Posttraumatic Stress Responses in Children: Awareness and Practice Among a Sample of Pediatric Emergency Care Providers
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《小儿科》
the Departments of Pediatrics and Emergency Medicine, Division of Pediatric Emergency Medicine, Emory University School of Medicine/Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
ABSTRACT
Background. Research suggests that up to 4 of 5 children experience symptoms of an acute stress response (ASR) after a motor vehicle–related injury, and 25% will develop posttraumatic stress disorder (PTSD). The degree to which physicians recognize this problem has not been reported. Our objective was to evaluate current awareness and practices of a cohort of pediatric emergency care providers regarding posttraumatic stress in children.
Methods. Participants were identified from a list of the American Academy of Pediatrics Section on Emergency Medicine and surveyed on their awareness of ASR after motor vehicle–related injury, risk factors for developing PTSD, and practices regarding emergency department (ED) interventions. Surveys from physicians not practicing clinical emergency medicine were excluded.
Results. Of 322 surveys returned, 287 responses met inclusion criteria. Among these respondents, 198 (69%) were pediatric emergency medicine board certified or eligible and 260 (91%) practiced in a designated pediatric ED. Only 20 of 287 respondents (7%) believed that children were likely to develop symptoms of posttraumatic stress at levels previously described. Also in contrast to recent literature, 248 respondents (86%) felt that severity of injury was associated with future development of PTSD. Associated parental injury was identified accurately as a risk factor by 250 respondents (87%). Of interest, only 31 respondents (11%) were aware of any available tools to assess risk for PTSD. In addition, 56 of 287 respondents (20%) indicated that they would not use such tools in the ED, most commonly citing time and cost constraints. Finally, only 52 respondents (18%) reported giving any verbal guidance and only 9 (3%) provided any written instructions about posttraumatic stress to their patients and families.
Conclusions. Findings suggest that physicians underestimate the likely development of an ASR and PTSD in the pediatric population. At present, few physicians offer written or even verbal instruction related to the development of posttraumatic symptoms. Physician education along with a systematic approach of assessment and intervention is necessary to address the gap between underrecognition of this concern and desired clinical practice.
Key Words: anticipatory guidance child behavior posttraumatic stress disorder trauma
Abbreviations: PTSD, posttraumatic stress disorder ASD, acute stress disorder ASR, acute stress response ED, emergency department STEPP, Screening Tool for Early Predictors of PTSD AAP, American Academy of Pediatrics CI, confidence interval OR, odds ratio
Childhood trauma as a predictor of future psychiatric disability as a result of posttraumatic stress disorder (PTSD) was first suggested in studies conducted with Vietnam War survivors in which veterans with PTSD were more likely to have had childhood trauma than those without PTSD.1–4 Another study found that patients who suffered assaultive violence as children were almost 5 times as likely to develop PTSD after a recurrent stressor in adulthood than adults without history of childhood trauma.5 Most studies have focused on the correlation between the development of PTSD and the type and severity of traumas, history of previous or repetitive traumas, and the immediate stress reaction severity in the adult population.
More attention has been paid recently to PTSD in children. Children seem to be more susceptible to the development of symptoms of acute stress disorder (ASD) and PTSD than adults. Previous studies have described the overall prevalence of PTSD in the adult population to be 8% to 9%,6–8 whereas studies in the pediatric population have described the overall prevalence in children to be 13% to 45%9–12 after traumatic stressors. Other studies have found similar rates of PTSD in children who have witnessed community violence (34%),13 been victims of physical and/or sexual abuse (34–58%),14 or survived war (15–50%).15 One study reported that the prevalence of PTSD in children who witness domestic violence is 93%.16
A growing body of medical research suggests that >4 of 5 children experience symptoms of ASD within the first month after a motor vehicle–related injury,17 and 27% to 36% will have a full diagnosis of ASD or a clinically significant acute stress reaction within days to weeks after the injury.18–20 The presence of ASD symptoms within the first month after injury has been linked to increased risk for subsequent PTSD in adult patients.17,21 Fein et al21 found that 30% of violently injured youths already had evidence of at least 1 acute stress symptom in every diagnostic category when evaluated in the emergency department (ED). Di Gallo et al19 and de Vries et al15 reported that 25% to 33% of pediatric patients would develop PTSD after a motor vehicle–related injury. Peters et al22 showed that 5 of 22 children who were victims of dog attacks met full diagnostic criteria for PTSD within 7 months of the attack and that an additional 7 of 22 children had some symptoms of PTSD within the same time frame. None of these patients received psychological support.
The loss or injury of a loved one during a traumatic event is a highly associated risk factor in the development of PTSD for all patients, especially children.15,17,23,24 Several studies have reported that the severity of injury is not associated as a significant risk factor for developing PTSD.15,21 This phenomenon is felt to be partially due to the perception of injury being more important to future psychiatric disability than the actual injury itself. These same publications reported that although very young age was somewhat protective, risk of PTSD generally increased as the age of the child decreased. Gender differences for risk of developing PTSD exist in most types of trauma, with female gender being more associated with the development of the disorder. Studies by Mirza et al25 and Stallard et al9 showed similar gender differences among victims of motor vehicle injuries as seen in other forms of trauma; however, no significant gender differences were seen among victims of motor vehicle–related injuries15 and violence-related injuries21 in 2 recent prospective studies of PTSD and ASD.
In addition to the demographic risk factors for ASD and PTSD, a growing body of research suggests that the management of pain after a trauma is also predictive of long-term psychiatric morbidity. Hyperadrenergic states such as those seen in painful situations enhance memory,26,27 especially if that pain occurs in the setting of negative emotions.28 Pitman29 proposed that hyperadrenergic states that occur in conjunction with trauma and pain may be responsible for the reexperiencing memory associated with PTSD by stimulating an overconsolidation of traumatic memory with a subsequent additional release of catecholamines and stress hormones in a positive feedback mechanism. Clinical studies in adult patients have shown that elevated heart rate as a marker of adrenergic function at the time of the trauma is predictive of the development of PTSD symptomatology in victims of motor vehicle–related injuries.30,31 Two recent review articles in the psychiatric literature have addressed the need for attention to be paid to the acute management of pain in pediatric trauma victims as a form of secondary prevention of PTSD and ASD.32,33 One prospective clinical trial by Saxe et al34 showed that the relative amount of morphine given to pediatric patients hospitalized in a burn unit was inversely related to the degree of PTSD symptoms 6 months after the injury. Because children generally receive less analgesia than adults in inpatient and outpatient settings, the acute management of pain after trauma is likely another important factor in the development of ASD and PTSD.
