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Medical illness and injuries

Medical illness and injuries. The research area. Interdisciplinary Pediatrics, Psychologists, Psychiatrists, other mental/health care disciplines Relatively new field (since mid-1980) Term ‘trauma’ can create problems for understanding across disciplines

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Medical illness and injuries

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  1. Medical illness and injuries

  2. The research area • Interdisciplinary • Pediatrics, Psychologists, Psychiatrists, other mental/health care disciplines • Relatively new field (since mid-1980) • Term ‘trauma’ can create problems for understanding across disciplines = physical injury (e.g. traumatic brain injury) for medical practitioner

  3. Terms and definitions • Medical traumatic stress • Pediatric traumatic stress • Medical trauma

  4. Pediatric Medical Traumatic Stress (PMTS) • “a set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences” (NCTSN, 2009) • Similar and related to ASD and PTSD • PTSS = continuum of key symptoms • E.g., Arousal, re-experiencing, avoidance

  5. Illness and Injuries frequently studied • Cancer • Organ transplant • Burns • Motor vehicle/ road traffic accidents • Traumatic brain injury

  6. Potentially Traumatic Medical Events (PTME) (Kazak et al., 2006) • Injury • Most common experience (1 in 4 children receive medical care each year) (National Safe Kids Campaign, 2004) • Other conditions, burns, sickle cell disease, diabetes, sever asthma • Painful procedures and frightening treatment experiences • Affect large groups • Cancer and other complications of other chronic and potentially dehabilitating conditions • From epidemiological perspective less common (but common in medical settings) • Unintentional injuries and neoplasms are most common cause of death in childhood (Arias et al., 2003)

  7. Some Questions (Stuber et al, 2003) • Basic questions about diagnostic requirements • Symptoms cause real functional impairment or clinical important distress? • What number of symptoms, severity of symptoms, or level of impairment necessary (to be clinically significant) • Applied theoretical/practical questions • What constitutes the traumatic event in medical illness • Event differs for children and parents • Who develop and sustain symptoms • Similar symptoms to children exposed to other types of traumatic events

  8. Prevalence of ASD and PTSD Debate about prevalence and suitability of PTSD framework

  9. ASD vs. PTSD ASD PTSD A: (1) + (2) B: re-experiencing (1) C: Avoidance (3) D: Increased arousal (2) E: lasts for more than 1 mo F: clinically significant distress or impairment Duration and onset Duration: < 3 mo = acute, >3mo = chronic Onset: >6mo = delayed • A: (1) traumatic event, and (2) subjective response • B: dissociative symptoms (3) • C: persistent re-experiencing (1) • D: marked avoidance (?) • E: marked anxiety or increased arousal (?) • F: clinically significant distress or impairment • G: Lasts for min. 2 days, max. 4 weeks, within 4 weeks of event • H: not due to effects of substance (drug) or medical conditions

  10. Illness: Childhood Cancer • Bone marrow transplant (cancer) (Stuber et al., 1991) • All children increased PTSD symptoms even 12 months post • Cancer vs. other traumas (Pelcovitz et al., 1998) • 35% of adolescent cancer met PTSD criteria vs. ‘only’ 7% physically abused (life-time PTSD) • 17% cancer vs. 11% abuse (current PTSD)

  11. Illness: Childhood Cancer • Disease-free childhood cancer survivors at end of treatment (Barakat et al., 1997; Kazak et al., 1997) • No sign. difference between Cancer survivors and controls • Cancer: 2.6% severe, 12.1% moderate symptoms • Controls: 3.4% sever, 12.3% moderate • Young adult survivors (Hobbie et al., 2000; Rourke et al., 1999) • 20.5% met DSM-IV criteria (at some point after end of treatment)

