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Posttraumatic stress and behavior in injured and severly ill infants and preschoolers


Graf, Anna. Posttraumatic stress and behavior in injured and severly ill infants and preschoolers. 2013, University of Zurich, Faculty of Arts.

Abstract

Abstract Objective: Infants and preschoolers comprise a large segment of paediatric patients treated for injuries and severe illness. Due to their developmental stage, infants and preschoolers are particularly prone to unintentional injuries, like burns. Furthermore, there is a peak cancer incidence in early childhood, relative to later childhood and adolescence (Schiestl, Beynon, & Balmer, 2006; Mitter, Michel, Strippoli, Rüegg, & Rebholz, 2011). Both severe injuries and cancer typically require intensive medical treatment and procedures, often followed by long and recurrent periods of hospitalization. The psychological effects of paediatric medical events on children and family members are well established for school-age children and adolescents. Scientific attention on infants and preschoolers has been limited, due to the long- held misconception that young children are not affected or will recover quickly after exposure to distressing situations (Liebermann, Chu, Van Horn, & Harris, 2011). Over the last two decades, a small number of researchers and clinicians has started to work with traumatized young children, mostly children who have witnessed domestic violence or natural disasters, or have been sexually abused (Scheeringa, Zeanah, Drell, & Larrieu, 1995). This research group eventually proposed developmentally-sensitive diagnostic criteria for posttraumatic stress disorder (PTSD), as well as an alternative diagnostic algorithm for PTSD, and facilitated research on early childhood mental health after traumatic experiences. The aim of this thesis was to examine posttraumatic stress and behavioral problems, and individual, medical and family-related predictors in infants and preschoolers with medical experiences like burn injuries and cancer. Prior to this investigation, a detailed literature review of posttraumatic stress disorder (PTSD) and its assessment in infants and preschoolers was conducted. Methods: 76 children with burn injuries and 48 children with cancer (age 8-49 months) were assessed, an average of 15 months after their medical diagnosis or injury. Mothers were used as proxy informants for the Posttraumatic Stress Disorder Semi-Structured Interview and Observational Record for Infants and Young Children in both patient groups and on the Child Behavior Checklist in burn-injured children. Parents were asked to complete questionnaires on individual and family-related characteristics, as well as their own posttraumatic stress symptoms. Medical data on the burn injury sample were retrieved from patient records, whereas medical data for the cancer sample stemmed from questionnaires filled out by attending physicians. Results: Overall, 19 children (15.3%) met the age appropriate criteria and algorithm for PTSD proposed by Scheeringa et al., including 10 children (13.2%) with burn injuries and nine children (18.8%) with cancer. However, behavior was found to be normal in young children with burns. In children with burn injuries, the number of PTSD symptoms was primarily associated with family-related variables like maternal PTSD and quality of family relationships. Higher child age at diagnosis and maternal PTSD increased the risk of full or partial PTSD in children with cancer. Conclusions: This thesis provides evidence for a substantial prevalence of PTSD in young children after severe illness or injury and medical treatment. Maternal PTSD consistently emerged as a risk factor for childhood PTSD in both patient groups. Furthermore, children of higher age at diagnosis are at special risk of developing PTSD after cancer is diagnosed. Several implications for clinical care of young pediatric patients with burns and cancer can be drawn from the studies. Paediatricians should be aware of PTSD symptoms and should take a good history for emotional and behavioral problems. In order to minimize traumatic experiences and maximize the continuity of care, it makes sense to: 1) reduce unnecessary exposure to the traumatic elements of the medical condition and its treatment as much as possible (e.g., optimize pain management); 2) increase the child’s feelings of security (e.g., by allowing parents to room-in with them, by increasing the predictability and stability of daily routines, by allowing the parent-child dyad some control over aspects of medical treatment wherever possible, and by listening to evaluate each child’s understanding of events and possible misconceptions); 3) treat parental distress or PTSD; and 4) address physical health problems as traumatic reminders in the long- term, after treatment ends (e.g., rehabilitative options). Finally, vulnerable children have to be identified as early as possible and linked with specialized mental health services. Zusammenfassung In Kinderspitälern werden verhältnismässig viele Säuglinge und Kleinkinder mit schweren Verletzungen und Krankheiten behandelt. Als objektiv und/oder subjektiv bedrohliche Ereignisse erfüllen Unfälle und lebensbedrohliche Krankheiten die Definitionskriterien für ein psychisches Trauma. Es gibt jedoch kaum Wissen dazu, wie Kinder unter dem Alter von vier Jahren solche intensive medizinische Behandlungen bewältigen. Die vorliegende Dissertation untersucht die psychische Anpassung bei brandverletzten und krebskranken Säuglingen und Kleinkindern nach intensiven medizinischen Behandlungen im Rahmen von einer Übersichtsarbeit und zwei Studien. Nach einem einleitenden Kapitel wird in einer Übersichtsarbeit die Literatur zu Traumafolgestörungen bei Säuglingen und Kleinkindern aufgearbeitet. Erstmals wird dabei die autorisierte deutsche Version des semistrukturierten Interviews zur Erfassung der posttraumatischen Belastungsstörung (PTBS) im Säuglings- und Kleinkindalter (Scheeringa & Zeanah, 2005b) vorgestellt. Der aktuelle Forschungsstand bezüglich Erfassung, Prävalenz und Therapie von PTBS im Säuglings- und Kleinkindesalter wird dargelegt und die Forschungslücken aufgezeigt. In der ersten Studie werden die Resultate einer quantitativen Untersuchung zu PTBS und Verhaltensauffälligkeiten bei brandverletzten Säuglingen und Kleinkindern vorgestellt. Insgesamt wurden 76 Kinder im Altern zwischen 12 und 49 Monaten untersucht. 13.2% der Kinder erfüllten durchschnittlich 15 Monate nach dem Verbrennungs- oder Verbrühungsunfall das Vollbild einer PTBS. Das Verhalten der Kinder war jedoch im Vergleich zu gesunden Gleichaltrigen im Normbereich. Die kindliche PTBS war assoziiert mit medizinischen Faktoren wie einem höheren Schweregrad der Verletzung, längerem Spitalaufenthalt und mehr Verbandswechsel als auch mit familiären Faktoren wie einer mütterlichen PTBS sowie der Qualität der familiären Beziehungen. In der zweiten Studie werden die Resultate einer quantitativen Untersuchung zu PTBS bei krebskranken Säuglingen und Kleinkindern vorgestellt. Die Stichprobe umfasste 48 Kinder im Alter von 8-48 Monaten. 18.8% der untersuchten Kinder zeigten durchschnittlich 15 Monate nach der Krebsdiagnose eine PTBS und 41.7% der Kinder erfüllten die Kriterien einer sogenannt partiellen PTBS. Als Risikofaktoren für eine volle und/oder partielle PTBS konnten ein höheres Alter der Kinder zum Zeitpunkt der Diagnose sowie eine mütterliche PTBS identifiziert werden. Abschliessend werden die Ergebnisse aller drei Arbeiten in einer allgemeinen Diskussion integrierend besprochen.