Previous literature has suggested that problems of acute and chronic stress reactions in children are more likely to go unnoticed and /or untreated than in their adult counterparts, with subsequently increased risk for additional psychiatric disturbances.15,18,23,35,36 Cost to the health care system and loss of productivity compounds the problem.37,38 Treatments, primarily cognitive-behavioral therapy and pharmacotherapy, have been successful in preventing negative coping behaviors, poor general health, and loss of productivity.24,39,40 Early identification of those at risk for developing PTSD and subsequent intervention may reduce acute morbidity, societal cost, and long-term disability.
Emergency physicians are in a unique position to manage pain and disability immediately after trauma, identify children at risk, provide anticipatory guidance, and refer children to appropriate health care providers if necessary. Fein et al21 and Winston et al41 have developed and refined tools of assessment such as Screening Tool for Early Predictors of PTSD (STEPP) and the Immediate Stress Response Checklist21 to aid in rapid screening of patients in the ED. STEPP has a negative predictive value of 95% in children and 99% in their parents for predicting persistent traumatic stress after injury. Another tool of assessment involves a cartoon-based measure of the cardinal symptoms of PTSD.42 This tool has not been tested as a rapid assessment tool for use in the ED. The ability to provide close follow-up and continuity of care may make the primary care system more effective at both assessment and intervention of PTSD. Despite a number of studies15,17,21,41 and policy statements from the American Academy of Pediatrics (AAP)43,44 suggesting that emergency physicians intervene in the natural history of PTSD through assessment, education, and referral, the degree to which children at risk are recognized and interventions are made has not been reported.
A review of current literature revealed no studies of physician awareness or practice in relation to posttraumatic behavioral changes in children. The objective of this investigation was to evaluate current opinions and practices of a cohort of pediatric emergency care providers regarding their knowledge of PTSD and its associated symptoms, risk factors associated with its development, and their attempts, if any, to intervene in its natural history.
METHODS
A 2-page, anonymous, cross-sectional survey was developed by the investigational team and mailed to members of the AAP Section on Emergency Medicine. Survey items were developed after extensive review of the available literature to address respondents' level of awareness of ASD and PTSD after pediatric trauma and their intervention in its natural history. A pilot administration of the survey was done among 10 members of the division to ascertain problems with individual items and overall ease of survey completion. Changes to the survey were then made to clarify items and improve ease of completion. Respondents were instructed that items in the survey deal only with patients involved in motor vehicle–related injuries. The 30-item survey has (a) 4 items that address level of awareness of the extent to which PTSD and its associated symptoms occur in children and adults, (b) 2 items related to the extent to which parents are aware of problems in their own children and how often they intervene, (c) 6 items concerning the understanding of associated risk predictors, (d) 3 items related to awareness of available tools of assessment and their use, and (e) 6 items regarding approaches used, if any, to provide guidance on these issues to patients and families. All remaining items address demographics of responders. Demographic data include age and gender of respondents, type of facility in which care is provided, type and level of training of the respondents, years of practice, and percentage of total patient population that is pediatric (<18 years old). Both quantitative and qualitative data were collected. The qualitative data consist of comments that respondents were encouraged to provide, primarily regarding ED intervention.
Inclusion criteria were clinical practice within an ED (either general or pediatric) and training or clinical practice track leading to board certification or eligibility for board certification in general emergency medicine, general pediatrics, or pediatric emergency medicine. Surveys returned from physicians not actively practicing in areas of emergency medicine were excluded. Physician members of the AAP Section on Emergency Medicine with addresses outside of the United States were not mailed a survey so that our results would be limited to the unique systems that exist within the United States.
Demographic subgroups such as gender, training background, practice setting, and age were analyzed by using the 2 test, Student's t test, and Fisher's exact test, and other data were reported by using descriptive statistics. EpiInfo (version 3.01) was used for descriptive frequencies. All comparative analysis was performed by using Compare 2 with confidence intervals (CIs) calculated where appropriate. No specific identifiers of person or affiliations were available to the investigators at the time of data entry or analysis. The Emory University Institutional Review Board approved this study.
RESULTS
A total of 923 surveys were mailed to members of the AAP Section on Emergency Medicine. Six surveys were returned by the postal service due to incorrect addresses. A total of 322 completed surveys were returned, for an overall response rate of 35%. Of these respondents, 287 (89%) met the criteria for inclusion. These respondents included 260 (91%) who practice primarily in a pediatric ED and 27 (9%) who practice in a general ED setting caring for children. Most providers (223 [78%]), practiced in a level I or II trauma center. The respondents excluded consisted of 10 physicians who returned their surveys but declined to participate, 17 physicians in primary care practices, 7 physicians in clinical practice outside of general pediatrics or emergency medicine (ie, critical care and anesthesia), and 1 respondent who did not provide information on type of practice. Of the 287 surveys included for analysis, 198 (69%) were from respondents board certified or eligible in pediatric emergency medicine via a fellowship-training track or clinical practice track, 19 (7%) were from respondents board certified or eligible in emergency medicine, and 58 (20%) were from respondents board certified or eligible in general pediatrics who practiced in an ED setting. Demographic information showed a mean and median age of 42 years, with 52% male. Of the respondents, 220 (77%) were in practice 15 years, with 83 (29%) being in the 11- to 15-years-of-practice range.
Of the 287 responses included for analysis, 130 (45%) responded that they believed children were more likely to develop PTSD after a traffic-related injury than adults, whereas 149 (52%) felt that children were equally or less susceptible than adults to developing PTSD (see Table 1). The majority of respondents (164 [57%]), felt that <1 in 5 children would develop symptoms of an acute stress response (ASR) within 1 month after a motor vehicle injury, with only 20 (7%) responding that symptoms would occur at levels previously described (4 in 5 children)23 (see Table 1). Similar findings were found when respondents were asked about the frequency of individual symptom types. Of these respondents, 154 (54%) stated they thought that <1 in 5 patients would develop symptoms of hyperarousal, 171 (60%) felt that <1 in 5 would develop symptoms of reexperiencing, and 201 (70%) stated that <1 in 5 would develop symptoms of avoidance. Most respondents (223 [78%]), felt that <1 in 4 parents would be able to assess posttraumatic stress problems in their children. Likewise, 177 (62%) respondents believed that <1 in 4 parents would seek help if their children developed symptoms of PTSD (see Table 1).
