The relationship between Why look at this group? memory and PTSD - PDF document

The relationship between Why look at this group? memory and PTSD symptoms in • Theoretical high risk of PTSD in children children after admission to PICU and parents Gillian Colville, Christine Pierce Great Ormond St Hospital, London UK Why look at this group? Why look at this group? • Theoretical high risk of PTSD in children • Theoretical high risk of PTSD in children and parents and parents • Evidence of distress in adult ICU patients • Evidence of distress in adult ICU patients • Potential for preventative work and intervention Why look at this group? Inherent Difficulties • Theoretical high risk of PTSD in children • Significant risk of death and parents • Evidence of distress in adult ICU patients • Potential for preventative work and intervention • Predictable steady workload (as compared with after disaster) 1

Inherent Difficulties Inherent Difficulties • Significant risk of death • Significant risk of death • Majority of patients aged under 5y • Majority of patients aged under 5y • Patients unconscious Inherent Difficulties Inherent Difficulties • Significant risk of death • Significant risk of death • Majority of patients aged under 5y • Majority of patients aged under 5y • Patients unconscious • Patients unconscious • Carers in extreme distress (?capable of • Carers in extreme distress (?capable of informed consent) informed consent) • No formal follow up structure Inherent Difficulties Deprivation • Significant risk of death F r e q u e n c y • Majority of patients aged under 5y • Patients unconscious • Carers in extreme distress (?capable of informed consent) Townsend Deprivation Quintile • No formal follow up structure • High proportion of deprived families 2

www.NCTSNet.org Adult ICU findings • Menzel (1998) fear tube in situ • Schelling et al (1998) PTSD 4yrs later • Scragg (2001) link between ICU experiences and PTSD • Jones et al (2001) on link between delusional memories and PTSD Child ICU findings: short term Child ICU findings: longer term • PTSD higher in children (52% v 9%) 6-8 wks after critical illness • Only 67% remember anything, Landolt et al (1998) predominantly neutral/positive (n=40) Playfor et al (2000) • PTSD higher in children (26% v 0%) 6-12m after • 100% remembered something, 50% critical illness (n=35) negative memories (n=50) Rees et al (2004) Karande et al (2005) • Association between no. of invasive procedures and PTSD symptoms at 6 months (n=60) Rennick et al (2004) Pilot Work Child interviews 9 months post PICU (n=15) 3

Quotes: Feeling changed Child Interviews Depression 4/15 above cut off • “I am not as scared as I was …now when I (Birleson Scale) get a cut it is just nothing” Post traumatic stress 4/15 above cut off (IES) • “I really miss the way I was before” Behaviour problems 2/15 above cut off (CBCL) Great Ormond Street Hospital Fear Schedule SD scores 6 5 4 Frequency 3 2 1 0 -2.50 -2.00 -1.50 -1.00 -.50 0.00 .50 1.00 1.50 2.00 2.50 SD 4

GOS Research Project Sample • Survivors over 7 years of age • Relationship between memories and PTSD symptomatology Exclusions • Learning difficulties; readmitted to PICU; • Relationship with parental psychopathology professional refusal (eg palliative care) Design Psychological measures • Info sheet included in discharge pack Child • Peds QL (physical, emotional, school, social, fatigue level) • Family invited to o/p appt at 2 months (with option of home visit if preferred) • ICU Memory Tool (factual v delusional memories) • Child Impact of Event Scale (post traumatic • Postal/telephone follow up at 1 year stress) Psychological measures How got good response (75%)? • Chased original letter by phone Parent • Willingness to do home visits/ fit in round • Hospital Anxiety and Depression Scale other appts at GOS • SPAN (brief post traumatic stress scale) • Use of interpreters • ?offer to pay fares (only minority asked) • GOS effect? 5

Sample characteristics Reason for admission • 21 male, 18 female Elective surgery • Mean child age 12yrs (7-17) Trauma Other • Mean parent age 39yrs (30-50) • Mean length of stay 4 days (1-25) Case example: John 13y Case example: John 13y • Sustained serious head injury falling from • Sustained serious head injury falling from bike (no helmet) bike (no helmet) • Remembers getting into ambulance to local hospital Case example: John 13y Case example: John 13y • Sustained serious head injury falling from • Sustained serious head injury falling from bike (no helmet) bike (no helmet) • Remembers getting into ambulance to local • Remembers getting into ambulance to local hospital hospital • Deteriorated in A&E  GOS PICU • Deteriorated in A&E  GOS PICU • Transferred back to local after 2 day admission 6

