COGNITIVE FACTORS ARE ASSOCIATED WITH ...

COGNITIVE FACTORS ARE ASSOCIATED WITH CHILDREN’S PTSS

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Cognitive/Affective Factors are Associated with Children’s Acute Posttraumatic Stress Following Pediatric Intensive Care

Belinda L. Dow and Justin A. Kenardy The University of Queensland Deborah A. Long Lady Cilento Children’s Hospital Robyne M. Le Brocque The University of Queensland

Author Note Belinda L. Dow, RECOVER Injury Research Centre, University of Queensland; Justin A. Kenardy, RECOVER Injury Research Centre, University of Queensland; Deborah A. Long, Paediatric Intensive Care Unit, Lady Cilento Children’s Hospital; Robyne M. Le Brocque, University of Queensland. Belinda Dow was supported by an Australian Postgraduate Award, Royal Children’s Hospital Foundation Top-Up Scholarship, CONROD Top-Up Scholarship, and the UQ Joseph Sleight Bursary. This study was also supported in part by a Royal Children’s Hospital Foundation “Near Miss” Research Grant, Grant no. 10261. The authors would like to thank all families who participated in this research study. Correspondence concerning this article should be addressed to Belinda Dow, University of Queensland, Centre for Children’s Health Research, Level 7, 62 Graham Street, South Brisbane Qld 4101, Australia. Email: [email protected]

©American Psychological Association, 2017. This paper is not the copy of record and may not exactly replicate the authoritative document published in the APA journal. Please do not copy or cite without author's permission. The final article is available, upon publication, at: http://psycnet.apa.org/PsycARTICLES/journal/tra


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Abstract Objective: This study aimed to explore children’s experiences and memories of the Pediatric Intensive Care Unit (PICU) and identify the relative importance of premorbid, trauma and cognitive/affective variables associated with acute posttraumatic stress symptoms (PTSS). Method: Participants were 95 children aged 6-16 admitted to the PICU, and their parents. Children completed questionnaires and an interview assessing PTSS, peri-trauma affect, and their memory of the admission 3 weeks following discharge. Medical data were extracted from patient charts. Premorbid and demographic data were provided by parent questionnaire. Results: Most children remembered some aspects of their admission. Younger age, admission for traumatic injury (rather than non-injury-related reasons), and cognitive/affective factors including confusion, peri-trauma panic, and sensory memory quality were associated with acute PTSS. Age and traumatic injury accounted for 18% of the variance in PTSS (p 28 days; (d) non-accidental injury; and (e) developmental delay or intellectual impairment. Of 196 eligible families, 19 were missed at recruitment, 34 refused (15 – too busy/overburdened, 7 – child refused, 8 – not interested, 2 – too distressing, 2 – involved in other research), 37 did not consent or provide data, 6 consented but dropped out before the assessment (2 – overburdened, 4 – did not provide data) and 5 had missing interview data. Thus, 95 children completed the interview about their memories of PICU. Of these, 70 children and 60 parents provided questionnaire data (for all other analyses, n = 70). Sample characteristics (n = 70) are presented in Table 1. Measures Table 2 outlines the constructs and their relative assessment measures. Child PTSS. The Children’s Revised Impact of Event Scale (CRIES-13; Smith, Perrin, Dyregrov, & Yule, 2003) is a 13-item self-report screen for PTSS in children. The scale was modified from an adult measure (Horowitz, Wilner, & Alvarez, 1979) for use with children aged 8 years and above, although other versions have been used with children as young as 6 years (Rennick, Johnston, Dougherty, Platt, & Ritchie, 2002). The scale provides a continuous