Abstract

Abstract Objective: Infants and preschoolers comprise a large segment of paediatric patients treated for injuries and severe illness. Due to their developmental stage, infants and preschoolers are particularly prone to unintentional injuries, like burns. Furthermore, there is a peak cancer incidence in early childhood, relative to later childhood and adolescence (Schiestl, Beynon, & Balmer, 2006; Mitter, Michel, Strippoli, Rüegg, & Rebholz, 2011). Both severe injuries and cancer typically require intensive medical treatment and procedures, often followed by long and recurrent periods of hospitalization. The psychological effects of paediatric medical events on children and family members are well established for school-age children and adolescents. Scientific attention on infants and preschoolers has been limited, due to the long- held misconception that young children are not affected or will recover quickly after exposure to distressing situations (Liebermann, Chu, Van Horn, & Harris, 2011). Over the last two decades, a small number of researchers and clinicians has started to work with traumatized young children, mostly children who have witnessed domestic violence or natural disasters, or have been sexually abused (Scheeringa, Zeanah, Drell, & Larrieu, 1995). This research group eventually proposed developmentally-sensitive diagnostic criteria for posttraumatic stress disorder (PTSD), as well as an alternative diagnostic algorithm for PTSD, and facilitated research on early childhood mental health after traumatic experiences. The aim of this thesis was to examine posttraumatic stress and behavioral problems, and individual, medical and family-related predictors in infants and preschoolers with medical experiences like burn injuries and cancer. Prior to this investigation, a detailed literature review of posttraumatic stress disorder (PTSD) and its assessment in infants and preschoolers was conducted. Methods: 76 children with burn injuries and 48 children with cancer (age 8-49 months) were assessed, an average of 15 months after their medical diagnosis or injury. Mothers were used as proxy informants for the Posttraumatic Stress Disorder Semi-Structured Interview and Observational Record for Infants and Young Children in both patient groups and on the Child Behavior Checklist in burn-injured children. Parents were asked to complete questionnaires on individual and family-related characteristics, as well as their own posttraumatic stress symptoms. Medical data on the burn injury sample were retrieved from patient records, whereas medical data for the cancer sample stemmed from questionnaires filled out by attending physicians. Results: Overall, 19 children (15.3%) met the age appropriate criteria and algorithm for PTSD proposed by Scheeringa et al., including 10 children (13.2%) with burn injuries and nine children (18.8%) with cancer. However, behavior was found to be normal in young children with burns. In children with burn injuries, the number of PTSD symptoms was primarily associated with family-related variables like maternal PTSD and quality of family relationships. Higher child age at diagnosis and maternal PTSD increased the risk of full or partial PTSD in children with cancer. Conclusions: This thesis provides evidence for a substantial prevalence of PTSD in young children after severe illness or injury and medical treatment. Maternal PTSD consistently emerged as a risk factor for childhood PTSD in both patient groups. Furthermore, children of higher age at diagnosis are at special risk of developing PTSD after cancer is diagnosed. Several implications for clinical care of young pediatric patients with burns and cancer can be drawn from the studies. Paediatricians should be aware of PTSD symptoms and should take a good history for emotional and behavioral problems. In order to minimize traumatic experiences and maximize the continuity of care, it makes sense to: 1) reduce unnecessary exposure to the traumatic