and their families, found that 33% of parents reported 6
ACCEPTED MANUSCRIPT symptoms meeting ASD criteria during hospitalization, and that at 4-month follow-up, 6.6% of parents met criteria for PTSD. Also, the duration and extent of the parents’ initial response during hospitalization and their subjective perception of the extent of the danger to the child’s
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life were predictors of child PTSD development [24]. Indeed, the parents’ emotional reaction
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may affect the emotional coping of their children. A study of children with cancer found that stress and distress experienced by one of the parents predict the development of posttraumatic distress in the child at 6- to 8-month follow-up [25]. Additionally, a positive
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correlation was found between the level of ASD symptoms in children with burns and that of their parents [26]. Similar findings were found in studies of children hospitalized due to
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injury or illness. In one study, the level of maternal anxiety in the first hours following hospitalization was a significant predictor of negative behavioral symptoms in children aged 2–7 at 6 months following discharge [27]. Others have found a positive association between post-traumatic symptoms among parents and their children [20]. However, another study found no associations between post-traumatic symptoms in parents and adolescents [28]. This
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discrepancy may be due to the stronger effect of parental symptoms of stress and distress on children in comparison to adolescents.
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1.1.3.5. History of Previous Psychopathology It has been found that the child’s psychological function pre-hospitalization and history of
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psychopathology are associated with increased risk for developing chronic post-traumatic stress due to injury or hospitalization [29]. A study of children with cancer found that having a high level of anxiety and psychological difficulties pre-hospitalization predicted post-
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traumatic stress [30]. Nonetheless, others have found no associations between psychological background and distress following hospitalization [31]. This study, however, examined referrals to mental health services rather than direct measures of psychopathology, which may limit its representativeness. 1.1.3.6. History of Traumatic Events Regarding trauma history, a single study found that children who were previously exposed to a traumatic event had a lesser tendency to develop post-hospitalization symptoms in comparison to other children [32]. It may be that the traumatic event can, under special conditions, have a strengthening effect, if experienced as an event that can be overcome. However, widely based evidence on general trauma supports the opposite conclusion. Indeed, previous experience of a traumatic event was found to be a risk factor for developing PTSD among children who were hospitalized at an intensive care unit [19]. Similarly, large number of stressful events prior to experiencing a burn were found to predict subsequent ASD 7
ACCEPTED MANUSCRIPT development [26]. The researchers suggested that children’s self-image served as a mediator so that the past experience of stressors negatively affects the child’s self-image and vulnerability, which in turn increases the risk for post-traumatic stress [26]. Most often
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traumatic events involve experiences of helplessness, increase vulnerability, and are a risk
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factor for developing post-traumatic symptoms in the event of future trauma exposure [17]. 1.1.3.7. Family Function and Support
Family dysfunction is a main risk factor for PMTS. The level of family and social support
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among children with cancer has been found to be inversely associated with the emergence of post-traumatic symptoms [33]. Others have found that a high level of family conflicts is
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associated with the development of post-traumatic symptoms following hospitalization [34]. The same study found that children in achievement-oriented families with low levels of emotional expression tend to develop post-traumatic symptoms following hospitalization [34].
