Post-traumatic stress disorder in children and adolescents following road traffic accidents KA Mirza, BR Bhadrinath, IM Goodyer and C Gilmour The British Journal of Psychiatry 1998 172: 443-447 Access the most recent version at doi:10.1192/bjp.172.5.443
References
Reprints/ permissions You can respond to this article at Email alerting service Downloaded from
Article cited in: http://bjp.rcpsych.org/cgi/content/abstract/172/5/443#otherarticles To obtain reprints or permission to reproduce material from this paper, please write to
[email protected] http://bjp.rcpsych.org/cgi/eletter-submit/172/5/443 Receive free email alerts when new articles cite this article - sign up in the box at the top right corner of the article or click here bjp.rcpsych.org on July 13, 2011 Published by The Royal College of Psychiatrists
To subscribe to The British Journal of Psychiatry go to: http://bjp.rcpsych.org/subscriptions/
P R E L I M I N A R Y R E P O R T
B R I T I S H J O U R N A L O F P S Y C H I A T R Y ( 1 9 9 8 ) . 171. 4 4 3 - 4 4 7
Post-traumatic stress disorder in children and adolescents following road traffic accidents K. A. H. MIRZA,
B. R. BHADRINATH, I. M. GOODYER and
C. GILMOUR
The Bethel Child and Family Centre, Nonvich, and the Developmental Psychiatry section of the University of Cambridge are engaged in longitudinal research into this subject. This paper reports the results of a preliminary study.
SUBJECTS
Background
Post-traumatic stress
disorder (PTSD) can be a persistent and disabling psychiatricdisorder.There is little systematic research into the psychiatric consequences of road traffic accidents (RTAs) in children and adolescents.
Method Aconsecutive sample of 816-year-oldsattending an accident and emergency department following RTAs were screened for PTSD. Potential cases and their parent(s) were interviewed with semi-structured research instruments about six weeks and six months after the accident.
Results Fifty-three (45%) ofthe 119 subjects fell above PTSD cut-offon the Frederick's Reaction Index.Thirty-three
(75%) ofthe 44 cases met DSM- IV criteria for PTSD. In halfofthese other psychiatricdisorders were present, including major depressive disorder and
Studies of disasters show that most children exposed to severe traumatic events react adversely, and about 30% (range 2 7 4 6 % ) are likely to develop post-traumatic stress disorder (PTSD) symptoms which may persist for long periods (McFarlane et al, 1987; F'ynoos et al, 1987; Yule & Williams, 1990). Several studies using different methodologies have shown that PTSD occurs in adults (Mayou et al, 1993; Blanchard et al, 1994) and children following road traffic accidents (RTAs) (Stallard & Law, 1993; Di Gallo et al, 1997). Mayou et a1 (1993) have suggested that RTAs may be the most common cause of PTSD symptoms in the general population. Many of the above studies suffer from methodological shortcomings such as small sample size, sampling bias, lack of control groups, use of non-standardised instruments, lack of direct interviews, unstructured interviews or self-rated questionnaires. Large-scale, prospective studies into the psychological consequences of trauma, using standardised diagnostic criteria and direct interviews, are required to collect valid information on which service planning can be based.
anxiety disorders.Being female, involvement in car accidents and preexisting depression and anxiety were associated with developing PTSD. Seventeen per cent ofthe sample continued to be symptomatic six months after the accident.
Conclusions PTSD is a common consequence of RTAs. Liaison with accident and emergency departments would enhance the early detection and follow-up ofchildren at riskofdeveloping PTSD.
AIMS We wanted to determine whether PTSD constitutes a significant psychiatric disorder in children and young persons involved in RTAs. We also wished to determine the prevalence of comorbid psychiatric disorders and to examine the association between the development of PTSD and (a) degree of severity of physical injury sustained by the young person; ( b ) preaccident psychopathology; (c) demographic variables (e.g. age, gender); (d) type of RTA; and (e) involvement of family members in the accident. Additionally, we were interested in identifying factors at presentation which were associated with the persistence of PTSD symptoms at six months.
A consecutive series of 156 children and young people involved in RTAs and meeting the entry criteria were identified from 255 children under the age of 16 brought to the accident and emergency department of the Norfolk and Norwich Hospital. The inclusion criteria were: age between 8 and 16 years and residency in the catchment area of Norwich Health Authority. The exclusion criteria were: non-accidental injury; history of any loss of consciousness; presence of formal special educational needs; inability to speak English. Of 156 such subjects, 119 ( 7 6 % ) agreed to take part in the study. Thirtyseven subjects were not included in the study: 16 refused to take part, 15 could not be traced and six dropped out after the initial visit. The subject group contained 81 boys and 38 girls. Their mean age was 163.35 months (13.61 years) with a standard deviation of 29.3 months (2.44 years) and a range of 8-16 years. Fourteen children were under the age of 12. Their socio-economic status distribution was: I=2, II=8, III=40, N = 4 9 and V=19.