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measure of PTSS and demonstrates good internal consistency, α = .80 - .87 (Dow, Kenardy, Le Brocque, & Long, 2012; Giannopoulou et al., 2006; Smith et al., 2003) and convergent validity (Giannopoulou et al., 2006). Cronbach’s α was 0.81 in this study. Scores greater than 30 indicate clinically elevated PTSS (Perrin, Meiser-Stedman, & Smith, 2005). Premorbid variables. Prior trauma exposure. The Life Events Checklist (LEC), developed for use with the Clinician Administered PTSD Scale for Children and Adolescents (Nader et al., 1996), is a 17item trauma history screen. Parent’s report of events that the child personally experienced were summed to provide a continuous measure of prior trauma exposure. Premorbid child emotional/behavioural problems. The Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) is a 113-item parent-report measure of emotional and behavioral functioning in children aged 6-18 years. The Total Problem scale was used to identify children with premorbid clinical/subclinical problems (T-scores ≥60). The scale has demonstrated good content, criterion and construct validity and has excellent internal consistency and test–retest reliability (Achenbach & Rescorla, 2001). Internal consistency was also excellent in the current study (α = .92). Peri-trauma variables. Length of stay. Length of stay was operationalized as less than or more than 48 hours, as in Colville et al. (2008). This separated the majority of children who had short stays (for observation/procedures) from the minority who had prolonged stays. Risk of death. The Revised Paediatric Index of Mortality (PIM2; Slater, Shann, & Pearson, 2003) is a regression-based index that predicts risk of mortality from ten variables collected upon admission. Risk of death was calculated such that a score of 0.5 indicates a 0.5% risk of death.


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Medications. Administration of the most frequently administered agents (midazolam, morphine, propofol, ketamine) was reported as a dichotomous variable. Cognitive/affective variables. Most cognitive/affective variables (except trauma memory quality) were assessed by the Intensive Care Unit Memory Tool (ICUMT; Jones, Humphris, & Griffiths, 2000). The ICUMT contains a checklist assessing factual recall, recall of delusional experiences and recall of emotions. It was developed for use in adults, but it has been successfully used in a sample of PICU survivors aged 7-17 years (Colville et al., 2008). In this study, the tool was administered to children by interview and the wording of some items was modified for all participants in this study to facilitate understanding in younger children (e.g. Suctioning = having a suction tube in your mouth or throat; Ward Round = the doctor checking up on you; Do you remember being transferred from ICU to the general wards = Do you remember leaving ICU; Hallucinations = Did you see/hear something no one else could see/hear, do you remember things happening that might not have really happened or that you couldn’t believe, did you see or hear impossible things?). The ICUMT has shown good internal consistency in child respondents (Colville et al., 2008) and in the current study, Cronbach’s α was 0.74 for factual recall, 0.60 for recall of emotions, and 0.70 for recall of delusional experiences. Peri-trauma affect. Items were from the ICUMT and were scored dichotomously. Peritrauma fear was assessed by the item “When you were in Intensive Care, did you feel scared, frightened or worried?” Peri-trauma panic was assessed by the item “When you were in Intensive Care, did you feel like you were going to panic?” Peri-trauma cognitive processing. Items were from the ICUMT. Confusion was assessed by the item “When you were in Intensive Care, were you confused?” This question was also used as a measure of cognitive processing (data-driven processing) by Ehlers et al.,


