Case Study Psychiatric Sequelae after Traumatic Injury: The Pittsburgh Regatta Accident D. RICHARD MARTINI , M.D ., CHRISTOPHER RYAN , PH.D ., DON NAKAYAMA, M.D. , AND MAX RAMENOFSKY , M.D .
.' Abstract. Accidental injury in a child is sudden, often violent, and emotionally stressful, particularly when it is accompanied by hospitalization and rehabilitation. The following case report examines the presence of posttraumatic stress disorder and other psychiatric illnesses in five children involved in a boating accident during the 1988 Pittsburgh Regatta and considered severity of injury as well as complicating psychosocial stressors in the development of the disorders. The presence of symptoms was not related to the nature or extent of the injury but was instead the by-product of additional factors, including level of family stress, coping styles of the patient and family, positive psychiatric history in the child and/or family, and experience in effectively dealing with stressful episodes in the past. J . Am . Acad. Child Adolesc. Psychiatry, 1990, 29, 1:70-75. Key Words: trauma, posttraumatic stress disorder. trauma; (2) the loss of recently acquired developmental skills or regression to an earlier maturational level as a manifestation of withdrawal and diminished interest in significant activities; (3) a sense of a foreshortened future and/or an inability to achieve expected life goals in a career and family; (4) the development of omens that are thought to predict future untoward events ; (5) psychological symptoms such as generalized fearfulness , separation anxiety , and personality changes . Additional problems that may indicate emotional distress and possible psychiatric diagnosis include sleep disturbance, nightmares, phobias , enuresis, restlessness, irritability, dependent and demanding behavior, eating disturbances , guilt, mistrust, and sexual problems (Terr, 1983; Yates, 1983; Goodwin , 1985). During evaluation of these children, it has often been noted that the child may remain unresponsive or tentative after a trauma, leading to incorrect assumptions about amnesia or constriction of affect. As a consequence, assessment of traumatized children should be supplemented by parent and teacher reports (Brett, 1988). Some writers (i.e., Terr, 1987) have made a distinction between acute and chronic forms of stress, characterizing them as type 1 and type 2, respectively. Children exposed to repeated trauma (type 2) may have additional symptoms related to the development of personality styles in response to persistent denial , anger, and/or depression . In children, the presentation of PTSD symptoms after a single tragic event is determined by several factors . The child's developmental stage predicts the level of understanding; a child that comprehends the scope of a trauma will have more difficulty rationalizing the justification for such an event. Man-made trauma , uncertainty about the source of the trauma , and a more tragic outcome increase the likelihood of a psychological reaction in the child (Ayalon, 1982). Although preexisting psychiatric illness is not necessary for this problem to develop in children , these patients are at a higher risk for PTSD. The type and extent of social support available through family and/or caretakers, the child's
The psychological response to stress in children has been examined in victims of sexual or physical abuse, witnesses to violence, or victims of extraordinary , life-threatening events (Terr, 1979; Gislason and Call, 1982; Anthony, 1985; Malmquist, 1985; Pynoos et al., 1987). DSM-III-R classifies responses to these types of stressors under the diagnosis of post-traumatic stress disorder (PTSD). Although there are no criteria listed that distinguish the presentation in children from that in adults , DSM-III-R recommends that the guidelines established for adults be followed and then supplements additional information more specific to children . The three basic diagnostic criteria for PTSD include persistent reexperiencing of the trauma , persistent avoidance of stimuli associated with the trauma or a general numbing of responsiveness, and persistent symptoms of increased arousal. The "stress" is considered to have one or more of the following features: (a) life-threatening, (b) threatening to a major attachment figure, (c) jeopardizing the child's physical condition, (d) isolating the child from others, and (e) misinforming the child about important life circumstances (Goodwin, 1985). In their recent review of studies of PTSD in children , Brett et al. (1988) listed the following characteristics of the disorder unique to children: (1) reexperiencing the episode through repetitive play containing themes or aspects of the
Accepted April 4, 1989. Dr. Martini and Dr. Ryan are Assistant Professors of Psychiatry, Behavioral Science Division , Children's Hospital ofPittsburgh, Western Psychiatric Institute and Clinic, University of Pittsburgh. Dr. Nakayama is Assistant Prof essor of Surgery and Dr. Ramenof sky is Professor of Surgery, Department of Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine. Reprint requests to Dr . Martini, Children's Hospital of Pittsburgh, One Children' s Place, 3705 Fifth Avenue at De Soto Street, Pittsburgh, PA 15213-2583 . 0890-8567/90/2901-0070$2.00/0© 1990 by the American Academy of Child and Adolescent Psychiatry.