Case example: Tim 15y Case example: Tim 15y • Friedreich’s Ataxia with unstable gait and • Friedreich’s Ataxia with unstable gait and back pain back pain • Elective Spinal fusion operation Case example: Tim 15y Case example: Tim 15y • Friedreich’s Ataxia with unstable gait and • Friedreich’s Ataxia with unstable gait and back pain back pain • Elective Spinal fusion operation • Elective Spinal fusion operation • Extubated spontaneously in recovery but • Extubated spontaneously in recovery but admitted to PICU as planned for obs admitted to PICU as planned for obs • Transferred to GOS surgical ward next day Case example: Nina 10y Case example: Nina 10y • In treatment at local hospital for chemo • In treatment at local hospital for chemo • Suffered allergic reaction to new drug  seizures  intubated and ventilated 7

Case example: Nina 10y Case example: Nina 10y • In treatment at local hospital for chemo • In treatment at local hospital for chemo • Suffered allergic reaction to new drug  • Suffered allergic reaction to new drug  seizures  intubated and ventilated seizures  intubated and ventilated • Retrieved to GOS PICU for 1 day • Retrieved to GOS PICU for 1 day • Transferred back to local hospital Preliminary results (n=39) Factual Memories • Pre PICU 67% remembered some factual accident, collapse, feeling unwell • During PICU information about PICU family, staff, (monitors), (tubes) • Post PICU ward, injections, ambulance to local hospital “It was very hard to be sick lying down obviously…” 13y boy, head injury 8

Delusional Memories Content of Hallucinations Family members (inc deceased) • 11 children (28%) experienced hallucinations • 12 children (31%) experienced nightmares or unusually vivid dreams Content of Hallucinations Content of Hallucinations Family members (inc deceased) Family members (inc deceased) Cup of coffee Cup of coffee Bleeding cat on ceiling Content of Hallucinations Content of Hallucinations Family members (inc deceased) Family members (inc deceased) Cup of coffee Cup of coffee Bleeding cat on ceiling Bleeding cat on ceiling Bob the builder with hammer Bob the builder with hammer Giant talking flower (+) 9

Content of Hallucinations Family members (inc deceased) “When I came back from the hospital I was Cup of coffee seeing lots of things on the walls…..Um wherever I looked I would see some things Bleeding cat on ceiling ……Yea crawly things” Bob the builder with hammer Giant talking flower (+) 10y girl, cancer Butterflies and clouds (+) Proportions of parents and children scoring above PTSD cut offs 60% 50% 40% 30% 20% 10% 0% Parents Children Intrusive thoughts Associations with PTSD score “It came into my mind … sort of like a video • Age NS clip … going towards the edge … and then the whole of my body just chucked itself forward as if I was crashing. It was really weird” 13y boy, head injury 10

Associations with PTSD score Associations with PTSD score • Age NS • Age NS • Sex NS • Sex NS • Length of stay NS Associations with PTSD score Associations with PTSD score • Age NS • Age NS • Sex NS • Sex NS • Length of stay NS • Length of stay NS • Elective v emergency p=0.04 • Elective v emergency p=0.04 • Parent’s PTSD score p=0.01 Associations with PTSD score Associations with PTSD score • Age NS • Age NS • Sex NS • Sex NS • Length of stay NS • Length of stay NS • Elective v emergency p=0.04 • Elective v emergency p=0.04 • Parent’s PTSD score p=0.01 • Parent’s PTSD score p=0.01 • Factual memories NS • Factual memories NS • Delusional memories p=0.03 11

Child’s PTSD score by type of memory 25 20 Preliminary 1 yr follow up data 15 10 5 0 no yes deusional memories Child PTSD at 3 months Child PTSD at 1 year Child PTSD above cut off Child PTSD below cut off at 3 mths and 1yr at 3 mths and 1yr 30 30 25 25 20 20 15 15 10 10 5 5 0 0 1 2 1 2 12