Severity of injury as a risk factor was felt to be "commonly," "usually," or "always" associated with the development of PTSD by 248 (86%) of the respondents. Conversely, only 19 (7%) reported believing that severity of injury is a risk factor "never" or "rarely" as found by de Vries et al15 (see Table 1). Associated parental injury was identified as a risk factor by 250 (87%) of the participants. Most respondents (159 [55%]), felt that younger age was "commonly," "usually," or "always" a risk factor for subsequent PTSD, but 109 (38%) reported believing it was "never" or "rarely" a risk factor. Low income was reported as "never" or "rarely" a risk factor by 133 respondents (46%). Responses regarding female gender as a risk factor showed that 106 (37%) believed that being female was "never" or "rarely" an associated risk factor. Physicians were also asked whether acute pain control after injury was an associated risk factor for subsequent PTSD. Results showed that 202 respondents (70%) answered that acute pain control was "commonly," "usually," or "always" an associated risk factor for the development of PTSD.
Awareness of available tools to assess risk for subsequent PTSD was reported by only 31 respondents (11%; see Table 1). Of those respondents aware of such instruments, 13 (42%) cited the STEPP program.34 Even fewer of the total respondents (6 [2%]) were actually using any tools of assessment at the time of the survey. The tools in use included STEPP, individual psychiatric evaluations, and drawing tools. Most physicians (213 [74%]) stated that they would implement tools of assessment if an effective tool existed, whereas 56 (20%) would not implement such tools in the ED setting (Table 1). Of these 56 physicians, 42 (75%) expressed concerns through their comments that the emergency medical system was an inappropriate venue in which to deal with these concerns. Cost and time constraints were cited by 24 of those that would not implement tools of assessment. The lack of ability to follow-up and refer patients, inadequate psychiatric support in their communities, lack of preexisting relationships with families, and feelings that interventions should be solely under the purview of the primary care and inpatient systems were other reasons cited. Those that would implement tools of assessment left similar comments. Approximately half of the respondents (140 [49%]) had staff resources they believed could administer tools of assessment. Social workers and child life specialists were the most commonly cited staff available.
Physicians reported on their current practices of providing information about posttraumatic stress to their patients and their families. Verbal forms of anticipatory guidance were reportedly given at least once by only 52 (18%) of the physicians in our study population (Table 1). Only 9 of the study physicians (3%) reported ever providing any written forms of information about posttraumatic stress. Most of those responding (242 [84%]) recommend follow-up with the primary care system at least part of the time, but as many as 35 (12%) state that they never recommend follow-up with primary care as part of their discharge instructions. It is interesting that 34 (12%) stated that they have referred patients for psychological evaluation at least once directly from the ED.
Physician gender, subspecialty training, and practice location did not reveal statistically significant differences in responses pertaining to implementation of assessment tools or awareness of the prevalence of posttraumatic symptoms. However, some trends were seen. Female providers tended to be more likely to respond that they would implement tools of assessment than their male counterparts (odds ratio [OR]: 1.89; 95% CI: 0.98–3.73). Physicians in practice for >20 years tended to be more likely to respond that they wouldn't implement tools of assessment when compared with those in practice for 20 years (OR: 1.98; 95% CI: 0.77–4.74). There were no differences seen based on training background or type of practice except that those in academic practice had a trend toward being more aware of available tools of assessment than those in nonacademic practice (OR: 3.93; 95% CI: 0.94–34.97).
Respondents offered overall comments about the survey. Of 44 respondents who left comments, 8 felt that they had little to no education regarding PTSD, 9 expressed a belief that this issue should be addressed in other areas, and 2 expressed comments that suggested doubt in the validity of PTSD as a significant diagnostic entity. One physician reported concern that attempts at intervention might presuggest a problem to occur by reminding patients of the trauma.
DISCUSSION
Children are not just little adults. They have their own set of concerns such as what predisposes them to illness, when their reactive behavior to stress is considered normal or abnormal, and how we as physicians best identify and treat them. Despite data suggesting an increased prevalence of PTSD in children when compared with the adult population, more than half of the respondents were not aware of any increased risk in the pediatric population. Furthermore, the majority of respondents reported that they believed that 25% of children were likely to develop any symptoms of ASRs after injury, which is in contrast to the current literature, which shows that >80% of children will develop at least 1 symptom of an ASR.17 This greatly underestimates the scope of a problem that already has certain diagnostic dilemmas, particularly the use of criteria for diagnosis that do not consider appropriate developmental differences in children of different ages. The Diagnostic and Statistical Manual of Mental Disorders,45 4th edition, criteria require a subject to have coexistent symptom clusters of reexperiencing, avoidance, and hyperarousal in conjunction with an inciting stressor for 1 month for a diagnosis of PTSD and symptom clusters of dissociation, reexperiencing, avoidance, and hyperarousal for <1 month for a diagnosis of ASD. Investigators have recognized that children pose a special diagnostic dilemma, because they often have alternating symptom clusters of reexperiencing and avoidance.36 Reexperiencing symptoms include nightmares, recurrent thematic play, and fear or distress that the trauma will reoccur. Avoidance symptoms include avoiding any reminders or thoughts of the traumatic event, apparent amnesia, sense of a foreshortened future, and loss of interest in usual routine. Avoidance symptoms are also often difficult to assess in children,46 which can lead to potential underdiagnosis of ASD and PTSD by Diagnostic and Statistical Manual of Mental Disorders criteria. ASRs and posttraumatic stress–related symptoms are terms that have been used to describe syndromes in which many but not all criteria for full diagnosis of ASD or PTSD exist in children. One study has shown that children who have incomplete compliments of diagnostic criteria may still have the same level of impairment and distress as children who meet full diagnostic criteria for ASD or PTSD, supporting the belief that many of these children are excluded from full diagnoses simply because of the diagnostic dilemmas mentioned previously.47 Another diagnostic dilemma involves the dependency of children on parents and guardians to express their symptoms for them. Studies have shown that parents tend to minimize their children's symptoms and rarely seek help for these symptoms unless prompted by a clinician.15,18,23,36 de Vries et al15 found that only 46% of parents actually sought assistance for their children with diagnostic PTSD after traffic-related injuries. The results of this investigation suggest that most respondents seem to be aware of parental deficiencies in recognizing problems and seeking help, making it more imperative that the clinician elicit information or give reasonable education about posttraumatic stress. Unfortunately, the results suggest that this is not happening.
