Article

Clinical predictors of posttraumatic stress disorder after closed head injury in children

Duke University, Durham, North Carolina, United States
Journal of the American Academy of Child & Adolescent Psychiatry (Impact Factor: 6.35). 03/2002; 41(2):157-65. DOI: 10.1097/00004583-200202000-00009
Source: PubMed

ABSTRACT To describe injury, demographic, and neuropsychiatric characteristics of children who develop posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) after closed head injury (CHI).
Ninety-five children with severe CHI and amnesia for the event were prospectively followed for 1 year. Structured interviews were administered twice to the parents: shortly after injury to cover the child's premorbid status, and 1 year after injury. The child was also interviewed twice: shortly after injury to cover current status, and 1 year after injury. Outcome measures were diagnostic status (PTSD by parent or child) and symptom severity (PTSS by parent or child).
Twelve children developed PTSD by 1 year after injury, 5 according to parent report, 5 according to child report, and 2 according to both parent and child report. Predictors of PTSD at 1 year post-CHI included female gender and early post-CHI anxiety symptoms. Predictors of PTSS at 1 year post-CHI were (1) premorbid psychosocial adversity, premorbid anxiety symptoms, and injury severity; and (2) early post-CHI depression symptoms and nonanxiety psychiatric diagnoses.
PTSD developed in 13% of children with severe CHI accompanied by traumatic amnesia. Predictors of PTSD and PTSS after CHI, according to parent and child report, are consistent with predictors of PTSD and PTSS that develop after non-head injury trauma.