1.1.3.8. Medical Intervention and Hospitalization Characteristics
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Intrusive medical interventions are a significant predictor of post-traumatic stress in children following hospitalization [19, 32]. Severity of disease or injury as well as exposure to
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medical interventions were found to be positively associated with the experience of fear, lack of control, and post-traumatic symptoms at 6 month following hospitalization [19]. Also, the
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level of noise in the department was a significant predictor of emotional distress among children [19]. Another study found a relationship between duration of intensive care hospitalization and the severity of post-traumatic symptoms among children who have had
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heart surgery [8]. Moreover, experiencing and treating pain during hospitalization have been associated with subsequent chronic stress. For example, it has been found that administering morphine to children aged 1–4 after burn experience reduces the level of post-traumatic symptoms at 3- and 6-month follow-up [35], suggesting that early pain treatment may contribute to reducing mental stress risks. 1.1.4. PMTS Awareness A study of 287 pediatricians found that PMTS awareness is low: only 7% believed that children could develop psychological symptoms due to hospitalization, and only 11% were familiar with methods to assess such symptoms [36]. Also, it was found that due to insufficient awareness, the identification of emotional distress often occurs only once the difficulties had become more severe. Late identification hinders the possibility of early intervention, which has been proven to be effective in children [1]. One of the factors explaining the low PMTS awareness is that the treatment during acute hospitalization is 8
ACCEPTED MANUSCRIPT focused on the physical status of the child [37], and not enough attention is paid to the psychological consequences of the situation. Despite growing awareness to the emotional and mental outcomes of medical care among medical professionals in recent years [17], this
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awareness is often unsatisfactory [19], as some children do not receive the proper preparation
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prior to surgery or other medical procedures and consequently develop emotional distress. Another important reason for this lack of awareness is the misconception (which is unfortunately still very common, even among some health professionals) about infants and
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young children not being candidates for post-traumatic stress since “they do not understand” the experience. Widely based evidence has established that traumatic experiences have a
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significant effect on very young infants and that they can have even more devastating and longer lasting effects than on older children [38]. 1.1.5. Preventive Interventions
According to the Pediatric Psychosocial Preventative Health Model [1], the first stage of preventive interventions in children who are exposed to medical trauma involves providing
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them with information regarding the expected emotional response to treatment, thus normalizing their feelings. Moreover, the American Academy of Pediatrics Committee
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recommends allowing parents to be present during medical procedures, because their support has been associated with lower PMTS rates in children [3]. Additionally, it was found that
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providing relevant information to parents via leaflets increases awareness and the probability of early PMTS identification [3]. Providing safe maximal sedative treatment during the initial care increases the probability of arriving to subsequent treatments and reduces PMTS [3, 26].
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One study described and tested a 3-sessions intervention plan focusing on identifying parental perceptions regarding the disease, coping with it, and processing it. This plan has been found effective in reducing PMTS symptoms among children with cancer [1]. These findings suggest that preventive interventions can be effective, but we are not aware of any similar data concerning pediatric surgery. Once PMTS symptoms have developed and persist, they can be treated using Trauma-Focused Cognitive-Behavioral Treatment (TFCBT) that includes the provision of psycho-educational information, acquisition of emotional regulation, family communication skills, and narrative and emotional processing of trauma. These components of TFCBT have been found effective in treating children who experienced medical trauma and in hindering the development of chronic PTSD [3]. This literature review emphasizes the importance of improving the awareness to PMTS, in order to promote its prevention, its early identification, and its treatment. As a first 9
ACCEPTED MANUSCRIPT step towards this goal, the aim of the following study is to assess the frequency and characteristics of PMTS in children following hospitalization in a pediatric surgery ward. 2. Methods and Procedure
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2.1. Objective
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To assess the frequency and characteristics of psychological symptoms persisting 3 months after hospitalization in a pediatric surgery ward. 2.2. Methods
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2.2.1. Study Procedure
The study was approved by the Institutional Reviewing Board of the Medical Center.
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Participants were recruited consequentially from a list of all the patients hospitalized in the pediatric surgery ward of the Hadassah-Hebrew University Medical Center in Jerusalem between 1 June 2015 and 1 January 2016, sorted according to their date of admittance. All the Hebrew-speaking parents were approached. Eighteen patients )18% of the sample) declined to participate; their age averaged 4.9 years (σ=2.3) and their average period of hospitalization
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was 5.1 days (σ=9.3). The remaining parents of 79 children compose the final study sample. After signing an Informed Consent form, the parents were contacted three to five months
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following discharge and answered questionnaires via telephone. The telephone conversations were conducted by one of the authors, who is a licensed rehabilitational psychologist, and
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each lasted for one hour on average. 2.2.2. Participants
Seventy-nine children (65% boys) participated in the study, aged 1–6 years old, the average
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being 4.5 (σ=2.8). Half of the participants (50%) were hospitalized for minor surgery, 32% for other kinds of surgery, 15% were hospitalized without surgery, and 3% were treated for burns. The surgical procedures captured were in urology (32%), orthopedics (11%), ENT (10%), dermatology (10%), gastroenterology (10%), nephrology (10%), neurology (3%), cardiology (3%), ophthalmology (2%), combined (3%), and other (6%). The period of hospitalization ranged from a few hours to 90 days, averaging 5.6 days (σ=12.1). For 57% the hospitalization was elective. Furthermore, 58.3% of the children were hospitalized without receiving prior preparation. Regarding the education of the parents, 51.6% had a bachelor’s degree, 39.8% secondary education, and 8.6% a master’s degree. As for their level of religiosity, 35.8% were either highly religious or Haredi Jews, 35.8% religious, 18.9% secular, and 9.5% Masortim (neither strictly observant nor secular). Concerning their marital status, 94.6% were married, while only 5.4% were divorced or separated. Furthermore, regarding their financial 10
ACCEPTED MANUSCRIPT situation, 61.5% were in no economic distress, 28.1% had some financial troubles, and 10.4% were in difficult financial straits. Not all of the participants completed all of the questionnaires: 77 parents completed
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the PTSDSSI and PCASS questionnaires, while 76 parents answered the CBCL. There was
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no overlap among the parents who did not complete the different questionnaires. 2.3. Measures 2.3.1. Demographic Questionnaire
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This questionnaire includes: age and gender of the child; reason of hospitalization; gender of the parent who answered the questionnaire; religious denomination; and the parent’s level of
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education. Information regarding hospitalization characteristics and medical intervention was taken from the hospital’s medical records.
