The Course of Posttraumatic Stress in Children: Examination of Symptom Trajectories and Predictive Factors Following Admission to Pediatric Intensive Care*

Abstract

Objectives: This study investigated trauma symptom trajectories of children 2–16 years old following admission to pediatric intensive care and identified factors that predicted a child’s trauma symptom trajectory. Design: Prospective longitudinal design. Setting: Two tertiary care PICUs in Brisbane, Qld, Australia. Patients: Children 2–16 years old admitted to PICU for longer than 8 hours. Measurements Main Results: Maternal reported child posttraumatic stress symptoms (n = 272) on the Trauma Symptom Checklist for Young Children were used to assess posttraumatic stress symptoms up to 12 months post admission. Semiparametric group-based trajectory analyses were completed to identify patterns over time. Age, gender, length of stay, premorbid functioning, maternal perceived threat to life, and maternal acute distress were assessed as potential risk factors. Three likely trajectory groups were identified. The majority of children were resilient (83.8%); however, a significant minority experienced chronic symptoms (12.9%) or elevated stress symptoms which resolved quickly (3.3%). After controlling for other variables, maternal report of premorbid internalizing behavior significantly predicted both chronic (odds ratio, 6.3) and recovery (odds ratio, 38.0) trajectories. Maternal acute distress significantly predicted child chronic symptom trajectories (odds ratio, 5.2). Conclusions: Children with elevated trauma symptoms postintensive care need timely and effective intervention. The majority of children with high levels of acute symptoms will continue to have chronic, ongoing posttraumatic stress symptoms. In addition, acute maternal distress and preexisting internalizing child behavior predict ongoing psychologic distress after discharge from the PICU. Screening in the acute period post-PICU admission may identify children likely to experience ongoing chronic posttraumatic distress symptoms and enable targeted treatment of children at risk. This is the first study to examine symptom trajectories in children following pediatric intensive care admission and includes a sample of very young children.

Transitions from short to long-term outcomes in pediatric critical care: considerations for clinical practice

“…However, several child factors have been identified that contribute to poorer outcome. Le Brocque et al found that child internalizing behaviors (e.g., shy, withdrawn, prefers to be alone) were a risk factor for the development of elevated post-PICU post-traumatic stress symptoms (PTSS), in particular membership to the chronic PTSS trajectory (6). Similar to other cohorts [e.g., congenital heart disease (CHD)], the presence of premorbid impairment and chronic co-morbidities are more prevalent in the PICU cohort and subsequently make them more susceptible to the impact of critical illness on development and behavior (7,(43)(44)(45)(46)(47)(48).…”

“…It is proposed that social disadvantage may expose children to poor health prevention strategies, delays in recognition of deterioration, limited access to healthcare, and less support for their recovery and development post PICU (74,75). Maternal acute distress significantly predicts child PTSS, particularly chronic symptom trajectories that extend beyond 12 months post PICU (6). Additionally, Judge et al reported that maternal PTSS levels were correlated with child behaviour up to 12 months post PICU admission (76).…”

“…Declining mortality rates have led to a new health care need: an increasing number of children who have survived pediatric critical illness but with incomplete functional and neurodevelopmental recovery. Many studies report that PICU survivors experience from a broad range of physical (2,3), cognitive (4)(5)(6), emotional (7,8), and social problems (9) along with adverse healthrelated quality of life (HRQoL) (10)(11)(12)(13)(14)(15). These adverse outcomes are unique and can be experienced both alone or in combination by children and families (16)(17)(18).…”

The early course and treatment of posttraumatic stress disorder in very young children: diagnostic prevalence and predictors in hospital‐attending children and a randomized controlled proof‐of‐concept trial of trauma‐focused cognitive therapy, for 3‐ to 8‐year‐olds

“…Study 1: DSM-5 acute stress disorder and PTSD-YC in trauma exposed young children following emergency room attendance Many young people show natural attenuation of posttraumatic stress symptoms in the months following exposure (Hiller et al, 2016;Le Brocque et al, 2020). In terms of very young children, to date, there have been a small number of longitudinal studies charting the course of PTSD symptoms and/ or of the PTSD-YC diagnosis using the alternative algorithm (e.g.…”

Post intensive care syndrome across the life course: Looking to the future of paediatric and adult critical care survivorship

“…For the paediatric ICU population survivorship outcome trajectories are largely undefined across the four health domains, with inconsistencies in the measurement and reported prevalence evident. However, at 6 months post‐ICU, 38% had fatigue and 72% experienced sleep disturbances, 4,6 and at 1 year after their PICU stay, up to 75% can have impaired health related quality of life, over half have functional morbidities, including weakness and feeding problems, 4,7 and greater than 25% have negative psychological and behavioural responses, including post‐traumatic stress disorder PTSD, symptoms of depression, fears, and anxiety 8,9 …”