Journal of Traumatic Stress, Vol. 16, No. 5, October 2003, pp.
523–526 ( C 2003)
Follow-Up of Young Road Accident Victims
Marjorie L. Gillies,1,3 Joanne Barton,1 and Alain Di Gallo2
The aim of this study was to follow-up a group of children and young people previously examined for psychological sequelae following road trafﬁc accidents. The group was assessed 18-month postaccident to assess the severity of continuing symptoms and examine any emergence of delayed onset of posttraumatic stress reactions. Participants (N = 31) completed the Revised Impact of Event Scale and the Child Posttraumatic Stress Reaction Index. Parents completed the Child Behavior Check-List and participated in a semistructured interview. Symptoms of PTSD were noted in a quarter of participants as was delayed onset of symptoms. The role of avoidance in symptom reporting and continuing disorder is discussed.
KEY WORDS: children; young people; posttraumatic stress disorder; psychological distress; delayed onset; road accidents.
The occurrence of traumatic stress reactions in children and young people is well established (Parry-Jones & Barton, 1995) but in practice symptoms are often not identiﬁed (Stallard, Velleman, & Baldwin, 2001). Studies have described PTSD and other adverse psychological reactions in children and young people following a variety of traumatic events, including major disaster (Saigh, Green, & Korol, 1996) and road trafﬁc accidents (RTAs; Di Gallo, Barton, & Parry-Jones, 1997; Mirza, Bhadrinath, Goodyer, & Gilmour, 1998; Stallard, Velleman, & Baldwin, 1998). In general, research has focused on adverse reactions occurring in the 6 months following traumatic events. With the exception of Milgram et al. (1988) who referred brieﬂy to onset of PTSD in children 9 months after a bus accident, there is little research examining
1 Department of Child and Adolescent Psychiatry, University of Glasgow,
Glasgow, Scotland. Universitaetsklinik und-poliklinik fuer Kinder und Jugendliche, Basel, Switzerland. 3 To whom correspondence should be addressed at Nursing & Midwifery Research & Practice Development Unit, Yorkhill Court (Block 8), Yorkhill NHS Trust, Glasgow G3 8SJ, Scotland; e-mail: email@example.com.
delayed-onset PTSD, that is, onset of symptoms at least 6 months after the traumatic event (American Psychiatric Association, 1994). There is a need for further long-term follow-up studies of children and young people who present with traumatic stress reactions (Saigh et al., 1996). In 1997 we reported a prospective study of 57 participants, aged 5–18 years, injured in RTAs (Di Gallo et al., 1997). Stress symptoms were elicited 2–16 days (Time 1) and 12–15 weeks (Time 2) postaccident. Reduction in symptom severity occurred between Time 1 and Time 2 but at Time 2, 14% suffered from moderate or severe PTSD, and 17% from serious trafﬁc-related fears. Parents reported increased mood disturbance in their children. High levels of distress during and immediately after the accident were associated with severe posttraumatic stress symptoms as was parental perception of the severity of the injury. In light of the need for further long-term follow-up studies, we took the opportunity to explore symptomatology in this sample on one more occasion. The aim of the follow-up project was to examine a group of children and young people, 18 months after their involvement in RTAs, for persistent and delayed onset of adverse psychological reactions.
2003 International Society for Traumatic Stress Studies
524 Method Di Gallo et al. (1997) described the sample, procedures, and measures. Children and young people aged 5– 18 years (n = 57), who were consecutive attenders at ﬁve Accident and Emergency Departments, following road accidents, were recruited and assessed twice: 2–16 days (Time 1) and 12–15 weeks (Time 2) postaccident. Participants and their parents were notiﬁed by letter of the third (Time 3) and ﬁnal assessment and informed consent obtained. None of the sample had received psychiatric intervention in the ensuing period. Ethical approval was obtained. Participants completed the Revised Impact of Event Scale (RIES; Dyregrov, Kuterovac, & Barath, 1996; Horowitz, Wilner, & Alvarez, 1979) and the Child Posttraumatic Stress Reaction Index (CPTS-RI; Pynoos et al., 1987). At this assessment, children and parents were asked about any persisting accident-related physical symptoms. Parents completed the Child Behavior Check-List (CBCL; Achenbach, 1991) and were interviewed using a shorter version of the original semistructured interview (Di Gallo et al., 1997) which included questions about parental perception of their child’s reactions to the accident, general behaviour, and details of any intercurrent life and traumatic events. Severity of physical injury had been measured at the ﬁrst assessment using medical casenotes and the Injury Severity Score (Greenspan, McLellan, & Greig, 1985). Statistical analysis was primarily descriptive but paired t-test analyses were used to make between group comparisons.