2.3.2. Achenbach’s Child Behavior Checklist (CBCL)
A self-report questionnaire filled out by parents of children aged 1.5–5 years, used in many studies in order to assess emotional and behavioral problems among children. It yields a
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General (total) scale, two sub-scales (Internalizing and Externalizing Problems) and refers to seven domains—emotional reactivity, anxiety/depression, somatic problems, avoidance,
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sleeping problems, attention, and aggressive behavior—through 100 items with an amount of agreement of 0–2 on a Likert scale [39]. Internal consistency estimates range from a= 0.89
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for internalizing scale and a=0.91 for externalizing scale [39]. In the current study, internal consistency for internalization scale yielded a=0.94 and a=0.92 for externalization scales. 2.3.3. Assessment of PTSD Symptoms
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It is difficult to assess symptoms of PTSD in infants and preverbal children. We have to rely on parents’ reports, who can find it difficult to be accurate and consistent in the interpretation and the description of their child’s behavior. That is why we opted to use two different questionnaires targeting the same symptoms. The integration of the results from these two questionnaires can help make the assessment more accurate. 2.3.3.1. The Post-Traumatic Stress Disorder Semi-Structured Interview (PTSDSSI) A parent-report questionnaire assessing symptoms of PTSD among children aged 1–6. It is concerned with the child’s response during and after the traumatic event and with developmental changes, and includes 29 items with an amount of agreement of 1–3 on a Likert scale. The internal reliability of this measure is 0.87, and a correlation of 0.66 has been found between the results of this measure and the severity and number of symptoms found in a clinical interview several months later [40]. Internal reliability in the current study yielded a=0.91. 11
ACCEPTED MANUSCRIPT 2.3.3.2. The Preschool Children’s Assessment of Stress Scale (PCASS) A parent-report questionnaire assessing symptoms of PTSD among children aged 1–6. This measure is concerned with symptoms of anxiety, fear, sleep difficulties, mood changes, and
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developmental regression, and includes 29 items with an amount of agreement of 1–5 on a
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Likert scale. The internal reliability of this measure is 0.89 [41]. In the current study, internal reliability yielded a= 0.96. 3. Results
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In the CBCL’s General Scale, 4% of children were in the borderline range and 11% in the clinical range. The results in the subscales show that the most prevalent symptoms are in the
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Internalizing category, where 20% of the children were in the clinical range. The domains in which the symptoms were more frequent were Emotional Reactivity, Anxiety/Depression, and Attention.
The PTSDSSI questionnaire, assessing the frequency of PTSD symptoms, shows that 55.7% of the children have significant symptoms of re-experiencing, 30.4% have significant
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symptoms of avoidance and 32.9% have significant symptoms of hyperarousal. In addition, 28.6% of parents reported that the child’s distress causes dysfunction and adjustment
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difficulties.
