Effective coping/mental health interventions for critically ill adolescents: an evidence review

Pediatric Nursing, July-August, 2007 by Melanie Brewer, Bernadette Mazurek Melnyk

Approximately 1.6 million adolescents and children between the ages of 10 and 19 years are hospitalized annually due to injuries and other causes, and the numbers are increasing (Centers for Disease Control, National Hospital Discharge Survey [NHDS], 2004; Mackay, Fingerhut, & Duran, 2000). Critical care hospitalization following these potentially life-threatening situations from serious illness or injury increases the risk for acute and chronic psychological distress, including post-traumatic stress disorder (PTSD) (Rennick et al., 2004). Unfortunately, PTSD is often not diagnosed or goes untreated in adolescents who have been hospitalized (Berrong, Kassam-Adams, Marks, & Winston, 2006; Mirza, Bhadrinath, Goodyer, & Gilmour, 1998).

Significant short- and long-term behavioral, emotional, and physical health consequences may occur following critical illness or injury, along with cognitive, academic, and relationship impairments (Horowitz, Kassam-Adams and Bergstein, 2001; Jones, Fiser & Livingston, 1992; Saigh, Mrouch, Bremmer, 1997). Teens report heightened anxiety, post-traumatic stress symptoms, depression, and other adverse mental health effects, often long after the stressful event (Baxter, 2004; Berrong, Kassam-Adams, Marks, Winston, 2006; Daviss et al., 2000b; Kaminer, Seedat, & Stein, 2005; Kean, Kelsay, Wamboldt & Wamboldt, 2006; Stoddard & Saxe, 2001: Zatzick et al., 2006;: Rees, Gledhill, Garralda, & Nadel, 2004).

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association [APA], 2000), in order to meet criteria for PTSD, both of the following must be met: "the person (has) experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others" resulting in "intense fear, helplessness, or horror", and in children, "disorganized or agitated behavior." This event is persistently re-experienced with "persistent avoidance of stimuli associated with the trauma, symptoms of increased arousal, duration of symptoms for more than 1 month, and significant psychological distress or impairment in functioning." Post-traumatic stress disorder may include re-experiencing a traumatic event, avoiding reminders of the event, and hyperarousal in response to a catastrophic event, traumatic injury or severe medical illness (APA, 2000). However, symptoms of PTSD may be undetected in the hospital due to the severity of the adolescent's illness or injuries, other immediate care needs, or lack of screening.

The National Center for Post-Traumatic Stress Disorder (Hamblen, 2006) has estimated that up to 43% of children and adolescents have experienced a traumatic event. Of those, up to 15% of girls and up to 6% of boys meet criteria for PTSD, and rates are estimated to be even higher among at-risk populations. Other research has noted PTSD rates as high as 43% in adolescents following a traumatic event (Michaels et al., 1999). High rates of PTSD also have been noted among adolescents hospitalized after mild to moderate trauma. Schreier and colleagues (2005) found that 59% of adolescents who were hospitalized for injuries continued to have at least mild PTSD 6 months after the traumatic event. In a long-term study of adolescent trauma survivors, Holbrook and colleagues (2005a) found an overall rate of PTSD of 27% (n = 284) during the 18-month follow-up period with rates as high as 40% in the 16-19 year age group. Higher rates were noted for females and among those who perceived a threat to life (58%) or no control over the event (61%). In another study of children and adolescents admitted to a pediatric intensive care unit (PICU) for serious injuries or illness, Aaron, Zaglul and Emery (1999) found that nearly half of the sample (n = 40) met diagnostic criteria for at least two of the three symptom clusters of PTSD, while 67.5% met criteria for the re-experiencing symptom cluster, and 22% met full diagnostic criteria for PTSD 1 month after the traumatic event. Perceived life threat was again associated with higher rates of PTSD.

Furthermore, Rennick and colleagues (2004) found that over 30% of children discharged from a PICU for injury or medical illness experienced psychological trauma 6 months after hospital discharge. In yet another study, Zatzick and colleagues (2006) found that 42% (n = 108) of randomly selected adolescents who sustained traumatic injuries had PTSD symptoms at baseline (mean of 11.7 days following the traumatic event). During the follow-up period, symptoms decreased to 30% at 5 months. However, 19% of adolescents in this study continued to experience PTSD at 12 months. Rates of PTSD in other studies have ranged from 12.5% to 50% or higher for full syndrome PTSD in children and adolescents experiencing traumatic injury or traumatic events (Aaron, Zagul, & Emery, 1999; Burleson, et al., 2000; Landolt, et al., 2005; Sturms, et al., 2000).