  12. Illness: Organ Transplant • Adolescent heart, liver, kidney transplant recipients (1 year post-transplant) (Mintzer et al, 2005) • 16% met criteria of PTSD, another 14.4% met 2/3 symptom clusters • Children in pediatric ICU (intensive care unit) vs. children in general pediatric wards (after discharged) (Rees et al., 2004) • 21% of ICU, none in general ward

  13. Other Illnesses • Adolescents with life-threatening asthma (Kean et al., 2006) • 20% met PTSD criteria • Children undergoing surgery for congenital heart disease (CHD) (Toren & Horesh, 2007) • CHD most common birth defect (1/125), twice as many as all cancers combined • 30% met PTSD criteria

  14. No studies on ASD in illness

  15. Injury (PTSD) • Children with motor vehicle/ traffic injury (see O’Donnell et al, 2003; Saxe et al., 2003) • PTSD assessed 1-6 mo post-injury range from 17.5% to 42% • 12 mo. post-injury 2% to 36% • Children with burns (e.g., Stoddard et al., 1989) • 50% PTSD symptoms • 6.7% met DSM-III PTSD criteria (8.9 years post-burn) • No studies using DSM-IV

  16. Injury (ASD) • Diagnosis widely criticized (Bryant & Harvey, 1997) • Only few studies, mostly physical injuries • 14-16% MVA (Bryant & Harvey, 1998; Harvey & Bryant, 1999) • 12% burns (Harvey & Bryant, 1999) • Other injuries 6-16% (Mellman et al., 2001; Fuglsang et al., 2002)

  17. Traumatic brain injury (TBI) • TBI = insult to the brain typically resulting in loss of consciousness • Discussion: Do you think PTSD is possible in TBI?

  18. Traumatic brain injury (TBI) • Argued that if experiences not encoded one cannot posses trauma-related memories (Mayou et al., 1993) • Empirical Review (Bryant, 2001) • Mild TBI: 24-33% met PTSD criteria • Sever TBI: 27% PTSD • Childhood PTSD: 4-14%, but 68% at least one PTSD symptomn

  19. Debate about prevalence and suitability of PTSD framework • Variations most likely due to methodological issues (O’Donnell et al., 2003) • Physical injury (symptoms due to organic pathology) • Role of traumatic brain injury (e.g., amnesia) • Influence of subsequent and prior traumatization • Symptoms may be caused by medication (i.e. Narcotic analgesia) • Timing of assessment • Sample size and selection • Role of litigation (compensation)

  20. Direct comparison of different conditions • Walker et al (1999) • Transplant vs. chronic illness and routine surgery • PTS sign. greater in transplant group • LTX=20.83, CHA=12.50, ENT=4.77 (mean CPTS-RI) • Landolt et al (2003) • Diabetes, cancer and accident-related injury • Accident-related injury associated with higher PTSS scores • 14.6% accidents, 10% cancer, 5.4% diabetes (moderate to sever)

  21. Comparison with other types of traumatic events • Stoppelbein et al., 2006 • Cancer vs. parental bereavement (traumatic?) • Lower levels in cancer (m=24.03) than in bereaved children (m=37.15) (CPTS-RI score)

  22. Comparison with health peers • Gerhardt et al., 2007 • No sign. Difference: 3% cancer past PTSD vs. 6% controls (?), 20% cancer vs. 13% control at leats one PTSS • Brown et al., 2003 • PTSD higher in cancer than in comparions • Schwartz & Drotar, 2006 • PTSD more likely in cancer, no difference on sub-clinical PTSD symptoms

  23. Conclusion about prevalence • PTSD is not a universal side-effect of childhood medical illness or injury • Expect perhaps acute burns • However, PTSS in majority of these children • Move beyond debating prevalence (Manne, 2009)

  24. Adopting a broader perspective(Manne, 2009) • cross-situation perspective • Unique and common characteristics of childhood illness and injury • Cognitive, psychological, biological characteristics of child, parents, family’s social context • Sub-clinical PTSS syndromes, other psychological problems • Quality of life