In the PCASS questionnaire, responding to the question “Since the surgery, how
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concerned are you about the following domains?” 15.6% of the parents reported that they are very concerned about the child’s separation difficulties. For example, 18.4% reported that the child is more protective of family members (item 1), and 28.9% reported that since the
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hospitalization the child clings more to family members (item 2). Moreover, 19.5% of parents reported being concerned about the child’s mood, and 26% reported being very concerned about the child’s fears since the surgery. For example, 17.1% reported that since the hospitalization the child is more afraid of objects, places, and specific people (item 8); 22.1% reported that since the hospitalization the child reacts with fright or panic to sudden changes (item 9); 23.4% reported that the child asks too many questions about what will happen during the day (item 10); and 22.1% reported that since the hospitalization the child’s games consistently revolve around one scary or dangerous subject (item 11). Additionally, 20.8% were very concerned about the child’s health. Furthermore, many parents reported considerable concern about the child’s state after the surgery in the domains of separation difficulties, mood, fears, and health. The parents’ reports show a significant rise (p=.000, T(76)=4.291) between their perceptions of the child’s state after the surgery (SD=0.59, M=1.36) and those before it (SD=0.34, M=1.13). 12
ACCEPTED MANUSCRIPT All three measures used in this study assess the same dependent variable (PMTS). The assessment of the dependent variable by the three measures points to convergent validity. As seen in Table 2, a high correlation has been found among the three questionnaires, indicating
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consistency at the individual patient level across the three tools.
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4. Discussion and Conclusions
This is the first study documenting the prevalence of PMTS among a representative sample of children hospitalized in a pediatric surgery ward. Our findings help improve understanding of
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an under-researched field, as they indicate that a significant portion of children aged 1–6 suffer from psychological difficulties 3–5 months after hospitalization or surgery. The data
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collected from the CBCL shows that many participants suffered from emotional distress following their hospitalization. The responses to the PTSDSSI questionnaire, moreover, indicate that 10.39% of the children exhibit symptoms of PTSD, and that 28.6% of parents reported that the child’s distress causes dysfunction and adjustment difficulties. Furthermore, the findings of the PCASS questionnaire emphasize the parents’ concerns regarding the
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child’s behavior, function, and health following hospitalization, with a significant rise between the parents’ reports of their conception of the child’s state before the surgery and
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after it. 4.1. Conclusions
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Our findings emphasize the fact that a significant portion of children experience posttraumatic symptoms following surgical procedures, which may persist beyond several weeks and inflict functional and psychological difficulties. It is important to increase awareness to
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this issue among medical staff in hospitals in order to decrease hospitalization-related trauma, thus preventing emotional distress and increasing compliance with medical follow-up care. The evidence-based recommendations in this field include providing guidance to the child and parents about the expected response to the medical treatment in order to minimize the experience of lack of control and death anxiety. In addition, safe maximal sedative treatment is recommended, as well as enabling parents to be present during medical procedures and support their child. In case of indications of mental distress, TFCBT strategies may be useful. Also, family factors should be considered when evaluating psychological symptoms and designing intervention programs. Currently, the low awareness among medical professionals to the field of medical trauma limits the possibility of conducting preventive interventions. Also, due to lack of awareness among parents, children who suffer from psychological distress following hospitalization are often not referred to treatment. In order to promote the incorporation of 13
ACCEPTED MANUSCRIPT this issue into routine procedures in pediatric surgery departments and intensive care units, a small group of high-risk children should be identified for a focused use of limited public resources. To that aim, we are conducting a study to develop a validated screening instrument
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designed to detect risk factors for PMTS that would enable early intervention and in some
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cases prevention.
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ACCEPTED MANUSCRIPT References 1. Kazak AE, Kassam-Adams N, Schneider S, Zelikovsky N, Alderfer MA, Rourke M. An
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integrative model of pediatric medical traumatic stress. J Pediatr Psychol 2006; 31: 343–55. 2. Judge D, Nadel S, Vergnaud S, Garralda EM. Psychiatric adjustment following
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meningococcal disease treated on a PICU. Intensive Care Med 2002; 28: 648–50. 3. Forgey M, Bursch B. Assessment and management of pediatric iatrogenic medical trauma.
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Curr Psychiatry Rep 2013; 15: 1–9.
4. Rennick JE, Johnston CC, Dougherty G, Platt R, Ritchie JA. Children’s psychological responses after critical illness and exposure to invasive technology. J Dev Behav Pediatr 2002; 23: 133–44.
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5. Colville G, Kerry S, Pierce C. Children's factual and delusional memories of intensive
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care. Am J Respir Crit Care Med 2008; 177: 976–82. 6. Gemke R, Bonsel GJ, Van Vught A. Long-term survival and state of health after paediatric
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intensive care. Arch Dis Child 1995; 73: 196–201.