Gillies, Barton, and Gallo birth of a sibling (n = 4). Serious adverse events affected 13 families (deaths, serious illness, further RTA). On-Going Physical Injury Four participants consulted their General Practitioner between Time 2 and Time 3 because of accident-related complaints. Two participants attended outpatient clinics whereas seven had received treatment for physical injuries sustained in the original RTA. Six participants (19%) had continuing problems with physical injury and a seventh had developed alopoecia (hair loss) since the accident. Psychological Morbidity RIES and CPTS-RI ratings at Time 3 were strongly correlated, r (29) = .67, p < .001. The RIES scores of 32% of participants (n = 9) were high (score >20). Scores on the Avoidance subscale were higher than those on the Intrusion subscale (Table 1). There was no statistical difference between Time 2 and Time 3 mean total RIES scores, t(29) = 0.05, which indicates a continuation of symptomatology. The Time 3 total RIES scores provide evidence of this in eight participants: seven had high scores at both Time 2 and Time 3 and one participant scored the same (n = 48) on both occasions, an indication of severe stress. CPTS-RI scores at Time 3 revealed moderate or severe PTSD symptoms in 29% of participants (n = 8) and mild symptoms in 44% (n = 12). The proportion of participants with mild or moderate symptoms was higher than at Time 2 (Table 2). There was a statistical difference between Time 2 and Time 3 CPTSRI scores, t(29) = −2.19, p < .05, with symptom severity rising in 17 (71%) participants at Time 3. Continuing or delayed onset symptoms were found in 10 (34%) participants. One had moderate-severe PTSD (CPTS-RI) at each assessment with a second showing moderate symptoms at Time 2 and severe PTSD at Time 3. RIES ratings revealed that six participants had high scores at Time 1, Time 2, and Time 3. These ﬁndings suggest
Table 1. Mean Revised Impact of Event Scale Scores (RIES) at Times 1, 2, and 3 Time 1 Intrusion Avoidance Total 8.68 (6.8) 14.48 (10.1) 23.16 (13.7) Time 2 3.53 (4.8) 10.87 (11.8) 14.40 (15.1) Time 3 5.90 (5.8) 10.52 (8.3) 16.17 (12.4)
Results Demographic Data Time 3 assessments occurred 67–96 weeks (M = 78 weeks) postaccident. Thirty-three of the 53 families (62%) from Time 2 participated. Of the 20 remaining families, 13 could not be contacted and 7 refused. The Time 3 sample was representative of the Time 1 sample in terms of gender, age, social class, and injury severity. The 33 contactable families yielded 31 participants aged 6–20 years (M = 11.7 years), mostly male (n = 19); data for the remaining 2 participants were incomplete and were excluded, giving a sample of 29. However, when CPTSRI scores were being analysed, only participants with a Time 1, Time 2, and Time 3 score were included, reducing the sample for this analysis to 27 participants. Family circumstances had altered for eight children and young people since Time 2, most commonly by the
Note. N = 29. Standard deviations appear in parentheses.
Follow-Up of Young Road Accident Victims
Table 2. Child Posttraumatic Stress Reaction Index Scores at Times 1, 2, and 3 Degree of PTSD Doubtful or none Mild Moderate Severe Very severe Time 1a 9 (33) 13 (48) 5 (18) 0 0 Time 2 14 (52) 9 (33) 2 (7) 2 (7) 0 Time 3 7 (26) 12 (44) 6 (22) 2 (7) 0
525 Discussion Adverse psychological reactions were identiﬁed in 42% of the children and young people 18 months after their RTA. Evidence of both continuing and delayed onset symptoms was found (high RIES scores and moderate/severe ratings for CPTS-RI). The inﬂuence of intercurrent life events on the ﬁndings was considered. Parents and children were asked about such events. The available data did not reveal any relationship between intercurrent life events and the development of posttraumatic symptoms (RIES or CPTS-RI). CBCL results indicated differences between child behaviour at Time 1 and Time 3 with Time 3 scores higher than sex/age-equivalent normative data suggesting that the accident may have negatively affected behavior in some cases. Argumentativeness occurred in nearly all participants with behavioral problems including frequent temper tantrums and poor concentration occurring in more than half the sample. These behaviors could be seen as part of the spectrum of increased symptoms characteristic of PTSD. Di Gallo et al. (1997) suggested that risk factors for the development of posttraumatic stress following RTA included young age, prior behavioral problems, and more severe injury. Although at Time 3 RIES scores were unrelated directly to injury severity, PTSD as measured by the CPTS-RI was more severe in participants who had sustained severe injury. Spontaneous resolution of symptoms accounts for the drop in numbers of symptomatic participants at Time 2. A number of new participants became symptomatic at Time 3 whereas PTSD in others persisted. The phenomenon of avoidance may account for these ﬁndings. Following a traumatic event, participants may be avoidant to the extent that they cannot answer, or may even avoid, questions so that an asymptomatic false negative result is produced. With time, avoidance may resolve such that participants are able to describe their experiences of the accident and, in turn, achieve signiﬁcant scores on rating scales. It is possible, therefore, that participants with false negative scores, created by avoidance, at Time 1, appeared to be symptomatic for the ﬁrst time at Time 3. Consequently, reported intrusion may only develop as the child’s ability to talk about the event increases. Avoidance may actively hinder recovery by preventing participants from confronting feared situations and addressing associated anxiety. It is important that health professionals, for example, Accident and Emergency (A & E) staff and Primary Care Teams, working with children and young people who have been involved in RTAs are aware of potential predictive factors. Such
Note. N = 27; only the data of the participants assessed at all three Times were included for statistical analysis. Percentages appear in parentheses. a PTSD at Time 1 should be replaced with posttraumatic symptoms because the diagnostic criteria for PTSD require duration of symptoms greater than 1 month.
