Ten-Year Research Review of Physical Injuries

RESEARCH

UPDATE

REVIEW

This series of 10-year updates in child and adolescent psychiatry began in July 1996. Topics are selected in consultation with the AACAP Committee on Recertification, both for the importance of new research and its clinical or developmental significance. The authors have been asked to place an asterisk before the five or six most seminal references. M.K.D.

Ten-Year Research Review of Physical Injuries FREDERICK J. STODDARD, M.D., AND GLENN SAXE, M.D.

ABSTRACT Objective: To review the past 10 years of research relevant to psychiatry on injuries in children and adolescents. Method: A literature search of databases for “wounds and injuries, excluding head injuries,” was done with Medline and PsycINFO, yielding 589 and 299 citations, respectively. Further searching identified additional studies. Results: Progress is occurring in prevention, pain management, acute care, psychiatric treatment, and outcomes. The emotional and behavioral effects of injuries contribute to morbidity and mortality. Psychiatric assessment, crisis intervention, psychotherapy, psychopharmacological treatment, and interventions for families are now priorities. Research offers new interventions for pain, delirium, posttraumatic stress disorder, depression, prior maltreatment, substance abuse, disruptive behavior, and end-of-life care. High-risk subgroups are infants, adolescents, maltreated children, suicide attempters, and substance abusers. Staff training improves quality of care and reduces staff stress. Conclusions: Despite the high priority that injuries receive in pediatric research and treatment, psychiatric aspects are neglected. There is a need for assessment and for planning of psychotherapeutic, psychopharmacological, and multimodal treatments, based on severity of injury, comorbid psychopathology, bodily location(s), and prognosis. Psychiatric collaboration with emergency, trauma, and rehabilitation teams enhances medical care. Research should focus on alleviating pain, early psychiatric case identification, and treatment of children, adolescents, and their families, to prevent further injuries and reduce disability. J. Am. Acad. Child Adolesc. Psychiatry, 2001, 40(10):1128–1145. Key Words: pediatric injury, pain, stress, burns, psychiatric treatment.

Injuries have been the single largest cause of morbidity and mortality among children in the United States for many years (Baker et al., 1984; Dershewitz and Williamson, 1977). The child and adolescent psychiatrist’s role extends from emergency assessment and treatment through rehabilitation, to care of the grieving family. The Centers for Disease Control and Prevention (CDC) reported that 8.7 million children under the age of 15 were seen in hospital Accepted March 20, 2001. Dr. Stoddard is Associate Clinical Professor at Harvard Medical School at the Massachusetts General Hospital, Boston, and Chief of Psychiatry at the Shriners Burns Hospital, Boston. Dr. Saxe is Chairman of Child and Adolescent Psychiatry, Boston University School of Medicine, Boston Medical Center. This article was supported in part by Shriners Hospitals for Children grant 8760 and grants by The Alden Trust and The Deborah M. Noonan Fund awarded to Dr. Stoddard, and NIMH grant R01-MH57370 to Dr. Saxe. Reprint requests to Dr. Stoddard, SBH 6, Massachusetts General Hospital, Fruit Street, Boston, MA 02114. 0890-8567/01/4010–1128䉷2001 by the American Academy of Child and Adolescent Psychiatry.

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emergency departments for injuries in 1992 (Burt, 1995). The U.S. Department of Transportation (1993) reported that 894,000 children and adolescents were injured in motor vehicle accidents in the United States in 1992. Nonfatal injuries that were medically attended ranged from 12.9 per 100 children for 1- to 4-year-olds up to 22.5 per 100 children for 14- to 17-year-olds (Scheidt et al., 1995). Fatal injuries account for 61.6% of deaths from age 1 through 19, exceeding deaths from disease; in 1998, a total of 16,349 children aged 1 through 19 died from injuries (Guyer et al., 1999). The economic costs of injury, disability, and death of children are well over 16 billion dollars each year (U.S. Department of Transportation, 1993). While almost 16 million children are evaluated for injuries in the United States each year, the number with psychiatric sequelae is unknown. Despite its clear public health importance, there has been little formal research on psychiatric aspects of physiJ . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

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cal injuries in children. In 1966 the National Academy of Sciences termed injuries the “neglected disease of modern society” (National Academy of Sciences, 1985). The psychiatric sequelae of injuries continue to be understudied, notwithstanding the fact that the incidence of injuries is increasing in most developing nations (Smith and Barss, 1991), and by 2020 injuries and infectious disease are projected by the World Health Organization (WHO) to account for equal amounts of potential life lost worldwide (Murray and Lopez, 1996). The following review of the research literature on injuries in the past 10 years begins with definitions and epidemiology of injury. We then review what is known about psychiatric sequelae of injuries in children. Finally, we outline the psychiatric assessment and treatment of children who have sustained injuries. Because epidemiology, sequelae, and assessment and treatment are very broad topics, this review cannot address each area fully, but directs the reader to more detailed references. DEFINITIONS, CLASSIFICATION, AND MEASUREMENT OF INJURY

In this review, injuries are generally defined by cause (e.g., burns) and by anatomic location (e.g., face). The standardized classifications are ICD-9 and ICD-10. ICD9-CM classifies injuries, poisonings, other effects of external causes, complications of trauma, and complications of medical and surgical care. ICD-10 allows greater specificity and changes certain terms such as replacing the word “amputation” with “detachment” to be applicable to a wider range of procedures. Intentional injuries include child abuse, homicide, and suicide. Unintentional injuries include all other causes. This distinction in classification may not continue to be useful because many “unintentional” injuries are found to be intentional on full investigation, and it may make sense to strengthen mutually applicable methods of injury prevention because the same interventions reduce injuries in both areas (Peterson and Brown, 1994). EPIDEMIOLOGY

To identify the areas for psychiatric clinical and research focus, a brief review follows. Impressive progress in epidemiology research and injury prevention began in the 1980s with major initiatives: • The Massachusetts Statewide Childhood Injury Prevention Program (1979–1982) “provided estimates of J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

the relationship between fatal and nonfatal injuries,” revealing that the rate of injuries requiring hospitalizations (1977–1978) were 44.31 times the rate of injury deaths (average for 1969–1978) (Gallagher et al., 1982; Scheidt et al., 1995). This initiated the development and study of models for pediatric community-based injury prevention programs. • The U.S. Congress passed the Injury Prevention Act of 1986 (Public Law 99-649). This was intended to (1) promote research into the causes, diagnosis, treatment, prevention, and rehabilitation of injuries; (2) promote cooperation between specialists in fields involved in injury research; and (3) promote coordination between public and private entities in injury prevention (Division of Injury Control, CDC, 1990). • Within PL 99-649, Section 393 requests that the CDC analyze incidence and causes of childhood injuries (Division of Injury Control, CDC, 1990). • The Child Health Supplement to the 1988 National Health Interviews Survey investigated “circumstances, causes and impact of all medically attended nonfatal injuries for a representative sample of U.S. children and adolescents” (Scheidt et al., 1995). The incidence of injury morbidity greatly exceeds injury mortality, but data on nonfatal injuries have not been routinely available in the same way as vital statistics regarding fatal injuries. • The Tufts National Pediatric Trauma Registry, which began in 1985, is a “multi-institutional shared database designed to create and evaluate information concerning all aspects of pediatric trauma care” (Tepas et al., 1989). An outgrowth of these alternatives was the National Institute of Child Health and Human Development recommendation for standardized definitions for childhood injury research (Christoffel et al., 1992). Internationally, in 1998, at the 50th World Health Assembly, the Surgeon General, David Satcher, M.D., Ph.D., reiterated the interdependence of American medicine and global health, and our support of WHO-led efforts to address poverty, violence, disasters, and mental health, among other areas. The United Nations Children’s Fund (UNICEF) has increased its focus on childhood injuries. Comprehensive injury data, unlike that on deaths, are not gathered nationally, but estimates are available. The following discussion briefly reviews the epidemiological data on injuries in U.S. children. Scheidt et al. (1995) found that rates of nonfatal injuries in 1988 were from 12.9% for young children (aged 1–4 years) and 22.5% for 1129

