Preventing Posttraumatic Stress Following Pediatric Injury
Objective The study objective is to evaluate the feasibility and efficacy of a web-based intervention for parents (AfterTheInjury.org [ATI]) in promoting emotional recovery following pediatric injury.
Methods 100 children with injuries requiring medical attention and their parents were randomly assigned to the intervention or usual care. Efficacy outcomes included parent knowledge and child and parent posttraumatic stress symptoms (PTSS).
Results All parents in the intervention group completed the intervention (directed use of ATI) in the hospital. 56% reported using ATI online post-discharge, and 100% of these parents found it helpful. Parent knowledge increased immediately post-intervention, but there was no significant intervention impact on parent knowledge or PTSS at a 6-week follow-up. Relationships between knowledge and PTSS were identified.
Conclusions Brief web-based interventions introduced during child hospitalization are a feasible strategy to reach many parents following pediatric injury. Preventing psychological symptoms may require more than parental education alone.
Each year, 20 million children in the United States incur a potentially traumatic injury. This results in 8.7 million emergency department visits and 241,000 inpatient admissions. Boys have a higher incidence of accidental injury than girls (Grossman, 2000). In the aftermath of pediatric injury, children and their families must manage both the physical and emotional aspects of medical trauma. Within the first month after pediatric injury (e.g., motor vehicle crash, physical assault, recreational injuries), upwards of 75% of children and their parents report posttraumatic stress symptoms (PTSS) (Aaron, Zaglul, & Emery, 1999; Winston et al., 2002). Six months post-injury, 15–20% of children and their parents continue to exhibit persistent and impairing PTSS. Five to ten percent of children and parents meet diagnostic criteria for posttraumatic stress disorder (PTSD) (Daviss et al., 2000b; DeVries et al., 1999; Di Gallo, Barton, & Parry-Jones, 1997; Winston, Kassam-Adams, Garcia-Espana, Ittenbach, & Cnaan, 2003). PTSS include avoidant behaviors, re-experiencing of the trauma, and hyperarousal (American Psychiatric Association, 1994, 2010). For children with injuries, this can include the following symptoms: Avoiding activities associated with the injury (e.g., riding a bike, getting in a vehicle), having nightmares or re-enacting the injury event or subsequent medical treatment via play, or becoming agitated or jumpy when reminded of the injury or injury event. PTSS can develop in children and parents, regardless of injury severity and other medical characteristics (e.g., length of hospital stay, injury mechanism or type) (Bryant, Mayou, Wiggs, Ehlers, & Stores, 2004; Daviss et al., 2000a; Kenardy, Spence, & Macleod, 2006; Landolt, Buehlmann, Maag, & Schiestl, 2009; Landolt, Vollrath, Timm, Gnehm, & Sennhauser, 2005; McDermott & Cvitanovich, 2000). Empirical research suggests that PTSS contribute to poor physical recovery and may interfere with optimal adherence to medical regimens (Holbrook et al., 2005; Stoddard & Saxe, 2001; Wesson et al., 1989). Additionally, PTSS are a key predictor of functional outcome and quality of life post-injury (Holbrook et al., 2005; Stoddard & Saxe, 2001; Wesson et al., 1989). The high prevalence and impact of PTSS for injured children necessitates secondary prevention interventions; that is, interceding after the injury has occurred to prevent long-term complications.
Parents are a primary source of support for children following an injury ("Family-centered care and the pediatrician's role," 2003), but research indicates that many parents have difficulty assessing their child's emotional responses to injury (Dyb, Holen, Brænne, Indredavik, & Aarseth, 2003; Kassam-Adams, Garcia-España, Miller, & Winston, 2006; Meiser-Stedman, Smith, Glucksman, Yule, & Dalgleish, 2007; Schreier, Ladakakos, Morabito, Chapman, & Knudson, 2005). Parents also may have difficulty determining the best methods to help their child cope with these reactions (Marsac, Mirman, Kohser, & Kassam-Adams, 2011). Increasing knowledge about reactions to trauma has the potential to prevent PTSS (Litz, 2008; Litz, Gray, Bryant, & Adler, 2001; Norris et al., 2001; Resnick, Acierno, Holmes, Dammeyer, & Kilpatrick, 2000). Thus, interventions that teach parents how to recognize their child's early reactions and help their child cope may be useful in preventing or reducing PTSS following pediatric injury.