70
PSYCHIATRIC SEQUELAE AFtER TRAUMATIC INJURY
age, family psychiatric history, individual coping styles , and a history of having faced and mastered similar experiences in the past all contribute to the child's presentation (Pynoos and Eth, 1985; Rutter, 1985). Accidental injury in a child is sudden, often violent, and emotionally stressful, particularly when it is accompanied by hospitalization and rehabilitation . Physical injury as a cause of PTSD in children has usually been examined in the context of a single violent and/or abusive event. Studies that have explored the psychiatric reaction in children to acute physical trauma are usually descriptive and focus on the interplay between the medical and psychological presentations (Ravenscroft, 1982). PTSD resulting from physical injury may be represented by an affective disorder. Children who are scarred, who must take medication that has disfiguring side effects, and who have limitations on activities or a decrease in academic performance that are by-products of the trauma may find themselves more socially isolated and depressed. Children with psychiatric illness are at greater risk for PTSD after sudden injury not only because of their vulnerabilities, but also because the stress of hospitalization tends to make them more symptomatic. When the hospital staff is unaware of the child's premorbid level of functioning , there is a tendency to view these children as uncooperative, argumentative, and dysfunctional (Nir, 1985). A single traumatic event has frequently provided an opportunity to examine symptoms of a stress disorder in children. Such an event occurred during a speedboat race on the rivers of Pittsburgh in August 1988. A boat lost control and went into the crowd . In this study , we interviewed five children who were among 24 people involved in the accident. Physical injury became a factor in the assessment. The children had injuries of varying severity and were treated on a inpatient and outpatient basis at Children's Hospital of Pittsburgh. The purpose of the study was to evaluate these children for the presence of PTSD and consider contributions made by the severity of injury, previous psychiatric illness, and family environment. Event Description The Pittsburgh Regatta is a 4-day-long event that highlights several activities on the city's three rivers . The showcase event is the Formula one speedboat race that usually draws 100,000 to 150,000 people to the riverside , with many of these spectators sitting on the river's edge . On August 3, 1988, during the feature race, a boat, buffeted by the wind and the choppy water, suddenly veered into the crowd. Twenty-three people were injured in this accident, 12 of whom were children. The event was witnessed not only by the thousands attending the race but by a live television audience in the tri-state area. The tragedy received extensive media coverage over the subsequent 6 weeks. Method .Subje cts
Eight children were transported to Children's Hospital of Pittsburgh and admitted to the Benedum Pediatric Trauma J.Am .A cad.ChildAdolesc.Psychiatry , 29:1 , Jan. 1990
Service . Two were treated on an inpatient basis , one for several weeks . The remaining six children were treated in the emergency room and released, with their injuries followed in the outpatient clinics . Seven families were contacted for participation in this study 2 months after the accident. One family had moved out of the area in the interim. Six out of the seven families agreed to participate; however, one family did not appear for the scheduled appointment. The following is a description of the patients and the nature of their injuries. Case 1. A 3.6-year-old girl was struck and pinned by the boat. She suffered fractures to both legs and her right arm and required a skin graft to the left leg as a result of blunt trauma. She began to walk during the week prior to this interview, 2 months after the accident. This family had lost a son in the accident, and the father suffered a partial amputation of the left foot. He was recovering at the time of the evaluation. The father was referred for outpatient psychiatric treatment due to adjustment problems secondary to his injury and to the death of his son. His physical rehabilitation was continuing at the time of the assessment and did not allow him to return to work . As a result, the family was experiencing financial difficulties . During the parent interview, the mother described herself as depressed with decreased concentration, deteriorating work performance, sleep continuity disorder, tearfulness , irritability, and repeated intrusive thoughts of the accident. She witnessed the event from a hill overlooking the riverside and watched as the boat overwhelmed her family . She was referred for outpatient psychiatric treatment at