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adolescents (aged 14–17 years). Their overall estimated adjusted injury rate was 27%. Almost half of those treated were between the ages of 14 and 17 years old and had the most severe injuries. In the 10- to 13-year age group, nonfatal injuries from sports were almost as common as those from falls and being struck or cut. In the 14- to 17-year age group, sports-related injuries were the leading cause of nonfatal injuries (DiScala et al., 1997). Motor vehicle traffic (MVT) injuries far exceeded all other causes of death, but only accounted for slightly more than 6% of nonfatal injuries. Animal attacks, primarily by dogs, cause 1% of emergency visits (Rossman et al., 1997). With regard to suicide, about 5% of suicide attempters are injured, and 2% to 3% seek medical attention (Bell and Clark, 1998). Burn injuries have dropped about 50% to an estimated annual rate of 1.25 million in the United States as a result of legislation, education, and burn prevention with devices such as sprinkler systems and smoke alarms (Brigham and McLoughlin, 1996). Important settings for injury include juvenile detention and correction, where 3.12 injuries per 100 juveniles and 2.40 suicidal acts per 100 juveniles occurred in the 30 days before a large survey (Parent et al., 1994), and the workplace, where as many as 24% of injuries to 14- to 19-year-olds occur (Runyan and Gerken, 1989). Overall, these data indicate that injuries occur to about a quarter of children, with very young children and adolescents at highest risk, and that sports, falls, MVT injuries, and burns are among the common causes. Juvenile offenders in detention and correction environments are also among those most vulnerable psychiatrically and are at highest risk. Regarding fatal injuries in 1998 (the most recent year for which data are available), 16,349 children and teenagers aged 1 through 19 years died from injuries, a rate of 22.1 per 100,000 children. The age distribution by number and rate per 100,000 is as follows: 1 through 4 years: 2,249, 14.8; 5 through 9 years: 1,640, 8.3; 10 through 14 years: 2,208, 11.5; and 15 through 19 years: 10,245, 52.4 (Guyer et al., 1999). Further analysis of categories, available for 1997 only (Guyer et al., 1998), revealed MVT and firearms to be the two major causes of injury. The death rate due to MVT injuries in young children (aged 1–4 years) was 4.3 per 100,000. MVT and firearm-related injuries account for 79% of all deaths in adolescents (aged 15–19). Combining data from all age categories, suicide and homicide accounted for 2.9 and 4.4 deaths per 100,000 children, compared with unintentional injuries, which accounted for 15.9 deaths per 100,000 children. 1130

The distributions of nonfatal medically attended injuries differ vastly from those of fatal injuries (Scheidt et al., 1995). Adolescents are at the highest risk for death. In 1997 adolescents aged 15 through 19 accounted for 62.8% of all deaths due to injuries. Of these injuries, 10.5% were due to suicide, 14.2% were due to homicide, 37.2% were unintentional, and 0.9% were from other causes. The firearm-related death rate was nearly 12 times higher in the United States than among 26 other industrial nations combined (MMWR, 1997), and prevention of violent injuries was a national goal for the year 2000 (Durkin et al., 1996). Suicide is the third leading cause of death for adolescents, with firearms accounting for 67% of these (Bell and Clark, 1998). Because of advances in transport and treatment, deaths from burns, the fourth leading cause of accidental death, have dropped to 5,500 deaths per year (Brigham and McLoughlin, 1996). In summary, injuries are a large public health problem accounting for very high rates of morbidity and mortality in children and adolescents. Adolescents are at particular risk. PSYCHIATRIC OUTCOMES

The aforementioned review of the epidemiology research demonstrates great advances in tracking the prevalence of injuries in the United States. Unfortunately, there are few studies of psychiatric outcomes following injuries. Table 1 outlines outcomes related to the anatomic location of the injury. Posttraumatic stress disorder (PTSD) is the psychiatric disorder that has been most clearly established following injuries, and so this review will focus largely, but not exclusively, on this outcome. Comorbid diagnoses such as mood, anxiety, and conduct disorders occur in trauma patients and affect outcome. Prior trauma, particularly head trauma, may predispose to psychiatric disorder, particularly attention-deficit/hyperactivity disorder (ADHD). PTSD represents some of the core features of a child’s psychological reactions to a diverse range of injuries such as motor vehicle accidents, violent assaults, natural disasters, political violence, and burns (Daviss et al., 2000a,b; de Vries et al., 1999; Green et al., 1991; Lonigan et al., 1994; Martini et al., 1990; McFarlane, 1986; Pynoos et al., 1987; Sack et al., 1993; Stallard et al., 1998; Stoddard et al., 1989). Symptoms of this disorder include intrusive recollections, numbing and avoidance, and hyperarousal (American Psychiatric Association, 2000). PTSD causes tremendous problems for a child’s social, educational, and biological development (Cicchetti and Rogosche, 1994; J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

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TABLE 1 The Injury: Implications of Anatomic Location(s) Location of Injury

Implications

Head and scalp

Most children with head injuries survive. Scalp injuries may cause painful wounds, disability, and disfigurement.

Face

Facial appearance is related to attributed intelligence from birth, and attractiveness corresponds to popularity with peers or stigmatization (Berscheid and Gangestad, 1982). Facial disfigurement has implications for sense of self, social interaction, coping, and risks for depression throughout development (Macgregor, 1990; Stoddard, in press).

Eye

Injuries to the eye acutely threaten independent functioning. Bilateral patching may precipitate depression or psychosis.

Ear

Deafness may result in social isolation. The age at onset for deaf or “hard-of-hearing” children is either before (prelingual) or after (postlingual) learning spoken language. They may require interpreters for signed language, and they require empathy and efforts to assist in communication.

Upper extremity

Hand injuries are common, and loss of a dominant hand or of opposition is most important. Selfesteem and skill are associated with hand sensation, appearance, and functions. Injuries to the upper extremity can be disfiguring or disabling.

Lower extremity

Injury interferes with ambulation and can cause disability. The self-esteem of active children is especially impacted.

Amputations

These cause pain and massive psychic trauma and impact body image. Arm and leg amputations are disfiguring and disabling. Other amputations with psychiatric sequelae include nose, ear, digits of the hand or foot, breast, or penis.

Breast

This may result in anxiety or depression in girls affecting the sense of self and body image, for the breasts are associated with feminine identity, sexuality, and motherhood (Rowland and Massie, 1996).

Trunk, including back and pelvis

These are among the “hidden” injuries that affect development and overall well-being. Pelvic fractures may be disabling and affect reproduction.

Lung

The lung is commonly injured as a result of major trauma; mechanical ventilation may be required. Lung injuries can be disabling.

Other internal organs

Injury to the thorax, heart, liver, spleen, gastrointestinal tract, kidneys, and female reproductive system can be acutely painful and stressful, life-threatening, and disabling.

Urogenital tract and anus

Recognition of the need for psychiatric care resulted from treating sexual abuse, but these injuries often have other causes including nonabusive burns and nonsexual assault to the genitals by peers. These injuries are stigmatized, which interferes with reporting by the child, documentation by staff, and psychiatric care.