Participants seemed to be aware of associated parental injury as a risk factor. Their responses veered from current literature when most expressed the belief that severity of injury is a positive predictor of risk and younger age is an equivocal predictor of risk. This perception of injury severity as a positive risk marker of subsequent PTSD could lead to an underestimation of risk for posttraumatic stress in patients with apparently minor injuries. Furthermore, the increased risk associated with younger age of the patient necessitates a more careful assessment and counseling of younger patients and their families. Responses do not suggest awareness of this particular risk marker among many of the participants. Likewise, female gender and low income were equivocally seen as associated and unassociated risk markers, respectively. Another interesting finding concerned acute pain control after injury as a risk factor for developing PTSD. Seventy percent of the respondents indicated that they believe "[poorly treated]" pain is "commonly," "usually," or "always" a risk factor. Treatment of burn patients with narcotics has been shown to provide some protection against developing symptoms of PTSD, although the mechanism of action is currently not well understood.34 Despite the majority of physicians responding in a manner that suggests they believe pain control is an important factor in the development of future PTSD, recent studies show that pain is still relatively undertreated in pediatric trauma patients cared for in the ED.48,49
Despite the publication of a validated tool of assessment,41 88% of respondents remained unaware of any existing screening tools, and only 6 (2%) actually used such tools. However, the majority (74%) stated that they would implement such tools. Participants who were not likely to implement tools of assessment in the ED argued that the emergency medical system might be an inappropriate point of contact for concerns about posttraumatic stress. Although some respondents seemed to doubt the validity of PTSD as a true entity in their communities, most saw time and cost constraints to additional interventions in the ED as impediments for a system currently stressed in many communities. Several respondents cited poor access to mental health follow-up in their communities. Only half of the respondents could identify staff in their EDs other than physicians who could potentially help administer assessment tools. Although most of the physicians reportedly counseled patients to follow-up with their primary care providers, few counseled them about PTSD. If physicians caring for children in the ED after injury have limited awareness or understanding of risk factors associated with future persistent stress outcomes, it is not surprising that the practice of offering anticipatory guidance is essentially nonexistent. One respondent even suggested that anticipatory guidance might increase the patients' risk for developing PTSD.
Written comments left by physician respondents in this study include admissions that they have little to no knowledge or previous education about posttraumatic stress in children. Other comments included an even mix between praise for our efforts and expressions that our survey was inappropriate for physicians working in emergency care. These written comments highlight the diversity of opinions that many physicians may harbor regarding efforts to include posttraumatic stress concerns into their practice.
Children suffering from posttraumatic stress and potential lifelong morbidity may be falling through the cracks because of the poor ability of families to recognize the problem, difficulties in applying diagnostic criteria, and less than optimal understanding by physicians. It is certain that accurate diagnosis of ASD or PTSD depends on a careful and direct clinical interview by trained personnel; however, clinicians and parents must be aware of the problem and its risk factors and when to be concerned before referrals will occur. Many of those participating in the survey expressed beliefs that the primary care system is already dealing with this problem or should be the point of contact for this problem. The belief that the primary care system is dealing with this problem is not supported by any recent literature. Furthermore, this still leaves those victims of trauma that have no or poor access to a primary care system unattended. These may often be the very children with few other resources of support at greatest risk because of other comorbidities such as community violence and preexisting psychiatric illness. Also, because ASR symptoms occur in >80% of victims of traffic-related injury within 1 month after injury,20 some reassurance to patients and their families about the development of these symptoms and the likelihood that they will diminish with time also seems warranted.
PTSD by its very definition cannot be diagnosed in an initial encounter; therefore, medical follow-up is appropriate. Many, if not most, conditions are best handled in a continuum of effort between the emergency medical system and the primary care system. This problem could be handled in a similar manner. Ideally, timely and effective posttrauma care in the ED could be coupled with follow-up in either the primary care or trauma system. An initial global screening with an assessment tool such as STEPP could help to stratify the risk for levels of anticipatory guidance and intensity of follow-up. Follow-up with a primary care or trauma system could further assess development or resolution of symptoms and the extent to which a patient may be debilitated. Many patients will make a spontaneous recovery from the symptoms of ASD and will not require additional care, but patients of high concern for long-term sequelae could be referred for more specialized psychiatric evaluation and treatment. Two previous AAP policy statements on youth violence43 and the ED's role in enhancing follow-up care for all children44 direct physicians providing emergency care to address issues such as these. As such, children's physical and emotional concerns should be addressed, and follow-up care should be facilitated. However, the already-strained emergency medical system may not be able or willing to assume more responsibilities of long-term or preventive care.
For physicians providing emergency care, the first step is to improve awareness of posttraumatic stress as a problem that children face, markers of increased risk, and available interventions that may be used in the ED such as screening tools and anticipatory guidance. Efforts to improve the link between the primary care and the emergency medical systems should continue to improve follow-up availability and necessary interventions. The majority of respondents seem interested in providing good care for these patients but may differ on where or when the most appropriate point to provide such care is. Assuming more responsibility to a system that has significant resource constraints is a valid concern and cannot be ignored if care for these patients is to improve.
Limitations
Inclusion criteria limited the data to information from physicians who provide emergency care for children. The study can make no generalization to physicians whose scope of practice is outside of the ED, although some of the respondents listed both primary care and emergency care within their scope of practice. Some significant differences may be seen among a cohort of primary care physicians in both their understanding of PTSD and their practice regarding care of patients at risk.
Because of the fact that data acquisition is from an anonymous survey, no follow-up information can be obtained to compare responders to nonresponders or to further qualify certain information left by participants. It remains unclear if nonresponders' level of understanding and practice would differ greatly from participants. Results may be biased toward physicians with a greater interest in PTSD or those with greater resources, such as might be seen at larger academic institutions, which may exaggerate the overall physician awareness of the problem and practices of anticipatory guidance. However, given the apparent level of understanding and practice found in the responses, this result further highlights the need for education and change.
Reporting bias is expected because of a desire of individuals to demonstrate knowledge and report that they provide the most comprehensive care. Likewise, the central tendency bias of the responders will affect outcomes. Because these results are a collection of memories, opinions, and experiences, they cannot be said to definitively represent clinical practice. However, one would expect recall to, if anything, overreport best-practice patterns, raising even more concerns regarding the poor level of understanding and interventions reported.
Conclusions and Implications
PTSD and ASD are problems that occur in children after injury. Many of these children will present to an ED for care. Access to primary care is poor or absent in many of the patients we treat, who are often those at the most risk of repetitive injury, exposure to community violence, preexisting psychiatric disorders, and strained parental support. Unfortunately, the findings suggest that many physicians who provide emergency care for children underestimate the likely development of an ASR and PTSD in the pediatric population. Few physicians are providing even basic anticipatory guidance in current practice. The majority of physicians surveyed show an interest in attempts to improve care for these children, but they desire effective tools of assessment and evidence that these efforts will improve the outcome of their patients. A disconnect exists in attempts to provide this care for children who are victims of trauma. Therefore, education to improve physician awareness of posttraumatic behavioral changes in children is paramount. More study is necessary to determine if time- and cost-effective tools can be accepted and implemented in the emergency care system or if primary care systems can provide follow-up, assessment, and treatment in conjunction with effective anticipatory guidance from the ED.
