Course and predictors of posttraumatic stress disorder in parents after pediatric intensive care treatment of their child

Paediatric Post-Traumatic Stress Risk for Young People and Parents following Acute Admission for Paediatric Multisystem Inflammatory Syndrome: Retrospective Analysis of Psychological Screening and Support

BACKGROUND

Paediatric Multisystem Inflammatory Syndrome (PIMS-TS) is a novel condition that was identified for the first time during the COVID-19 pandemic. Limited research exists that describes the psychological needs of children and young people (CYP) following an acute hospital admission for PIMS-TS.

METHODS

A retrospective cohort study was conducted to explore both psychological need and access to psychology services for CYP and their families who were admitted to a paediatric tertiary hospital in London, UK, for PIMS-TS between April 2020 and May 2021.

RESULTS

We included 121 CYP and a parent/caregiver for each. In total, 23.3% of the CYP were at risk of developing a traumatic stress response and 11.6% were at risk of experiencing emotional disturbance. Of the parents screened, 40.5% also scored above clinical cut-off for a trauma response. There was a significant relationship observed between CYP and parents identified as having a trauma risk.

CONCLUSIONS

The importance of proactive screening for both trauma and emotional distress in CYP and their parents/caregivers following acute hospital admission is highlighted. In addition, there is a need to think about a CYP as part of a system of care and to ensure that clinicians pay attention to parental wellbeing and mental health when understanding the psychological impact on a child.

Psychological Outcomes in Families of PICU Survivors: A Meta-Analysis

BACKGROUND

Pediatric critical illness exposes family members to stressful experiences that may lead to subsequent psychological repercussions.

OBJECTIVE

To systematically review psychological outcomes among PICU survivors' family members.

DATA SOURCES

Four medical databases (PubMed, Embase, CINAHL and PsycInfo) were searched from inception till October 2023.

STUDY SELECTION

Studies reporting psychological disorders in family members of PICU patients with at least 3 months follow-up were included. Family members of nonsurvivors and palliative care patients were excluded.

DATA EXTRACTION

Screening and data extraction was performed according to PRISMA guidelines. Data were pooled using a random-effects model.

RESULTS

Of 5360 articles identified, 4 randomized controlled trials, 16 cohort studies, and 2 cross-sectional studies were included (total patients = 55 597; total family members = 97 506). Psychological distress was reported in 35.2% to 64.3% and 40.9% to 53% of family members 3 to 6 months and 1 year after their child's PICU admission, respectively. Post-traumatic stress disorder was diagnosed in 10% to 48% of parents 3 to 9 months later. Parents that experienced moderate to severe anxiety and depression 3 to 6 months later was 20.9% to 42% and 6.1% to 42.6%, respectively. Uptake of mental counseling among parents was disproportionately low at 0.7% to 29%. Risk factors for psychiatric morbidity include mothers, parents of younger children, and longer duration of PICU stay.

LIMITATIONS

The majority of studies were on parents with limited data on siblings and second degree relatives.

CONCLUSIONS

There is a high burden of psychological sequelae in family members of PICU survivors. Risk stratification to identify high-risk groups and early interventions are needed.

The impact of clinically relevant health conditions on psychosocial outcomes in survivors of childhood cancer: results of the DCCSS-LATER study

PURPOSE

Investigate the association between presence, number and type of clinically relevant health conditions and a range of psychosocial outcomes (emotional, social, cognitive, physical) in survivors of childhood cancer (CCS).

METHODS

CCS from the Dutch Childhood Cancer Survivor Study (DCCSS)-LATER cohort (diagnosed between 1963-2001, attained age ≥ 18, diagnosed < 18, ≥ 5 years since diagnosis) completed a questionnaire on health conditions (2013-2014), and questionnaires on psychosocial outcomes (2017-2020): Hospital Anxiety and Depression Scale, Short form 36, TNO-AZL Questionnaire for Adult Health-Related Quality of Life, and the Self-Rating Scale for Post-Traumatic Stress Disorder. Associations among health conditions and psychosocial outcomes were assessed with regression analysis, adjusting for attained age, sex, and time since diagnosis, and adjusting for multiple testing (p < 0.004).

RESULTS

A total of 1437 CCS, mean age 36.3 years, 51.1% female, ≥ 15 years since diagnosis, completed questionnaires on health and psychosocial outcomes. CCS with a clinically relevant health condition, and those with more conditions had worse emotional, social, and physical outcomes; regression coefficients were small to moderate. CCS with gastro-intestinal conditions, endocrine, nervous systems, eye, or ear conditions, and especially those with secondary malignant neoplasms, reported worse psychosocial functioning; regression coefficients were small/moderate to large.

CONCLUSION AND IMPLICATIONS

Health care professionals should be aware of the increased risk for psychosocial problems among CCS with health conditions, especially for survivors with secondary malignant neoplasms, gastro-intestinal, endocrine, nervous system, eye, and ear conditions. CCS may benefit from psychological interventions to develop coping strategies to manage health conditions and psychosocial consequences of the cancer trajectory.

Stress Symptoms Among Children and Their Parents After ICU Hospitalization

Objective: Child survival after intensive care unit (ICU) hospitalization has increased, yet many children experience acute stress that may precipitate mental/behavioral health comorbidities. Parents report stress after their child's hospitalization. Little is known about the individual and family characteristics that may moderate intergenerational relationships of acute stress. Design: Following ICU admission at a large academic medical center, a prospective cross-sectional cohort study assessed the associations between intergenerational characteristics and acute stress among children and families. Patients: Parent-child dyads (N = 88) were recruited from the pediatric ICU and pediatric cardiovascular ICU (CVICU) following ICU discharge. Eligible children were between 8 and 18 years old with ICU stays longer than 24 hours. Children with developmental delays were excluded. Caregivers were proficient in English or Spanish. Surveys were collected before hospital discharge. Measurements/Main Results: The primary outcome was "child stress" defined as a score≥17, measured by the Children's Revised Impact of Events Scale (CRIES-8). "Parent stress" was defined as an elevated composite score on the Stanford Acute Stress Reaction Questionnaire. We used validated scales to assess the child's clinical and family social characteristics. Acute stress was identified in 34 (39.8%) children and 50 (56.8%) parents. In multivariate linear regression analyses adjusting for social characteristics, parent stress was associated with increased risk of child stress (adjusted odds ratio 2.58, 95% confidence interval 0.69, 4.46, p < .01). In unadjusted analyses, Hispanic ethnicity was associated with greater child stress. In adjusted analyses, race, income, ICU length of stay, and language were not associated with child stress and did not moderate the parent-child stress relationship. Conclusions: Parent stress is closely correlated with child stress during ICU hospitalization. Hispanic ethnicity may be associated with increased risk for child stress, but further studies are required to define the roles of other social and clinical measures.

Challenges of Families of Patients Hospitalized in the PICU: A Preplanned Secondary Analysis From the Navigate Dataset

OBJECTIVES

To describe challenges experienced by parents of children hospitalized in the PICU during PICU admission as reported by family navigators.

DESIGN

A preplanned secondary analysis of open-response data coded via inductive qualitative approach from the Navigate randomized controlled trial (RCT) dataset (ID NCT02333396).

SETTING

Two university-affiliated PICUs in the Midwestern United States as part of an RCT.

PATIENTS

Two hundred twenty-four parents of 190 PICU patients.

INTERVENTIONS

In 2015-2017, trained family navigators assessed and addressed parent needs, offered weekly family meetings, and provided post-PICU discharge parent check-ins as part of a study investigating the effectiveness of a communication support intervention ("PICU Supports").

MEASUREMENTS AND MAIN RESULTS

We analyzed qualitative data recorded by family navigators weekly across 338 encounters. Navigators described families' "biggest challenge," "communication challenges," and ways the team could better support the family. We used an inductive qualitative coding approach and a modified member-checking exercise. The most common difficulties included home life , hospitalization , and diagnosis distress (45.2%, 29.0%, and 17.2% of families, respectively). Navigators often identified that parents had co-occurring challenges. Communication was identified as a "biggest challenge" for 8% of families. Communication challenges included lack of information, team communication , and communication quality (7.0%, 4.8%, and 4.8% of families, respectively). Suggestions for improving care included better medical communication, listening, rapport, and resources.

CONCLUSIONS

This study describes families' experiences and challenges assessed throughout the PICU stay. Family navigators reported families frequently experience stressors both internal and external to the hospital environment, and communication challenges between families and providers may be additional sources of distress. Further research should develop and assess interventions aimed at improving provider-family communication and reducing stressors outside the hospitalization itself, such as home life difficulties.

Epidemical trends and risk factors of PTSD in parents of critically ill children: Evidence from both meta-analysis and subgroup analysis

BACKGROUND

Post-Traumatic Stress Disorder (PTSD) in parents traumatized by a child's critical illness, while differences in prevalence and risk factors for parental PTSD in previous studies. This study aimed to assess trends in the prevalence and risk factors for PTSD in parents of critically ill children.