Spinal cord injury

Spinal cord injury can be life-threatening, disabling, and disfiguring. Adolescent males, particularly, require psychiatric treatment for pain, depression including suicidality, psychosis, substance abuse, or psychosomatic disturbances.

Cicchetti and Toth, 1995; Pynoos, 1993). Children with PTSD are often so preoccupied with intrusive recollections and are so hyperaroused that they have difficulty processing social information. This preoccupation with the trauma and extreme levels of arousal interfere with learning at school. Traumatized children frequently are so frightened that the traumatic event will recur that they avoid social situations and school. Intrusive recollections of the traumatic event may become manifest in behavioral reenactments, and thus children who have been victims of violence may themselves perpetrate violence (Lewis, 1992). Children with trauma histories may also develop mood, J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

anxiety, sleep, conduct, elimination, learning, and attentional problems (Pelcovitz and Kaplan, 1996; Pynoos, 1993, 1996; Stoddard et al., 1989; van der Kolk, 1994). Two distinctions regarding trauma-related outcomes are relevant to injury. These distinctions relate to (1) time following the trauma (the distinction between acute stress disorder [ASD] and PTSD), and (2) the degree of comorbidity: Time Course

The differences between posttraumatic symptoms expressed in the proximal and distal aftermath of a trauma 1131

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are formalized in the DSM-IV-TR (American Psychiatric Association, 2000) with the distinction between ASD and PTSD. ASD describes the psychopathological responses in the immediate aftermath of a traumatic event that occur until 1 month after the trauma. PTSD describes the psychopathological responses that persist after 1 month. In addition to the temporal distinction between ASD and PTSD, these disorders are also distinguished by prominent dissociative symptoms. Individuals with ASD often have significant dissociative symptoms; these individuals feel detached from their bodies and experience their environment as unreal and dreamlike. Such individuals often experience a decrease in emotional responsiveness, numbness, and difficulty recalling elements of the traumatic event. They also tend to reexperience the traumatic event, avoid reminders of the event, and are hyperaroused to stimuli reminiscent of the event (Cardena and Spiegel, 1993; Koopman et al., 1995; Spiegel et al., 1994). Dissociative symptoms, as outlined below, may be a primary marker of psychopathology. Evidence suggests that individuals who dissociate around the time of trauma are at high risk of developing PTSD (Dancu et al., 1996; Koopman et al., 1994; Marmar et al., 1994; Shalev et al., 1996). Although dissociation is a well-established phenomenon in children who have histories of traumatic events (Hornstein and Putnam, 1992; Putnam, 1996), the acute dissociative response to trauma has not been systematically studied in children. In addition, there are concerns that the inclusion of dissociative symptoms as a necessary criterion of ASD may falsely lower the rate of this disorder as symptoms of reexperiencing, avoidance, and hyperarousal frequently occur in the acute aftermath of a trauma, without dissociative symptoms (Marshall et al., 1999). Degree of Comorbidity

As mentioned above, traumatic events are often associated with many comorbid diagnoses in addition to PTSD including mood, anxiety, sleep, conduct, elimination, learning, and attentional problems (Pelcovitz and Kaplan, 1996; Pynoos, 1993, 1996; Stoddard et al., 1989, 1992; van der Kolk, 1994). We believe that the increase in comorbid conditions is related to the complexities of the context of the injury. In particular, children who have preexisting psychiatric problems, who have difficult family problems, or who experience community or societal disruption are at higher risk for more comorbid responses (Cicchetti and Lynch, 1993; Pynoos, 1996). As will be outlined below, we reserve the term “complex injury” to denote injuries that 1132

occur in the context of such preexisting problems and familial, community, and societal disruption. CONTEXT OF INJURY

Historically, injuries were mistakenly termed “accidents” because they are sudden and may appear unpredictable and uncontrollable (Division of Injury Control, CDC, 1990). In fact, injuries often occur in predictable patterns and their sequelae can be understood from the context in which they occurred. Injuries may result from serious family problems such as child abuse and neglect. They may also result from serious societal problems such as poverty, community violence, and war. Injuries may be influenced by factors within the child such as impulsivity, hyperactivity, suicidality, and substance abuse. Frequently these various contextual factors interact synergistically to increase the risk of injury. There is little research designed to predict the likelihood of injury based on risk factors, although burns are an exception and are increased in young children from poverty backgrounds. Injuries are infrequently random. The psychiatric consequences of injury may be as related to the contextual factors related to the injury (child maltreatment, war, community violence, etc.) as to the direct impact of the injury itself. We reserve the term “simple” injury for those situations that were at one time called accidents, that is to say, single, unpredictable events that cause bodily damage and are minimally related to factors within the child and his or her social context. As mentioned above we use the term “complex injury” to describe those injuries that are more predictable because of significant individual, family, or societal problems. Our approach is consistent with a social ecological model of human behavior in which the child’s mental health outcomes are related to the dynamic interaction of the individual child and the various levels of his or her social environment such as family, school, neighborhood, society, and culture (Bronfenbrenner, 1979). Such a model has been used to describe outcomes related to traumatic events (Cicchetti and Lynch, 1993; Harvey, 1996). Problems Within the Individual

A variety of constitutional factors put a child at increased risk for injury. These factors then serve to complicate a child’s postinjury course and place him or her at increased risk for deleterious outcome. Among these factors, several that relate to the construct of impulsivity are suicidality, inattention, and substance abuse. These will be reviewed briefly below. J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

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Suicidality. Although there is much attention in the psychiatric literature to suicide and suicide attempt, there is minimal attention to the physical injuries sustained as a result of them. Suicide attempt may result in a range of major physical injuries, pain, alterations in body image, necessity for complex surgical and medical care, and longterm physical disability. These are in addition to preexisting psychiatric illness, and they have their own emotional sequelae and may lead to additional psychiatric disorders. Only about 5% of those who attempt suicide sustain any injury, and only 2% to 3% seek medical attention (Bell and Clark, 1998). There is an association between affective disorder, personality disorders, and substance abuse and suicide (Holinger, 1990). Suicide is also increasing as a cause of adolescent death in other countries of the world in addition to the United States (Borges et al., 1995). As stated earlier, the presence of guns in the home is a significant risk factor for adolescent suicide, as demonstrated in an elegant case-control study of 67 adolescent suicide victims and 67 matched community controls (Brent et al., 1993). This group as well as others has also found that substance abuse renders suicide by firearms more likely as confirmed by positive alcohol levels at the time of death. A wide range of injuries may result from suicide attempts, but there are few data on these. These may include wrist slashing, fractures, injuries from jumping from a height, injuries from hanging, effects of stabbing oneself, and nonlethal effects of shooting oneself with a gun. Injury due to violence, such as self-inflicted gunshots or wounds due to gang activities, requires assessment of pain and the effect on self-esteem from the injury (e.g., paraplegia), psychiatric diagnosis, and targeted psychotherapy and pharmacotherapy (discussed below) of comorbid predisposing risks such as aggressive impulsivity or substance abuse, as well as posttraumatic stress. Inattention and Impulsive Behavior. DiScala et al. (1998) evaluated children with ADHD and the risk for injury as one of the studies growing from the National Pediatric Trauma Registry. They reported children admitted to the hospital for injuries who had preinjury ADHD (n = 240) compared with those who did not (n = 21,902), aged 5 through 14 years. They found that children with ADHD were more likely to be boys, to be injured as pedestrians or bicyclists, to inflict injury on themselves, to be injured in multiple places on their body, to sustain head injuries, and to be severely injured as measured by the Injury Severity Score (ISS) and the Glasgow Coma Scale. These children with ADHD had a longer J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