FOOTNOTES
Accepted Sep 28, 2004.
No conflict of interest declared.
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ABSTRACT
Background. Research suggests that up to 4 of 5 children experience symptoms of an acute stress response (ASR) after a motor vehicle–related injury, and 25% will develop posttraumatic stress disorder (PTSD). The degree to which physicians recognize this problem has not been reported. Our objective was to evaluate current awareness and practices of a cohort of pediatric emergency care providers regarding posttraumatic stress in children.
Methods. Participants were identified from a list of the American Academy of Pediatrics Section on Emergency Medicine and surveyed on their awareness of ASR after motor vehicle–related injury, risk factors for developing PTSD, and practices regarding emergency department (ED) interventions. Surveys from physicians not practicing clinical emergency medicine were excluded.
Results. Of 322 surveys returned, 287 responses met inclusion criteria. Among these respondents, 198 (69%) were pediatric emergency medicine board certified or eligible and 260 (91%) practiced in a designated pediatric ED. Only 20 of 287 respondents (7%) believed that children were likely to develop symptoms of posttraumatic stress at levels previously described. Also in contrast to recent literature, 248 respondents (86%) felt that severity of injury was associated with future development of PTSD. Associated parental injury was identified accurately as a risk factor by 250 respondents (87%). Of interest, only 31 respondents (11%) were aware of any available tools to assess risk for PTSD. In addition, 56 of 287 respondents (20%) indicated that they would not use such tools in the ED, most commonly citing time and cost constraints. Finally, only 52 respondents (18%) reported giving any verbal guidance and only 9 (3%) provided any written instructions about posttraumatic stress to their patients and families.
Conclusions. Findings suggest that physicians underestimate the likely development of an ASR and PTSD in the pediatric population. At present, few physicians offer written or even verbal instruction related to the development of posttraumatic symptoms. Physician education along with a systematic approach of assessment and intervention is necessary to address the gap between underrecognition of this concern and desired clinical practice.
Key Words: anticipatory guidance child behavior posttraumatic stress disorder trauma
Abbreviations: PTSD, posttraumatic stress disorder ASD, acute stress disorder ASR, acute stress response ED, emergency department STEPP, Screening Tool for Early Predictors of PTSD AAP, American Academy of Pediatrics CI, confidence interval OR, odds ratio
Childhood trauma as a predictor of future psychiatric disability as a result of posttraumatic stress disorder (PTSD) was first suggested in studies conducted with Vietnam War survivors in which veterans with PTSD were more likely to have had childhood trauma than those without PTSD.1–4 Another study found that patients who suffered assaultive violence as children were almost 5 times as likely to develop PTSD after a recurrent stressor in adulthood than adults without history of childhood trauma.5 Most studies have focused on the correlation between the development of PTSD and the type and severity of traumas, history of previous or repetitive traumas, and the immediate stress reaction severity in the adult population.
More attention has been paid recently to PTSD in children. Children seem to be more susceptible to the development of symptoms of acute stress disorder (ASD) and PTSD than adults. Previous studies have described the overall prevalence of PTSD in the adult population to be 8% to 9%,6–8 whereas studies in the pediatric population have described the overall prevalence in children to be 13% to 45%9–12 after traumatic stressors. Other studies have found similar rates of PTSD in children who have witnessed community violence (34%),13 been victims of physical and/or sexual abuse (34–58%),14 or survived war (15–50%).15 One study reported that the prevalence of PTSD in children who witness domestic violence is 93%.16
A growing body of medical research suggests that >4 of 5 children experience symptoms of ASD within the first month after a motor vehicle–related injury,17 and 27% to 36% will have a full diagnosis of ASD or a clinically significant acute stress reaction within days to weeks after the injury.18–20 The presence of ASD symptoms within the first month after injury has been linked to increased risk for subsequent PTSD in adult patients.17,21 Fein et al21 found that 30% of violently injured youths already had evidence of at least 1 acute stress symptom in every diagnostic category when evaluated in the emergency department (ED). Di Gallo et al19 and de Vries et al15 reported that 25% to 33% of pediatric patients would develop PTSD after a motor vehicle–related injury. Peters et al22 showed that 5 of 22 children who were victims of dog attacks met full diagnostic criteria for PTSD within 7 months of the attack and that an additional 7 of 22 children had some symptoms of PTSD within the same time frame. None of these patients received psychological support.
The loss or injury of a loved one during a traumatic event is a highly associated risk factor in the development of PTSD for all patients, especially children.15,17,23,24 Several studies have reported that the severity of injury is not associated as a significant risk factor for developing PTSD.15,21 This phenomenon is felt to be partially due to the perception of injury being more important to future psychiatric disability than the actual injury itself. These same publications reported that although very young age was somewhat protective, risk of PTSD generally increased as the age of the child decreased. Gender differences for risk of developing PTSD exist in most types of trauma, with female gender being more associated with the development of the disorder. Studies by Mirza et al25 and Stallard et al9 showed similar gender differences among victims of motor vehicle injuries as seen in other forms of trauma; however, no significant gender differences were seen among victims of motor vehicle–related injuries15 and violence-related injuries21 in 2 recent prospective studies of PTSD and ASD.
In addition to the demographic risk factors for ASD and PTSD, a growing body of research suggests that the management of pain after a trauma is also predictive of long-term psychiatric morbidity. Hyperadrenergic states such as those seen in painful situations enhance memory,26,27 especially if that pain occurs in the setting of negative emotions.28 Pitman29 proposed that hyperadrenergic states that occur in conjunction with trauma and pain may be responsible for the reexperiencing memory associated with PTSD by stimulating an overconsolidation of traumatic memory with a subsequent additional release of catecholamines and stress hormones in a positive feedback mechanism. Clinical studies in adult patients have shown that elevated heart rate as a marker of adrenergic function at the time of the trauma is predictive of the development of PTSD symptomatology in victims of motor vehicle–related injuries.30,31 Two recent review articles in the psychiatric literature have addressed the need for attention to be paid to the acute management of pain in pediatric trauma victims as a form of secondary prevention of PTSD and ASD.32,33 One prospective clinical trial by Saxe et al34 showed that the relative amount of morphine given to pediatric patients hospitalized in a burn unit was inversely related to the degree of PTSD symptoms 6 months after the injury. Because children generally receive less analgesia than adults in inpatient and outpatient settings, the acute management of pain after trauma is likely another important factor in the development of ASD and PTSD.