METHODS

Nine main databases were searched to extract the prevalence, sample size and risk factors from the published literature. Random effects model analysis, I2 statistic, quality assessment, subgroup analysis and sensitivity analysis were performed.

RESULTS

Twenty-five studies met the inclusion criteria, with pooled prevalence rates of 13.8 % (95 % CI: [confidence interval, CI] 10.0 %-17.7 %) in fathers and 20.2 % (95 % CI:16.1 %-24.3 %) in mothers. Mothers had a significantly higher prevalence of PTSD compared to fathers. The prevalence of PTSD generally increased after discharge, with the highest prevalence at 6 months, but then decreased (fathers: 18.0 %, CI: 6.1 %-29.9 %; mothers: 20.2 %, CI: 12.8 %-27.6 %), respectively. The results showed five risks, positive acute stress disorder (ASD) screening (OR [odds ratio, OR] =2.45), disease severity (OR = 3.78), perceived stress (OR = 1.44), unemployed status (OR = 2.52) and length of hospital stay (OR = 1.01).

LIMITATIONS

Due to the limitations of the original study, we could not explore trends in the prevalence of PTSD in this particular population over a more extended period after hospital discharge.

CONCLUSION

The prevalence of PTSD among parents of critically ill children is high and significantly different. Therefore, it is crucial to focus on this vulnerable group, providing them with essential psychological counseling and comprehensive social support to reduce the occurrence of PTSD.

"We Aren't Meant to Go Through the Hardest Parts of Our Lives Alone": Family Experience With Restricted PICU Presence During the COVID-19 Pandemic

CONTEXT

PICUs across Canada restricted family presence (RFP) in response to the COVID-19 pandemic from allowing two or more family members to often only one family member at the bedside. The objective of this study was to describe the experiences and impact of RFP on families of critically ill children to inform future policy and practice.

HYPOTHESIS

RFP policies negatively impacted families of PICU patients and caused moral distress.

METHODS AND MODELS

National, cross-sectional, online, self-administered survey. Family members of children admitted to a Canadian PICU between March 2020 and February 2021 were invited to complete the survey. RFP-attributable distress was measured with a modified distress thermometer (0-10). Closed-ended questions were reported with descriptive statistics and multivariable linear regression assessed factors associated with RFP-attributable distress. Open-ended questions were analyzed using inductive content analysis.

RESULTS

Of 250 respondents who experienced RFP, 124 (49.6%) were restricted to one family member at the bedside. The median amount of distress that families attributed to RFP policies was 6 (range: 0-10). Families described isolation, removal of supports, and perception of trauma related to RFP. Most families (183, 73.2%) felt that policies were enforced in a way that made them feel valued by PICU clinicians, which was associated with less RFP-attributable distress. Differential impact was seen where families with lower household income indicated higher RFP-attributable distress score (2.35; 95% CI, 0.53-4.17; p = 0.03). Most respondents suggested that future policies should allow at least two family members at the bedside.

INTERPRETATIONS AND CONCLUSIONS

Families of children admitted to PICUs during the COVID-19 pandemic described increased distress, trauma, and removal of supports due to RFP policies. Vulnerable families showed an increased odds of higher distress. Healthcare professionals played an important role in mitigating distress. Allowance of at least two family members at the bedside should be considered for future policy.

Emergency Inter-Hospital Transfer of Children to PICUs in the United Kingdom: Qualitative Exploration of Parents' Experiences of Retrieval Teams

OBJECTIVES

Each year in the United Kingdom there are around 5,000 inter-hospital transfers of critically ill children into PICUs. There are few published descriptions of what this experience is like for parents. The objective was to describe parents' experiences of the inter-hospital transfer of their critically ill child to a PICU.

DESIGN

Qualitative in-depth interviews.

SETTING

Twenty-four PICUs in England and Wales.

PARTICIPANTS

Parent interview participants ( n = 30) were purposively sampled from a larger pool of parent questionnaire respondents to create a sample diverse in child's age, presenting medical illness, retrieval team and whether a parent traveled in the ambulance.

MEASUREMENT AND MAIN RESULTS

Open-ended semi-structured interviews using topic guides to encourage parents to describe their experiences of transfer. Interviews were audio recorded, transcribed verbatim and thematically analyzed using Framework Analysis. Parents' perceptions of transport staff as confident and competent through observation of clinical care, and positive communication experiences during the transfer process, were related to feelings of trust and being supported, as well as relief from distress. Parents varied in their needs for conversation and support. Parents who did not travel in the ambulance had fewer opportunities to interact with the transport team and experienced different challenges in the period prior to their child's admission to the PICU.

CONCLUSIONS

Retrieval teams can influence how parents experience their child's emergency transfer to the PICU, offering parents proximity to knowledgeable staff. Satisfaction may be related to matching parents' needs. Understanding parents' needs and optimizing opportunities for effective communication between parents and staff are beneficial to parents.

Predictors of parental anxiety in a paediatric emergency department

BACKGROUND

Children experience significant anxiety in the paediatric ED. Although research from preoperative and primary care samples indicates that parents experience anxiety surrounding their children's medical procedures, less is known about parental anxiety and factors that contribute to higher parental anxiety in the ED. This study aimed to assess parental anxiety in families presenting to a paediatric ED with a variety of presenting concerns and examine demographic and psychological factors associated with parental anxiety.

METHODS

This cross-sectional study included parents of children <18 years old presenting to a paediatric ED in Orange County, California, USA, for a non-psychiatric complaint between 20 January 2021 and 26 March 2021. Parents were, on average, 34.76±9.10 years old, 87.5% were mothers, 59.2% identified as non-Latinx and parents reported average levels of mental health (T-score=51.21±9.84). Parent state anxiety was assessed via the State-Trait Anxiety Inventory and validated instruments were used to measure child temperament (ie, emotionality, activity, sociability, shyness), previous medical anxiety, and parent physical and mental health. Data were analysed using multiple linear regression models.

RESULTS

Out of 201 families screened, 150 were eligible, and 120 enrolled. In the sample, 42.5% of parents endorsed clinically significant levels of anxiety in the ED. Regression analyses indicated that lower child activity temperament (ie, tendency to be less active/energetic; B=-3.20, 95% CI -5.70 to -0.70, p=0.012) and poorer parent mental health (B=-0.31, 95% CI -0.52 to -0.09, p=0.006) were independently associated with higher parent anxiety (F(5, 99)=6.77, p=0.004).

CONCLUSION

Over 40% of parents sampled endorsed clinically significant anxiety in the paediatric ED. Child temperament, specifically lower activity temperament, and poorer parental mental health were identified as contributors to parent anxiety, whereas clinical condition or severity did not influence parent anxiety. Current results may help identify families in need of additional intervention and may improve patient outcomes.

Psychosocial functioning of adult siblings of Dutch very long-term survivors of childhood cancer: DCCSS-LATER 2 psycho-oncology study

OBJECTIVE

To describe psychosocial outcomes among adult siblings of very long-term childhood cancer survivors (CCS), to compare these outcomes to reference populations and to identify factors associated with siblings' psychosocial outcomes.

METHODS

Siblings of survivors (diagnosed <18 years old, between 1963 and 2001, >5 years since diagnosis) of the Dutch Childhood Cancer Survivor Study DCCSS-LATER cohort were invited to complete questionnaires on HRQoL (TNO-AZL Questionnaire for Adult's HRQoL), anxiety/depression (Hospital Anxiety and Depression Scale), post-traumatic stress (Self-Rating Scale for Post-traumatic Stress Disorder), self-esteem (Rosenberg Self-Esteem Scale) and benefit and burden (Benefit and Burden Scale for Children). Outcomes were compared to a reference group if available, using Mann-Whitney U and chi-Square tests. Associations of siblings' sociodemographic and CCS' cancer-related characteristics with the outcomes were assessed with mixed model analysis.

RESULTS

Five hundred five siblings (response rate 34%, 64% female, mean age 37.5, mean time since diagnosis 29.5) of 412 CCS participated. Siblings had comparable HRQoL, anxiety and self-esteem to references with no or small differences (r = 0.08-0.15, p < 0.05) and less depression. Proportions of symptomatic PTSD were very small (0.4%-0.6%). Effect sizes of associations of siblings' sociodemographic and CCS cancer-related characteristics were mostly small to medium (β = 0.19-0.67, p < 0.05) and no clear trend was found in the studied associated factors for worse outcomes.

CONCLUSIONS

On the very long-term, siblings do not have impaired psychosocial functioning compared to references. Cancer-related factors seem not to impact siblings' psychosocial functioning. Early support and education remain essential to prevent long-term consequences.

