Psychological Impact of Injury in Children Justin Kenardy Professor, SchoolS of Medicine & PSYCHOLOGY. Deputy Dire

1. Psychological Impact of Injury in ChildrenJustin KenardyProfessor, SchoolS of Medicine & PSYCHOLOGY.Deputy Director, CONROD.j.kenardy@uq.edu.au

2. Research Team • Dr Robyne Le Brocque • Dr Michelle Heron • Dr Sonja March • Ms Caitlin McGuire • Ms Katherine Olsson • Mr Greg Islen • Ms Erin Charlton • Ms Alexandra De Young • Ms Belinda Murray • Ms Rachael Dunne • Ms Cheryl Huang • Ms Melissa Kaultner

3. Some Collaborators • Nancy Kassam-Adams (Children’s Hospital of Pennsylvania) • Vicki Anderson (Murdoch Children’s Research Institute) • Lynne McKinlay (RCH, Brisbane) • Louise Newman (Monash) • Andrew MacKinnon (Monash) • Michele Sterling (CONROD) • Luke Connelly (CONROD) • Gwen Jull (UQ) • Kim Bennell (U Melbourne) • Paul Hodges (UQ) • Reg Nixon (Flinders) • Doug Delahanty (Kent State) • Susan Spence (Griffith Uni) • Richard Meiser-Stedman (Cambridge) • Beverley Raphael (ANU) • Helen Christensen (ANU) • Ian Cameron (UNSW) • Michael Nicholas (UNSW)

4. Our Group • Application of behavioural science theories and methods, to the facilitation of psychological adjustment, and prevention and early intervention of psychological morbidity following injury. • Research involves • Adults and children including infants. • Hospital and community populations. • Multidisciplinary approaches. • All cause injury.

5. What is Post-traumatic stress disorder (PTSD)? • Exposure to traumatic event in which BOTH the following were present: • Experienced, witnessed, or confronted with perceived threat to life • Response involved intense fear, helplessness, or horror • Traumatic event persistently re-experienced (e.g., intrusive recollections, dreams/nightmares, reliving/flashbacks, psychological distress at exposure to cues, physiological reactivity to cues) • Persistent avoidance of trauma-related stimuli / numbing of general responsiveness (e.g. avoid trauma-related thoughts, feelings, conversations; activities/places/people, inability to recall important aspect of trauma, restricted range of affect, detachment) • Hyperarousal symptoms (e.g. startle response, anger/irritability, hypervigilance, difficulty concentrating, sleep disturbances) • Duration of at least 1 month • Functional impairment or clinically significant distress

6. Injury and Psychological morbidity in adults • In a study* 1084 adults admitted to 4 major hospitals in Australia following trauma: • 31% had psychiatric diagnosis • 20% had a new psychiatric diagnosis • PTSD • major depression • generalised anxiety disorder • agoraphobia • Diagnosis significantly impaired function over and above physical injury *Bryant et al, 2010, American journal of Psychiatry

7. Youth, accidental injury and PTSD • Most common ‘traumatic event’ to which youth are exposed • 2,500 per 100,000 youth experience accidental injury necessitating hospital admission each year • Psychosocial and health-related effects of accidental injury well established • Traumatic stress reactions (>50%) • Depression • Generalised anxiety / Specific phobia’s • Family stress • Prevalence of PTSD following accidental injury • Approx 15-20%

8. Traumatic injury in children Serious non-intentional traumatic injury resulted in at least 2,500 hospital admissions per 100,000 children in Australia in 2003-2004. (AIHW, 2007) Disasters vs. playground accidents. Hospitals are the nexus for serious physical and psychological trauma in children.