Previous literature has suggested that problems of acute and chronic stress reactions in children are more likely to go unnoticed and /or untreated than in their adult counterparts, with subsequently increased risk for additional psychiatric disturbances.15,18,23,35,36 Cost to the health care system and loss of productivity compounds the problem.37,38 Treatments, primarily cognitive-behavioral therapy and pharmacotherapy, have been successful in preventing negative coping behaviors, poor general health, and loss of productivity.24,39,40 Early identification of those at risk for developing PTSD and subsequent intervention may reduce acute morbidity, societal cost, and long-term disability.
Emergency physicians are in a unique position to manage pain and disability immediately after trauma, identify children at risk, provide anticipatory guidance, and refer children to appropriate health care providers if necessary. Fein et al21 and Winston et al41 have developed and refined tools of assessment such as Screening Tool for Early Predictors of PTSD (STEPP) and the Immediate Stress Response Checklist21 to aid in rapid screening of patients in the ED. STEPP has a negative predictive value of 95% in children and 99% in their parents for predicting persistent traumatic stress after injury. Another tool of assessment involves a cartoon-based measure of the cardinal symptoms of PTSD.42 This tool has not been tested as a rapid assessment tool for use in the ED. The ability to provide close follow-up and continuity of care may make the primary care system more effective at both assessment and intervention of PTSD. Despite a number of studies15,17,21,41 and policy statements from the American Academy of Pediatrics (AAP)43,44 suggesting that emergency physicians intervene in the natural history of PTSD through assessment, education, and referral, the degree to which children at risk are recognized and interventions are made has not been reported.
A review of current literature revealed no studies of physician awareness or practice in relation to posttraumatic behavioral changes in children. The objective of this investigation was to evaluate current opinions and practices of a cohort of pediatric emergency care providers regarding their knowledge of PTSD and its associated symptoms, risk factors associated with its development, and their attempts, if any, to intervene in its natural history.
METHODS
A 2-page, anonymous, cross-sectional survey was developed by the investigational team and mailed to members of the AAP Section on Emergency Medicine. Survey items were developed after extensive review of the available literature to address respondents' level of awareness of ASD and PTSD after pediatric trauma and their intervention in its natural history. A pilot administration of the survey was done among 10 members of the division to ascertain problems with individual items and overall ease of survey completion. Changes to the survey were then made to clarify items and improve ease of completion. Respondents were instructed that items in the survey deal only with patients involved in motor vehicle–related injuries. The 30-item survey has (a) 4 items that address level of awareness of the extent to which PTSD and its associated symptoms occur in children and adults, (b) 2 items related to the extent to which parents are aware of problems in their own children and how often they intervene, (c) 6 items concerning the understanding of associated risk predictors, (d) 3 items related to awareness of available tools of assessment and their use, and (e) 6 items regarding approaches used, if any, to provide guidance on these issues to patients and families. All remaining items address demographics of responders. Demographic data include age and gender of respondents, type of facility in which care is provided, type and level of training of the respondents, years of practice, and percentage of total patient population that is pediatric (<18 years old). Both quantitative and qualitative data were collected. The qualitative data consist of comments that respondents were encouraged to provide, primarily regarding ED intervention.
Inclusion criteria were clinical practice within an ED (either general or pediatric) and training or clinical practice track leading to board certification or eligibility for board certification in general emergency medicine, general pediatrics, or pediatric emergency medicine. Surveys returned from physicians not actively practicing in areas of emergency medicine were excluded. Physician members of the AAP Section on Emergency Medicine with addresses outside of the United States were not mailed a survey so that our results would be limited to the unique systems that exist within the United States.
Demographic subgroups such as gender, training background, practice setting, and age were analyzed by using the 2 test, Student's t test, and Fisher's exact test, and other data were reported by using descriptive statistics. EpiInfo (version 3.01) was used for descriptive frequencies. All comparative analysis was performed by using Compare 2 with confidence intervals (CIs) calculated where appropriate. No specific identifiers of person or affiliations were available to the investigators at the time of data entry or analysis. The Emory University Institutional Review Board approved this study.
RESULTS
A total of 923 surveys were mailed to members of the AAP Section on Emergency Medicine. Six surveys were returned by the postal service due to incorrect addresses. A total of 322 completed surveys were returned, for an overall response rate of 35%. Of these respondents, 287 (89%) met the criteria for inclusion. These respondents included 260 (91%) who practice primarily in a pediatric ED and 27 (9%) who practice in a general ED setting caring for children. Most providers (223 [78%]), practiced in a level I or II trauma center. The respondents excluded consisted of 10 physicians who returned their surveys but declined to participate, 17 physicians in primary care practices, 7 physicians in clinical practice outside of general pediatrics or emergency medicine (ie, critical care and anesthesia), and 1 respondent who did not provide information on type of practice. Of the 287 surveys included for analysis, 198 (69%) were from respondents board certified or eligible in pediatric emergency medicine via a fellowship-training track or clinical practice track, 19 (7%) were from respondents board certified or eligible in emergency medicine, and 58 (20%) were from respondents board certified or eligible in general pediatrics who practiced in an ED setting. Demographic information showed a mean and median age of 42 years, with 52% male. Of the respondents, 220 (77%) were in practice 15 years, with 83 (29%) being in the 11- to 15-years-of-practice range.
Of the 287 responses included for analysis, 130 (45%) responded that they believed children were more likely to develop PTSD after a traffic-related injury than adults, whereas 149 (52%) felt that children were equally or less susceptible than adults to developing PTSD (see Table 1). The majority of respondents (164 [57%]), felt that <1 in 5 children would develop symptoms of an acute stress response (ASR) within 1 month after a motor vehicle injury, with only 20 (7%) responding that symptoms would occur at levels previously described (4 in 5 children)23 (see Table 1). Similar findings were found when respondents were asked about the frequency of individual symptom types. Of these respondents, 154 (54%) stated they thought that <1 in 5 patients would develop symptoms of hyperarousal, 171 (60%) felt that <1 in 5 would develop symptoms of reexperiencing, and 201 (70%) stated that <1 in 5 would develop symptoms of avoidance. Most respondents (223 [78%]), felt that <1 in 4 parents would be able to assess posttraumatic stress problems in their children. Likewise, 177 (62%) respondents believed that <1 in 4 parents would seek help if their children developed symptoms of PTSD (see Table 1).
Severity of injury as a risk factor was felt to be "commonly," "usually," or "always" associated with the development of PTSD by 248 (86%) of the respondents. Conversely, only 19 (7%) reported believing that severity of injury is a risk factor "never" or "rarely" as found by de Vries et al15 (see Table 1). Associated parental injury was identified as a risk factor by 250 (87%) of the participants. Most respondents (159 [55%]), felt that younger age was "commonly," "usually," or "always" a risk factor for subsequent PTSD, but 109 (38%) reported believing it was "never" or "rarely" a risk factor. Low income was reported as "never" or "rarely" a risk factor by 133 respondents (46%). Responses regarding female gender as a risk factor showed that 106 (37%) believed that being female was "never" or "rarely" an associated risk factor. Physicians were also asked whether acute pain control after injury was an associated risk factor for subsequent PTSD. Results showed that 202 respondents (70%) answered that acute pain control was "commonly," "usually," or "always" an associated risk factor for the development of PTSD.
