Prospective study of post-traumatic stress disorder in children involved in road traffic accidents

British Medical Journal, Dec 12, 1998 by Paul Stallard, Richard Velleman, Sarah Baldwin

Abstract

Objective To determine the prevalence of severe psychological trauma--that is, post-traumatic stress disorder--in children involved in everyday road traffic accidents.

Design 12 month prospective study.

Setting Accident and emergency department, Royal United Hospital, Bath.

Subjects 119 children aged 5-18 years involved in road traffic accidents and 66 children who sustained sports injuries.

Main outcome measure Presence of appreciable psychological distress; fulfilment of diagnostic criteria for post-traumatic stress disorder.

Results Post-traumatic stress disorder was found in 41 (34.5%) children involved in road traffic accidents but only two (3.0%) who sustained sports injuries. The presence of post-traumatic stress disorder was not related to the type of accident, age of the child, or the nature of injuries but was significantly associated with sex, previous experience of trauma, and subjective appraisal of threat to life. None of the children had received any psychological help at the time of assessment.

Conclusions One in three children involved in road traffic accidents was found to suffer from post-traumatic stress disorder when they were assessed 6 weeks after their accident. The psychological needs of such children after such accidents remain largely unrecognised.

Introduction

Accidents in children are common and in 1996 in the United Kingdom accounted for about two million presentations at accident and emergency departments.[1] Parental reports indicate that most children display emotional distress immediately after an accident, although for most this distress is short lived and comparatively mild. Questionnaires completed by children indicate that some experience higher levels of emotional distress, particularly those involved in road traffic accidents or who have fallen from heights. This distress can persist for several months, although the emotional needs of these children are rarely recognised and seldom receive any ongoing planned intervention.[1]

In 1997 the number of road traffic accidents involving young people under the age of 19 years totalled 72 154.[2] Fatalities and serious injuries accounted for almost 16%, with most suffering physical injuries of mild to moderate severity. Research focusing on adult survivors of road traffic accidents has consistently shown high rates of psychological morbidity, particularly mood disorders, travel anxiety, depression, and post-traumatic stress disorder.[3-5] Although there has been little systematic research into the psychological effects of road traffic accidents on children, there is increasing recognition that they too will be affected.[6 7]

Individual case studies detailing the effects of road traffic accidents on children have been described.[7 8] Similarly, reports from major traffic accidents indicate that children display considerable psychological reactions and in many cases present with a range of symptoms characteristic of post-traumatic stress disorder.[9 10] The diagnostic criteria of this disorder involve the experiencing of a traumatic event that is outside the range of usual human experience. This event results in persistent re-experiencing of the trauma, avoidance of stimuli associated with it, and increased rates of arousal. These symptoms have to persist for longer than 1 month and cause clinically measurable distress or impairment in social, occupational, or other areas of functioning (Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)).[11] For young people symptoms may include sleep disturbance and nightmares, separation anxiety, difficulties in concentration, intrusive thoughts, difficulties in talking with parents and friends, mood disturbance, deterioration in academic performance, specific fears, and accident related play.[12]

Much of the research into the effects of traffic accidents on children has been retrospective. It has either described specific individual cases or focused on major accidents involving groups of children.[8 13] Individual clinical assessment of the children has not always been undertaken, with studies relying extensively on scores from self administered questionnaires to detect the possibility of post-traumatic stress disorder.[9 10 14] The time at which the assessment was undertaken has varied, and the effects of everyday individual traffic accidents have rarely been systematically assessed.[14 15] We determined the prevalence of post-traumatic stress disorder by individual clinical assessment of children involved in everyday traffic accidents.

Methods

Study cohort

The study was prospective and ran for 12 months from March 1996 to February 1997. The experimental group consisted of children and young people aged 5-18 years who attended the accident and emergency department at the Royal United Hospital, Bath, after a road traffic accident. To control for the possible effects of hospital attendance on psychological distress[16] we recruited a control group of children who experienced unexpected trauma after a sports injury.