9. Consequences of PTSD in children • Chronic course if left untreated • Significant adverse effects • Emotional and behavioural difficulties • Poor health-related outcomes • Poor school and academic performance • Increased risk for other psychiatric disorders (anxiety, depression) • Impairment also evident with partial/subclinical PTSD

10. A definition Medical Traumatic Stress “a set of psychological and physiological responses of children and their families to pain, injury, medical procedures, and invasive or frightening treatment experiences” -National Child Traumatic Stress Network, 2003

11. Experiences “I thought I was going to die. Thought I must really be hurt. I was so scared because my mum was not there.” “It all happened so quickly. I was ‘out of it’ and in pain. I was given the first chemo treatment without being told what was going on – that upset me for a long time after that.” “I saw my son lying in the street. Bleeding, crying, the ambulance, everybody around him. It was a horrible scene. I thought I was dreaming.” “We went from taking him to our family doctor, thinking that he had some kind of virus or flu, to by the end of the afternoon being in the ICU and having him inundated with needles, and tubes, and… Wow! How did the day end up like this?”

12. Evidence for Medical Traumatic Stress across pediatric patient groups and settings =UQ Data  =Other

13. Impact of traumatic stress on health & functioning PTSD associated with: • wide range of adverse health outcomes in children preschool thru adolescence (Graham-Bermann & Seng 2005; Seng et al 2005) • poorer treatment adherence post-transplant (Shemesh et al 2000; Shemesh 2004) • lower health-related quality of life & functional outcomes (e.g., more missed school days) after injury (Holbrook et al 2004; CHOP data)

14. Traumatically Injured Children aged 6-15 (N=184): CHQ Physical: PTSD x time (mo.)

15. Traumatically Injured Children aged 6-15 (N=184): CHQ Psychosocial: PTSD x time (mo.)

16. Traumatic Stress in Early Childhood Research on infant, toddler & preschool mental health has only just start to emerge Considerable gaps exist re: diagnostic validity, prevalence & course of psychopathology following trauma in young children Paucity of literature due to: Resistance to notion that young children can experience psychopathology Complexities of assessment Difficulties conceptualizing traumatic stress

17. Alternative PTSD Criteria (Scheeringa) for very young children A. Traumatic event (A2 not required) B. Reexperiencing (1 or more) - Recurrent & intrusive recollections (not necessarily distressing) - Increased nightmares - Sense of event recurring (objective features of flashback) - Psychological & physiological distress from reminders C. Avoidance (1 or more) - Avoidance of any type of reminder - Diminished interest in activities (constriction of play) - Detachment or estrangement (social withdrawal) - Restricted affect - Loss of acquired developmental skills (instead of foreshortened future)

18. Alternative Criteria cont D. Hyperarousal (2 or more) - Sleep disturbance - Irritability (or extreme temper tantrums & fussiness) - Decreased concentration - Hypervigilance - Exaggerated startle response New Cluster: - New separation anxiety - New onset of aggression - New fears without obvious links to trauma Note: The superior validity of this criteria has been demonstrated in 7 studies by 5 different research groups.

19. Burn Injury • Burns have been identified as one of the priority injury issues in Australia • Burns share characteristics of both acute & chronic illness & therefore can be source of ongoing stress • Paediatric burns are one of the leading causes of hospitalisation in Australia with approximately 70% of burns occurring in children under the age of five

20. Psychosocial Impact of Burn Injury School-aged Children & Adolescents: Research has consistently shown that burns are associated with: • PTSD (6-50%) • Anxiety (33-47%) • Depression (26%) • Nightmares (37%) • Enuresis (24%) • Body & self-esteem issues Families: • Marital discord and stress –guilt, over-protection, PTSD. • Sibling distress • Mothers may actually experience more distress than their child • Burns are more distressing than other injuries or illnesses • Relationship between parental distress & child distress

21. Method Participants: Unintentionally burned children between 1-6 yrs & their parent/s Exclusion criteria: • Primary caregiver doesn’t speak English • Child has an additional disability • Suspected child abuse or neglect (SCAN) • Child under care of Department of Child Safety (DOCS) Sample Details: • 130 children (mean age = 2 yrs 2 mths) • 130 mothers (age range 19-46yrs; mean = 32 yrs ) & • 63% married, 28% defacto, 4% single, 4% separated, 2% divorced • 63% sample have an education level of trade or higher • 22% attrition at T1