Family resilience processes among guardians caring for children and youths with leukemia

Based on Walsh's concept of family resilience, this study aims to explain the processes and factors related to family resilience of guardians caring for children and youths with leukemia (GCYL) at a university-affiliated hospital in central Thailand. An explanatory case study is conducted. Semi-structured in-depth interviews were conducted with 21 guardians from 15 families caring for children and youths with leukemia (CYL). The interviews were recorded and transcribed for content analysis. The researcher categorized and coded the data to summarize, interpret, and validate the key study results of family resilience. This study found that families undergo three phases when facing the situation: pre-family resilience, family resilience, and post-family resilience. In each phase, these families face changes in emotions, perspectives, and behaviors related to the factors promoting family resilience. The results of this study will benefit multidisciplinary teams providing care for families with CYL by applying the information about family resilience processes to provide services that cultivate behavioral, physical, psychological, and social growth for the families and enable them to maintain peace in family life.

Neurocognitive, Psychosocial, and Quality of Life Outcomes After Multisystem Inflammatory Syndrome in Children Admitted to the PICU

OBJECTIVES

To investigate neurocognitive, psychosocial, and quality of life (QoL) outcomes in children with Multisystem Inflammatory Syndrome in Children (MIS-C) seen 3-6 months after PICU admission.

DESIGN

National prospective cohort study March 2020 to November 2021.

SETTING

Seven PICUs in the Netherlands.

PATIENTS

Children with MIS-C (0-17 yr) admitted to a PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Children and/or parents were seen median (interquartile range [IQR] 4 mo [3-5 mo]) after PICU admission. Testing included assessment of neurocognitive, psychosocial, and QoL outcomes with reference to Dutch pre-COVID-19 general population norms. Effect sizes (Hedges' g ) were used to indicate the strengths and clinical relevance of differences: 0.2 small, 0.5 medium, and 0.8 and above large. Of 69 children with MIS-C, 49 (median age 11.6 yr [IQR 9.3-15.6 yr]) attended follow-up. General intelligence and verbal memory scores were normal compared with population norms. Twenty-nine of the 49 followed-up (59%) underwent extensive testing with worse function in domains such as visual memory, g = 1.0 (95% CI, 0.6-1.4), sustained attention, g = 2.0 (95% CI 1.4-2.4), and planning, g = 0.5 (95% CI, 0.1-0.9). The children also had more emotional and behavioral problems, g = 0.4 (95% CI 0.1-0.7), and had lower QoL scores in domains such as physical functioning g = 1.3 (95% CI 0.9-1.6), school functioning g = 1.1 (95% CI 0.7-1.4), and increased fatigue g = 0.5 (95% CI 0.1-0.9) compared with population norms. Elevated risk for posttraumatic stress disorder (PTSD) was seen in 10 of 30 children (33%) with MIS-C. Last, in the 32 parents, no elevated risk for PTSD was found.

CONCLUSIONS

Children with MIS-C requiring PICU admission had normal overall intelligence 4 months after PICU discharge. Nevertheless, these children reported more emotional and behavioral problems, more PTSD, and worse QoL compared with general population norms. In a subset undergoing more extensive testing, we also identified irregularities in neurocognitive functions. Whether these impairments are caused by the viral or inflammatory response, the PICU admission, or COVID-19 restrictions remains to be investigated.

Post-traumatic growth in caregivers of children hospitalized in the PICU due to traffic accident: a qualitative study

BACKGROUND

Globally, tens of millions of children are hospitalized every year for non-fatal traffic accident injuries, being confronted with an injured child can be extremely stressful for parents. Understandably, a significant level of psychological distress may ensue. Traumatic losses may lead parents to find new insights in life and develop a greater sense of spirituality and strength.

METHOD

Semi-structured interviews were conducted with caregivers of children who were hospitalized in the pediatric intensive care unit (PICU) with traffic accident injuries at children's hospitals in China between January and June 2022. Caregivers were selected using a purposive sampling method until no new data were generated (n = 24).

RESULTS

We identified eleven sub-themes and four higher-order themes based on these sub-themes: (1) changes in their life philosophy, (2) personal strength enhancement, (3) relationship improvements, and (4) effective responses. The findings of our research contribute to a better understanding of the psychological status of the caregivers of children injured by traffic accidents.

CONCLUSION

Professionals should guide caregivers from a positive perspective, stimulate their strengths and potential, increase personnel support and communication, promote positive coping, formulate targeted management countermeasures to improve the PTG level of caregivers, and develop strategies to maintain stable mental health and well-being.

Cost analysis of hospitals performing continuous albuterol in non-intensive care settings

OBJECTIVE

To compare hospital costs and resource utilization for pediatric asthma admissions based on the hospitals' availability of continuous albuterol aerosolization administration (CAA) in non-intensive care unit (ICU) settings.

METHODS

We conducted a retrospective cohort study of children ages 2-17 years admitted in 2019 with a principal diagnosis of asthma using the Pediatric Health Information System. Hospitals and hospitalizations were categorized based on location of CAA administration, ICU-only versus general inpatient floors. Hospitals preforming CAA in an intermediate care unit were excluded. We calculated total cost, standardized unit costs and rates of interventions. Groups were compared using Chi-Square, t-test and Wilcoxon rank-sum test as indicated. A log linear mixed model was created to evaluate potential confounders.

RESULTS

Twenty-one hospitals (7084 hospitalizations) allowed CAA on the floor.Twenty-four hospitals (6100 hospitalizations) allowed CAA in the ICU-only. Median total cost was $4639 (Interquartile Range (IQR) $3060-$7512) for the floor group and $5478 (IQR $3444-$8539) for the ICU-only group (p < 0.001) (mean cost difference of $775 per patient). Hospitalization costs were $4,726,829 (95% CI $3,459,920-$5,993,860) greater for the children treated at hospitals restricting CAA to the ICU. We observed higher standardized laboratory, imaging, clinical and other unit costs, along with higher use of interventions in the ICU-only group. After adjustment, we found that ICU stay and hospital LOS were the main drivers of cost difference between the groups.

CONCLUSIONS

There was cost savings and decreased resource utilization for hospitals that performed CAA on the floor. Further studies exploring variations in asthma management are warranted.

Pediatric Critical Care-Associated Parental Traumatic Stress: Beyond the First Year

OBJECTIVES

Perform a longitudinal analysis of parental traumatic stress up to 30 months after PICU discharge.

DESIGN

Prospective observational cohort study.

SETTING

Two tertiary care children's hospitals with mixed medical/surgical/cardiac PICUs.

SUBJECTS

Parents of patients unexpectedly admitted to the PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two hundred sixty-five parents of 188 children were enrolled. Of the 195 parents who completed the 3-9-month assessments, 29 (14.8%) met posttraumatic stress disorder (PTSD) qualification on the PTSD Symptom Scale Interview for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Multivariable analysis showed parents who met acute stress disorder (ASD) qualification (odds ratio [OR] 8.01; 95% CI 2.64-24.3), parents of children with Pediatric Overall Performance Category score of severe or coma at discharge (OR 5.21; 95% CI 1.65-16.4), parents who had concerns for their child's permanent injury (OR 1.82; 95% CI 1.36-2.43), and parents who reported increased knowledge of child illness during admission (OR 1.82; 95% CI 1.13-2.93) had increased odds of developing parental PTSD. Of the 175 parents (66%) who completed the 18-30-month assessments, 22 (12.5%) met PTSD qualification. Multivariable analysis showed parents who met ASD qualification (OR 4.19; 95% CI 1.12-15.7), parents who had a history of a family member or themselves being admitted to ICU (OR 6.51; 95% CI 1.43-29.6), and parents who had concerns of child's susceptibility to death post discharge (OR 1.58; 95% CI 1.19-2.09) had increased odds of developing parental PTSD. At 18-30 months post discharge, parents who met the PTSD qualification were more likely to report a decrease in household income following discharge (OR 9.23; 95% CI 1.71-49.9).

CONCLUSIONS

Parental PTSD remains a significant morbidity of PICU admission for a subgroup of parents greater than 18 months post admission. Identifiable risk factors will inform the development of targeted interventions.

Impact of ethnicity on parental health outcomes and experiences after paediatric intensive care unit discharge: a mixed-methods systematic review

The impact of ethnicity on parental health outcome after paediatric intensive care unit (PICU) discharge remains unclear. Thirteen medical and healthcare databases, unpublished studies and grey literature were searched up to November 5, 2021. We performed a mixed-method systematic review to understand the impact of ethnicity on parental outcomes after PICU discharge, including eight quantitative and eight qualitative studies. Among 1529 parents included, 1064 (72%) were White. Higher prevalence of post-traumatic stress disorder was seen in Black parents (17% White vs 36% Black, p = .03). Latino ethnicity was found to have protective effect against anxiety as compared to White parents (coefficient - 4.27, p < .001). A total of 91 findings were aggregated into 14 categories, and the five synthesized themes from the eight qualitative studies were long-term psychological impact after PICU, use of coping strategies, challenges of re-integration, changes in relationships and the utilization of formal support services and resources. Mixed-method synthesis found that parents of ethnic minority group were underrepresented (18%) and had higher attrition rates in a longitudinal study as compared to White parents following childhood critical illness.   Conclusion: There are significant gaps in evidence related to the impact of ethnicity on long-term parental health outcomes after PICU discharge. Ethnic diversity and inclusiveness in long-term PICU research may aid understanding of the parental experiences and outcomes to close the gap in health disparity.

