суббота, 15 сентября 2012 г.

PICU stays often result in psychological sequelae.(BEHAVIORAL PEDIATRICS)(pediatric intensive care units) - Pediatric News

Los ANGELES -- Children experience persistent anxiety, behavior changes, and posttraumatic stress disorder symptoms following severe illnesses or injuries that require treatment in pediatric intensive care units.

This has led to the development of developmentally appropriate scales to better characterize their distress and identify those in need of follow-up psychological care.

In fact, according to a meta-analysis of 28 studies, up to a quarter of children who are discharged from pediatric intensive care units (PICUs) experience long-lasting psychological sequelae, including anxiety, behavior disturbances, delusions / hallucinations, and symptoms of PTSD.

Psychological outcomes research emerged slowly from the fields of nursing, medicine, and psychiatry during 1970-2008, generating only 28 studies that were specifically focused on PICU experiences and their aftermath, Janet E. Rennick, Ph.D., nurse researcher at the Montreal Children's Hospital and McGill University Health Centre, explained.

However, when the investigators analyzed the conclusions, the studies consistently demonstrated elevated levels of anxiety for up to 6 months post discharge (J. Child Health Care 2009;13:128-49).

Negative behavioral changes were apparent even a year following hospitalization, as were declines in broadly defined measures of 'emotional well-being' in health-related quality of life scales.

In one U.K. study, 32% of children had at least one delusional memory that tracked back to their PICU stays, and 25% still had hallucinations 3 months later. Criteria for PTSD were met in up to 21% of children at 1 year.

The studies primarily involved children who were at least 5 years old at the time of hospitalization and were followed for between 3 months and 1 year.

A range of studies, including Dr. Rennick's work, has shown that younger school-age children and those who are more severely ill are more likely to experience lasting psychological difficulties, including medical fears, symptoms of PTSD, and a lower sense of control over their health.

Invasive procedures are strongly correlated with negative psychological outcomes, and are extremely common in the PICU, she said.

One study showed that the average number of invasive procedures experienced during a PICU stay was 89, compared with 22.5 in an average stay on a pediatric medical ward.

Dr. Rennick's own research, beginning in 2002 was hampered by a seeming disconnect between stressful responses reported by parents and the items endorsed on standardized posttraumatic stress scales, such as the Horowitz Impact of Event Scale.

She and her colleagues set about designing a new scale that was specifically aimed at capturing the experiences of children whose trauma involved intensive care following a serious illness or injury.

Questions were generated by parental focus groups and the observations of children themselves, the youngest depicting stressful memories with felt boards and hospital play sets and the oldest simply recounting their memories and subsequent feelings and actions.

Responses fell into the following five domains:

* Altered behaviors. Having trouble falling or staying asleep, having bad dreams, or wanting to be alone.

* Relationships. Being reluctant to discuss being sick, not wanting to be ''different,' or feeling that no one understood or that there was ''no one to talk to.'

* Worries. Being concerned that they would never get better, that they perhaps had caused their illness or injury, or that something else was going to happen.

* Fears. Having anxiety about being in situations without their parents, about going back to the hospital, or about 'tests.'

* Sense of self. Making observations about life / childhood changing, feeling a loss of normalcy, asking ''Will I ever be the same as before?' or ''Why me?'

The resulting Children's Critical Illness Impact Scale (CCIIS) was developed, revised, reduced to 23 items, and validated with a content validity index of 0.87 for 9- to 12-year-olds. Construct and convergent validity were established with testing on children who had experienced a PICU stay.

Currently, Dr. Rennick and her associates are completing a pictorial scale that uses developmentally appropriate measures of psychological distress in 6- to 9-year-olds, she said.

The new version of the scale will use 46 drawings to depict 23 items, allowing children to choose which pictures best represent their memories and feelings about a PICU stay.

Pilot testing found that the scales were well understood even by 5-year-olds, but that children younger than 5 years had difficulty distinguishing their own emotions from those of their parents and had trouble assessing changes in feeling over time.

Dr. Rennick said the hope is that the CCIIS (and the Y-CCIIS for younger school-age children) will help characterize the range of psychological responses children have to PICU admissions, and to identify those who may require monitoring or a referral for counseling based on their responses.

In addition, better quantification of the emotional impact of the PICU might be used to educate and enlighten specialists about children's distress reactions that they might otherwise overlook, she added.

She recounted the annoyed reaction of a cardiologist who was given feedback about the elevated distress scores of a young patient who had been treated in the PICU.

'What do you mean this kid's having problems?' the cardiologist said. 'I just saw him and he was not having any problems.''

Disclosures: None was reported.

BY BETSY BATES

EXPERT ANALYSIS FROM AN INTERNATIONAL CONFERENCE ON PEDIATRIC PSYCHOLOGICAL TRAUMA