22. Preliminary Data: Clinical Interview

25. Children’s psychological response to admission to PICU • PICU focus on saving the lives of critically ill children • Admission to PICU increases the risk for child PTSD and other psychopathology • PTSD diagnosis up to 21% (Rees, 2004) • Significant symptoms of PTSD up to 62% (Judge, 2002) • PTSD in paediatric patients can negatively impact physical health outcomes

26. Child Health Questionnaire Psychosocial Total ** ** **p<.01; Adjusted for injury severity

27. Parent’s psychological response to their child’s admission to PICU • Exposure of loved one to traumatic event or witnessing event can result in PTSD • Not just witnesses • decision makers and participants in treatment • Up to half of parents of children admitted to PICU may have clinically significant symptoms (Judge et al., 2002)

28. Parent IES-R ** ** P<.001, adjusted for injury severity

29. PICU and PTSD Study • Prospective longitudinal study June 2008 with assessments • Acute (approach in PICU and on discharge to ward) • 3 months post discharge • 6 months post discharge • Recruiting 400 children from RCH and MCH • Inclusion criteria • Children aged 2-16 years with minimum 8 hour stay in PICU • Exclusion criteria • Children in PICU >28 days or who have ongoing PTA >28 days • All other illnesses and injuries included • Second and repeated admissions included

30. What we hope to achieve… • More information about children’s psychological health following PICU • Identify children who are at risk of posttraumatic distress following PICU • Ideas for possible interventions after PICU discharge that might reduce distress • Contribute to better psychological and physical health outcomes in children following PICU

31. Pediatric Psychosocial Preventative Health Model Clinical/Treatment Consult psychological health specialist • Persistent and/or escalating distress • High risk factors Targeted • Acute distress • Risk factors present Provide intervention and services specific to symptoms. Monitor distress. Universal • Children and families are • distressed but resilient Provide general support – help family help themselves Provide information and support. Screen for indicators of higher risk

32. Prevention of Traumatic Stress • Aim to evaluate the effectiveness of Web + Brochure-based intervention • 85 Children (age 7-15) admitted to RCH following traumatic injury. • Randomised to either • Web + Brochure-based intervention • Control (TAU) • Assessed pre-, one-month post- and 6-month post.

33. Prevention of Traumatic Stress in Children • kidsaccident.psy.uq.edu.au • Normalising reactions • Promoting positive outcomes as norm. • Encouraging use of good coping strategies • Stratified for age cohort (younger v adolescent). • Parent information including advice to seek help only if worsening or failure to improve. Cox, C., Kenardy, J. & Hendrikz, J.K. (2009) A randomised controlled trial of a web-based early intervention for children and their parents following accidental injury. Journal of Pediatric Psychology. 35, 581-592.

34. Child outcomes- TSCC

35. Integrated Model of early intervention for posttraumatic stress following trauma • Can we reliably predict those children who are at-risk of developing PTSD following traumatic injury? (Olsson, Kenardy et al. 2008; DeYoung et al.2007; Kenardy et al. 2006) • Child Trauma Screening Questionnaire (CTSQ) • 10-item self-report or nurse-administered screen tool • Admission to 2 weeks following trauma • Can an early intervention at 6-weeks post trauma ameliorate posttraumatic stress in children and families? • Ongoing NHMRC-funded Multi-site Randomised Controlled Trial.

36. Child Trauma Screening Questionnaire-CTSQ* Quick, accurate and cost effective method for identifying children at risk of developing PMTS. Derived by adapting the adult Trauma Screening Questionnaire for use with children. Assess hyper-arousal and re-experiencing symptoms. Very effective at identifying children with PTSD symptoms at one and six months post injury. Best screening properties of all available screeners. *Kenardy, J., Spence, S., & Macleod, A. (2006). Screening for Posttraumatic Stress Disorder in children after accidental injury. Pediatrics. 118, 1002-1009.

