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Trajectory of Post-Traumatic Stress During the First Year after Pediatric Traumatic Brain or Orthopedic Injury
Linda Ewing-Cobbs1, Charles S Cox2, Amy Clark3
1Department of Pediatrics and Children's Learning Institute, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas, USA.
Insights
Children with traumatic brain injury (TBI) show higher post-traumatic stress symptoms (PTSS) than orthopedic injury patients. Mild TBI and adolescent females are particularly at risk, highlighting the need for targeted interventions.
Area of Science:
- Pediatric Traumatology
- Neuropsychology
- Child Psychiatry
Background:
- Post-traumatic stress symptoms (PTSS) affect up to 50% of children after physical injury.
- Limited research exists on PTSS trajectories following traumatic brain injury (TBI), especially compared to orthopedic injuries (OI).
- Understanding injury type and severity's influence on PTSS is crucial for effective intervention.
Purpose of the Study:
- To examine the longitudinal course of self-reported PTSS severity in children after TBI versus OI.
- To investigate the impact of injury variables, demographics, and pre-injury functioning on PTSS.
- To identify specific risk factors for persistent PTSS in pediatric injury populations.
Main Methods:
- A longitudinal prospective cohort study involving 265 children (ages 9-15) with TBI or OI recruited from trauma centers.
- Children's self-reported PTSS were assessed using the Children's PTSD Symptom Scale (CPSS) at 3, 6, and 12 months post-injury.
- General linear mixed models analyzed the influence of injury type, severity, age, sex, and time on CPSS scores, with pre-injury functioning as predictors.
Main Results:
- Patients with TBI exhibited significantly higher mean CPSS scores than those with OI across all follow-up points.
- Mild TBI (mTBI) was associated with the highest PTSS scores compared to OI and more severe TBI.
- Adolescent females reported higher PTSS than younger males, particularly at 6 and 12 months post-injury.
Conclusions:
- PTSS persist in a significant minority of children with TBI, especially those with mTBI, throughout the first year.
- Poorer pre-injury family functioning and higher child anxiety, affective, and conduct problems predict increased symptom burden.
- Screening for PTSS risk factors is essential to target interventions for children with TBI, aligning with trauma care standards.
Abstract:
Up to 50% of children sustaining physical injury develop post-traumatic stress symptoms (PTSS). Most studies of PTSS have not included patients with traumatic brain injury (TBI); consequently, the influence of injury type and severity on the longitudinal course of PTSS is unclear. To address this gap, we completed a longitudinal prospective cohort study examining the trajectory of self-reported PTSS severity during the first year after TBI or orthopedic injury (OI). Within a biopsychosocial framework, we examined PTSS in relation to injury variables, demographic characteristics, and pre-injury child and family functioning. Patients ages 9-15 years with TBI or OI were recruited from two level I pediatric trauma centers. Online surveys were completed as soon as possible following injury (mdn = 8 days). Caregivers rated pre-injury family, sociodemographic, and child characteristics. Follow-up surveys assessing children's self-reported PTSS using the Children's PTSD Symptom Scale (CPSS) were scheduled 3,6, and 12 months after injury. English-speaking families completed surveys either online or by telephone interview; Spanish-speaking families were interviewed. Baseline surveys were completed by 303 families; 265 (87%) completed at least 1 follow-up and comprised the cohort. General linear mixed models examined the influence of injury group and severity, age, sex, and time of assessment on CPSS scores. Pre-injury estimates of child and family functioning were examined as predictors in supplemental models. Participants (72% boys, mean [SD] age 12.7 [1.9] years) included 204 with TBI (76 mild, 82 complicated-mild/moderate, 46 severe) and 61 with OI. Relative to OI, patients with TBI had significantly elevated mean CPSS scores at 3 (3.7 points, 95% confidence intervals [CI]: 1.1, 6.3); 6 (3.2, 95% CI: 0.7, 5.7) and 12 months (2.3, 95% CI: 0.1, 4.5). The primary model indicated that TBI severity had a nonlinear relation with CPSS. Mild TBI (mTBI) had the highest mean scores; with significant differences relative to OI at 3 (4.6 points, 95% CI: 1.6, 7.6); 6 (5.7, 95% CI: 2.7, 8.6) and 12 months (3.2, 95% CI: 0.6, 5.8). This model also revealed that adolescent females had higher CPSS scores than children or adolescent males. Differences relative to younger males at 6 and 12 months were 4.9 (95% CI: 1.6, 8.3) and 5.0 points (95% CI: 2.1, 8.0). In supplemental models, higher symptom burden was associated with poorer baseline family functioning and with higher levels of children's pre-injury anxiety, affective problems, and conduct problems. PTSS persisted for a significant minority of patients with TBI across the first year of recovery, particularly those with mTBI. Screening should emphasize risk factors to target patients with the greatest need for trauma-focused intervention. Cost-effective, scalable, evidence-based trauma-focused interventions are essential to meet American College of Surgeons standards to provide psychological screening and treatment to children sustaining PTSS.