METHOD The Frederick's Reaction Index (FRI: Frederick & Pynoos, 1988) was administered four weeks after the event. For all subjects scoring above cut-off on the FRI the subject and a parent were interviewed using a semistructured interview schedule (KiddieSADS; Ryan et al, 1994) by a trained interviewer to detect PTSD symptoms and/ or other psychopathology. For the purposes of the study, accidents were classified into five categories: (a) passenger in a motor vehicle (n=29); (b) pedal cyclists (n=61); ( c ) pedestrian (n=21); (d) travel by public transport (n=O) and (e) other (n=8). The degree of severity of physical injuries sustained by the young person was assessed using the Abbreviated Injury Scale (AIS-90), an instrument of demonstrable reliability and validity (Yates, 1990).
All children were re-assessed six months after the accident using the FRI to evaluate the persistence of PTSD symptoms.
MEASURES Parental interview In the first interview socio-demographic details, past medical and psychiatric history, and pre-accident adjustment of the young person were systematically elicited. These data were collected within 2-3 weeks (mean=16.9 days, s.d.=7.26 days) after the accident. Rutter's Questionnaire (Rutter, 1976) (parent's version) and a Young Persons' Questionnaire (parent's version) were completed by the parents to record the young person's mental state before the accident. The Young Persons' Questionnaire is a composite measure of 95 items consisting of the Mood Feeling Questionnaire (Costello & Angold, 1988), Leyton Obsessional Inventory - Child Version (Berg et al, 1986), Revised Manifest Anxiety Scale (Reynolds & Richmond, 1978) and Behaviour Indicator Scale, a symptom check-list derived from conduct disorder diagnostic criteria in DSM-111-R (American Psychiatric Association, 1987). It measures reported symptoms of depression, obsessive-compulsive disorder, anxiety, and conduct disorder.
Screening interview The parents were interviewed again at 4-7 weeks (mean=39.43 days, s.d.=7.49 days) after the accident using the checklist derived from DSM-IV criteria (American Psychiatric Association, 1994). Parents completed the FRI adult version (Frederick & Pynoos, 1988) if they were also involved in the accident. The child or adolescent was interviewed on his or her own using the PTSD symptom checklist derived from DSM-IV and the FRI (Child Version) (Frederick & Pynoos, 1988).
Semi-structured interview If the young person scored more than 7 in the FRI, they were interviewed by an experienced clinician using Kiddie-SADSL, a research instrument shown to have reliability and validity (Ryan et al, 1994). This occurred about 9-13 weeks after the accident (mean=77.53 days s.d.=16.02 days).
Follow-up interview After six months (mean=187.3 days; s.d.=7.47 days) the young person and the parents were interviewed again using the FRI and the PTSD symptom checklist (derived from DSM-N).
A N A L Y T I C A L STRATEGY The main measure of this study was FRI score. Previous unpublished empirical comparisons of FRI scores with a diagnosis of PTSD in a clinical population have suggested the following guidelines: subjects whose scores fell within the range 7-9 were considered to suffer from a mild degree of PTSD, those in the range 10-12 a moderate degree of the disorder and greater than 12 a severe degree of PTSD (Pynoos et al, 1987). The subjects who were positive and negative for PTSD on the FRI six weeks ('FRI 1') and six months after the accident ('FRI 2') were compared on age, gender, injury severity, type of accident, involvement of a family member in the accident, the young person's pre-accident scores on sub-scales of the Young Persons' Questionnaire and Rutter's Questionnaire (Parent Version), and past history of professional help to the child (defined as having seen a mental health professional). Since those subjects with 'severe' PTSD on the FRI were much more likely to be PTSD-positive on Kiddie-SADS, the analysis was carried out using two different FRI cut-off scores (i) FRI> 7 'FRI positive' and (ii) FRI > 12 'FRI severe'. The statistical techniques used were single factor analysis of variance and ,y2 test.
RESULTS Out of the 119 subjects interviewed 53 (44.5%) scored 7 or more on the FRI. Twenty-seven subjects (23%) had severe PTSD (FRI 1 > 12), seven ( 6 % ) had moderate PTSD (FRI 1 9-12), 19 (16%) had mild PTSD (FRI 1 7-9) and 66 (55%) were FRI 1 negative. At six-month followup 19 subjects (17%) scored 7 or more, of whom 13 (12%) continued to have severe PTSD, two had moderate PTSD, four had mild PTSD and 94 were FRI negative. Six subjects were lost to follow-up. One subject was PTSD positive after six months but did not score above cut-off on the FRI six weeks after the accident.
Age A single factor analysis of variance showed no significant age difference between groups of subjects who were positive for FRI 1 (six weeks), FRI 2 (six months) and all 119 subjects (P