37. Child Trauma Screening Questionnaire (CTSQ)

38. Results – Six months post injury

39. CTSQ utility Clinical: CTSQ could be implemented in field or clinical settings to aid in prevention of PTSD following trauma. Research: Identify children who could benefit from early intervention

40. Early Intervention Trial NHMRC funded 2009-2011 Multisite RCH Brisbane, RWCH Adelaide. Persisting (>6 weeks) PTS in children 7-16 post traumatic injury. Waitlist vs child-focus vs family-focus CBT

41. Overall Model of Care Youth admitted to hospital following trauma Medical intervention / follow-up Screening for trauma symptoms (CTSQ) ‘Low-risk’ ‘At-risk’ of PTSD Assessed for PTSD Clinical symptoms of PTSD Access to information-based intervention No clinical symptoms Access to information-based intervention Access to CBT Early intervention

42. Where to from here? Our research filling in some gaps Children with burns Children with traumatic brain injuries Bereavement and trauma Impact of NICU on parents and infants Effective intervention Prevention of psychological morbidity in mTBI. Early intervention RCT w. Injured children Early intervention RCT w. TBI

43. Some references to our work Iselin, G., Le Brocque, R., Kenardy, J., Anderson, V., McKinlay, L. (2010). Which method of posttraumatic stress disorder classification best predicts psychosocial function in children with traumatic brain injury? Journal of Anxiety Disorders. doi:10.1016/j.janxdis.2010.05.011. Le Brocque, R., Hendrikz, J. & Kenardy, J. (2010). Parental Response to Child Injury: Examination of Parental Posttraumatic Stress Symptom Trajectories Following Child Accidental Injury. Journal of Pediatric Psychology. 35, 646-655. Sterling, M., Hendrikz, J. & Kenardy, J. (2010). Compensation claim lodgement and health outcome developmental trajectories following whiplash injury: A prospective study. Pain. doi:10.1016/j.pain.2010.02.013. Cox, C., Kenardy, J. & Hendrikz, J.K. (2009) A randomised controlled trial of a web-based early intervention for children and their parents following accidental injury. Journal of Pediatric Psychology. 35, 581-592. Le Brocque, R., Hendrikz, J. & Kenardy, J. (2009) The Course of Post Traumatic Stress in Children: Examination of Recovery Trajectories Following Traumatic Injury. Journal of Pediatric Psychology. 35, 637-645. Olsson, K.A., Kenardy, J.A., De Young, A.C. & Spence, S.H. (2008) Predicting children’s posttraumatic stress symptoms following hospitalization for accidental injury: Combining the Child Trauma Screening Questionnaire and heart rate. Journal of Anxiety Disorders, 22, 1447-1453. Olsson, K.A., Kenardy, J.A., Le Brocque, R., Spence, S.H., & Anderson, V.A. (2008) The influence of pre-injury behavior on children’s type of accident, type of injury, and severity of injury. Brain Injury, 22, 595-602. Kenardy, J., Thompson, K., Le Brocque, R. &  Olsson, K. (2008) Information provision intervention for children and their parents following paediatric accidental injury. European Child and Adolescent Psychiatry 17, 316-325. Cox, C., & Kenardy, J (2008).A Meta-Analysis of Risk Factors that Predict Posttraumatic Stress Symptoms Following Pediatric Accidental Trauma. Journal for Specialists in Pediatric Nursing, 13, 98-110. Murray, B. L., Kenardy, J. A., & Spence, S. H. (2008). Brief Report: Children's Responses to Trauma- and Nontrauma-related Hospital Admission: A Comparison Study. Journal of Pediatric Psychology, 33(4), 435-440. Macleod, A., Kenardy, J., & Spence, S.H. (2007). Elevated Heart Rate as a Predictor of PTSD Following Accidental Pediatric Injury. Journal of Traumatic Stress.20, 751-756. O’Kearney, R., Speyer, J. & Kenardy, J. (2007). Children’s narrative memory for accidents and their posttraumatic distress. Applied Cognitive Psychology.21, 821–838 Kenardy, J., Smith, A., Spence, S.H., Lilley, P-R., Newcombe, P., Dob, R., & Robinson, S. (2007). Dissociation in children's trauma narratives: An exploratory investigation. Journal of Anxiety Disorders. 21, 456-466. Kenardy, J., Spence, S., & Macleod, A. (2006). Screening for risk of Persistent Posttraumatic Morbidity in children following traumatic injury. Pediatrics. 118, 1002-1009.