the conclusion of the session. Prior to the accident , the son was followed in the local mental health center with a diagnosis of attention deficit-hyperactivity disorder (ADHD) . Case 2 . A 9.6-year-old boy was hit by a piece of debris from the boat's engine. He suffered a superficial, soft tissue injury to the left leg. The bleeding was minimal and the wound did not require sutures. The laceration was dressed in the emergency room, and the patient was discharged. No other family member was injured in the accident. At one time, this patient was considered to be suffering from ADHD and was treated with stimulant medication and a group therapy program. He was neither on medication nor participating in group therapy at the time of the assessment. A diagnosis of autism was also entertained at a younger age , but the patient did not meet DSM-III-R criteria . The parental relationship had deteriorated in the year before the accident due to financial and emotional strains. The father lost his job and was unable to find employment. The resulting financial difficulties affected the family's ability to buy food and clothing and to pay for the child 's educational needs. The mother gave birth approximately 9 months before the evaluation after a difficult pregnancy. In the past year, she had also suffered through a debilitating illness in a parent that resulted in his death. Case 3 . A 9-year-old boy was brushed back and knocked down by the passing boat. He suffered superficial cuts and scrapes over the left chest and abdomen. The lacerations did not require suturing and were dressed in the emergency 71
MARTINI ET AL.
room prior to his discharge. No other family member was injured in the accident. The child had no previous psychiatric history and was considered to be popular and an above average student. In the 3 months before the evaluation, the parents were involved in a new business that kept them away from home for 50 to 60 hours per week, necessitating several changes in the family routine. With the mother no longer at home, the patient balked at the increased number of caretaking responsibilities he was assigned as the oldest of three children. He particularly regretted the prolonged absences of his father from the home. Case 4. A 3-year-old boy, with a history of a malignant spinal cord tumor, was thrown down behind a park bench by his father in an attempt to protect him from the force of the oncoming boat. He suffered superficial injuries to the back and abdomen, but no complications to his condition. At age 7 months, the patient underwent a T lO-L3 laminectomy for the removal of a spinal cord neuroblastoma. He was left paraplegic with neurogenic bowel and bladder. An adductor lengthening procedure was performed at age 2. There was no evidence of a recurrence of metastasis of the primary tumor at the time of the assessment. As a result of the spinal cord tumor, the child required crutches to walk and had a history of repeated hospitalizations at Children's Hospital of Pittsburgh for urinary tract infections and physical therapy. The patient was not developmentally delayed in motor or speech and language skills. The father did not suffer any injury while protecting his son. Case 5. A seven-year-old boy suffered blunt trauma to the back and left arm that produced hematuria, extensive bruising, a stiff neck, and superficial scarring. There was no disability at the time of evaluation. All of the children in the family suffered injuries with a serious laceration to the left leg in the daughter, a knee injury to the older son, and the injuries to the target patient. All of the children were recovering without serious complication. The daughter, however, required additional operations to repair the leg scarring. The older son, after having demonstrated considerable skill in high school basketball, was hobbled by the injury and could not return to his previous competitive level. The parents were not injured. The mother and father .had decided to pursue legal action against the city of Pittsburgh and sought advice from counsel at the time of the evaluation. Procedures The primary goal of the psychiatric/psychosocial evaluation was to obtain immediate post-injury information on the child's recollection of the accident and their reaction to it as well as their current level of stress and adjustment to the injury. To that end, the parent and child were interviewed with either the Kiddie SADS-P (Schedule for Affective Disorders in School-Age Children) or the Preschool Symptom Self-Report (PRESS), and the Post-Traumatic Stress Disorder Reaction Index-Child Revision. DSMIll-R diagnoses, including PTSD, were made based on the parent and child interviews. A number of additional psychosocial instruments were administered to the child and the parent in an effort to obtain detailed information about