length of stay and 37% were admitted to the intensive care unit, versus 24% of the non-ADHD population. Similarly, Leibson et al. (2001), in a population-based cohort study, found that 309 children with ADHD, compared with those without ADHD, had a significant increase in major injuries (59% versus 49%; p < .001). However, Wozniak et al. (1999), in a study of 140 children with ADHD and 120 normal control children, found that the diagnosis of bipolar disorder with comorbid ADHD which is associated with “explosiveness, aggression, impulsivity and poor judgment,” but not ADHD alone, was the most significant predictor for later trauma exposure over the next 4 years. They suggest that the reason other studies found an association of ADHD with trauma may be that children with ADHD have poorer outcomes after trauma and are therefore more likely to be referred for treatment. Oppositionality in childhood may also be a risk factor for injury. According to a longitudinal study from Finland with subjects who were entered at age 8 and followed up at ages 14 and 27, noncompliance in childhood and heavy drinking in adulthood increased the risk of accidents for men (Pulkkinen, 1995). Life stress may also be a risk factor, contributing to inattention and injury. An excellent study by Slap et al. (1991) compared injured and ill children aged 13 through 19 years admitted to the Children’s Hospital of Philadelphia from 1985 to 1988, including 149 injured children and 258 who were ill. While the groups did not differ in use of drugs or alcohol, they did differ in sex (with males being at risk), previous serious injury, previous hospitalization for injury, injury after alcohol or drug use, and stressful event scores, particularly a relative having been ill or died, school failure or suspension, getting a summer job, or breaking up with a girlfriend or boyfriend. Substance Abuse. Several studies have found a relationship between alcohol use or use of other substances and injuries in adolescence (Li et al., 1996; Spirito et al., 1997). A very interesting contribution to the discussion of the role of alcohol has been made by Li et al. (1997b), who concluded from a review of studies that include adults and children that “the alcohol-severity relationship reported in the studies is attributed to a great extent to the effects of correlates such as speeding and not wearing seat belts, rather than the biological effects of alcohol.” Several current studies, many of which include older adolescents, conclude that seriously injured trauma center patients often suffer from psychoactive substance use disorders, 1133

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particularly alcoholism (Barnas et al., 1992; Brickley and Shepherd, 1995; Rivara et al., 1992; Soderstrom et al., 1997; Spain et al., 1997; Tabares and Peck, 1997). Finally, there is an extensive body of literature on the association of substance abuse and adolescent suicidal behavior. Li et al. (1997a) used data from the National Pediatric Trauma Registry for children younger than age 15 admitted from 1988 to 1996 and identified self-inflicted injuries by firearms, hanging, and jumping from heights. Toxicological tests were conducted at the time of admission on 40 of the patients, of whom 8 were positive for alcohol or other illicit drugs; 29% had preexisting mental disorders such as conduct disorder or depression. Crumley (1990) reviewed the literature on adolescent suicidal behavior and concluded that the increased adolescent suicidal behavior was significantly related to increased incidence of psychoactive substance use. Some of the studies he referred to showed associations as high as 35% to 40% of adolescent suicide attempters having positive blood alcohol determinations. Problems Within the Family

Children growing up in chaotic and disorganized families are at higher risk for injury (Cicchetti and Lynch, 1993). Maltreatment includes physical abuse, sexual abuse including rape, and neglect. Each may result in physical injuries and disability. Disability may be physical, psychological, or both. Neglect accounts for more injuries and deaths than does physical abuse, and the filings for both steadily increased from “660,000 in 1976 to 3.0 million in 1995” of which “36% (1.0 million) were ‘substantiated’” (Johnson, 2000). Once injury occurs, attachment patterns developed in chaotic and disorganized families may lead to difficulty regulating affect, self-blame, and lack of trust in others. Such families may be lacking in the capacity to assist the child in the physical and psychological recovery from injury. The true incidence of fatalities is thought to be higher than the recorded 1,200 to 1,500 cases per year, with estimates ranging from 2,000 to 5,000 per year (Jellinek et al., 1990; Murphy et al., 1991). Studies now address specific populations with different types of neglect or abuse. A usually less severe, but common area of concern is children in the 1- to 5-year age range who are at risk of burn injuries, mainly from nonabusive small scalds. Injuries due to neglect or abuse range from 5.9% to 26% of pediatric burn admissions (Renz and Sherman, 1993; Yeoh et al., 1994), but no psychiatric studies have focused on this subgroup of young burned children. A different, but also important, area is child mal1134

treatment in family foster care, where neglect and abuse occur in a significant minority of placements (Zuravin et al., 1993). Another area where physical injuries can occur is sexual abuse, and these range from evidence of assault on the genitals or on other parts of the body, infection, and in a few cases pregnancy. Physical injury is a severe additional compounding complication of rape (Holmes and Slap, 1998; Parrish et al., 1997). The study of sudden infant death syndrome has differentiated this from fatal child abuse, with the number of infant deaths due to fatal infant abuse probably exceeding 1 in 10 cases of unexplained, unexpected deaths (Reece, 1994). Family chaos and disruption is a major factor in these and other types of injury, and interventions addressing familial risk factors may reduce the risk of injury to children. Problems Within the Community or Society

Injuries sustained in disasters or war may lead to more pervasive psychiatric responses due to their inevitable and ongoing disruption of the child’s social environment. Children growing up in poverty have ongoing and sustained disruptions of their social environments. Children injured in such situations of extreme environmental disruption may not have access to appropriate medical attention or have sufficient attention and care from parents and guardians who themselves may be injured, overwhelmed, or dead (Blakeney et al., 1993). Alternatively, the community can often support the injured child, even in the face of devastating loss. Early studies of communities in disaster found lower levels of PTSD and suggested that the shared experience allowed individuals to seek and obtain community support. Parental or other adult participation in a child’s emotional recovery from physical trauma can alleviate the more serious aspects of PTSD, and adults can model for the child with accurate explanations, appropriate responses to trauma rather than silence, and the need to be goal-directed in recovery (Green et al., 1991). Although children are injured during disasters and war (Emergency Services and Disasters Relief Branch, DHHS, 1995), studies of psychiatric sequelae of these events have generally not assessed physical injury. It is clear that children who have been injured in disasters such as earthquakes (Goenjian et al., 1995), hurricanes, bus or train or boat crashes, airplane crashes, bombings, or other major disasters have sustained complex psychological stress in addition to the physical injuries. In natural disasters, children’s reactions relate, in addition to any injuries, to the severity of the disaster, degree of home damage, and displacement (Lonigan et al., 1994). J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

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Injuries to children as a result of war probably number in the tens of thousands, and some years in the hundreds of thousands, but the exact numbers are not known. It is beyond the scope of this review to detail the research literature regarding injuries related to war in children. It is clear, however, that injuries related to war are tragically common worldwide and related to major societal disruption and consequential psychiatric morbidity (Aboutanos and Baker, 1997; Crossette, 1998; Eisenberg, 1998; Executive Director, UNICEF, 1996; Ladd and Cairns, 1996; Laor et al., 2001; Toole et al., 1993). ASSESSMENT AND TREATMENT

The assessment and treatment of the injured child proceeds from the aforementioned discussion. We believe it is useful to make two general distinctions in the approach to the injured child: (1) whether the time course is acute or chronic, and (2) whether the injury is simple or complex. Acute Phase