  25. Other relevant clinical conditions • Co-morbitity in PTSD is the norm • 80-85% of individuals with PTSD meet criteria for another psychiatric condition (in large community samples) (Bradley et al., 2000; Creamer et al., 2001) • Depression: 60% at discharge to 9% at 12 mo post) (Schnyder et al., 2001; Shalev et al., 1998; Holbrook et al., 1998) • Anxiety disorders (other than PTSD) and substance use (Blanchard et al., 1995; Mayou et al., 2001)

  26. Other psychological problems: Beyond disorders • Quality of life (QOL) • Far reaching consequences for quality of life • Burn survivors (Landolt et al., 2007) • Overall QOL impaired in children with PTSD • PTSD severity associated with impaired physical, cognitive and emotional dimensions of QOL • Limited physical (e.g. more bodily complaints) and emotion functioning (e.g. more feelings of sadness)

  27. Factors predict PTSD and PTSS • Child characteristics • Persistent, unmanaged pain (Saxe et al., 2001; Stoddard et al., 2006) • Medical complications (Mintzer et al., 2005) • Sustained bodily disfigurement (Rusch et al., 2000) • Cognitive impairment (Vasa et al., 2004) • Life-threatening episode (e.g., asthma episode) (Kean et al., 2006) • Recurrence of illness (Jurbergs et al., 2007)

  28. Cognitive characteristics of child • Current perception of threat posed by illness injury • Perceive the illness as life-threatening (Barakat et al., 1997; Rourke et al, 2007) • Perceive treatment as more intense (Barakat et al., 1997; Rourke et al, 2007) • Perceive higher risk for recurrence (Stoppelbein et al., 2006) • Perceive that medical complications are more sever (Copeland et al., 2007)

  29. Psychological characteristics • Pre-trauma psychological problems • Trait anxiety (Ozono et al., 2007) • Anxiety disorder (Muris et al., 2003) • Emotional response during illness or immediately post-injury • Significant distress and/or traumatic symptomatology in children (Bryant et al., 2007; DiGallo et al., 1997) and parents (Manne et al., 2004; Ribi et al., in press)

  30. Biological and genetic factors • Physiological arousal indices (e.g., increased heart rate) (De Young et al., 2007; Stoddard et al., 2006) • High epinephrine and cortisol levels (Delahanty et al., 2005; Glover & Poland, 2002) • Genes/genetic polymorphism involved in dopamine and serotonin regulation (Koene et al., 2005; Lu et al, in press)

  31. Factors predict PTSD and PTSS • Family contextual factors • Perceived social support from family members (protective) (Kazak et al., 1999) • Family conflict (risk) (Manne et al., 2002)

  32. Resilience and Posttraumatic growth • In acute phase majority shows symptoms • Long-term majority seems to be resilient • Posttraumatic Growth in a considerable proportion (e.g. Barakat et al., 2006)

  33. Developmental considerations • Developmental difference may alter type of response (Widows et al., 2000) • Medical illness and injury at different developmental stages may result in different psychopathology (Stuber et al., 1996) • Depends on children’s understanding of illness • Some PTSD symptoms may not appear until adolescent (Hobbie et al., 2000; Rourke et al., 1999)

  34. Scheeringa et al. (1995) suggest • Requirement of effortful avoidance and memory gaps to be deleted • Behavioral symptoms, such as play re-enactment, separation anxiety, nightmares, and aggression to be added

  35. Children’s understanding of illness • Depends on cognitive development (Salmon & Bryant, 2002) • Theory of mind? • awareness of own and others mental states such as beliefs, desire, intentions and emotions • Seems highly relevant! • Especially relevant = understanding of symptoms (and control of symptoms) • Medical symptoms? • Psychological symptoms (e.g. intrusive thoughts)

  36. Developmental aspects • Landolt et al. (2009) report poorer physical, motor, cognitive + emotional functioning in children with PTSD symptoms • Is it possible that PTSD and PTSS impede development?

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