72
preexisting psychosocial problems and stressors and to supplement clinical data on the patients . For that reason, all children completed our modification of the Family Environment Scale-FRI Version, the child version of the Spielberger State/Trait Questionnaire (STAlC) , and the Children's Depression Inventory (CDI). In addition, all parents completed the Family Environment Scale-FES Version, the Family Inventory of Life Events and Changes (FILE), the Achenbach Child Behavior Checklist (CBCL), the Child Depression Inventory (CDI), and the Spielberger Trait Inventory (STAlC). The CDI and the STAIC were screening instruments for the presence of affective and anxiety symptoms respectively. The CBCL allowed for the evaluation of PTSD in the context of more general behavior problems. Instruments
The K-SADS-P was developed by J. Puig-Antich, M.D., and W. Chambers, M.D., to record information on the functioning of children and adolescents between the ages of 7 and 18, focusing on the presence of symptoms consistent with psychiatric disorder. It was administered in a semistructured format first to the parents and then to the child alone (Chambers et aI., 1985). Although the instrument has not been used with a preschool population, the parent report of the K-SADS-P was thought to adequately review possible behavioral changes in the 3.6- and 3.0-yearold children. The PRESS is a self-report instrument designed by the author for use in the diagnosis of behavior problems in preschool children. The interview consists of 25 sets of two illustrations each, one drawing showing a problem behavior and the second without it. A test-retest reliability study on the PRESS has been recently completed demonstrating high levels of reliability and internal consistency. The PTSD Reaction Index was based on the criteria for PTSD as defined by DSM-lll and has been used to assess responses in adults and children (Frederick, 1985b; Frederick, 1986). The present version was modified by Frederick and Pynoos to more specifically target the language abilities of school-age children. The reaction index scores correlated highly with clinical cases of PTSD in children and had high levels of inter item agreement between two raters (Pynoos et al., 1987). The diagnosis of PTSD was, therefore, based on the severity scores of the PTSD Reaction Index and the responses from the instrument that met the DSM-III-R criteria for the illness. Symptoms of PTSD were gathered from other interviews and questionnaires , but the data were not considered in the diagnostic formulation because the sources of information were not consistent, and the questions did not specifically target psychological reactions consonant with PTSD. Although the instrument had not been tested with a preschool population, the parents of the 3.6 and 3.0-yearold children (case 1 and case 4) were interviewed. The PTSD Reaction Index was administered to these younger children, and in case 1 the child understood and responded to the questions. The CDI is a 27-item, self-report scale developed by Marika Kovacs, Ph.D., that is symptom-oriented and focused on the severity of depression in children. The quesl.Am.Acad. ChildAdolesc .Psychiatry, 29:1 .Jan. 1990
PSYCHIATRIC SEQUELAE AFfER TRAUMATIC INJURY
tions have been constructed at the first-grade level (Kovacs, 1985). The STAIC is a self-report scale developed by Spielberger as a measure of anxiety. It is divided into two segments, one consisting of "trait" items that ask about how the child is best described , and a second consisting of "state" items that ask the child to describe how she or he feels "at this very moment. " Spielberger has modified the ' 'trait" portion of the inventory for administration to the parents (Spielberger, 1973). The CBCL (ages 4 to 16) is designed to record a broad range of childhood behavior problems as reported by the primary caretaker . The responses are based on the child 's behavior in the previous six months (Achenbach and Edelbrock, 1983). The checklist requires a fifth grade reading level and takes approximately 20 minutes to complete (Achenbach and Edelbrock, 1981). The FES was developed as a means of recording the family' s perceptions of its social environment. The FRI is based on three subscales within the " relationship" domain of the FES; cohesion, expressiveness , and conflict. The FRI was modified by the investigators for a younger population by simplifying the vocabulary and sentence structure to a first grade level (Moos and Moos, 1981). The FILE is a 71-item self-report instrument that is designed to record significant life events experienced by the family in the previous year. The instrument includesquestions on the family history and should be completed by the child's primary caretaker (McCubbin, 1982).