Clinical research, while limited, is strongest for children in the acute phase of postinjury treatment. Acute symptoms taper as pain lessens and the injury heals (Krane and Heller, 1995; Saxe et al., 1998). An essential approach to diagnosis is to elicit the narrative review of the trauma, recognizing the stage of postinjury adaptation. Children aged 2 to 12 years are able to recall details of stressful events following injury (Peterson and Bell, 1996). The narrative of the injury is obtained from the child if possible, with his or her description of associated memories, feelings, and thoughts, including the presence of distortions, recurrent themes, and omen formation, and rarely including hallucinations or night terrors (Terr, 1991). The assessment can support the child’s adaptation to an injury, in which he or she usually had little control. It may lessen fears of death and dismemberment, shame or guilt, and provide hope, initiating a therapeutic relationship. Physiological changes in response to injury and treatment are mirrored by changes in neurobiology and mental status, with the emergence of pain, adjustment disorders, sleep disorders, delirium, depression, and ASD (Stoddard, in press). With current treatments, the child’s body may heal rapidly after injury, but the emerging research base on burns, which is the most extensive on injuries, indicates that emotional recovery is slower but, for most children, apparently successful (Blakeney and Meyer, 1996; Sheridan et al., 2000b). J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

In addition to current symptoms, assessment includes the child’s developmental history and preexisting psychopathology. Children injured in the context of a suicide attempt, inattention or impulsive behavior, or substance abuse may have a more complicated course of recovery and more comorbid responses. Assessment requires an understanding of other contextual factors such as child abuse, neglect, or family disorganization. Environments in which there is parental mental illness or substance abuse, economic hardship, or societal upheaval such as disaster or war may have great difficulty helping the child recover after injury. Injury Assessment. The child and adolescent psychiatrist assesses injury severity in planning interventions related to pain, risk of death or disability, and effect on body image. For major trauma, there are various physical scoring methods for adults and children that rate such areas as the severity and anatomy of the injury, resulting functional disability, and degree of cosmetic disfigurement (Lund and Browder, 1944; Pollack et al., 1996). For example, the Injury Severity Score (ISS) is a well-validated index of the severity of the traumatic injury. This score is used internationally by trauma surgeons and other medical staff to rate the severity of injury. The ISS is related to the likelihood of survival after injury. The ISS is determined through rating the severity of injury on a 5-point scale in each body area injured (head or neck, face, chest, abdominal or pelvic contents, extremities or pelvic girdle, and general). The 5-point scale ranges from 1 (minor injury) to 5 (critical injury). The ISS is derived from the sum of the squares of the three most severe injuries (for multiply traumatized patients) (Baker et al., 1974). For severe burn injuries, the standard scoring is by percentage of the total body surface area burned, specifying anatomic locations on a human figure chart front and back and including delineation of specific areas of facial burns and burns to genital, perianal, and other areas. Generally children with high ISSs, if conscious, require interventions for pain, fear, and preparation for major surgery while those with low scores require pain relief and support in adapting to injury to a specific location, e.g., face, back, hand, etc. Pain Assessment and Management. Pain management is critical in the acute phase following injury and will diminish the impact of the traumatic event. For injured children who must experience ongoing painful medical procedures (e.g., dressing changes in burned children), pain management is particularly important (Stoddard et al., in press). The first psychiatric intervention in the acute 1135

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phase following injury is pain management, which lessens confusion, fear, anxiety, and suffering. There are multiple steps in the assessment and monitoring of pain. Most injury pain is acute and transient, but is long remembered. Research is clarifying the metabolic, genetic, and neural pathways controlling endogenous opioids, and, in turn, pediatric pain (Hyman and Nestler, 1996; Schechter, 1997). Preempting the memory of pain offers a way to prevent possible neurophysiological damage such as reduced hippocampal size and amygdala-modulated fear conditioning (Carr, 1998; Sapolsky, 2000; Wintgens et al., 1997). Consistent with this idea, we have recently found that the higher the dose of morphine a burned child receives while in the hospital, the more significantly is PTSD attenuated over 6 months (Saxe et al., 2001). A few patients develop PTSD requiring treatment from awareness while under neuromuscular blockade (NMB) and on mechanical ventilation (Stoddard and Todres, 2001). The problem was highlighted by Loper et al. (1989), who found it to be a common misconception by staff that NMB is a painless state. They advocated for appropriate analgesia and anxiolytics for those paralyzed with NMB. Many severely injured children are treated with NMB, but a study of 20 children aged 1 through 15 years concluded that the benefits in reduced oxygen consumption and energy expenditure were small (Vernon and Witte, 2000). In most burn centers, for children on NMB, estimates for maximum analgesic requirement for body weight are made and administered. The level of sedation is increasingly monitored with bispectral EEG assessment to ensure adequate sedation (Johansen and Sebel, 2000). In the rare instances in which a patient has recall after NMB or after surgery, validation of his or her accurate memories may relieve milder symptoms (Aitkenhead, 1990). Since “some studies suggest that patients may be affected by intraoperative sensory input without postoperative recall, surgical teams that conduct themselves as if patients are aware of their actions at all times probably maximize the potential for good operative outcomes” (Peden, 2000, p. 992). Melzack and Wall (1965) introduced the gate control theory, clarifying that pain is a multidimensional, subjective, uniquely personal experience, with physiological, affective, cognitive, behavioral, and sociocultural dimensions. Consequently, treatment of an injured child’s pain requires clinical assessment of these dimensions. Assessment starts with differentiating types of pain by anatomic location (Table 1), nerve pathways, effects of CNS injury, 1136

and the type of tissue damage. The types of pain include acute pain of the injury, continuing injury pain not fully relieved (e.g., amputation site), pain related to medical devices (intravenous line, chest tube), procedural pain (e.g., bone marrow aspiration; Stuber et al., 1998), repeated procedural pain (e.g., venipuncture, burn dressings, physical therapy), and chronic pain. Assessing pain is a process involving history taking and clinical observations. Measuring pain is quantitative, with various scales and structured ratings, using behavioral and physiological measures for infants and ventilated patients, with the addition of self-ratings for older children. An important area is developmentally appropriate pain ratings, especially self-ratings, for instance using a Visual Analogue Scale (Matthews et al., 1993). Pain management involves both psychological and pharmacological treatment. Preparation for procedures, patient participation, cognitive therapies, relaxation, and hypnosis have essential therapeutic roles in reducing pain (Leith and Weisman, 1997). Children’s concepts of pain follow developmental progression from simpler and less precise, to a more complex and accurate understanding. Parents participate in pain relief and help by explaining their child’s temperament and usual response to pain. Among the exciting directions of this research are recognition of undertreatment of pain and Joint Commission on Accreditation of Healthcare Organizations and federal insistence on better pain management (American Pain Society Quality of Care Committee, 1995; US Department of Health and Human Services, 1992). For acutely burned children, for instance, pain management from acutely ventilated through rehabilitative stages postburn may be guided by protocols (Sheridan et al., 2000a; Stoddard, in press). EMLA威 (lidocaine and prilocaine) cream, nonsteroidal anti-inflammatory drugs, oral morphine, midazolam, propofol, patient-controlled analgesia, and methods such as regional analgesia make it feasible to relieve brief episodes of pain, as well as chronic pain. Prescribing practices have changed, with the use of far higher dosages and more prescriptions for analgesics after procedures such as burns, traumatic amputations, and other surgeries (Schechter, 1997). Increased responsiveness to the needs of children for adequate analgesia reduces postoperative morbidity (Anand et al., 1997) and pain-related distress and enhances their locus of control over aversive procedures such as wound dressing changes. This reduces memories of uncontrollable pain, contributing to improved outJ . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