elements of the medical condition and its treatment as much as possible (e.g., optimize pain management); 2) increase the child’s feelings of security (e.g., by allowing parents to room-in with them, by increasing the predictability and stability of daily routines, by allowing the parent-child dyad some control over aspects of medical treatment wherever possible, and by listening to evaluate each child’s understanding of events and possible misconceptions); 3) treat parental distress or PTSD; and 4) address physical health problems as traumatic reminders in the long- term, after treatment ends (e.g., rehabilitative options). Finally, vulnerable children have to be identified as early as possible and linked with specialized mental health services. Zusammenfassung In Kinderspitälern werden verhältnismässig viele Säuglinge und Kleinkinder mit schweren Verletzungen und Krankheiten behandelt. Als objektiv und/oder subjektiv bedrohliche Ereignisse erfüllen Unfälle und lebensbedrohliche Krankheiten die Definitionskriterien für ein psychisches Trauma. Es gibt jedoch kaum Wissen dazu, wie Kinder unter dem Alter von vier Jahren solche intensive medizinische Behandlungen bewältigen. Die vorliegende Dissertation untersucht die psychische Anpassung bei brandverletzten und krebskranken Säuglingen und Kleinkindern nach intensiven medizinischen Behandlungen im Rahmen von einer Übersichtsarbeit und zwei Studien. Nach einem einleitenden Kapitel wird in einer Übersichtsarbeit die Literatur zu Traumafolgestörungen bei Säuglingen und Kleinkindern aufgearbeitet. Erstmals wird dabei die autorisierte deutsche Version des semistrukturierten Interviews zur Erfassung der posttraumatischen Belastungsstörung (PTBS) im Säuglings- und Kleinkindalter (Scheeringa & Zeanah, 2005b) vorgestellt. Der aktuelle Forschungsstand bezüglich Erfassung, Prävalenz und Therapie von PTBS im Säuglings- und Kleinkindesalter wird dargelegt und die Forschungslücken aufgezeigt. In der ersten Studie werden die Resultate einer quantitativen Untersuchung zu PTBS und Verhaltensauffälligkeiten bei brandverletzten Säuglingen und Kleinkindern vorgestellt. Insgesamt wurden 76 Kinder im Altern zwischen 12 und 49 Monaten untersucht. 13.2% der Kinder erfüllten durchschnittlich 15 Monate nach dem Verbrennungs- oder Verbrühungsunfall das Vollbild einer PTBS. Das Verhalten der Kinder war jedoch im Vergleich zu gesunden Gleichaltrigen im Normbereich. Die kindliche PTBS war assoziiert mit medizinischen Faktoren wie einem höheren Schweregrad der Verletzung, längerem Spitalaufenthalt und mehr Verbandswechsel als auch mit familiären Faktoren wie einer mütterlichen PTBS sowie der Qualität der familiären Beziehungen. In der zweiten Studie werden die Resultate einer quantitativen Untersuchung zu PTBS bei krebskranken Säuglingen und Kleinkindern vorgestellt. Die Stichprobe umfasste 48 Kinder im Alter von 8-48 Monaten. 18.8% der untersuchten Kinder zeigten durchschnittlich 15 Monate nach der Krebsdiagnose eine PTBS und 41.7% der Kinder erfüllten die Kriterien einer sogenannt partiellen PTBS. Als Risikofaktoren für eine volle und/oder partielle PTBS konnten ein höheres Alter der Kinder zum Zeitpunkt der Diagnose sowie eine mütterliche PTBS identifiziert werden. Abschliessend werden die Ergebnisse aller drei Arbeiten in einer allgemeinen Diskussion integrierend besprochen.

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Item Type:Dissertation (monographical)
Referees:Landolt Markus A, Hornung Rainer
Communities & Collections:UZH Dissertations
Dewey Decimal Classification:Unspecified
Language:English
Place of Publication:Zurich
Date:2013
Deposited On:09 Apr 2019 14:20
Last Modified:25 Sep 2019 00:14
Number of Pages:119
Additional Information:Landolt, Markus
OA Status:Green
Related URLs:https://www.recherche-portal.ch/primo-explore/fulldisplay?docid=ebi01_prod009988402&context=L&vid=ZAD&search_scope=default_scope&tab=default_tab&lang=de_DE (Library Catalogue)

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