Distress and post-traumatic stress in parents of patients with congenital gastrointestinal malformations: a cross-sectional cohort study

Background

Congenital gastrointestinal malformation (CGIM) require neonatal surgical treatment and may lead to disease-specific sequelae, which have a potential psychological impact on parents. The aim of this study is to assess distress and symptoms of post-traumatic stress disorder (PTSD) in parents of patients with CGIM. In this cross-sectional study, seventy-nine parents (47 mothers and 32 fathers) of 53 patients with CGIM completed the Distress Thermometer for Parents (DT-P) and the Self Rating Scale for Posttraumatic Stress Disorders (SRS-PTSD) as part of the multidisciplinary follow-up of their children (aged 5–35 months). Group differences were tested between parents and representative Dutch reference groups with regard to rates of (clinical) distress and PTSD, and severity of overall distress and PTSD, for mothers and fathers separately. Mixed model regression models were used to study factors associated with the risk of (clinical) distress, PTSD and with severity of symptoms of PTSD (intrusion, avoidance and hyperarousal).

Results

Prevalence of clinical distress was comparable to reference groups for mothers (46%) and fathers (34%). There was no difference in severity of overall distress between both mothers as well as fathers and reference groups. Prevalence of PTSD was significantly higher in mothers (23%) compared to the reference group (5.3%) (OR = 5.51, p < 0.001), not in fathers (6.3% vs 2.2.%). Symptoms of intrusion were commonly reported by all the parents (75%). Longer total length of child’s hospital stay was associated with more severe symptoms of intrusion, avoidance and hyperarousal. Child’s length of follow-up was negatively associated with severity of intrusion.

Conclusions

Having a child with CGIM has a huge impact on parents, demonstrated by a higher prevalence of PTSD in mothers, but not fathers, compared to parents in the general population. Monitoring of symptoms of PTSD of parents in follow-up is necessary.

A Systematic Review of the Factors Associated with Post-Traumatic Growth in Parents Following Admission of Their Child to the Intensive Care Unit

This systematic review aims to identify the demographic, clinical and psychological factors associated with post-traumatic growth (PTG) in parents following their child's admission to the intensive care unit (ICU). Papers published up to September 2021 were identified following a search of electronic databases (PubMed, Medline, Web of Science, PsycINFO, CINAHL, PTSDpubs and EMBASE). Studies were included if they involved a sample of parents whose children were previously admitted to ICU and reported correlational data. 1777 papers were reviewed. Fourteen studies were eligible for inclusion; four were deemed to be of good methodological quality, two were poor, and the remaining eight studies were fair. Factors associated with PTG were identified. Mothers, and parents of older children, experienced greater PTG. Parents who perceived their child's illness as more severe had greater PTG. Strong associations were uncovered between PTG and post-traumatic stress, psychological well-being and coping. PTG is commonly experienced by this population. Psychological factors are more commonly associated with PTG in comparison with demographic and clinical factors, suggesting that parents' subjective ICU experience may be greater associated with PTG than the objective reality.

Caregivers' and Young Children's Emotional Health Needs After Pediatric Traumatic Injury

Pediatric traumatic injury (PTI) is associated with emotional health difficulties, but most US trauma centers do not adequately address emotional recovery needs. This study aimed to assess families' emotional health needs following PTI and determine how technology could be used to inform early interventions. Individual semi-structured, qualitative interviews were conducted with caregivers of children admitted to a Level I trauma center in the Southeastern United States to understand families' experiences in-hospital and post-discharge. Participants included 20 caregivers of PTI patients under age 12 (M = 6.4 years; 70% male, 45% motor vehicle collision). Thematic analysis was used to analyze data from interviews that were conducted until saturation. Caregivers reported varying emotional needs in hospital and difficulties adjusting after discharge. Families responded enthusiastically to the potential of a technology-enhanced resource for families affected by PTI. A cost-effective, scalable intervention is needed to promote recovery and has potential for widespread pediatric hospital uptake.

Post-traumatic stress symptoms in parents of adolescents hospitalized with Anorexia nervosa

The current study was a planned secondary analysis to examine post-traumatic stress symptoms (PTSS) in parents of youth hospitalized for medical stabilization due to anorexia nervosa (AN). Questionnaires were administered to 47 parents (34 mothers, 13 fathers; 10 parental dyads) after admission; follow-up occurred at discharge and 4 weeks, 3 months, and 6 months post-discharge. PTSS were present in the majority of mothers (55.9%) and fathers (61.5%). PTSS were not associated with illness severity, but were associated with parental report of mood symptoms, avoidance, inflexibility, and symptom accommodation. Parental PTSS may negatively impact the adolescent rate of weight gain post-discharge. As hospitalization of a child for medical management of AN can be a traumatizing experience for parents, astute attention should be paid by medical staff to their needs. More work needs to be done to understand the impact of PTSS on parents of adolescents with AN.

Association of Illness Severity With Family Outcomes Following Pediatric Septic Shock

It is unknown which families are at risk for poor outcomes following a child’s critical illness.

Siblings' experience during pediatric intensive care hospitalization

PURPOSE

The impact on children who visit an ill sibling in the pediatric intensive care unit (PICU) is unknown. The aim of this study was to describe the experiences of siblings of acutely critically ill or injured children hospitalized in the PICU.

DESIGN AND METHODS

A qualitative approach using one-to-one interviews was conducted to gain an understanding of the experience of 9- to 17-year-old children who visited their siblings in the PICU. Thematic analysis was used to develop a description of the experiences of the siblings.

FINDINGS

Sixteen siblings (mean age, 12.5 years) indicated that visiting their critically ill sister or brother in the PICU can cause negative reactions. The data revealed two major themes within the overall sibling experience-stressors, coping-and nine subthemes. Predominant sibling stressors included pre-illness stressors, the PICU environment, the appearance of the ill child, uncertainty, and parental stress. Siblings coped mainly via distractions, social support, and spirituality and by reflecting on the sibling relationship. Support from friends, family members, and the community was reported to be helpful.

CONCLUSIONS

Siblings visiting the PICU may experience a broad range of physical, emotional, and social responses.

PRACTICE IMPLICATIONS

Future research should fully incorporate the sibling perspective when designing interventions to mitigate the potentially distressing effects of PICU visitation on the family.

Acute and Posttraumatic Stress in Family Members of Children With a Prolonged Stay in a PICU: Secondary Analysis of a Randomized Trial

OBJECTIVES

To identify the prevalence of screening criteria for acute and posttraumatic stress disorders (PTSDs) and stress symptoms among family members of children in the PICU for more than 8 days and examine risk factors for stress symptoms.

DESIGN

Secondary analysis of data from a randomized trial of a palliative care intervention conducted between 2010 and 2014.

SETTING

An urban pediatric hospital in Seattle, WA.

SUBJECTS

The sample included 377 family members of 220 children.

INTERVENTIONS

Family Communication Study.

MEASUREMENTS AND MAIN RESULTS

Outcomes were symptom scores and diagnostic screening criteria for acute stress disorder (ASD) and PTSD. Predictors included demographic- and admission-related characteristics and hypothesized risk factors for developing stress-related mental health disorders. The mean score for acute stress symptoms during the ICU stay was 40.3 (sd = 13.8) and 59 family members in total met diagnostic screening criteria for ASD during hospitalization (15.6%). At 3-month follow-up, the mean score for posttraumatic stress symptoms was 30.8 (sd = 12.9) and 52 family members met diagnostic criteria for PTSD (13.8%). Factors associated with meeting ASD screening criteria were unplanned admission and poorer family relationships. Factors associated with PTSD symptoms and diagnosis were longer length of stay, meeting ASD criteria during admission, child's death, and less perceived social support.

CONCLUSIONS

Meeting screening criteria for PTSD was associated with demographic, length of stay, and family relationships among family members of seriously ill children. PTSD outcomes were higher among family members whose child died. This study helps identify risk factors that can be used to target needed psychosocial screening, monitoring and support during and following a prolonged PICU admission, as well as family-centered interventions and supportive bereavement intervention for the family members of a deceased child.

Parent post-traumatic growth after a child's critical illness

OBJECTIVE

Post-traumatic growth is the experience of a positive change after a traumatic event. Our objective is to characterize the factors associated with post-traumatic growth in parents after a child's pediatric intensive care unit (PICU) admission.