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.' Abstract. Accidental injury in a child is sudden, often violent, and emotionally stressful, particularly when it is accompanied by hospitalization and rehabilitation. The following case report examines the presence of posttraumatic stress disorder and other psychiatric illnesses in five children involved in a boating accident during the 1988 Pittsburgh Regatta and considered severity of injury as well as complicating psychosocial stressors in the development of the disorders. The presence of symptoms was not related to the nature or extent of the injury but was instead the by-product of additional factors, including level of family stress, coping styles of the patient and family, positive psychiatric history in the child and/or family, and experience in effectively dealing with stressful episodes in the past. J . Am . Acad. Child Adolesc. Psychiatry, 1990, 29, 1:70-75. Key Words: trauma, posttraumatic stress disorder. trauma; (2) the loss of recently acquired developmental skills or regression to an earlier maturational level as a manifestation of withdrawal and diminished interest in significant activities; (3) a sense of a foreshortened future and/or an inability to achieve expected life goals in a career and family; (4) the development of omens that are thought to predict future untoward events ; (5) psychological symptoms such as generalized fearfulness , separation anxiety , and personality changes . Additional problems that may indicate emotional distress and possible psychiatric diagnosis include sleep disturbance, nightmares, phobias , enuresis, restlessness, irritability, dependent and demanding behavior, eating disturbances , guilt, mistrust, and sexual problems (Terr, 1983; Yates, 1983; Goodwin , 1985). During evaluation of these children, it has often been noted that the child may remain unresponsive or tentative after a trauma, leading to incorrect assumptions about amnesia or constriction of affect. As a consequence, assessment of traumatized children should be supplemented by parent and teacher reports (Brett, 1988). Some writers (i.e., Terr, 1987) have made a distinction between acute and chronic forms of stress, characterizing them as type 1 and type 2, respectively. Children exposed to repeated trauma (type 2) may have additional symptoms related to the development of personality styles in response to persistent denial , anger, and/or depression . In children, the presentation of PTSD symptoms after a single tragic event is determined by several factors . The child's developmental stage predicts the level of understanding; a child that comprehends the scope of a trauma will have more difficulty rationalizing the justification for such an event. Man-made trauma , uncertainty about the source of the trauma , and a more tragic outcome increase the likelihood of a psychological reaction in the child (Ayalon, 1982). Although preexisting psychiatric illness is not necessary for this problem to develop in children , these patients are at a higher risk for PTSD. The type and extent of social support available through family and/or caretakers, the child's
The psychological response to stress in children has been examined in victims of sexual or physical abuse, witnesses to violence, or victims of extraordinary , life-threatening events (Terr, 1979; Gislason and Call, 1982; Anthony, 1985; Malmquist, 1985; Pynoos et al., 1987). DSM-III-R classifies responses to these types of stressors under the diagnosis of post-traumatic stress disorder (PTSD). Although there are no criteria listed that distinguish the presentation in children from that in adults , DSM-III-R recommends that the guidelines established for adults be followed and then supplements additional information more specific to children . The three basic diagnostic criteria for PTSD include persistent reexperiencing of the trauma , persistent avoidance of stimuli associated with the trauma or a general numbing of responsiveness, and persistent symptoms of increased arousal. The "stress" is considered to have one or more of the following features: (a) life-threatening, (b) threatening to a major attachment figure, (c) jeopardizing the child's physical condition, (d) isolating the child from others, and (e) misinforming the child about important life circumstances (Goodwin, 1985). In their recent review of studies of PTSD in children , Brett et al. (1988) listed the following characteristics of the disorder unique to children: (1) reexperiencing the episode through repetitive play containing themes or aspects of the
Accepted April 4, 1989. Dr. Martini and Dr. Ryan are Assistant Professors of Psychiatry, Behavioral Science Division , Children's Hospital ofPittsburgh, Western Psychiatric Institute and Clinic, University of Pittsburgh. Dr. Nakayama is Assistant Prof essor of Surgery and Dr. Ramenof sky is Professor of Surgery, Department of Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine. Reprint requests to Dr . Martini, Children's Hospital of Pittsburgh, One Children' s Place, 3705 Fifth Avenue at De Soto Street, Pittsburgh, PA 15213-2583 . 0890-8567/90/2901-0070$2.00/0© 1990 by the American Academy of Child and Adolescent Psychiatry.