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7. Taylor A, Butt W, Ciardulli M. The functional outcome and quality of life of children after admission to an intensive care unit. Intensive Care Med 2003; 29: 795–800. 8. Connolly D, McClowry S, Hayman L, Mahony L, Artman M. Posttraumatic stress disorder in children after cardiac surgery. J Pediatr 2004; 144: 480–4. 9. Mintzer LL, Stuber ML, Seacord D, Castaneda M, Mesrkhani V, Glover D. Traumatic stress symptoms in adolescent organ transplant recipients. Pediatrics 2005; 115: 1640–4. 10. Kazak AE, Alderfer M, Rourke MT, Simms S, Streisand R, Grossman JR. Posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in families of adolescent childhood cancer survivors. J Pediatr Psychol 2004; 29: 211–9. 11. DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance 15
ACCEPTED MANUSCRIPT with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000; 160: 2101–7.
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12. Shemesh E, Lurie S, Stuber ML, Emre S, Patel Y, Vohra P, et al. A pilot study of
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posttraumatic stress and nonadherence in pediatric liver transplant recipients. Pediatrics 2000; 105: e29.
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13. Winston FK, Kassam-Adams N, Garcia-España F, Ittenbach R, Cnaan A. Screening for risk of persistent posttraumatic stress in injured children and their parents. JAMA 2003; 290:
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643–9.
14. Kassam-Adams N, Garcia-Espana JF, Fein JA, Winston FK. Heart rate and posttraumatic stress in injured children. Arch Gen Psychiatry 2005; 62: 335–40. 15. Bryant RA, Salmon K, Sinclair E, Davidson P. Heart rate as a predictor of posttraumatic
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stress disorder in children. Gen Hosp Psychiatry 2007; 29: 66–8.
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16. Olsson KA, Kenardy JA, De Young AC, Spence SH. Predicting children's post-traumatic stress symptoms following hospitalization for accidental injury: Combining the Child Trauma
CE
Screening Questionnaire and heart rate. J Anxiety Disord 2008; 22: 1447–53.
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17. Rennick JE, McHarg LF, Dell’Api M, Johnston CC, Stevens B. Developing the Children’s Critical Illness Impact Scale: Capturing stories from children, parents, and staff. Pediatr Crit Care Med 2008; 9: 252–60. 18. Morse M, Castillo P, Venecia D, Milstein J, Tyler DC. Childhood near-death experiences. Am J Dis Child 1986; 140: 1110–4. 19. Rennick JE, Rashotte J. Psychological outcomes in children following pediatric intensive care unit hospitalization: a systematic review of the research. J Child Health Care 2009; 13: 128–49. 20. Cox CM, Kenardy JA, Hendrikz JK. A meta-analysis of risk factors that predict psychopathology following accidental trauma. J Spec Pediatr Nurs 2008; 13: 98–110.
16
ACCEPTED MANUSCRIPT 21. Tichy A, Braam C, Meyer T, Rattan N. Stressors in pediatric intensive care units. Pediatr Nurs 1987; 14: 40–2.
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22. Rees G, Gledhill J, Garralda ME, Nadel S. Psychiatric outcome following paediatric
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intensive care unit (PICU) admission: a cohort study. Intensive Care Med 2004; 30: 1607–14. 23. Pai AL, Patiño-Fernández AM, McSherry M, Beele D, Alderfer MA, Reilly AT, et al.
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The Psychosocial Assessment Tool (PAT2. 0): psychometric properties of a screener for psychosocial distress in families of children newly diagnosed with cancer. J Pediatr Psychol
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2008; 33: 50–62.
24. Balluffi A, Kassam-Adams N, Kazak A, Tucker M, Dominguez T, Helfaer M. Traumatic stress in parents of children admitted to the pediatric intensive care unit. Pediatr Crit Care Med 2004; 5: 547–53.
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25. Best M, Streisand R, Catania L, Kazak AE. Parental distress during pediatric leukemia and posttraumatic stress symptoms (PTSS) after treatment ends. J Pediatr Psychol 2001; 26:
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299–307.