STUDY DESIGN

A cross-sectional survey study examining post-traumatic growth and select independent variables in parents 1 year after a child's ≥72 h PICU admission for an acute illness or injury. The study was completed in parents of children discharge alive from a tertiary care PICU from January 1, 2017 to December 31, 2017. A mixed-effects linear regression model was built to evaluate the association of post-traumatic stress, anxiety, depression, resiliency, family function, and child function with post-traumatic growth.

RESULTS

Eighty-two parents of 52 children discharged alive in 2017 completed the survey. Fifty-two percent were ≥35 years and 64.3% were mothers. Median age of their children was 2.8 years (IQR 0.5-11.3) with a median hospital stay of 12 Days (IQR 6-20). Moderate-to-high levels of post-traumatic growth occurred in 67.1% of parents. Increased hospital length of stay (β Coeff 0.85; p = 0.004, 95% CI 0.27, 1.43) and parent post-traumatic stress symptoms (β Coeff 1.04; p = 0.006, 95% CI 0.29, 1.78) were associated with increased post-traumatic growth, and increased parent depression symptoms (β Coeff -1.96; p = 0.015; 95% CI -3.54, -0.38) with decreased post-traumatic growth.

CONCLUSION

Longer child hospital stays and increased parent post-traumatic stress symptoms were associated with increased post-traumatic growth, while increased depression was associated with less post-traumatic growth. The impact of future PICU parent psychosocial interventions on parents may be best assessed using a dual outcome focused on both reducing negative mental health symptoms while concurrently promoting skills to facilitate parent adaptation and post-traumatic growth.

Family Outcomes After the Pediatric Intensive Care Unit: A Scoping Review

BACKGROUND

Intensivists are increasingly attuned to the postdischarge outcomes experienced by families because patient recovery and family outcomes are interdependent after childhood critical illness. In this scoping review of international contemporary literature, we describe the evidence of family effects and functioning postpediatric intensive care unit (PICU) as well as outcome measures used to identify strengths and weaknesses in the literature.

METHODS

We reviewed all articles published between 1970 and 2017 in PubMed, Embase, PsycINFO, Cumulative Index of Nursing and Allied Health Literature (CINAHL), or the Cochrane Controlled Trials Registry. Our search used a combination of terms for the concept of "critical care/illness" combined with additional terms for the prespecified domains of social, cognitive, emotional, physical, health-related quality of life (HRQL), and family functioning.

RESULTS

We identified 71 articles reporting on the postPICU experience of more than 2400 parents and 3600 families of PICU survivors in 8 countries. These articles used 101 different metrics to assess the various aspects of family outcomes; 34 articles also included open-ended interviews. Overall, most families experienced significant disruption in at least five out of six of our family outcomes subdomains, with themes of decline in mental health, physical health, family cohesion, and family finances identified. Almost all articles represented relatively small, single-center, or disease-specific observational studies. There was a disproportionate representation of families of higher socioeconomic status (SES) and Caucasian race, and there was much more data about mothers compared to fathers. There was also very limited information regarding outcomes for siblings and extended family members after a child's PICU stay.

CONCLUSIONS

Significant opportunities remain for research exploring family functioning after PICU discharge. We recommend that future work include more diverse populations with respect to the critically ill child as well as family characteristics, include more intervention studies, and enrich existing knowledge about outcomes for siblings and extended family.

Family Function, Quality of Life, and Well-Being in Parents of Infants With Hypoplastic Left Heart Syndrome

Survival for hypoplastic left heart syndrome (HLHS) has improved dramatically. Little is known about early family function, quality of life (QOL), or well-being/adjustment for parents of infants with HLHS. Parent/family outcomes over time, predictors, and differences in 143 mothers and 72 fathers were examined. Parents reported better family function compared with published norms, but 26% experienced family dysfunction. QOL and well-being were significantly lower than adult norms. QOL scores generally declined over time, whereas self-reported well-being improved. Responses from mothers and fathers showed different trends, with mothers having worse scores on most measures and at most time points. Being a single parent was a risk factor for poorer family function, but not for lower individual QOL or well-being. Family characteristics, stress, and coping skills were predictive of outcomes. Parents' psychosocial responses to the challenges of life with infants with HLHS change over time. Individually tailored psychosocial support is needed.

Exploratory model of parental stress during children's hospitalisation in a paediatric intensive care unit

OBJECTIVES

This exploratory study (a) examined pre-existing and peri-trauma risk factors of parental stress during a child's PICU hospitalisation using the Integrative Trajectory Model of Paediatric Medical Traumatic Stress and (b) identified the type of PICU-related stressors that predicted parental stress during the child's PICU hospitalisation.

METHODS

A cross-sectional, descriptive correlational design with 81 parents of children admitted 48 or more hours to a Paediatric Intensive Care Unit (PICU). Questionnaires measured parent's and child's demographic and clinical characteristics and parent-reported stressors using the Parental Stressors Scale (PSS:PICU). Analysis included descriptive statistics and multiple linear regression analyses with simultaneous predictor entry.

RESULTS

Male parents tended to be significantly more stressed than female parents. Parental stress was significantly increased when parents had one or more stressful life events one-month prior to PICU admission, when the child required ventilatory support, or the child had a cardiovascular diagnosis. Parental stress was also predicted by the child's appearance, procedures, child's behaviour, behaviour of staff, and parental role.

CONCLUSION

Nurses are in a prime position to identify parents at potentially high risk for psychological morbidity when they know a parent has had a stressful life event prior to admission, has a child with a cardiovascular diagnosis or requires ventilatory assistance. Nurses can diminish parental stress by interpreting the child's appearance for parents, helping parents understand the procedures being done for the child, interpreting the child's behaviour, explaining the staff's behaviour, and assisting parents to define their parental role during the child's hospitalisation.

Singapore's health outcomes after critical illness in kids: A study protocol exploring health outcomes of families 6 months after critical illness

AIM

To explore and understand the impact of paediatric intensive care unit (PICU) admission on longitudinal health outcomes, experiences and support needs of children and their parents in the first 6 months after PICU discharge and to examine the role of ethnicity.

DESIGN

This study uses a prospective, longitudinal design.

METHODS

The sample will include children (N = 110) and at least one parent (N = 110) admitted to the PICU (KKH-AM start-up fund, October 2020). Quantitative study: Participants will be recruited at PICU admission. Data will be collected at five time points: during PICU admission (T0), at PICU discharge (T1), 1 month (T2), 3 months (T3) and 6 months (T4) after PICU discharge. Questionnaires will assess physical and cognitive outcomes of the child survivor. Emotional and social health outcomes will be assessed for both the child and the parents. Qualitative study: At least 12 parents will take part in a semi-structured interview conducted at both 1 and 6 months after PICU to explore their experiences and support needs after PICU discharge. All interviews will be audio-recorded with verbatim transcription. We will use framework analysis for qualitative data analysis.

DISCUSSION

Understanding of Singapore health outcomes after critical illness in kids (SHACK) and their families is limited. There is an urgent need to comprehensively understand the health trajectory and consequences of the PICU child survivors and their families. This research will be the first to explore the health outcomes, needs and experiences after paediatric critical illness in Asia.

IMPACT

This study will provide an understanding of the health outcomes and trajectory of children and parents in the first 6 months after PICU discharge and examine the association between race and outcomes after PICU discharge. Identification of modifiable pre-disposing risk factors during the PICU admission will inform future interventions to improve long-term outcomes of children and parents following paediatric critical illness.

TRIAL REGISTRATION

Clinicaltrial.gov: ClinicalTrials.gov Identifier: NCT04637113.

Posthospitalization follow-up recommendations after pediatric critical illness due to respiratory failure

OBJECTIVES

To characterize the recommended posthospitalization follow-up by provider type and location after a pediatric critical illness due to respiratory failure.

WORKING HYPOTHESIS

After pediatric critical illness due to respiratory failure, patients will not have a standard follow-up pattern with regard to provider type or follow-up location.

STUDY DESIGN

A retrospective cohort study.

SUBJECT SELECTION

Children, 18 years or younger, admitted to a quaternary care pediatric intensive care unit with respiratory failure between January 1, 2013 and December 31, 2014.

METHODOLOGY

For eligible patients, recommendations for posthospitalization follow-up including provider type (primary care and specialty care) and location (community care center vs. tertiary care center) were characterized from medical chart review. Recommendations were examined for all patients and two patient subgroups (patients who received extracorporeal membrane oxygenation and patients with tracheostomy).

RESULTS

Of 155 patients alive at hospital discharge, the median age was 2.1 (interquartile range, 0.7-10.6) years. Eighty percent of patients were instructed to follow-up with a primary care provider but only 52.9% with a pulmonologist. We found 10 unique follow-up patterns between provider location (community care center, tertiary care center, or both) and global provider type (primary care versus specialty care). Primary care follow-up was recommended more often at community locations (74.2%), whereas specialty care was more often recommended at tertiary care centers (68.6%).

