The Course of Posttraumatic Stress in Children

In This Article

Abstract and Introduction

Abstract

Objective Group-based trajectory modeling was used to identify patterns of posttraumatic stress symptom (PTSS) in children 6–16 years following accidental injury. The aims were to: (a) identify probable groups of children following distinct trajectories, and (b) identify risk factors affecting the probability of group membership.
Method Children's Impact of Events Scale (n = 190) was used to assess PTSS up to 2 years post injury. Age, gender, type of injury, and preinjury behavior were assessed as risk factors.
Results Three distinct trajectory groups were identified: resilient (57%), elevated stress symptoms which recovered quickly (33%), and chronic (10%). Younger children were more likely to be in the recovery group. Those with serious injuries were more likely to be in the chronic group. Preinjury child behavior problems were predictive of recovery and high chronic symptoms.
Conclusion Identification of distinct PTSS trajectory groups has implications for understanding the course and treatment of PTSS in children.

Introduction

Accidental injury is one of the leading causes of death and disability in children (World Health Organization, 2006), yet there is a dearth of information on the social and emotional costs resulting from child accidental injury. Posttraumatic stress disorder (PTSD) is a diagnosis used to describe a constellation of child psychological symptoms resulting from exposure to traumatic events including accidental injury. Symptoms include re-experiencing such as flashbacks, avoidance of reminders of the trauma, and increased arousal such as hypervigilance, which persist for over 1 month and cause significant distress or impairment in functioning (World Health Organization, 2006). Subthreshold posttraumatic stress symptoms (PTSS) have also been associated with increased impairment in functioning, and other mental health and behavior problems (Daviss et al., 2000; De Vries et al.,1999). Although varying rates of symptoms have been observed following trauma, few studies have explored individual recovery patterns. This paper explores trajectory patterns of PTSS in children following accidental injury. The relationships between risk factors: child age, gender, type of injury, and pretrauma child behavior and symptom trajectory patterns are examined.

Posttraumatic stress disorder in children following accidental injury has been estimated to be around 20% with an additional 25% of children meeting partial criteria for PTSD (Kahana, Feeny, Youngstrom, & Drotar, 2006). Most studies report a decline in the prevalence of symptoms post injury (Di Gallo, Barton, & Parry-Jones, 1997; Gillies, Barton, & Di Gallo, 2003; Kassam-Adams & Winston, 2004; Mather, Tate, & Hannan, 2003; Max et al., 1998; Olsson, Kenardy, De Young, & Spence, 2008; Sturms et al., 2005). Although the majority of children recover quickly following exposure to traumatic events, there is also evidence that a small minority can develop chronic PTSS (Di Gallo et al., 1997; Gillies et al., 2003; Mather et al., 2003; Pine, Costello, & Masten, 2005). Max et al. (1998) found a pattern of high levels of PTSS up to 3 months posttraumatic brain injury (68%) which declined gradually to 12% at 2 years. While the body of evidence is scarce, some studies have found small numbers of children with delayed onset PTSS (Gillies et al., 2003; Mather et al., 2003; Yule et al., 2000). These cases are more likely to have subclinical symptoms preceding full diagnosis (Yule et al., 2000).

Cite this: The Course of Posttraumatic Stress in Children: Examination of Recovery Trajectories Following Traumatic Injury - Medscape - Jul 01, 2010.

Table I. Descriptive Statistics
	N	%	Mean (SD)	Min	Max
Total	190	100
Gender
Male	120	63	–	–	–
Female	70	37	–	–	–
Age (years)	190	100	10.7 (2.3)	6.75	16.00
Injury
Fracture/dislocation/laceration/other	166	87	–	–	–
Burns/internal injuries/multiple injuries	24	13
Length of stay in hospital (days)	182	96	4.2 (6.7)	0.33	57.3
Parent informant
Mother	159	84
Father	23	12
Other	8	4

Table II. Trajectory Symptom Profiles for Total Subjective Distress score ( N = 190) ^a
Time period (months)	Group size (%)	Symptom trajectory	Trajectory polynomials	Brief description^b
6	109 (57)	Resilient	Quadratic	Below 17 for entire period
	62 (33)	Recovery	Linear	Above 17 for 4–6 weeks and below by 6 months
	19 (10)	Chronic	Constant	Above 17 for entire period
24	105 (55)	Resilient	Cubic	Below 17 for entire period
	64 (34)	Recovery	Quadratic	Above 17 for 4–6 weeks and below by 6 months
	21 (11)	Chronic	Constant	Above 17 for entire period

^aAlthough only 51 children had data to 24 months, all data were included in the analysis in keeping with the fact that data does not have to be complete for the method.
^bClinical cutoff of 17 used (Stallard, 1999).

Table III. Univariate Effects of Child's Risk Factors on Child's Group Membership Using Total Subjective Distress
Risk factor	Outcome compared to resilient group	Sample size	Odds ratio	p
Gender
Female (cf. male)	Recovery	190	0.65 (0.27–1.56)	.34
	Chronic high		1.10 (0.27–4.49)	.90
Age^a	Recovery	190	0.81 (0.67–0.97)	.02
	Chronic high		0.86 (0.63–1.16)	.31
Injury
Complex/burns	Recovery	189	1.78 (0.46–6.90)	.41
(cf. fracture, dislocation, laceration)	Chronic high		6.54 (1.41–30.35)	.02
CBCL internalizing	Recovery	174	1.10 (1.04–1.16)	.00
	Chronic high		1.12 (1.01–1.26)	.04
CBCL externalizing	Recovery	179	1.05 (1.01–1.10)	.02
	Chronic high		1.19 (1.01–1.40)	.04

CBCL: Child Behavior Checklist.
^aA quadratic effect was added to the model but it was non-significant.

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