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26. Saxe G, Stoddard F, Chawla N, Lopez CG, Hall E, Sheridan R, et al. Risk factors for
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acute stress disorder in children with burns. J Trauma Dissociation 2005; 6: 37–49. 27. Small L, Melnyk BM. Early predictors of post-hospital adjustment problems in critically ill young children. Res Nurs Health 2006; 29: 622–35. 28. Zatzick DF, Jurkovich GJ, Fan M-Y, Grossman D, Russo J, Katon W, et al. Association between posttraumatic stress and depressive symptoms and functional outcomes in adolescents followed up longitudinally after injury hospitalization. Arch Pediatr Adolesc Med 2008; 162: 642–8. 29. Brosbe MS, Hoefling K, Faust J. Predicting posttraumatic stress following pediatric injury: a systematic review. J Pediatr Psychol 2011; 36: 718–29. 30. Manne S, DuHamel K, Ostroff J, Parsons S, Martini DR, Williams SE, et al. Anxiety, depressive, and posttraumatic stress disorders among mothers of pediatric survivors of 17
ACCEPTED MANUSCRIPT hematopoietic stem cell transplantation. Pediatrics 2004; 113: 1700–8. 31. Meiser-Stedman R, Dalgleish T, Smith P, Yule W, Glucksman E. Diagnostic,
RI P
in children and adolescents. J Abnorm Psychol 2007; 116: 63–79.
T
demographic, memory quality, and cognitive variables associated with acute stress disorder
32. Keppel-Benson JM, Ollendick TH, Benson MJ. Post-traumatic stress in children
SC
following motor vehicle accidents. J Child Psychol Psyc 2002; 43: 203–12.
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33. Young GS, Mintzer LL, Seacord D, Castañeda M, Mesrkhani V, Stuber ML. Symptoms of posttraumatic stress disorder in parents of transplant recipients: incidence, severity, and related factors. Pediatrics 2003; 111: e725–e31.
34. Schreier H, Ladakakos C, Morabito D, Chapman L, Knudson MM. Posttraumatic stress symptoms in children after mild to moderate pediatric trauma: a longitudinal examination of
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Crit Care 2005; 58: 353–63.
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symptom prevalence, correlates, and parent-child symptom reporting. J Trauma Injury Infect
35. Stoddard Jr FJ, Sorrentino EA, Ceranoglu TA, Saxe G, Murphy JM, Drake JE, et al.
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Preliminary evidence for the effects of morphine on posttraumatic stress disorder symptoms
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in one- to four-year-olds with burns. J Burn Care Res 2009; 30: 836–43. 36. Ziegler MF, Greenwald MH, DeGuzman MA, Simon HK. Posttraumatic stress responses in children: Awareness and practice among a sample of pediatric emergency care providers. Pediatrics 2005; 115: 1261–7. 37. Marcin JP, Pollack MM. Review of the methodologies and applications of scoring systems in neonatal and pediatric intensive care. Pediatr Crit Care Med 2000; 1: 20–7. 38. Chu AT, Lieberman AF. Clinical implications of traumatic stress from birth to age five. Annu Rev Clin Psychol 2010; 6: 469–94. 39. Achenbach TM, Edelbrock C. Manual for the Child's Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: Queen City Printers; 1983.
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ACCEPTED MANUSCRIPT 40. Scheeringa MS, Zeanah CH. PTSD semi-structured interview and observational record for infants and young children. New Orleans: Department of Psychiatry and Neurology,
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Tulane University Health Sciences Center; 1994.
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41. Laor N, Wolmer L, Mayes LC, Golomb A, Silverberg DS, Weizman R, et al. Israeli preschoolers under Scud missile attacks: A developmental perspective on risk-modifying
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factors. Arch Gen Psychiatry 1996; 53: 416–23.
42. Jones S, Rantell K, Stevens K, Colwell B, Ratcliffe JR, Holland P, et al. Outcome at 6
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months after admission for pediatric intensive care: a report of a national study of pediatric
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intensive care units in the United Kingdom. Pediatrics 2006; 118: 2101–8.
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ACCEPTED MANUSCRIPT Table 1: Summary of Findings on Pediatric Medical Traumatic Stress (PMTS) Prevalence Objective
Sample
Design and Data
Findings
Authors
T
Collection
Describing
39 UK children Exploratory study.
et al.
memories and
who were
Interviewing children
children met PTSD criteria.
(2008)
mental well-
hospitalized in
and parents,
There was no association
being of
intensive care.
administering PTSD
between self-reports of
children
measures at 2-months
children and parents. There
following
following discharge.
was no association between
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intensive care
(2004)
hospitalization. Children who reported delusional
when compared to those who reported actual memories.