CONCLUSIONS

Our study findings demonstrate significant variability in the recommendations for follow-up by provider type and location after hospitalization for acute respiratory failure and highlight areas for improvement in follow-up care after pediatric critical illness.

A thematic analysis exploring the psychological well-being of adults born with esophageal atresia

BACKGROUND

Living with a rare and chronic health condition can have a significant impact on psychological well-being and mental health. There is a growing understanding that Esophageal Atresia (EA), a rare birth defect often accompanied by a Trachea-Esophageal Fistula (TEF), is a complex health condition that requires lifelong medical attention beyond pediatric care into adulthood. Given the reciprocal relationship between one's physical and psychological well-being, the aim of this study was to develop a better understanding of the mental health of adults born with EA/TEF.

METHODS

An international online survey was designed and disseminated in collaboration with an EA/TEF patient charity. The qualitative data was analyzed using a reflexive and inductive Thematic Analysis to explore the research question "How can being born with EA/TEF affect psychological well-being in adulthood?"

RESULTS

A total of 92 adults born with EA/TEF completed the online survey from 11 different counties. Five themes were generated during the analysis: 'Negative Experience with Healthcare Professionals', 'The Perception of Surgical Scars', 'The Psychosocial Consequences of Dysphagia', 'The Legacy of Medical Trauma', and 'Resilience in the Face of Adversity'.

CONCLUSION

The results indicated that adults born with EA/TEF might face emotional challenges that can negatively affect their psychological well-being and mental health. It was also found that some adults born with EA/TEF demonstrate resilience through positive reappraisal of adverse experiences. The current study suggests that a multidisciplinary approach to the care of adults born with EA/TEF is necessary and directions for future research are discussed.

Parental Posttraumatic Stress Symptoms in the Context of Pediatric Post Intensive Care Syndrome: Impact on the Family and Opportunities for Intervention

OBJECTIVE

Pediatric intensive care unit (PICU) survivors and their families experience ongoing impacts on physical, cognitive, and psychosocial functioning, described as Post-Intensive Care Syndrome (PICS). The objective of this study was to determine whether the posttraumatic stress symptoms (PTSS) of parents predict the impact of critical illness on families following PICU admission beyond other factors (e.g., sex, race/ethnicity, age, insurance status, illness severity, family involvement or death).

METHOD

We conducted a retrospective analysis of data from 88 children aged 1 month to 18 years who were hospitalized with critical illness and acquired brain injury in the PICU and their families. Patients and their families participated in a 1-3 month post-discharge follow-up assessment, during which data on demographics, medical diagnoses, parent self-report of PTSS, and family impact of critical illness (via the Pediatric Quality of Life Family Impact Module) were collected. We used a hierarchical linear regression to determine whether parent PTSS predicted family impact above and beyond demographic and injury/illness factors.

RESULTS

One-third of parents reported elevated PTSS. Among those with complete available data (n = 56), PTSS were the only significant predictor of family impact (β = -.52, t = -3.58, p = .001), with the overall model accounting for 41% of variance.

CONCLUSION

In addition to the direct effects on parents of children who survive the PICU, PTSS may negatively impact families and interfere with rehabilitative progress. We provide a rationale and conceptual model for integrating interventions designed to address parent PTSS into post-PICU care.

Development of a parent experience measure for paediatric critical care transport teams

BACKGROUND

A third of children admitted to paediatric intensive care units (PICUs) in the United Kingdom (UK) are transported by paediatric critical care transport services (PCCTs). Parents have described the transfer journey as particularly stressful. Critical care nurses have a key role in mitigating the impact of the journey on parents. Evaluating parents' experiences is important to inform service improvements.

AIM AND OBJECTIVES

Our aim was to describe the development of a new measure of parents' experiences of PCCTs, derived from data collected in the Differences in access to Emergency Paediatric Intensive Care and care during Transport (DEPICT) study.

DESIGN

A descriptive cross-sectional survey was used.

METHODS

As part of the DEPICT study, a 17-item transport experience questionnaire was developed and given to parents of children transported by PCCTs to 24 UK PICUs during a 12-month period. Analyses included exploratory factor analysis and a validation review by a PCCT stakeholder group.

RESULTS

Families of 1722 children (1798 journeys) completed questionnaires. Five items were excluded from further analysis as correlation coefficients were <0.3. Two factors explained 53% of the variance and all 12 items loaded on one of these factors. Factor 1 (8 items) explained 47% of the variance, had excellent internal reliability and the clustered items were conceptually coherent with a specific relevance to PCCTs; these were offered for consideration, with other items possibly discarded. Twenty-eight PCCT clinicians reviewed the questions. Using a 70% agreement threshold, one additional, previously discarded, item was identified for inclusion, resulting in a nine-item experience measure.

CONCLUSION

Our brief measure of parents' experience of critical care transport provides a standardized measure that can be used across all PCCTs, enabling national benchmarking of services and potentially increasing the collection and use of parent experience data to improve services.

RELEVANCE TO CLINICAL PRACTICE

Being able to measure experience provides an opportunity to understand how to make services better to improve experience.

Long-Term Outcomes and the Post-Intensive Care Syndrome in Critically Ill Children: A North American Perspective

Advances in medical and surgical care for children in the pediatric intensive care unit (PICU) have led to vast reductions in mortality, but survivors often leave with newly acquired or worsened morbidity. Emerging evidence reveals that survivors of pediatric critical illness may experience a constellation of physical, emotional, cognitive, and social impairments, collectively known as the “post-intensive care syndrome in pediatrics” (PICs-P). The spectrum of PICs-P manifestations within each domain are heterogeneous. This is attributed to the wide age and developmental diversity of children admitted to PICUs and the high prevalence of chronic complex conditions. PICs-P recovery follows variable trajectories based on numerous patient, family, and environmental factors. Those who improve tend to do so within less than a year of discharge. A small proportion, however, may actually worsen over time. There are many gaps in our current understanding of PICs-P. A unified approach to screening, preventing, and treating PICs-P-related morbidity has been hindered by disparate research methodology. Initiatives are underway to harmonize clinical and research priorities, validate new and existing epidemiologic and patient-specific tools for the prediction or monitoring of outcomes, and define research priorities for investigators interested in long-term outcomes.

Outcomes following admission to paediatric intensive care: A systematic review

AIM

To describe the long-term health outcomes of children admitted to a paediatric intensive care unit.

METHODS

A systematic review of the literature was performed. Studies of children under 18 years of age admitted to a paediatric intensive care unit were included. Studies focussed on neonatal admissions and investigating specific paediatric intensive care unit interventions or admission diagnoses were excluded. A table was created summarising the study characteristics and main findings. Risk of bias was assessed using the Newcastle Ottawa Quality Assessment Scale for observational studies. Primary outcome was short-, medium- and long-term mortality. Secondary outcomes included measures of neurodevelopment, cognition, physical, behavioural and psychosocial function as well as quality of life.

RESULTS

One hundred and eleven studies were included, most were conducted in high-income countries and focussed on short-term outcomes. Mortality during admission ranged from 1.3 to 50%. Mortality in high-income countries reduced over time but this trend was not evident for lower income countries. Higher income countries had lower standardised mortality rates than lower income countries. Children had an ongoing increased risk of death for up to 10 years following intensive care admission as well as increased physical and psychosocial morbidity compared to healthy controls, with associated poorer quality of life.

CONCLUSIONS

There is limited high-level evidence for the long-term health outcomes of children after intensive care admission, with the burden of related morbidity remaining greater in poorly resourced regions. Further research is recommended to identify risk factors and modifiable factors for poor outcomes, which could be targeted in practice improvement initiatives.

Admission Psychosocial Characteristics of Critically Ill Children and Acute Stress

OBJECTIVES

Children are at increased risk for developing acute stress and post-traumatic stress following admission to the PICU. The primary objective of this investigation was to explore the prehospitalization psychosocial characteristics of children admitted to the PICU and their association with acute stress.

DESIGN

Observational.

SETTING

The PICU at an urban, academic, pediatric medical center.

PATIENTS

Children, 8-17 years old with an expected PICU stay greater than 24 hours were recruited.

MEASUREMENTS AND MAIN RESULTS

During the admission, they completed questionnaires and a semistructured interview evaluating prehospitalization psychosocial symptoms, including prehospitalization post-traumatic stress, quality of life, and current acute stress. One hundred eleven children were enrolled (mean age = 12.9 yr; 60% male; 58% Latino). Half (51%) reported a prehospitalization history of trauma and nearly all (96%) of these children had post-traumatic stress. They had significant impairment on all domains of quality of life. Children reported high rates of acute stress during their hospitalization, 74.8% acute stress symptoms, and 6% met diagnostic criteria for acute stress disorder. Univariate analysis showed associations between child age, quality of life, chronic illness, and post-traumatic stress with more severe acute stress. Multiple linear regression modeling of acute stress was done accounting for child age, acute versus chronic illness, quality of life, and post-traumatic stress; prehospitalization quality of life and post-traumatic stress remained significantly associated with the development of inhospital acute stress and accounted for 34% of the variance of the model.