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    ABSTRACT: ABSTRACT Main objectives: The main objectives of the Icelandic research project on early traumatic brain injury (TBI), the ICTBI research project, were: (1) to estimate the nationwide incidence and prevalence of early TBI and TBI-related long-term consequences; (2) to assess the prognostic value of injury-related and non-injury-related factors for late outcome; and (3) to serve as a foundation for the development of goal-oriented prevention and intervention in Iceland. Material and methods: Participants in the present series were: (1) all children and adolescents 0-14 years old diagnosed with TBI (ICD-9 850-854 (World Health Organization, 1977)) and admitted to hospital in Reykjavík during the five year period 1987-1991 (n = 359); (2) all children and adolescents 0-19 years old diagnosed with TBI in Iceland from 15 April 1992 to 14 April 1993 (n = 550; the ICTBI study group (SG)); and (3) a control group (CG) (n = 1232) selected from the Icelandic National Registry in 2008 using a stratified random sampling method. Data on the children and adolescents with TBI admitted to hospital in Reykjavík in 1987-1991 were collected retrospectively in 1992-1993, parallel to the launching of the prospective ICTBI research project. In study groups (1) and (2), numbers were recorded according to TBI severity, age at injury, gender and residence, and annual incidence rates calculated for the five-year period 1987-1991 and for the one-year period 1992-1993. In the ICTBI SG sub-sample of patients treated in the Reykjavík area in 1992-1993 (n = 408), outcome was assessed four years post-injury by means of a short questionnaire. In the majority of cases, parents answered the questionnaire due to the young age of the participants. The participation rate was 59.6%. Approximately 16 years post-injury, in 2008-2009, the late consequences of early TBI in the nationwide ICTBI SG were assessed by means of a comprehensive questionnaire. The newly selected CG, receiving the same questionnaire, provided information on the prevalence of TBI and TBI-related sequelae in a nationwide general population sample. Participants were not informed as to which group (ICTBI SG or CG) they belonged and the questionnaire was neutral as regards the TBI-status of respondents. Sixteen years post-injury, findings were mostly based on self-report. All participants received the questionnaire by mail. The questionnaire included questions on TBI and TBI-related conse-quences, socio-economic status (SES) and other demographic varia-bles, as well as four clinical outcome scales: (1) Memory Complaint Questionnaire (MCQ); (2) General Health Questionnaire (GHQ); (3) Frontal Systems Behavior Scale (FrSBe); and (4) European Brain Injury Questionnaire (EBIQ). Non-respondents were requested to answer an abbreviated version of the questionnaire by telephone. Overall participation was close to 70%. Self-reports of acute TBI severity were scored with reference to the Head Injury Severity Scale (HISS) criteria. Reports of late symptoms attributed to TBI were scored with reference to the King’s Outcome Scale for Childhood Head Injury (KOSCHI), the Glasgow Outcome Scale (GOS), and the Extended Glasgow Outcome Scale (GOS-E) criteria. The respondents in the CG who reported having sustained TBI formed a separate (clinical) CG (CG with TBI). Statistical analyses were used to compare groups and assess the prognostic value of injury-related and non-injury-related factors for late outcome. Results: In the two incidence studies, 1987-1991 and 1992-1993, the annual incidence of pediatric TBI (ICD-9 850-854) leading to hospitalization, the incidence of moderate/severe non-fatal TBI (ICD-9 851-854), and the incidence of fatal TBI compared well with previous incidence rates reported in Iceland and in other western countries. In 1992-1993, the incidence of minimal TBI treated at emergency departments (EDs) was markedly lower in rural areas (1.93 per 1000) than in the Reykjavík area (6.87 per 1000). This difference was most pronounced in the youngest age group, 0-4 years old. The incidence of minimal TBI (i.e. TBI treated at EDs) was highest in the youngest age group treated in the Reykjavík area. The incidence of hospitalized mild, moderate, and severe TBI was comparable across age and residence (urban/rural) groups. The incidence of TBI was higher among boys than among girls. Fall was the most common cause of TBI in the younger age groups, but unintentional blows and sport- and traffic-related TBIs became more common with age. Four years post-injury 39 (16.0%) of the 243 participants reported symptoms that they attributed to the previous TBI, and 16 (6.6%) described symptoms indicating disability according to the GOS criteria. Estimated force of impact to the head, based on causes and location of TBI derived from patient records, had prognostic value for late complaints independent of the medically confirmed acute severity of the TBIs sustained. Sixteen years post-injury 39 (11.8%) of the 331 participants in the ICTBI SG reported TBI-related symptoms indicating moderate disability. Self-reported minimal/mild TBI (n = 252) led to disability in 7.1% (n = 18) of cases and moderate/severe TBI (n = 79) in 26.6% (n = 21) of cases. In the late 1980s and the early 1990s, 1-2 children with TBI received rehabilitation each year, mostly in the form of short-term physiotherapy. This suggests that the rehabilitation effort was far from meeting the need. In the SG and the CG with TBI, early medically confirmed and self-reported TBI was reflected in worse results on each of the four clinical outcome scales, assessing aspects of cognition, mental health, adjustment and behavior, as compared to the CG without TBI. Force of impact to the head had prognostic value over and above estimated acute TBI-severity (HISS). Having sustained more than one TBI also predicted worse late outcome. Sixteen years post-injury age at injury, gender, urban/rural residence, and parental SES had a limited, nominal, or non-existent effect. In the nationwide CG, the prevalence of self-reported early TBI was 49.5%. As regards late sequelae, 7.0% of the total CG reported TBI-related symptoms indicating moderate disability. In the SG and CG combined, 75% of the participants who reported moderate disability had not been evaluated for or awarded compensation. In the moderately disabled group, not being evaluated for or awarded compensation was not associated with better results on the four clinical outcome scales. In the group with moderate disability, evaluation for compensation was related to age. In the age range older than 14 years at injury, 9.9% reported to have been evaluated for compensation while the corresponding ratio for the younger age groups combined was 2.2%. Close to one fifth of participants in the SG did not report ever having sustained TBI. This was more prevalent in the youngest age group at injury (35.7%) than in older age groups (12-16%). Not reporting, as compared to reporting, very early medically confirmed TBI was associated with better outcome on EBIQ and GHQ, but not on MCQ and FrSBe. Based on computerized patient records at Landspítali University Hospital the annual number of children and adolescents with the more severe TBI (ICD-9 851-854/ICD-10 S06.1-S06.9 (World Health Organization, 1992)) was relatively stable from 1990 to 2006, suggesting a continuous need for prevention and intervention. Main conclusions: The number of participants reporting late consequences of early TBI and the relatively stable annual number of children and adolescents with the more severe TBI in Reykjavík in recent years suggest the need for injury prevention and a broad-based intervention in Iceland. Moderate/severe TBI is more likely to lead to reports of late sequelae than minimal/mild TBI. However, due to the relatively high incidence of minimal/mild TBI, such injuries contribute substantially to the total number of TBI with late consequences. Force of impact to the head and repeated TBI were shown to have predictive value for late symptoms and outcome, independent of medically confirmed or self-reported acute TBI-severity (HISS). The findings suggest that these criteria or indicators may add to the prognostic value of scales aimed at assessing the severity of pediatric TBI in the acute phase. The low incidence of minimal TBI in the youngest age group in rural areas is a public health concern, as it may suggest under-diagnosis or under-recording. The relatively high incidence of minimal TBI caused by fall in the youngest age group in the Reykjavík area indicates a need for TBI prevention measures. As assessed by a questionnaire, the prevalence of self-reported early TBI and TBI-related disability was higher than previously reported internationally in general population studies. However, the incidence rates of pediatric TBI in Iceland suggest that the present findings on the prevalence of TBI are representative in the international context. The findings indicate an inconsistency in evaluation for compens-ation, most obviously in the youngest age groups. Very early medi-cally confirmed TBI not reported by parent or self may have unre-cognized late cognitive sequelae. The present reports on late sequelae suggest that in young age, a moderate/severe TBI or a TBI caused by strong or very strong im¬pact to the head or a repeated TBI requires specialized intervention and follow-up. In the case of ‘minimal’ or ‘mild’ TBI, young patients and parents should be informed of possible consequences and how to seek assistance if the need arises. The results of the present series of the ICTBI research project suggest that the scope of early TBI leading to moderate disability is a significant cognitive health concern affecting many individuals and their families. Key words: epidemiology, nationwide, pediatric, prognosis, traumatic brain injury
    04/2013, Degree: PhD, Supervisor: Eirikur Orn Arnarson
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    ABSTRACT: Pediatric traumatic brain injury (TBI) is a major public health problem. Psychiatric disorders with onset before the injury are more common than population base rates. Novel (postinjury onset) psychiatric disorders (NPD) are also common and complicate child function after injury. Novel disorders include personality change due to TBI, secondary attention-deficit/hyperactivity disorder, other disruptive behavior disorders, and internalizing disorders. This article reviews preinjury psychiatric disorders as well as biopsychosocial risk factors and treatments for NPD.
    The Psychiatric clinics of North America 03/2014; 37(1):125-140. DOI:10.1016/j.psc.2013.11.003 · 1.87 Impact Factor