continuing symptoms. Evidence of delayed onset at Time 3 was also found. Four participants with doubtful or mild CPTS-RI ratings at Time 1 and Time 2 became moderate at Time 3. Similarly RIES scores of three participants rose above 20 at Time 3. Both the Time 3 RIES and CPTS-RI scores of three participants indicated PTSD. Changes in family circumstances appeared unrelated to RIES scores as more of those with changes (85%), than without (63%), had lower scores. Reactions to the Accident Thirty percent of parents felt their child remained upset about the accident at Time 3 and 39% reported changed behaviour at school. Problems included being clingy, impaired concentration, mood swings, and short temper. The parents of two children felt that behavioural changes were not accident related. With the exception of females aged 12–18 years, CBCL scores at Time 3 were higher than the normative scores indicating behavioural difﬁculties. Behaviour problems occurring often or sometimes included frequent arguing (90%), talking too much (71%), day dreaming (58%), restlessness (55%), temper tantrums (55%), and poor concentration (52%). Forty-ﬁve percent of parents described their child as a “worrier” preaccident. This increased to 67% at Time 3 but was not statistically signiﬁcant ( p < .1). At Time 3, 21% of parents said that their child worried about health, for example, RTA injury-related problems or general complaints, and 39% of children were reported as having problems such as headaches. Forty-eight percent of children were described as having fears (some travel-related), while 25% suffered nightmares. Anecdotal comments, made by parents at Time 3, indicated that nine children (29%) were still “wary of roads” or had travel difﬁculties. In addition, the uninvolved siblings of three participants were also very distressed by the occurrence of the accident.
526 awareness will allow early referral and intervention where appropriate. Limitations The study had a number of limitations. First, the small sample size limited the statistical power of the study and the range of possible analyses. Participants examined at Time 3 were however representative of the original sample and a 62% response, 18 months on, is noteworthy. Secondly, it is possible that adverse psychological reactions may have developed and resolved during the time period between Time 2 and Time 3. Thirdly, these results may be a reﬂection of the nature of the instruments. The RIES and CPTS-RI rely on children being able to express their thoughts and feelings verbally or in writing. Younger children may be better able to describe their response to traumatic events through play and drawing (Bradding & Horstman, 1999). Finally, although it is recognised that different types of pain are linked with changes in emotional state, for example, depression, anxiety, sadness, and fears (Heiligenstein & Dietrich, 1993; McGrath, 1993), the presence, intensity, and nature of pain was not examined. Nevertheless, continuing physical dysfunction resulting from the RTA may have contributed to on-going psychological distress. Two of the six participants who reported on-going physical symptoms had high RIES scores, suggesting a possible relationship between physical injury and psychological morbidity. The role of pain in the development of posttraumatic psychological disturbance requires detailed examination. Conclusions The ﬁndings suggest that both persistent and delayed onset traumatic stress reactions occur in children after RTAs. The importance of avoidance is stressed. Health professionals who care for young victims of RTAs should be made aware of the possibility of psychological distress at the time and in the months and years to come. This applies particularly to Accident and Emergency Departments and Primary Care staff. Equipping health professionals with the skills to assess and monitor the psychological well-being of children and young people as well as physical injury may facilitate the reduction and prevention of long-term psychological morbidity. The obvious limitation of this study relates to sample size making deﬁnitive conclusions impossible, particularly those relating to predictive factors. Further support is provided, however, for the need for large, prospective, longitudinal studies. Acknowledgments
Gillies, Barton, and Gallo
Professor William Ll Parry-Jones, Department of Child and Adolescent Psychiatry, University of Glasgow, was a coinvestigator in the ﬁrst phase of this study. The authors are grateful for the unfailing support he offered until his untimely death. Our grateful thanks go to David Young, Statistician, Robertson Centre for Bio-statistics, University of Glasgow. References
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