CONCLUSIONS

The current investigation is a novel evaluation of the prehospitalization psychosocial characteristics of children admitted to a PICU. The children enrolled reported high rates of acute stress, which was associated with a history of post-traumatic stress and worsened quality of life. The relation with post-traumatic stress is consistent with prior research into complex post-traumatic stress disorder and increases concerns about long-term psychosocial outcomes. Our data advance understanding of the factors contributing to acute stress during hospitalizations and may add to recognizing the importance of models integrating psychosocial support.

Parental Mental Health Care After Their Child's Pediatric Intensive Care Hospitalization

OBJECTIVES

Post-traumatic stress disorder, depression, and anxiety have all been found in parents of PICU survivors. How these research findings translate to actual use of mental health services by parents remains unknown.

DESIGN

Retrospective observational cohort study.

SETTING

Insurance claims data from 2006 to 2013 obtained from the IBM MarketScan Commercial Database.

PATIENTS

Parents of PICU survivors.

INTERVENTIONS

We examined rates of: 1) mental health diagnoses, 2) outpatient mental health visits, and 3) prescriptions for antidepressants and anxiolytics among parents, 6 months before and 6 months after their child's PICU admission, using each parent as their own control.

MEASUREMENTS AND MAIN RESULTS

Of the 95,070 parents identified, 9.5% received a new mental health diagnosis in the 6 months after their child's PICU hospitalization, which represented a 110% increase from pre-PICU rates. A smaller proportion of parents were given new prescriptions for antidepressants (3.4%) and anxiolytics (3.9%) in the 6 months after their child's PICU hospitalization. Mothers were twice as likely to receive a new mental health diagnosis and be taking a new medication than fathers in the post-PICU period. The parental diagnosis of acute stress disorder or post-traumatic stress disorder increased by 87% from the pre-PICU to the post-PICU period.

CONCLUSIONS

After their child's PICU hospitalization, the proportion of parents with a new mental health diagnosis nearly doubled. Mothers were at nearly twice the risk of receiving a new mental health diagnosis and receiving a new mental health medication compared with fathers. The proportion of parents receiving mental healthcare is much lower than the proportion reporting mental health symptoms in long-term outcomes studies. Whether this indicates a gap in healthcare delivery for parents with mental health symptoms remains unknown.

Effect of Parental Adverse Childhood Experiences and Resilience on a Child's Healthcare Reutilization

BACKGROUND

Adverse childhood experiences (ACEs) are associated with poor health outcomes in adults. Resilience may mitigate this effect. There is limited evidence regarding how parents' ACEs and resilience may be associated with their children's health outcomes.

OBJECTIVE

To determine the association of parental ACEs and resilience with their child's risk of unanticipated healthcare reutilization.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a prospective cohort study (August 2015 to October 2016) at a tertiary, freestanding pediatric medical center in Cincinnati, Ohio. Eligible participants were English-speaking parents of children hospitalized on a Hospital Medicine or Complex Services team. A total of 1,320 parents of hospitalized children completed both the ACE questionnaire and the Brief Resilience Scale Survey.

EXPOSURE

Number of ACEs and Brief Resilience Scale Score among parents.

MAIN OUTCOMES

Unanticipated reutilization by children, defined as returning to the emergency room, urgent care, or being readmitted to the hospital within 30 days of hospital discharge.

RESULTS

In adjusted analyses, children of parents with 4 or more ACEs had 1.69-times higher odds (95% CI, 1.11-2.60) of unanticipated reutilization after an index hospitalization, compared with children of parents with no ACEs. Resilience was not significantly associated with reutilization.

CONCLUSION

Parental history of ACEs is strongly associated with higher odds of their child having unanticipated healthcare reutilization after a hospital discharge, highlighting an intergenerational effect. Screening may be an important tool for outcome prediction and intervention guidance following pediatric hospitalization.

Incidence and prevalence of acute stress disorder and post-traumatic stress disorder in parents of children hospitalized in intensive care units: a systematic review protocol

OBJECTIVE

The objective of this review is to determine the incidence and prevalence of acute stress disorder and post-traumatic stress disorder in parents who have a child hospitalized in an intensive care unit.

INTRODUCTION

Having a child admitted to an intensive care unit is known to be challenging and stressful for parents. This stress may lead to clinical stress disorders that may be improved through interventions. However, there is insufficient clarity around the incidence and prevalence of these disorders.

INCLUSION CRITERIA

This review will consider studies of parents who have had a child admitted to a neonatal or pediatric intensive care unit and who have developed associated acute stress disorder or post-traumatic stress disorder related to their child's hospitalization.

METHODS

The proposed review will follow JBI methodology for systematic reviews of prevalence and incidence. A strategic search for eligible studies will include multiple database sources and unpublished literature. Studies will be assessed for inclusion by two independent reviewers based initially on study titles and abstracts, and subsequently on full text. Methodological quality will be assessed by two independent reviewers, with inclusion criteria focusing on sampling and statistical analysis. Data extraction will be completed, and data synthesis will pool data where possible.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO (CRD42020190875).

Longitudinal Trajectories of Caregiver Distress and Family Functioning After Community-Acquired Pediatric Septic Shock

OBJECTIVES

To identify trajectories and correlates of caregiver distress and family functioning in families of children who survived community-acquired septic shock. We hypothesized that: 1) a substantial subset of families would demonstrate trajectories of persistent elevated caregiver distress and impaired family functioning 12 months after hospitalization and 2) sociodemographic and clinical risk factors would be associated with trajectories of persistent distress and family dysfunction.

DESIGN

Prospective cohort.

SETTING

Fourteen PICUs in the United States.

PATIENTS

Caregivers of 260 children who survived community-acquired septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Caregivers completed ratings of distress on the Brief Symptom Inventory and of family functioning on the Family Assessment Device at baseline, 1, 3, 6, and 12 months after hospitalization. Results from group-based trajectory modeling indicated that 67% of the current sample was characterized by persistent low caregiver distress, 26% by persistent moderate to high distress that remained stable across 12 months (high-risk caregiver distress group), and 8% by initial high distress followed by gradual recovery. Forty percent of the sample was characterized by stable high family functioning, 15% by persistent high dysfunction across 12 months (high-risk family functioning group), 12% by gradually improving functioning, and 32% by deteriorating function over time. Independently of age, child race was associated with membership in the high-risk caregiver distress group (non-white/Hispanic; effect size, -0.12; p = 0.010). There were no significant sociodemographic or clinical correlates of the high-risk family functioning group in multivariable analyses.

CONCLUSIONS

Although the majority of families whose children survived community-acquired septic shock were characterized by resilience, a subgroup demonstrated trajectories of persistently elevated distress and family dysfunction during the 12 months after hospitalization. Results suggest a need for family-based psychosocial screening after pediatric septic shock to identify and support at-risk families.

Quality of life and psychosocial outcomes in children with severe acute asthma and their parents

OBJECTIVES

To prospectively evaluate quality of life (QoL) and psychosocial outcomes in children with severe acute asthma (SAA) after pediatric intensive care (PICU) admission compared to children with SAA who were admitted to a general ward (GW). In addition, we assessed post-traumatic stress (PTS) and asthma-related QoL in the parents.

METHODS

A preplanned follow-up of 3-9 months of our nationwide prospective multicenter study, in which children with SAA admitted to a Dutch PICU (n=110) or GW (n=111) were enrolled between 2016-2018. Asthma-related QoL, PTS symptoms, emotional and behavioral problems, and social impact in children and/or parents were assessed with validated web-based questionnaires.

RESULTS

We included 100 children after PICU and 103 after GW admission, with a response rate of 50% for the questionnaires. Median time to follow-up was 5 months (range 1-12 months). Time to reach full schooldays after admission was significantly longer in the PICU group (mean of 10 vs 4 days, p=0.001). Parents in the PICU group reported more PTS symptoms (intrusion p=0.01, avoidance p=0.01, arousal p=0.02) compared to the GW group.

CONCLUSION

No significant differences were found between PICU and GW children on self-reported outcome domains, except for the time to reach full schooldays. PICU parents reported PTS symptoms more often than the GW group. Therefore, monitoring asthma symptoms and psychosocial screening of children and parents after PICU admission should both be part of standard care after SAA. This should identify those who are at risk for developing PTSD, in order to timely provide appropriate interventions. This article is protected by copyright. All rights reserved.

Effect of a Videoconference-Based Online Group Intervention for Traumatic Stress in Parents of Children With Life-threatening Illness: A Randomized Clinical Trial

IMPORTANCE

A substantial proportion of parents whose child is diagnosed with a life-threatening illness experience high levels of distress that can lead to long-term mental health difficulties. This can affect the child's recovery.