43 English
Pre-post design
At pre-surgery, no child met
speaking US
without a control
PTSD criteria. At post-
response to
children with
group. Assessed by the surgery, 12% of the children
heart surgery
no cognitive
Raven test (cognitive
and identifying
impairment
assessment),
its moderators.
aged 5–10,
temperament
who
questionnaire, and
underwent
diagnostic PTSD
heart surgery.
interview.
children’s
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et al.
age, gender, or duration of
higher level of symptoms
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Connolly Studying
level of symptoms, child’s
(imagined) memories had a
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hospitalization.
Twenty-three percent of
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Colville
developed PTSD.
Gemke
Evaluating
226 Swiss
Prospective design.
Twenty-two percent of
et al.
survival ability
parents to
Measurements:
parents reported that their
(1995)
and health status children aged 1 severity of disease at 1
child showed more
at 1-year
month to 16
year post-discharge
emotional difficulties and
following
years who
(by measure of
experienced durable fears.
20
ACCEPTED MANUSCRIPT were
Pediatric Mortality
According to parental
discharge.
hospitalized in
Risk), general medical
reports, 72.6% of children
intensive care
status 1 year post-
experienced no medical
due to non-
discharge (Multi
status exacerbation when
trauma
attribute Health Status
reasons.
Classification).
hospitalization.
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intensive care
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compared to pre-
Evaluating the
1455 UK
Prospective design.
Twenty-six percent of
al.
mental status of
children who
Administration of
children showed mild
(2006)
children
were
general medical-
emotional difficulties, 5%
following
hospitalized in
mental questionnaire
showed medium emotional
intensive care
intensive care.
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Jones et
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hospitalization.
at 6-month post-
difficulties, and 2% showed
discharge.
severe emotional difficulties. Most (67%) children showed no change in medical-mental status.
Evaluating
150 children
PTSD questionnaires
Posttraumatic stress
al.
posttraumatic
who had
were administered
development was reported
(2004)
symptoms
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Kazak et
cancer between after discharge.
by 43.7% of mothers,
the ages of 10–
Assessments: SCID,
35.3% of fathers, and
who recovered
19, and their
IES-R, PTSD-RI.
17.6% of children. PTSD
from cancer.
parents.
criteria were met by 13.7%
Follow-up took
of mothers, 9.6% of fathers,
place 1–10
and 8% of children.
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among children
years postrecovery.
Rennick
Comparing
120 Canadian
Prospective study.
An increase in the level of
et al.
psychological
children who
Predictors: child’s age,
intrusive interventions
(2002)
response of
speak English
severity of disease,
predicted an increase in
children
or French, aged rating of intrusive
psychological distress. The
hospitalized in
6–17, who
procedures,
former as well as younger
intensive care to
were
psychological
age predicted increase in
those of children hospitalized for evaluation at 6-week
medical fear in children.
hospitalized in
Increase in disease severity
a minimum of
and 6-month
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ACCEPTED MANUSCRIPT following discharge.
and younger age predicted a
departments and
Instruments: Children
decline in child’s sense of
identifying
Impact of Events
control. Child’s age was
response-
Scale; Children
significantly and inversely
associated
Medical Fears Scale;
factors.
Child Health Locus of
associated with severity of
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Control Scale,
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general pediatric 24 hours.
intrusive interventions.
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Behavioral Changes Questionnaire. Assessing
727 Australian
al.
function and
children aged
(2003)
quality of life in
0–29 who were phone interview with
of life (12.4% mild, 2.6%
children
hospitalized as
child or parents at 2-,
high, 1.4% very high).
following
children in
3-, and 6-years
There was an interaction
intensive care
intensive care.
following
between level of reports and
hospitalization.
time of measurements
Assessments included
among the groups.
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study that included
the Glasgow scale (function) and the Health state utility (quality of life).
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hospitalization.
Prospective follow-up
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Taylor et
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Of the parents, 16.4% reported a decline in quality
ACCEPTED MANUSCRIPT Table 2: Consistency across the Tools PTSDSSI
PCASS
CBCL
1
.576**
.540**
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Pearson Correlation Sig. (2-tailed)
.000
.000
77
77
1
.688**
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PTSDSSI
77
Pearson Correlation
.576**
Sig. (2-tailed)
.000
N
77
77
77
Pearson Correlation
.540**
.688**
1
Sig. (2-tailed)
.000
.000
76
76
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CBCL
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PCASS
SC
N
N
.000
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** Correlation is significant at the 0.01 level (2-tailed).
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76