70
PSYCHIATRIC SEQUELAE AFtER TRAUMATIC INJURY
age, family psychiatric history, individual coping styles , and a history of having faced and mastered similar experiences in the past all contribute to the child's presentation (Pynoos and Eth, 1985; Rutter, 1985). Accidental injury in a child is sudden, often violent, and emotionally stressful, particularly when it is accompanied by hospitalization and rehabilitation . Physical injury as a cause of PTSD in children has usually been examined in the context of a single violent and/or abusive event. Studies that have explored the psychiatric reaction in children to acute physical trauma are usually descriptive and focus on the interplay between the medical and psychological presentations (Ravenscroft, 1982). PTSD resulting from physical injury may be represented by an affective disorder. Children who are scarred, who must take medication that has disfiguring side effects, and who have limitations on activities or a decrease in academic performance that are by-products of the trauma may find themselves more socially isolated and depressed. Children with psychiatric illness are at greater risk for PTSD after sudden injury not only because of their vulnerabilities, but also because the stress of hospitalization tends to make them more symptomatic. When the hospital staff is unaware of the child's premorbid level of functioning , there is a tendency to view these children as uncooperative, argumentative, and dysfunctional (Nir, 1985). A single traumatic event has frequently provided an opportunity to examine symptoms of a stress disorder in children. Such an event occurred during a speedboat race on the rivers of Pittsburgh in August 1988. A boat lost control and went into the crowd . In this study , we interviewed five children who were among 24 people involved in the accident. Physical injury became a factor in the assessment. The children had injuries of varying severity and were treated on a inpatient and outpatient basis at Children's Hospital of Pittsburgh. The purpose of the study was to evaluate these children for the presence of PTSD and consider contributions made by the severity of injury, previous psychiatric illness, and family environment. Event Description The Pittsburgh Regatta is a 4-day-long event that highlights several activities on the city's three rivers . The showcase event is the Formula one speedboat race that usually draws 100,000 to 150,000 people to the riverside , with many of these spectators sitting on the river's edge . On August 3, 1988, during the feature race, a boat, buffeted by the wind and the choppy water, suddenly veered into the crowd. Twenty-three people were injured in this accident, 12 of whom were children. The event was witnessed not only by the thousands attending the race but by a live television audience in the tri-state area. The tragedy received extensive media coverage over the subsequent 6 weeks. Method .Subje cts
Eight children were transported to Children's Hospital of Pittsburgh and admitted to the Benedum Pediatric Trauma J.Am .A cad.ChildAdolesc.Psychiatry , 29:1 , Jan. 1990
Service . Two were treated on an inpatient basis , one for several weeks . The remaining six children were treated in the emergency room and released, with their injuries followed in the outpatient clinics . Seven families were contacted for participation in this study 2 months after the accident. One family had moved out of the area in the interim. Six out of the seven families agreed to participate; however, one family did not appear for the scheduled appointment. The following is a description of the patients and the nature of their injuries. Case 1. A 3.6-year-old girl was struck and pinned by the boat. She suffered fractures to both legs and her right arm and required a skin graft to the left leg as a result of blunt trauma. She began to walk during the week prior to this interview, 2 months after the accident. This family had lost a son in the accident, and the father suffered a partial amputation of the left foot. He was recovering at the time of the evaluation. The father was referred for outpatient psychiatric treatment due to adjustment problems secondary to his injury and to the death of his son. His physical rehabilitation was continuing at the time of the assessment and did not allow him to return to work . As a result, the family was experiencing financial difficulties . During the parent interview, the mother described herself as depressed with decreased concentration, deteriorating work performance, sleep continuity disorder, tearfulness , irritability, and repeated intrusive thoughts of the accident. She witnessed the event from a hill overlooking the riverside and watched as the boat overwhelmed her family . She was referred for outpatient psychiatric treatment at the conclusion