OBJECTIVE

To evaluate the efficacy of an acceptance and commitment therapy-based group intervention, delivered using videoconferencing, in reducing posttraumatic stress symptoms (PTSS) in these parents.

DESIGN, SETTING, AND PARTICIPANTS

This study was a randomized clinical trial of an intervention for parents with elevated acute stress symptoms. It was a single-site study conducted in a tertiary pediatric hospital in Australia. Parents of children aged 0 to 18 years admitted for a life-threatening illness or injury to the oncology, cardiology, or pediatric intensive care departments were eligible. Participants were screened for eligibility within the first month after diagnosis or admission and then were randomized to the intervention group or the waiting list control group 4 to 10 months after diagnosis or admission. Recruitment commenced January 2014, and final postintervention follow-up was completed in February 2018. Data analysis was performed from July to September 2018.

INTERVENTIONS

Treatment was a psychological acceptance and commitment therapy-based group therapy program called Take a Breath, which consisted of a 6-session parent-mediated psychological intervention delivered via online videoconferences over the course of 8 weeks. Waiting list control participants received treatment as usual and were offered the intervention 3 months after randomization.

MAIN OUTCOMES AND MEASURES

The primary outcome was PTSS, as measured by the Posttraumatic Stress Disorder Checklist-Version 5 (total score range, 0-80, with higher scores indicating greater symptom severity). The PTSS was measured both before and immediately after the intervention. Changes in psychological skills taught within the intervention were also evaluated, including acceptance, mindfulness, values-based living, and psychological flexibility.

RESULTS

Of 1232 parents who were assessed for eligibility, 313 were randomized; 161 were allocated to the waiting list control group, and 152 were allocated to the intervention group. Of those allocated, 44 parents in the waiting list group and 37 in the intervention group completed the postintervention questionnaire and were analyzed (81 participants total; mean [SD] age, 37.17 [6.43] years). Sixty-five participants (80.2%) were women, 48 participants (59.3%) were married, and 40 participants (49.4%) lived in rural or regional areas, or in a different state. In addition, 24 parents (29.6%) were in the cardiology illness group, 32 parents (39.5%) were in the oncology group, and 25 parents (30.9%) were in the pediatric intensive care unit group. The intervention group demonstrated significantly greater improvements in PTSS compared with the waiting list group (Cohen d = 1.10; 95% CI, 0.61-1.59; P = .03). The mean Posttraumatic Stress Disorder Checklist-Version 5 scores decreased from 31.7 (95% CI, 27.0-36.4) to 26.2 (95% CI, 21.8-30.7) in the waiting list control group and from 23.3 (95% CI, 18.6-28.1) to 17.8 (95% CI, 13.8-21.8) in the intervention group.

CONCLUSIONS AND RELEVANCE

The findings of this study support the use of acceptance and commitment therapy to reduce PTSS in parents of very ill children, regardless of diagnosis. These findings also suggest that a brief, group format using a videoconferencing platform can be used effectively to access hard-to-reach populations, particularly fathers and caregivers living in nonmetropolitan areas.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Identifier: ACTRN12611000090910.

Predicting Posttraumatic Growth in Mothers and Fathers of Critically Ill Children: A Longitudinal Study

Research on parental psychological effects related to a child's critical illness has focused on studying negative outcomes, while the possibility of posttraumatic growth (PTG), defined as the perception of positive changes after a traumatic event, has been overlooked. This study explores the degree of parental PTG after a child's hospitalization in a pediatric intensive care unit (PICU) and the role of resilience, emotions, perceived severity of the child's condition and stress in predicting PTG. In the first 48 h after their child's discharge from a PICU, N = 196 parents were assessed for resilience, emotions, perceived stress, and the degree to which they perceived their child's condition as severe. 6 months later N = 143 parents were assessed PTG. 6 months post discharge, 37.1% of parents reported PTG at least to a medium degree. Path analyses with latent variables showed that the psychological variables assessed at discharge predicted between 20 and 21% of the total variance in PTG. Resilience affected PTG indirectly, through the bias of positive emotions. PTG is a frequent phenomenon. Psychological interventions aimed at encouraging parental PTG after a child's critical admission should focus on boosting resilience and positive emotions.

Short and Long-Term Parental Posttraumatic Stress After a Child's Accident: Prevalence and Associated Factors

Studies on the long-term prevalence of parental posttraumatic stress symptoms (PTSS) following child accidental injury are scarce, and findings on risk factors vary. In this follow-up study (T2, n = 69) we determined the prevalence of parental PTSS 2-4 years after accidental injury of their child, compared with 3 months after the accident (T1, n = 135). Additionally, we examined the association between parental and child factors and PTSS severity. Children were 8-18 years old at the time of the accident. Parent and child PTSS was assessed by self-report. Other data were retrieved from medical records and a telephone interview. Parental PTSS was 9.6% at T1 and 5.8% at T2. Acute parental stress as measured within 2 weeks of the child's accident was significantly associated with parental PTSS severity (T1 and T2), as was the child's hospitalization of more than 1 day at T1 and the child's permanent physical impairment at T2. To prevent adverse long-term psychological consequences we recommend identifying and monitoring parents at risk and offering them timely treatment.

Psychosocial assessment of families caring for a child with acute lymphoblastic leukemia, epilepsy or asthma: Psychosocial risk as network of interacting symptoms

The purpose of this study is to assess psychosocial risk across several pediatric medical conditions and test the hypothesis that different severe or chronic pediatric illnesses are characterized by disease specific enhanced psychosocial risk and that risk is driven by disease specific connectivity and interdependencies among various domains of psychosocial function using the Psychosocial Assessment Tool (PAT). In a multicenter prospective cohort study of 195 patients, aged 5–12, 90 diagnosed with acute lymphoblastic leukemia (ALL), 42 with epilepsy and 63 with asthma, parents completed the PAT2.0 or the PAT2.0 generic version. Multivariate analysis was performed with disease as factor and age as covariate. Graph theory and network analysis was employed to study the connectivity and interdependencies among subscales of the PAT while data-driven cluster analysis was used to test whether common patterns of risk exist among the various diseases. Using a network modelling approach analysis, we observed unique patterns of interconnected domains of psychosocial factors. Each pathology was characterized by different interdependencies among the most central and most connected domains. Furthermore, data-driven cluster analysis resulted in two clusters: patients with ALL (89%) mostly belonged to cluster 1, while patients with epilepsy and asthma belonged primarily to cluster 2 (83% and 82% respectively). In sum, implementing a network approach improves our comprehension concerning the character of the problems central to the development of psychosocial difficulties. Therapy directed at problems related to the most central domain(s) constitutes the more rational one because such an approach will inevitably carry over to other domains that depend on the more central function.

Families' Experiences of Life in the Year after a Child's Critical Illness: Navigating the Road to a "New Normal"

Semistructured interviews were conducted with patients and family members ( n  = 18) postdischarge to examine how they managed their recovery in the year following a child's intensive care unit admission. Data were analyzed using the grounded theory. Participants described an ongoing need to develop and adapt their narratives about admission and recovery. Other key themes were as follows: just getting through, recognizing they had changed, striving for normality, and finding positive aspects related to their experiences. It took longer than they expected for families to build a coherent narrative of events postdischarge and to adjust to the "new normal." Implications for health professionals are discussed.

Surgical and Psychosocial Predictors of Mental Health in Parents of Children With Cardiac Admissions

BACKGROUND

This study investigated factors associated with long-term mental health outcomes of parents of children with a cardiac illness. The objective of the study was to investigate the hypothesis that acute mental health status and psychosocial risk factors (eg, acute stress reactions, quality of life) would be more strongly associated with long-term mental health outcomes than demographic, diagnostic, morphology, or procedure-related factors.

METHODS

Participants were 31 parents of children who underwent cardiac operations in a pediatric hospital. Acute mental health status, psychosocial risk, demographic information, morphology, and procedure-related data were collected within the first 4 weeks of the child's hospital admission. Mental health outcomes, including symptoms of posttraumatic stress, depression, anxiety, and general stress, were collected at a 2-year follow-up.

RESULTS

Acute mental health status and psychosocial risk, specifically acute stress reactions, contributed significantly to parent mental health, explaining 44% of the variance in the parent posttraumatic stress scores (P < .001) and 40% in depression scores (P < .001). Morphology and procedure-related factors (eg, prolonged mechanical ventilation) explained a further 12% of the variance in parent posttraumatic stress scores (P = .015) and a further 13% in depression scores (P = .014). No associations were found with demographic factors.

CONCLUSIONS

Results suggest that acute mental health status is more strongly related to parent mental health outcomes than morphology and procedure-related variables in children undergoing neonatal cardiac operations and that demographic variables are not associated with mental health outcomes.