Awareness of available tools to assess risk for subsequent PTSD was reported by only 31 respondents (11%; see Table 1). Of those respondents aware of such instruments, 13 (42%) cited the STEPP program.34 Even fewer of the total respondents (6 [2%]) were actually using any tools of assessment at the time of the survey. The tools in use included STEPP, individual psychiatric evaluations, and drawing tools. Most physicians (213 [74%]) stated that they would implement tools of assessment if an effective tool existed, whereas 56 (20%) would not implement such tools in the ED setting (Table 1). Of these 56 physicians, 42 (75%) expressed concerns through their comments that the emergency medical system was an inappropriate venue in which to deal with these concerns. Cost and time constraints were cited by 24 of those that would not implement tools of assessment. The lack of ability to follow-up and refer patients, inadequate psychiatric support in their communities, lack of preexisting relationships with families, and feelings that interventions should be solely under the purview of the primary care and inpatient systems were other reasons cited. Those that would implement tools of assessment left similar comments. Approximately half of the respondents (140 [49%]) had staff resources they believed could administer tools of assessment. Social workers and child life specialists were the most commonly cited staff available.
Physicians reported on their current practices of providing information about posttraumatic stress to their patients and their families. Verbal forms of anticipatory guidance were reportedly given at least once by only 52 (18%) of the physicians in our study population (Table 1). Only 9 of the study physicians (3%) reported ever providing any written forms of information about posttraumatic stress. Most of those responding (242 [84%]) recommend follow-up with the primary care system at least part of the time, but as many as 35 (12%) state that they never recommend follow-up with primary care as part of their discharge instructions. It is interesting that 34 (12%) stated that they have referred patients for psychological evaluation at least once directly from the ED.
Physician gender, subspecialty training, and practice location did not reveal statistically significant differences in responses pertaining to implementation of assessment tools or awareness of the prevalence of posttraumatic symptoms. However, some trends were seen. Female providers tended to be more likely to respond that they would implement tools of assessment than their male counterparts (odds ratio [OR]: 1.89; 95% CI: 0.98–3.73). Physicians in practice for >20 years tended to be more likely to respond that they wouldn't implement tools of assessment when compared with those in practice for 20 years (OR: 1.98; 95% CI: 0.77–4.74). There were no differences seen based on training background or type of practice except that those in academic practice had a trend toward being more aware of available tools of assessment than those in nonacademic practice (OR: 3.93; 95% CI: 0.94–34.97).
Respondents offered overall comments about the survey. Of 44 respondents who left comments, 8 felt that they had little to no education regarding PTSD, 9 expressed a belief that this issue should be addressed in other areas, and 2 expressed comments that suggested doubt in the validity of PTSD as a significant diagnostic entity. One physician reported concern that attempts at intervention might presuggest a problem to occur by reminding patients of the trauma.
DISCUSSION
Children are not just little adults. They have their own set of concerns such as what predisposes them to illness, when their reactive behavior to stress is considered normal or abnormal, and how we as physicians best identify and treat them. Despite data suggesting an increased prevalence of PTSD in children when compared with the adult population, more than half of the respondents were not aware of any increased risk in the pediatric population. Furthermore, the majority of respondents reported that they believed that 25% of children were likely to develop any symptoms of ASRs after injury, which is in contrast to the current literature, which shows that >80% of children will develop at least 1 symptom of an ASR.17 This greatly underestimates the scope of a problem that already has certain diagnostic dilemmas, particularly the use of criteria for diagnosis that do not consider appropriate developmental differences in children of different ages. The Diagnostic and Statistical Manual of Mental Disorders,45 4th edition, criteria require a subject to have coexistent symptom clusters of reexperiencing, avoidance, and hyperarousal in conjunction with an inciting stressor for 1 month for a diagnosis of PTSD and symptom clusters of dissociation, reexperiencing, avoidance, and hyperarousal for <1 month for a diagnosis of ASD. Investigators have recognized that children pose a special diagnostic dilemma, because they often have alternating symptom clusters of reexperiencing and avoidance.36 Reexperiencing symptoms include nightmares, recurrent thematic play, and fear or distress that the trauma will reoccur. Avoidance symptoms include avoiding any reminders or thoughts of the traumatic event, apparent amnesia, sense of a foreshortened future, and loss of interest in usual routine. Avoidance symptoms are also often difficult to assess in children,46 which can lead to potential underdiagnosis of ASD and PTSD by Diagnostic and Statistical Manual of Mental Disorders criteria. ASRs and posttraumatic stress–related symptoms are terms that have been used to describe syndromes in which many but not all criteria for full diagnosis of ASD or PTSD exist in children. One study has shown that children who have incomplete compliments of diagnostic criteria may still have the same level of impairment and distress as children who meet full diagnostic criteria for ASD or PTSD, supporting the belief that many of these children are excluded from full diagnoses simply because of the diagnostic dilemmas mentioned previously.47 Another diagnostic dilemma involves the dependency of children on parents and guardians to express their symptoms for them. Studies have shown that parents tend to minimize their children's symptoms and rarely seek help for these symptoms unless prompted by a clinician.15,18,23,36 de Vries et al15 found that only 46% of parents actually sought assistance for their children with diagnostic PTSD after traffic-related injuries. The results of this investigation suggest that most respondents seem to be aware of parental deficiencies in recognizing problems and seeking help, making it more imperative that the clinician elicit information or give reasonable education about posttraumatic stress. Unfortunately, the results suggest that this is not happening.