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comes, and makes shorter lengths of hospital stay feasible (Kavanaugh et al., 1991; Saxe et al., 2001). New methods, agents, and protocols are revolutionizing pain management. Opiates and short-acting benzodiazepines are the agents of choice to relieve severe pain and anxiety for injured children of all ages, and the literature supporting and detailing different agents, methods of administration, and effectiveness is extensive (Stoddard et al., 1997). Adjuvant medications enhancing analgesia may include stimulants, tricyclic antidepressants, and anticonvulsants. Evaluating treatment is facilitated by serial pain ratings and is key to effective protocols. The adverse effects of inadequately controlled pain include regression, stress, depression, and disability. Despite concerns, new addiction to opiates or benzodiazepines is very rare, although physiological dependence may occur. Monitoring for medication side effects, toxicity, and complications is essential. Brief Consultation and Crisis Intervention. Brief consultation and crisis intervention are integral to the psychiatric care of injured children in treatment in medical-surgical settings. These use some of the interviewing techniques outlined above, particularly obtaining the child’s narrative review of the trauma experience initially (Terr, 1991). While exclusive focus on procedures and avoidance of the emotional consequences of the injury may necessarily occur, this is balanced with the benefit of obtaining the narrative, aiding recovery, and initiating rehabilitation. Brief psychotherapy combines psychodynamic psychotherapy and cognitive-behavioral therapy (CBT) specifically oriented to pain (Berde and Masek, 1999), the injury, assisting coping with surgery and other medical care, grieving losses, and positive adaptation to disfigurement or disability. CBT has not been formally studied to our knowledge with injured children, but the principles of CBT for PTSD such as anxiety management, exposure-based interventions, coping with anger, and cognitive restructuring form the core of CBT with injured children with PTSD (March et al., 1998), as well as those with facial disfigurement (Robinson et al., 1996). For depressive disorders, however, the limited evidence suggests nonspecificity of response to different types of psychotherapy. Group therapy been little studied, but is used in play therapy groups and adolescent groups. Essential family interventions, usually with parents, include crisis intervention and grief counseling adapted to the family’s values and characteristics and supportive group therapy (Kaslow et al., 1994). J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

Psychopharmacology. There are few empirical studies of the efficacy of the initiation of psychotropic drugs following injury. Furthermore, the continuation of psychotropic medications that the child takes prior to the injury (e.g., stimulants, mood stabilizers, or antidepressants) may complicate care, but so may their discontinuation. Neurotransmitter functioning and pharmacokinetics are especially important, including drug absorption, distribution, metabolism, and excretion. Drug selection and administration must take into account off-label prescribing for many agents, as well as drug interactions. Side effects and toxic effects may limit use with injured children including opiate-induced respiratory depression, benzodiazepineinduced sedation or disinhibition, and withdrawal syndromes. Haloperidol may have a place in the treatment of acute delirium (Brown et al., 1996), especially for older children, although short-acting benzodiazepines may make it less necessary. Lithium carbonate and tricyclics are usually contraindicated acutely because of the risk of lithium intoxication and cardiovascular instability. However, targeted treatment may rapidly relieve an agitated delirium, panic, insomnia, acute stress, hyperactivity/ aggressiveness, major depression, or mania. Propranolol was shown to reduce PTSD arousal symptoms in survivors of sexual abuse (Famularo et al., 1988). Robert et al. (1999) studied severely burned children aged 2 to 17 years; they compared imipramine in 12 children to chloral hydrate in 13 children to treat ASD and found imipramine to be effective for 10 of the 12. Close monitoring for cardiovascular side effects or toxicity is advised. Nonacute Phase

There is less psychiatric and psychological research specific to injuries beyond the acute postinjury phase. As a result, some of what follows is not specific to injured children, for whom such research is needed. After a child’s acute hospitalization following injury, the transition can be fraught with difficulties. Children face family and friends and are repeatedly asked questions about the nature of the injury, and they must adjust to permanent changes in bodily function or appearance. They may face great uncertainty about their prognosis or need for further surgery or rehabilitative intervention. It is important to assess any difficulties in transition to the community and to offer reentry support to the child, family, and school. There is risk for anxiety disorders, depression, PTSD, and exacerbation of preexisting psychopathology. Diagnosis of treatable disorders occurs during medical treatment, and although no studies were found with injured patients, 1137

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maintenance psychopharmacological treatment is frequently indicated with the full range of anxiolytics, stimulants, antidepressants, mood stabilizers, or antipsychotics, and other agents singly or in combination (Famularo et al., 1988; Foa et al., 2000; Harmon and Riggs, 1996; Hughes et al., 1999). Changes in response to treatment failure, including discontinuation, must be coordinated with overall medical-surgical care. When children are readmitted, medication for preoperative or procedural anxiety or specific disorders often assists care. Children with complex injuries are at increased risk. Preexisting psychopathology requires aggressive treatment, as do any posttraumatic symptoms consequent to the injury. Children with self-inflicted injuries require psychotherapy to help manage feelings, such as guilt, related to how they have inflicted bodily damage that may have life-long consequences. Children whose injuries were related to child abuse or neglect may need help adjusting to out-of-home placements simultaneous to their adjustment to the injury. Family support is indispensable during the adjustment following injury, and family therapy is often helpful when injuries occur in the context of family stress and disorganization (Kaslow et al., 1994). Parents and guardians may be having their own difficulties coping, including PTSD (Rizzone et al., 1994). Therefore, psychiatric intervention to help stabilize families at risk, either through family therapy or parent’s individual treatment, is instrumental in helping the child. For children with PTSD, a number of empirically validated psychotherapy models have been developed. March and his colleagues (1998) evaluated the efficacy of a group-administered CBT protocol for a single-incident stressor. Their 18-week protocol delivered in a peer group format within the school setting, with individual “pullout” sessions that dealt with issues particular to each participant’s traumatic experience. They found that children and adolescents treated with CBT showed significant improvement on all main dependent measures and that these findings, which were both clinically and statistically significant, persisted for the duration of the study. Goenjian et al. (1997) evaluated the efficacy of a brief trauma/grief-focused psychotherapy among early adolescents exposed to the 1988 Armenian earthquake. They found that adolescents who received psychotherapy displayed significant improvements in intrusion, avoidance, and arousal symptoms of PTSD. Deblinger et al. (1990) examined the efficacy of a cognitive-behavioral treatment program for sexually abused children with PTSD. The 1138

results of this study revealed significant improvements across all PTSD subcategories, externalizing and internalizing behaviors, anxiety, and depression. All of these treatments have demonstrated efficacy for PTSD in children, but they have not been specifically tested for children who have experienced injuries. In the context of PTSD related to injury, it is therefore difficult to make recommendations regarding these three empirically validated treatments. All three appear to explicitly utilize cognitive-behavioral principles. The March et al. model is designed for single-incident stressors and so may be quite effective for PTSD related to “simple” injuries but is not designed for our categorization of “complex” injury. The Goenjian et al. model is more focused on grieving and loss, related to traumatic events. This model may be quite effective for an injured child who has lost a loved one as a consequence of the injury and also for an injured child who is grieving the loss of functioning or appearance of his or her body. The Deblinger et al. model is explicitly designed for children who have experienced sexual abuse. Its focus on the interpersonal nature of the trauma and the guilt and shame related to abuse suggests it can be very effective for children whose injury is related to sexual trauma and can probably be adapted to the injured child whose PTSD is related to physical abuse. Again, these recommendations must be interpreted with consideration that none of these treatments were explicitly studied with injured children. The psychotherapeutic treatment of PTSD and other disorders after injury is beginning to be studied in young children. While the symptoms of PTSD in young children are not fully established, significant progress has occurred (Scheeringa et al., 2001; Terr, 1988). They are reported to include reexperiencing of the injury demonstrated in posttraumatic play, distortions, nightmares, numbing of responsiveness, constriction of play, regressive loss or delay in acquisition of such skills as language or toilet training, increased arousal including night terrors and exaggerated startle response, and new fears (such as fear of the dark or separation anxiety) or new aggression. Children may also develop attachment disorders after injury. Recent studies of young burned children support these findings (Gorga et al., 1999; Meyer et al., 1999). Assessment and Treatment of Special Populations