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(2003). Peri-trauma delusions were indicated if a child endorsed any item from the ICUMT delusional scale (e.g. nightmares, bizarre dreams, hallucinations, paranoid delusions). Trauma memory. Descriptive information about children’s recall of PICU was obtained from the ICUMT checklist. Two additional items further explored children’s recollections of PICU: “What is the worst/best thing you can remember about PICU?” Verbatim responses were recorded and later grouped into thematic categories. Total PICU recall was assessed by one item, “How much do you remember of your stay in Intensive Care?” Children rated their recall on a 5-point scale from 0 (nothing) to 4 (everything). Sensory memory quality was assessed by the Trauma Memory Quality Questionnaire (TMQQ; MeiserStedman, Smith, Yule, & Dalgleish, 2007). The TMQQ is an 11-item self-report measure that assesses the sensory quality and temporal context of children’s trauma memories, and the extent to which the memories are verbally accessible. The scale has been used with children aged 7 years and older (McKinnon et al., 2008). Higher scores indicate memories of a more sensory, less verbally accessible nature. The scale has good internal consistency, α = .76-.82 (Howe, 1997). Cronbach’s α was acceptable in this study (.64). [Insert Table 2 here] Procedure Eligible families were invited to participate in the study face-to-face upon discharge from PICU (39%), or by letter immediately following discharge (61%). Once verbal consent was obtained, families were provided with information sheets, consent forms and questionnaire packs. Once written consent was obtained from parents (and children aged 10 and older), families completed an assessment 3 weeks following PICU discharge (Mdn = 23 days, R = 4 – 46 days) involving parent questionnaires (assessing demographic and premorbid information), child questionnaires (assessing child PTSS and memory quality) and child interviews (consisting of the ICUMT). Interviews were conducted over the phone or during outpatient


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visits by a graduate-level Psychologist. This study was approved and conducted in accordance with the University of Queensland Medical Research Ethics Committee and the Royal Children’s Hospital Human Research and Ethics Committee. Results Data analysis All analyses were performed using the Statistical Package for Social Sciences (SPSS 19.0; Chicago, IL). Risk of death was positively skewed. Non-parametric analyses did not change the substantive results so parametric analyses are reported. Bivariate correlations were conducted to identify associations between PTSS and premorbid, peri-trauma, and cognitive variables. Bivariate correlations between significant independent variables were also calculated. Phi coefficients were reported for correlations between dichotomous variables; point biserial correlations were reported between dichotomous and continuous variables. Significant bivariate associates were entered into a hierarchical multiple regression model to determine the relative importance of each block of variables in the prediction of PTSS. To determine whether the associations between predictor variables and PTSS was dependent on child age, four moderated multiple regression analyses were conducted (as preadmission and the three cognitive variables were not intercorrelated). The two continuous variables, age and memory quality, were centred before being entered into the models. Main effect variables were entered into the first step of each regression model, and interaction terms were computed and entered into the second step. Children’s recall of PICU Almost all children (95%) recalled at least one factual detail of their admission, although the majority (91%) reported that their memories were unclear and incomplete. Only four children (4%) reported that they recalled all of their PICU stay. Around half (48%)


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reported recall of at least one delusional experience, including nightmares (14%), bizarre dreams (18%), hallucinations (31%) and paranoid delusions (8%). When children were asked their worst recollection of PICU, about one third of children reported “nothing,” “don’t know,” or “can’t remember” (34%), with the remainder of children reporting pain (11%), invasive procedures (needles – 10%; in-dwelling catheter – 7%; nasogastric tube – 3%; other procedures/medical equipment – 11%), going to the toilet in front of others (3%), not being able to eat, drink or sleep (7%), effects of medications (2%), and other responses (12%; e.g. “seeing my leg whenever I got my dressing changed,” “lying in bed thinking about all the things I can’t do,” “Feeling like I didn’t know where I was”). Positive aspects of PICU were most commonly reported as “nothing” or “leaving PICU” (51%), having caring nurses/staff (15%), having food or water (10%), seeing family or visitors (6%), playing games (7%), sleeping (3%), receiving gifts (2%), talking to other people (2%) and other responses (4%; e.g. “people taking care of me,” “waking up”) Premorbid, peri-trauma and cognitive/affective variables associated with PTSS The mean PTSS score on the CRIES-13 was 18.56 (SD = 12.63). Fourteen of the 70 children scored above the threshold for elevated PTSS (20%). Bivariate correlations between premorbid, peri-trauma, or cognitive/affective variables and PTSS are shown in Table 3. Age, admission for traumatic injury (rather than non-injury-related reasons), peri-trauma panic, confusion, and sensory memory quality were associated with children’s acute PTSS (at p