Participants seemed to be aware of associated parental injury as a risk factor. Their responses veered from current literature when most expressed the belief that severity of injury is a positive predictor of risk and younger age is an equivocal predictor of risk. This perception of injury severity as a positive risk marker of subsequent PTSD could lead to an underestimation of risk for posttraumatic stress in patients with apparently minor injuries. Furthermore, the increased risk associated with younger age of the patient necessitates a more careful assessment and counseling of younger patients and their families. Responses do not suggest awareness of this particular risk marker among many of the participants. Likewise, female gender and low income were equivocally seen as associated and unassociated risk markers, respectively. Another interesting finding concerned acute pain control after injury as a risk factor for developing PTSD. Seventy percent of the respondents indicated that they believe "[poorly treated]" pain is "commonly," "usually," or "always" a risk factor. Treatment of burn patients with narcotics has been shown to provide some protection against developing symptoms of PTSD, although the mechanism of action is currently not well understood.34 Despite the majority of physicians responding in a manner that suggests they believe pain control is an important factor in the development of future PTSD, recent studies show that pain is still relatively undertreated in pediatric trauma patients cared for in the ED.48,49
Despite the publication of a validated tool of assessment,41 88% of respondents remained unaware of any existing screening tools, and only 6 (2%) actually used such tools. However, the majority (74%) stated that they would implement such tools. Participants who were not likely to implement tools of assessment in the ED argued that the emergency medical system might be an inappropriate point of contact for concerns about posttraumatic stress. Although some respondents seemed to doubt the validity of PTSD as a true entity in their communities, most saw time and cost constraints to additional interventions in the ED as impediments for a system currently stressed in many communities. Several respondents cited poor access to mental health follow-up in their communities. Only half of the respondents could identify staff in their EDs other than physicians who could potentially help administer assessment tools. Although most of the physicians reportedly counseled patients to follow-up with their primary care providers, few counseled them about PTSD. If physicians caring for children in the ED after injury have limited awareness or understanding of risk factors associated with future persistent stress outcomes, it is not surprising that the practice of offering anticipatory guidance is essentially nonexistent. One respondent even suggested that anticipatory guidance might increase the patients' risk for developing PTSD.
Written comments left by physician respondents in this study include admissions that they have little to no knowledge or previous education about posttraumatic stress in children. Other comments included an even mix between praise for our efforts and expressions that our survey was inappropriate for physicians working in emergency care. These written comments highlight the diversity of opinions that many physicians may harbor regarding efforts to include posttraumatic stress concerns into their practice.
Children suffering from posttraumatic stress and potential lifelong morbidity may be falling through the cracks because of the poor ability of families to recognize the problem, difficulties in applying diagnostic criteria, and less than optimal understanding by physicians. It is certain that accurate diagnosis of ASD or PTSD depends on a careful and direct clinical interview by trained personnel; however, clinicians and parents must be aware of the problem and its risk factors and when to be concerned before referrals will occur. Many of those participating in the survey expressed beliefs that the primary care system is already dealing with this problem or should be the point of contact for this problem. The belief that the primary care system is dealing with this problem is not supported by any recent literature. Furthermore, this still leaves those victims of trauma that have no or poor access to a primary care system unattended. These may often be the very children with few other resources of support at greatest risk because of other comorbidities such as community violence and preexisting psychiatric illness. Also, because ASR symptoms occur in >80% of victims of traffic-related injury within 1 month after injury,20 some reassurance to patients and their families about the development of these symptoms and the likelihood that they will diminish with time also seems warranted.
PTSD by its very definition cannot be diagnosed in an initial encounter; therefore, medical follow-up is appropriate. Many, if not most, conditions are best handled in a continuum of effort between the emergency medical system and the primary care system. This problem could be handled in a similar manner. Ideally, timely and effective posttrauma care in the ED could be coupled with follow-up in either the primary care or trauma system. An initial global screening with an assessment tool such as STEPP could help to stratify the risk for levels of anticipatory guidance and intensity of follow-up. Follow-up with a primary care or trauma system could further assess development or resolution of symptoms and the extent to which a patient may be debilitated. Many patients will make a spontaneous recovery from the symptoms of ASD and will not require additional care, but patients of high concern for long-term sequelae could be referred for more specialized psychiatric evaluation and treatment. Two previous AAP policy statements on youth violence43 and the ED's role in enhancing follow-up care for all children44 direct physicians providing emergency care to address issues such as these. As such, children's physical and emotional concerns should be addressed, and follow-up care should be facilitated. However, the already-strained emergency medical system may not be able or willing to assume more responsibilities of long-term or preventive care.
For physicians providing emergency care, the first step is to improve awareness of posttraumatic stress as a problem that children face, markers of increased risk, and available interventions that may be used in the ED such as screening tools and anticipatory guidance. Efforts to improve the link between the primary care and the emergency medical systems should continue to improve follow-up availability and necessary interventions. The majority of respondents seem interested in providing good care for these patients but may differ on where or when the most appropriate point to provide such care is. Assuming more responsibility to a system that has significant resource constraints is a valid concern and cannot be ignored if care for these patients is to improve.
Limitations
Inclusion criteria limited the data to information from physicians who provide emergency care for children. The study can make no generalization to physicians whose scope of practice is outside of the ED, although some of the respondents listed both primary care and emergency care within their scope of practice. Some significant differences may be seen among a cohort of primary care physicians in both their understanding of PTSD and their practice regarding care of patients at risk.
Because of the fact that data acquisition is from an anonymous survey, no follow-up information can be obtained to compare responders to nonresponders or to further qualify certain information left by participants. It remains unclear if nonresponders' level of understanding and practice would differ greatly from participants. Results may be biased toward physicians with a greater interest in PTSD or those with greater resources, such as might be seen at larger academic institutions, which may exaggerate the overall physician awareness of the problem and practices of anticipatory guidance. However, given the apparent level of understanding and practice found in the responses, this result further highlights the need for education and change.
Reporting bias is expected because of a desire of individuals to demonstrate knowledge and report that they provide the most comprehensive care. Likewise, the central tendency bias of the responders will affect outcomes. Because these results are a collection of memories, opinions, and experiences, they cannot be said to definitively represent clinical practice. However, one would expect recall to, if anything, overreport best-practice patterns, raising even more concerns regarding the poor level of understanding and interventions reported.
Conclusions and Implications
PTSD and ASD are problems that occur in children after injury. Many of these children will present to an ED for care. Access to primary care is poor or absent in many of the patients we treat, who are often those at the most risk of repetitive injury, exposure to community violence, preexisting psychiatric disorders, and strained parental support. Unfortunately, the findings suggest that many physicians who provide emergency care for children underestimate the likely development of an ASR and PTSD in the pediatric population. Few physicians are providing even basic anticipatory guidance in current practice. The majority of physicians surveyed show an interest in attempts to improve care for these children, but they desire effective tools of assessment and evidence that these efforts will improve the outcome of their patients. A disconnect exists in attempts to provide this care for children who are victims of trauma. Therefore, education to improve physician awareness of posttraumatic behavioral changes in children is paramount. More study is necessary to determine if time- and cost-effective tools can be accepted and implemented in the emergency care system or if primary care systems can provide follow-up, assessment, and treatment in conjunction with effective anticipatory guidance from the ED.
FOOTNOTES
Accepted Sep 28, 2004.
No conflict of interest declared.
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