of the session. Prior to the accident , the son was followed in the local mental health center with a diagnosis of attention deficit-hyperactivity disorder (ADHD) . Case 2 . A 9.6-year-old boy was hit by a piece of debris from the boat's engine. He suffered a superficial, soft tissue injury to the left leg. The bleeding was minimal and the wound did not require sutures. The laceration was dressed in the emergency room, and the patient was discharged. No other family member was injured in the accident. At one time, this patient was considered to be suffering from ADHD and was treated with stimulant medication and a group therapy program. He was neither on medication nor participating in group therapy at the time of the assessment. A diagnosis of autism was also entertained at a younger age , but the patient did not meet DSM-III-R criteria . The parental relationship had deteriorated in the year before the accident due to financial and emotional strains. The father lost his job and was unable to find employment. The resulting financial difficulties affected the family's ability to buy food and clothing and to pay for the child 's educational needs. The mother gave birth approximately 9 months before the evaluation after a difficult pregnancy. In the past year, she had also suffered through a debilitating illness in a parent that resulted in his death. Case 3 . A 9-year-old boy was brushed back and knocked down by the passing boat. He suffered superficial cuts and scrapes over the left chest and abdomen. The lacerations did not require suturing and were dressed in the emergency 71
MARTINI ET AL.
room prior to his discharge. No other family member was injured in the accident. The child had no previous psychiatric history and was considered to be popular and an above average student. In the 3 months before the evaluation, the parents were involved in a new business that kept them away from home for 50 to 60 hours per week, necessitating several changes in the family routine. With the mother no longer at home, the patient balked at the increased number of caretaking responsibilities he was assigned as the oldest of three children. He particularly regretted the prolonged absences of his father from the home. Case 4. A 3-year-old boy, with a history of a malignant spinal cord tumor, was thrown down behind a park bench by his father in an attempt to protect him from the force of the oncoming boat. He suffered superficial injuries to the back and abdomen, but no complications to his condition. At age 7 months, the patient underwent a T lO-L3 laminectomy for the removal of a spinal cord neuroblastoma. He was left paraplegic with neurogenic bowel and bladder. An adductor lengthening procedure was performed at age 2. There was no evidence of a recurrence of metastasis of the primary tumor at the time of the assessment. As a result of the spinal cord tumor, the child required crutches to walk and had a history of repeated hospitalizations at Children's Hospital of Pittsburgh for urinary tract infections and physical therapy. The patient was not developmentally delayed in motor or speech and language skills. The father did not suffer any injury while protecting his son. Case 5. A seven-year-old boy suffered blunt trauma to the back and left arm that produced hematuria, extensive bruising, a stiff neck, and superficial scarring. There was no disability at the time of evaluation. All of the children in the family suffered injuries with a serious laceration to the left leg in the daughter, a knee injury to the older son, and the injuries to the target patient. All of the children were recovering without serious complication. The daughter, however, required additional operations to repair the leg scarring. The older son, after having demonstrated considerable skill in high school basketball, was hobbled by the injury and could not return to his previous competitive level. The parents were not injured. The mother and father .had decided to pursue legal action against the city of Pittsburgh and sought advice from counsel at the time of the evaluation. Procedures The primary goal of the psychiatric/psychosocial evaluation was to obtain immediate post-injury information on the child's recollection of the accident and their reaction to it as well as their current level of stress and adjustment to the injury. To that end, the parent and child were interviewed with either the Kiddie SADS-P (Schedule for Affective Disorders in School-Age Children) or the Preschool Symptom Self-Report (PRESS), and the Post-Traumatic Stress Disorder Reaction Index-Child Revision. DSMIll-R diagnoses, including PTSD, were made based on the parent and child interviews. A number of additional psychosocial instruments were administered to the child and the parent in an effort to obtain detailed information about
72