While burned children are the subjects of ongoing studies, there is need for expansion of research to other types of injuries. A very common group, not covered in J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

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most research, are children with orthopedic injuries (Stancin et al., 2001). Most other populations that follow merit research specific to their injury, but conducted more broadly than the few centers whose studies are reported below. The Severely Burned Child. Children with severe burns present many specialized issues, beginning with the threat to survival, pain, and massive familial stress. The child with severe facial and other burns risks loss of identity, social stigmatization, and loss of attractiveness and physical competence. In specialized centers, these children commonly survive even massive burns and, with focused rehabilitation, including reconstructive surgery, psychiatric care, and broad support, are able to resume development and lead productive lives (Sheridan et al., 2000b; Stoddard, in press). Social skills training for cognitively coping with stigma and learning to manage teasing and other reactions to facial disfigurement holds promise for wider use (Robinson et al., 1996). The Child With a Genital Injury. Children with genital injuries are at risk for enuresis, encopresis, anxiety, depression, sexual or reproductive dysfunction, and body image problems. Accurate assessment requires great sensitivity, and children with genital injuries may require medical care in addition to counseling about the injury and possible emotional sequelae. Holmes and Slap (1998) advise assessment of boys within 3 days to confirm abuse; they found many boys with urogenital symptoms, including sexually transmitted diseases. Burns frequently cause genital injuries, which usually heal, with return of normal urinary function, relieving worry about appearance and sexual functioning. This is not true of less common, severe injuries which can require extensive surgery or be disabling and which require ongoing emotional support. Genital injuries to girls are difficult to assess because they may be out of sight, and children may ignore them (Pokorny, 1997). If untreated they could progress, because of unrecognized bleeding, to death within a period of hours. Infants are often abused. While it is extremely important not to retraumatize a child, the site of the possible injury needs to be examined, preferably under anesthesia. Wounds attributed to accidents are sometimes caused by sexual assaults, and vice versa. In the past 10 years, there has been more precise anatomic recording of genital and anal injuries, clinical recognition of emotional sequelae, and referral for psychiatric assessment and treatment. The Child Requiring Limb Amputation. The psychiatrist can play a role in preparation for limb and other amputations, when possible, and in treating pain, depresJ . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

sion, and PTSD, together with postoperative support in grieving the loss. In the United States, pediatric amputations may be necessary because of cancer, after trauma such as burns, or for congenital malformations (Gallagher and Verma, 2000); internationally, land mines are an additional cause. Common problems are denial and grief; depression; stress disorders; phantom limb pain, which is a disorder of body image; and causalgia, which is a postinjury neuropathic pain syndrome with major nerve trauma, often at the stump site. Phantom limb phenomena, which are reported by nearly all patients asked about them, are a “normal” consequence of amputation (Krane and Heller, 1995). They include continued sensation or pain as if the limb were present and may persist throughout life (Stoddard et al., 2000). Examples are the mental perception of an arm swinging when the person is walking or a leg straightening when the person stands. Phantom limb pain is characterized by “cramping, squeezing, lancinating, ‘electrical’ or burning sensations, by aberrant proprioception, or by a sensation of postural displacement in a nonexistent extremity” (Gallagher and Verma, 2000). It may greatly interfere with daily activities. The studies cited below reported that cancer, preamputation limb pain, and chemotherapy are associated with increased phantom limb pain. Smith and Thompson (1995) found phantom limb pain in 48% of 67 children with cancer but only 12% (1) of 8 trauma victims. Krane and Heller (1995) found phantom sensations in all 24 children; preoperative pain in 9 of 10 in the cancer group, 6 of 12 in the trauma/infection group, and 0 of 2 in the congenital deformity group; and phantom pain in 9 of 10 in the cancer group, 10 of 12 in the trauma/infection group, and 1 of 2 in the congenital deformity group. There has been little treatment research with children with amputations. Stump site pain often responds to nonsteroidal anti-inflammatory drugs and opiates. Thomas et al. (2000) identified 228 children with amputations resulting from burns to digits or limbs, of which 35 involved limbs, and highlighted the importance of differentiating pain at the amputation site from phantom limb pain. For phantom limb pain, adult studies suggest that tricyclic antidepressants, anticonvulsants, many other analgesics, and perhaps “preemptive” regional analgesia can be useful (Gallagher and Verma, 2000). Psychotherapeutically for the young child, “nonverbal and metaphorical ‘safe’ alternatives via play modalities,” such as dolls and drawing (Billig and Weaver, 1996), “and active facilitation of coping skills are useful clinical tools 1139

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to impart information, decrease anxiety and enhance mastery” (Atalar and Carter, 1992, p. 128). Varni et al. (1991) assessed children with limb amputations and congenital limb loss and found that 19% of children were at risk for depression and that social support from classmates predicted self-esteem. They found that essential interventions are education regarding the medical options and the usual course of recovery, provision of choice of prosthesis, and supportive psychotherapy. The Child With a Spinal Cord Injury. Several studies have examined people injured as children compared with those injured as adults and found no differences related to age at injury in depression, self-esteem, and self-perception (Kennedy et al., 1995). Psychiatric problems include chronic pain, depression, and psychosomatic disturbances. Suicide is two to six times more prevalent than in the general population and correlates with preexisting psychiatric risk factors such as alcohol abuse and depression (Charlifue and Gerhart, 1991). Passive suicidal behavior is a risk factor as well, as are problems with diagnosis and treatment of depression, substance abuse, psychosis, and sexual functioning (Stewart, 1997). Dewis (1989) highlighted thwarting of normal adolescent/young adult development and noted that patients felt “less normal,” being profoundly concerned about lack of privacy, the loss of bowel control, and the loss of muscle leading to a “quad belly,” “shrunken legs,” hair styles, and their inability to perform their own grooming and hygiene. The Child Dying After Injury, and His or Her Family. Death may be sudden in the community or in the hospital, or it may be protracted. End-of-life care should be integrated from the beginning of treatment (Field and Cassel, 1997; Schnitzer et al., 2000; Todres et al., 1998), but a child’s death often occurs with community caretakers or night emergency staff. A sudden death from an injury is one of the most stressful experiences which relatives or staff can endure. The responses before and after death combine grief and an acute traumatic response, or traumatic grief. Those caring for the child and family may have little experience with death of a child, may overidentify with the family, and may be traumatized secondarily themselves (Jellinek et al., 1993). Breaking “bad news” is especially difficult and is more effective when the news is conveyed privately, gradually, and quietly, with a summary toward the end (Ptacek and Eberhardt, 1996). If the child is conscious before death, to the extent that the parents wish, there is time for the child to learn in developmentally appropriate communications, optimally from a 1140

family member, about the injury and that death is possible or probable. It is crucial to listen to the family, as well as be direct, honest, and supportive. The support of a psychiatrist who is able to empathize with how painful this must be is helpful to the family and to staff. Follow-up appointments are essential, as indicated by a study of 42 grieving parents which found that they were isolated and that community support was not adequate (Dent et al., 1996). Special training of acute care staff may assist with their responses to the death of a child and may reduce pathological grief, depression, or PTSD, which occurred in 35% of parents and 45% of siblings of children who died from trauma or murder (Applebaum and Burns, 1991). Although no pediatric studies were identified, one controversial issue concerns offering family members the option to be in the resuscitation room with a consistent family care provider, which at least one pilot study found to lessen stress and grief (Robinson et al., 1998); a sampling of surgeons and emergency nurses revealed more physicians opposed to this than nurses (Helmer et al., 2000), but there is a trend toward acceptance of witnessed resuscitation as good practice because of positive benefits for relatives (Rattrie, 2000). Another issue concerning care of the family is the humane presentation of the option to donate tissue or organs after a child’s death. To prevent conflict of interest, the psychiatrist should support the physician in doing what is best for the child; questions regarding potential organ donation should be referred to a trained organ procurement or transplant team (Schnitzer et al., 2000). STAFF TRAINING AND EDUCATION

