New study says injured children can suffer post-traumatic stress disorder too

Posted 02/12/01

Editor's note: This story first appeared in the Winter 2000 issue of Dartmouth Medicine.

A car skidded off a snow-covered road and smashed into a tree. A 13-year-old passenger was knocked unconscious and severely wounded. Two adults with him, including one of his parents, were killed. The boy was admitted to Dartmouth-Hitchcock Medical Center, and within a few days his broken bones and cuts were on the mend.

But a month later, the boy was still suffering from psychological wounds, recalls child psychiatrist Robert Racusin, Associate Professor of Psychiatry. "He was having nightmares about the crash . . . It was intrusively coming up in his mind, even though he was trying to do other things like go to school." In short, says Racusin, the boy "had all of the cardinal symptoms of post-traumatic stress disorder," or PTSD.

PTSD has long been recognized as a problem for battle-scarred soldiers or survivors of major natural disasters. But for hospitalized children? Yet observations that this might be the case led Racusin and several colleagues to conduct a year-long study of children admitted to DHMC after accidental injuries. "The question was," Racusin explains, "is there any way of . . . determining which children who come into the hospital with an injury are likely to develop post-traumatic stress disorder?"

Every child admitted to DHMC for more than a single night was invited to participate. The children who joined the study and their parents were interviewed and given a series of tests at the time of their hospitalization. The researchers gathered quantitative data using various tools. They used the surgeons' Injury Severity Scale to assess the child's injuries. They used a tool called the Traumatic Events Screening Inventory, which they developed in conjunction with the White River Junction VA, to determine if the children had been traumatized by the accident or had previously been traumatized. And they screened the children for existing psychological problems and measured the parents' level of distress.

The researchers then followed up with all of the children about a month later, administering a test to determine if they had symptoms of PTSD and how much it was affecting their lives.

The study, which was published in the Journal of the American Academy of Child and Adolescent Psychiatry, turned up some surprises. Nearly 30 percent of the children had "significant post-traumatic symptomology," according to Racusin, and 12.5 percent developed full-blown PTSD.

"Thirty percent is a lot of kids when you're talking about an aftermath," adds Racusin. "Thirty percent of kids having infections following a procedure would be considered a very high rate. And people would want to know why and how to lower that."

The variables that the study found best predicted which children would develop problems with PTSD were "the children who had been traumatized before; the ones who already had some psychological problems to begin with; and, even more so, the children whose parents were themselves experiencing a lot of distress about the child's injuries." These factors all outweighed severity of injury, even though some of the children suffered long-term impairment and disfigurement.

The influence of parents' reactions was another surprise. But it makes sense, Racusin explains. "Parents serve as a very important buffer for children when children are faced with stress of various kinds. When parents are doing well, they can buffer stress quite well for children-and the opposite is also true."

Racusin adds that children tend not to put memories into words or to talk about intrusive thoughts. However, stress can come out in their play. "Traumatic play," he explains, "is like just a fragment out of a Stephen King novel . . . that gets played over and over again." This is represented in another finding of the study: while almost 95 percent of children felt that their lives had been in danger or felt horrified and helpless-the criteria for trauma-many fewer of the parents thought their children had been traumatized. "It's not something that the children necessarily communicate to parents," says Racusin, "or that parents necessarily infer."

Racusin feels the results suggest three ways to improve the care of injured children. First, he says, some simple screening questions may help identify high-risk children. Second, more support for parents may lessen the impact of parental stress. Finally, educating parents and children about the warning signs of PTSD may help them identify it after they leave the hospital; treatment "is much more effective when you do it very early on," Racusin says.

The boy mentioned above is a good example. After his PTSD was identified, he achieved significant recovery with the help of counseling and medication.

"One of the problems with PTSD is, if you start to have all of these intrusive memories about the trauma, . . . you're not able to do the actual grief work," Racusin points out. "He was able to get on to do a more normal kind of grief repair work."