To date, no early intervention has been identified as efficacious in preventing child PTSS following pediatric injury (Kramer & Landolt, 2011). In one study, providing families with psycho-education about children's reactions and traumatic stress symptoms post-injury resulted in lower child anxiety and parent PTSS compared with usual care (UC) (Kenardy, Thompson, Le Brocque, & Olsson, 2008), though no differences were found for child PTSS. An evaluation of the Child and Family Traumatic Stress Intervention, a four-session in-person psycho-educational and skills-based intervention, shows promise in preventing PTSS in children following acute potentially traumatic events including injury (Berkowitz, Stover, & Marans, 2011). However, this program requires trained mental health providers and multiple face-to-face family sessions.
There is growing empirical support for the efficacy of using the Internet to deliver high-quality interventions to children and parents (D'Alessandro, Kreiter, Kinzer, & Peterson, 2004; Ritterband et al., 2005). Web-based programs have improved symptom management and adherence to medical regimens for asthma, pain, encopresis, and obesity in children (Stinson, Wilson, Gill, Yamada, & Holt, 2009). These interventions have also helped to reduce symptoms of anxiety and depression in adults, children, and adolescents (Kenardy, McCafferty, & Rosa, 2006; O'Kearney, Kang, Christensen, & Griffiths, 2009). Combining printed information for parents with web-based information for children who have experienced injury has also shown promising results for reducing anxiety and a trend for reduced PTSS among higher risk children (Cox & Kenardy, 2009).
AfterTheInjury.org (ATI) is a web-based intervention for parents. ATI is designed to help promote emotional recovery and prevent PTSS in children with injuries. The intervention provides parents with evidence-based information and psycho-education related to pediatric injury. Tools on ATI go beyond the simple provision of information about injury care and reactions: For example, parents can complete a child symptom quiz that generates specific evidence-based tips on ways to assist in their child's emotional recovery. Objectives of this study were to examine the relationship between parent knowledge and PTSS, determine intervention feasibility, and evaluate the efficacy of the intervention in increasing parent knowledge of injury reactions and preventing child and parent PTSS following pediatric injury. Specifically, we predicted that (1) parent knowledge about injury reactions would be inversely related to child and parent PTSS, (2) parent knowledge about child injury reactions would increase immediately post-intervention as compared with baseline for parents in the intervention group, (3) parents in the intervention group would have greater knowledge about child injury reactions at 6-week follow-up compared with parents in the UC group, and (4) children in the intervention group would report fewer PTSS at 6-week follow-up compared with those in the UC group. We were also interested in exploring the potential impact of the intervention on parent PTSS.
Abstract and Introduction
Abstract
Objective The study objective is to evaluate the feasibility and efficacy of a web-based intervention for parents (AfterTheInjury.org [ATI]) in promoting emotional recovery following pediatric injury.
Methods 100 children with injuries requiring medical attention and their parents were randomly assigned to the intervention or usual care. Efficacy outcomes included parent knowledge and child and parent posttraumatic stress symptoms (PTSS).
Results All parents in the intervention group completed the intervention (directed use of ATI) in the hospital. 56% reported using ATI online post-discharge, and 100% of these parents found it helpful. Parent knowledge increased immediately post-intervention, but there was no significant intervention impact on parent knowledge or PTSS at a 6-week follow-up. Relationships between knowledge and PTSS were identified.
Conclusions Brief web-based interventions introduced during child hospitalization are a feasible strategy to reach many parents following pediatric injury. Preventing psychological symptoms may require more than parental education alone.
Introduction
Each year, 20 million children in the United States incur a potentially traumatic injury. This results in 8.7 million emergency department visits and 241,000 inpatient admissions. Boys have a higher incidence of accidental injury than girls (Grossman, 2000). In the aftermath of pediatric injury, children and their families must manage both the physical and emotional aspects of medical trauma. Within the first month after pediatric injury (e.g., motor vehicle crash, physical assault, recreational injuries), upwards of 75% of children and their parents report posttraumatic stress symptoms (PTSS) (Aaron, Zaglul, & Emery, 1999; Winston et al., 2002). Six months post-injury, 15–20% of children and their parents continue to exhibit persistent and impairing PTSS. Five to ten percent of children and parents meet diagnostic criteria for posttraumatic stress disorder (PTSD) (Daviss et al., 2000b; DeVries et al., 1999; Di Gallo, Barton, & Parry-Jones, 1997; Winston, Kassam-Adams, Garcia-Espana, Ittenbach, & Cnaan, 2003). PTSS include avoidant behaviors, re-experiencing of the trauma, and hyperarousal (American Psychiatric Association, 1994, 2010). For children with injuries, this can include the following symptoms: Avoiding activities associated with the injury (e.g., riding a bike, getting in a vehicle), having nightmares or re-enacting the injury event or subsequent medical treatment via play, or becoming agitated or jumpy when reminded of the injury or injury event. PTSS can develop in children and parents, regardless of injury severity and other medical characteristics (e.g., length of hospital stay, injury mechanism or type) (Bryant, Mayou, Wiggs, Ehlers, & Stores, 2004; Daviss et al., 2000a; Kenardy, Spence, & Macleod, 2006; Landolt, Buehlmann, Maag, & Schiestl, 2009; Landolt, Vollrath, Timm, Gnehm, & Sennhauser, 2005; McDermott & Cvitanovich, 2000). Empirical research suggests that PTSS contribute to poor physical recovery and may interfere with optimal adherence to medical regimens (Holbrook et al., 2005; Stoddard & Saxe, 2001; Wesson et al., 1989). Additionally, PTSS are a key predictor of functional outcome and quality of life post-injury (Holbrook et al., 2005; Stoddard & Saxe, 2001; Wesson et al., 1989). The high prevalence and impact of PTSS for injured children necessitates secondary prevention interventions; that is, interceding after the injury has occurred to prevent long-term complications.