preexisting psychosocial problems and stressors and to supplement clinical data on the patients . For that reason, all children completed our modification of the Family Environment Scale-FRI Version, the child version of the Spielberger State/Trait Questionnaire (STAlC) , and the Children's Depression Inventory (CDI). In addition, all parents completed the Family Environment Scale-FES Version, the Family Inventory of Life Events and Changes (FILE), the Achenbach Child Behavior Checklist (CBCL), the Child Depression Inventory (CDI), and the Spielberger Trait Inventory (STAlC). The CDI and the STAIC were screening instruments for the presence of affective and anxiety symptoms respectively. The CBCL allowed for the evaluation of PTSD in the context of more general behavior problems. Instruments
The K-SADS-P was developed by J. Puig-Antich, M.D., and W. Chambers, M.D., to record information on the functioning of children and adolescents between the ages of 7 and 18, focusing on the presence of symptoms consistent with psychiatric disorder. It was administered in a semistructured format first to the parents and then to the child alone (Chambers et aI., 1985). Although the instrument has not been used with a preschool population, the parent report of the K-SADS-P was thought to adequately review possible behavioral changes in the 3.6- and 3.0-yearold children. The PRESS is a self-report instrument designed by the author for use in the diagnosis of behavior problems in preschool children. The interview consists of 25 sets of two illustrations each, one drawing showing a problem behavior and the second without it. A test-retest reliability study on the PRESS has been recently completed demonstrating high levels of reliability and internal consistency. The PTSD Reaction Index was based on the criteria for PTSD as defined by DSM-lll and has been used to assess responses in adults and children (Frederick, 1985b; Frederick, 1986). The present version was modified by Frederick and Pynoos to more specifically target the language abilities of school-age children. The reaction index scores correlated highly with clinical cases of PTSD in children and had high levels of inter item agreement between two raters (Pynoos et al., 1987). The diagnosis of PTSD was, therefore, based on the severity scores of the PTSD Reaction Index and the responses from the instrument that met the DSM-III-R criteria for the illness. Symptoms of PTSD were gathered from other interviews and questionnaires , but the data were not considered in the diagnostic formulation because the sources of information were not consistent, and the questions did not specifically target psychological reactions consonant with PTSD. Although the instrument had not been tested with a preschool population, the parents of the 3.6 and 3.0-yearold children (case 1 and case 4) were interviewed. The PTSD Reaction Index was administered to these younger children, and in case 1 the child understood and responded to the questions. The CDI is a 27-item, self-report scale developed by Marika Kovacs, Ph.D., that is symptom-oriented and focused on the severity of depression in children. The quesl.Am.Acad. ChildAdolesc .Psychiatry, 29:1 .Jan. 1990
PSYCHIATRIC SEQUELAE AFfER TRAUMATIC INJURY
tions have been constructed at the first-grade level (Kovacs, 1985). The STAIC is a self-report scale developed by Spielberger as a measure of anxiety. It is divided into two segments, one consisting of "trait" items that ask about how the child is best described , and a second consisting of "state" items that ask the child to describe how she or he feels "at this very moment. " Spielberger has modified the ' 'trait" portion of the inventory for administration to the parents (Spielberger, 1973). The CBCL (ages 4 to 16) is designed to record a broad range of childhood behavior problems as reported by the primary caretaker . The responses are based on the child 's behavior in the previous six months (Achenbach and Edelbrock, 1983). The checklist requires a fifth grade reading level and takes approximately 20 minutes to complete (Achenbach and Edelbrock, 1981). The FES was developed as a means of recording the family' s perceptions of its social environment. The FRI is based on three subscales within the " relationship" domain of the FES; cohesion, expressiveness , and conflict. The FRI was modified by the investigators for a younger population by simplifying the vocabulary and sentence structure to a first grade level (Moos and Moos, 1981). The FILE is a 71-item self-report instrument that is designed to record significant life events experienced by the family in the previous year. The instrument includesquestions on the family history and should be completed by the child's primary caretaker (McCubbin, 1982).
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