Staff caring for injured children are under significant stress from the scene of the injury, at the time of a death, through rehabilitative care. The stress of critical care for trauma cases affects emergency physicians, several surgical specialties, nursing, pediatrics, social work, psychology, rehabilitation, psychiatry, and all staff members. In certain settings such as those with many critically ill patients or deaths, or with inadequate staffing, there is risk of demoralization, “burnout,” and high staff turnover (Danieli, 1996; Ursano et al., 1996), but also the opportunity to enhance coping, improve care, and increase job satisfaction (Wright et al., 1992). The ability of staff to manage the unique challenges of traumatized children is strengthened by their awareness of the following: the degree of the child’s developmental regression; patient behaviors which evoke staff anger; one’s own feelings of J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

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disgust, such as on smelling a foul odor; revulsion, as when viewing a raw wound; possible overidentification, for instance, when an injured child resembles one’s own; and awareness of one’s sense of vulnerability (Gunther, 1994). Such awareness enhances the capacity to hear the patient’s story, express empathy, treat pain, and relieve suffering. Physicians overburdened on critical care units may risk potential preoccupation with other activities, wishes to avoid the unit, inflexibility, aggression, and diminished clinical judgment (Jellinek et al., 1993; Walker, 1982). The psychiatrist, as an integrated member of the team, has a particularly important role to play in such affect-laden contexts. The psychiatrist can help facilitate the definition of roles of each member of the team and work with the team to foster open and active communication. Clear role definition and communication between members of the team are critically important for reducing conflict and stress among team members and for enhancing the acute care of injured or dying children and family satisfaction with care (Briggs, 1997). Research is beginning to focus on methods of staff training, prospectively addressing staff needs, setting quality improvement monitors, providing access to help when needed, and identifying and responding to particular unit stressors. Changes associated with managed care, such as downsizing, can be stressors. Planned rather than abrupt organizational change is important for those working in acute care. This review identified a serious lack of formal research in this area. CONCLUSIONS

Injuries in children are no longer a neglected disease of modern society, as progress has occurred in epidemiology, prevention, pain management, medical treatment, psychopharmacological treatment, and outcome assessment. Nevertheless, the psychiatric sequelae contribute to morbidity and mortality. While there has been progress in epidemiology and injury prevention, psychiatric assessment, crisis intervention, treatment of mental disorders, and family treatment are neglected clinical and research priorities. It is important that this not continue. Studies support the need to initiate treatment of pain, delirium, acute and posttraumatic stress, and depression, and of preexisting conditions such as maltreatment, substance abuse, and disruptive behavior disorders. Essential treatment includes individualized assessments, preventive interventions, and planned psychotherapeutic, psychopharmacological, and multimodal treatments related to J . A M . AC A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 0 : 10 , O C TO B E R 2 0 0 1

the injury, preexisting comorbidity, and the sequelae of the injury. There are subgroups at very high psychiatric risk including those injured because of substance abuse, violence, or suicide attempt; those with catastrophic injuries; and those injured in disasters and war. Collaboration with emergency teams, pediatricians, surgeons, and trauma and rehabilitation teams enhances the effective allocation of psychiatric and general medical resources. FUTURE DIRECTIONS FOR RESEARCH

A critical reading of this research literature reveals wide variation in the quantity and quality of injury research. One of the strongest areas is epidemiology of childhood injuries. Nevertheless, this review identified serious gaps in research knowledge even there. While demographic data on fatalities are comprehensive nationally, this is not true for injuries, which makes it more difficult to establish priorities for psychiatric research and treatment. Epidemiological data are strongest for children requiring hospitalization, a fraction of the total population of injured children. Despite substantial costs for care, psychiatric epidemiological data are nearly absent except for a few, relatively small studies, even for injuries secondary to psychiatric disorders, such as those due to suicide attempt or substance abuse. Future research should gather comprehensive data, including psychiatric epidemiology, to assist in the allocation of limited preventive and psychiatric treatment resources. Future research also might include large prospective studies to examine which children are injured, why, and what assists their emotional recovery and reduces future risks for mental disorders. Another strong area is research on acute pain and painassociated anxiety. Research on and treatment of pain in infancy have progressed greatly from no knowledge at all, but there remains a need for detailed study of the early phases of child development. For all of childhood, while pharmacological research is productively expanding with new agents appearing and being evaluated, there is a comparative lack of psychological studies, even in areas of identified importance such as preparation for procedures, psychological methods of pain and anxiety control, the role of play in coping, and emotional recovery after severe pain. There has so far been little study of the reciprocal relationship between pain and comorbid mental disorders. On the research horizon are imaging studies which may longitudinally clarify the CNS neurobiology of injury, pain, pain-associated anxiety, rehabilitation, and recovery. Burned children have been subjects of more child psychiatric and psychological research studies than any 1141

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other population, in part because of dramatic improvements in care and survival, and significantly because much of their care is inpatient. Despite progress, there remain unanswered questions regarding rates and types of mental disorder, coping with disfigurement, optimal psychotherapeutic and psychopharmacological treatments, and long-term outcomes. Other injured children have rarely been the subject of formal psychiatric or psychological research. Despite the focus in this review on PTSD, there are only a few studies of injured children, and none on PTSD treatment. There are fewer studies examining other relevant disorders such as delirium, phobias, depression, substance abuse, learning disabilities, ADHD, and conduct disorder. There are almost no studies of psychotherapy, few of psychopharmacological treatment, and none of multisystemic therapy for injured children. Specific subpopulations of children and adolescents merit focused assessment and treatment research: those injured because of neglect or abuse; amputees; those with eye, face, hand, or genital injuries; those with spinal cord injuries; those injured because of violence or suicide attempts; and those injured in juvenile detention or prison. An emerging area for research is care of the child who is dying from injuries and of the family after the death. Death due to injury may be rapid, or slow, but optimal methods for breaking bad news, supporting and involving survivors before and at the time of death, and assuaging traumatic grief are only beginning to be formally studied. This research direction has world-wide relevance, since many more children die of injuries outside than inside the United States. Research on staff training and staff education in the care of injured children is minimal. It is time to evaluate different systems of managed care, administration, staff training, and support in emergency and critical care settings to determine which lead to better acute patient care, assist staff in managing their own stress, and lead to better patient, family, and staff outcomes. REFERENCES Aboutanos MB, Baker SP (1997), Wartime civilian injuries: epidemiology and intervention strategies. J Trauma 43:719–726 Aitkenhead AR (1990), Awareness during anesthesia: what should the patient be told? Anesthesia 45:351–352 American Pain Society Quality of Care Committee (1995), Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA 274:1874–1880 American Psychiatric Association (2000), Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Association

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