Parents are a primary source of support for children following an injury ("Family-centered care and the pediatrician's role," 2003), but research indicates that many parents have difficulty assessing their child's emotional responses to injury (Dyb, Holen, Brænne, Indredavik, & Aarseth, 2003; Kassam-Adams, Garcia-España, Miller, & Winston, 2006; Meiser-Stedman, Smith, Glucksman, Yule, & Dalgleish, 2007; Schreier, Ladakakos, Morabito, Chapman, & Knudson, 2005). Parents also may have difficulty determining the best methods to help their child cope with these reactions (Marsac, Mirman, Kohser, & Kassam-Adams, 2011). Increasing knowledge about reactions to trauma has the potential to prevent PTSS (Litz, 2008; Litz, Gray, Bryant, & Adler, 2001; Norris et al., 2001; Resnick, Acierno, Holmes, Dammeyer, & Kilpatrick, 2000). Thus, interventions that teach parents how to recognize their child's early reactions and help their child cope may be useful in preventing or reducing PTSS following pediatric injury.
To date, no early intervention has been identified as efficacious in preventing child PTSS following pediatric injury (Kramer & Landolt, 2011). In one study, providing families with psycho-education about children's reactions and traumatic stress symptoms post-injury resulted in lower child anxiety and parent PTSS compared with usual care (UC) (Kenardy, Thompson, Le Brocque, & Olsson, 2008), though no differences were found for child PTSS. An evaluation of the Child and Family Traumatic Stress Intervention, a four-session in-person psycho-educational and skills-based intervention, shows promise in preventing PTSS in children following acute potentially traumatic events including injury (Berkowitz, Stover, & Marans, 2011). However, this program requires trained mental health providers and multiple face-to-face family sessions.
There is growing empirical support for the efficacy of using the Internet to deliver high-quality interventions to children and parents (D'Alessandro, Kreiter, Kinzer, & Peterson, 2004; Ritterband et al., 2005). Web-based programs have improved symptom management and adherence to medical regimens for asthma, pain, encopresis, and obesity in children (Stinson, Wilson, Gill, Yamada, & Holt, 2009). These interventions have also helped to reduce symptoms of anxiety and depression in adults, children, and adolescents (Kenardy, McCafferty, & Rosa, 2006; O'Kearney, Kang, Christensen, & Griffiths, 2009). Combining printed information for parents with web-based information for children who have experienced injury has also shown promising results for reducing anxiety and a trend for reduced PTSS among higher risk children (Cox & Kenardy, 2009).
AfterTheInjury.org (ATI) is a web-based intervention for parents. ATI is designed to help promote emotional recovery and prevent PTSS in children with injuries. The intervention provides parents with evidence-based information and psycho-education related to pediatric injury. Tools on ATI go beyond the simple provision of information about injury care and reactions: For example, parents can complete a child symptom quiz that generates specific evidence-based tips on ways to assist in their child's emotional recovery. Objectives of this study were to examine the relationship between parent knowledge and PTSS, determine intervention feasibility, and evaluate the efficacy of the intervention in increasing parent knowledge of injury reactions and preventing child and parent PTSS following pediatric injury. Specifically, we predicted that (1) parent knowledge about injury reactions would be inversely related to child and parent PTSS, (2) parent knowledge about child injury reactions would increase immediately post-intervention as compared with baseline for parents in the intervention group, (3) parents in the intervention group would have greater knowledge about child injury reactions at 6-week follow-up compared with parents in the UC group, and (4) children in the intervention group would report fewer PTSS at 6-week follow-up compared with those in the UC group. We were also interested in exploring the potential impact of the intervention on parent PTSS.
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