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Persistence of Posttraumatic Stress in Violently Injured Youth Seen in the Emergency Department
Joel A. Fein, MD;
Nancy Kassam-Adams, PhD;
Maureen Gavin, MPH;
Rex Huang, BA;
Deena Blanchard, MPH;
Elizabeth M. Datner, MD
Arch Pediatr Adolesc Med. 2002;156:836-840.
ABSTRACT
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Objective To determine if symptoms of posttraumatic stress, initially evaluated
in the emergency department (ED) setting, persist over time.
Design Prospective cohort study.
Setting Two urban, academic medical center EDs.
Patients Sixty-nine injured patients, aged 12 to 24 years, were assessed for
acute posttraumatic stress symptoms at the time of their enrollment in an
ongoing ED-based study of intentional youth violence, and assessed for posttraumatic
stress symptoms up to 5 months later.
Main Outcome Measures The Immediate Stress Reaction Checklist, administered during the ED
visit, and the Symptom Checklist of the Child and Adolescent Trauma Survey,
administered during routine telephone follow-up.
Results Patients in the emergency department reported a range of acute stress
symptoms on the Immediate Stress Reaction Checklist, with 25% reporting clinically
significant distress. On follow-up assessment, 15% reported significant posttraumatic
stress symptoms. The severity of acute stress symptoms was strongly associated
with the severity of posttraumatic stress symptoms at follow-up (r = 0.55, P<.005). Age, sex, injury type,
and time from injury to follow-up were not associated with the degree of acute
stress or posttraumatic stress symptom severity at initial or follow-up assessment.
Conclusion This study provides preliminary evidence that acute stress symptoms,
assessed in the ED in the immediate aftermath of a traumatic injury, are useful
indicators of risk for later posttraumatic stress.
INTRODUCTION
INTENTIONAL VIOLENCE is defined as "a threatened or actual use of physical
force against a person or group that either results in or is likely to result
in injury or death."1 Guidelines for the care
of violently injured youth suggest that we thoroughly evaluate the emotional
status of these patients as well as the need for psychological or psychiatric
services.2 The psychological sequelae of acute
injuries can often be more severe than the injuries themselves. One outcome
of concern is posttraumatic stress disorder (PTSD), a constellation of symptoms
(reexperiencing a trauma, avoiding reminders of it, and hyperarousal)3 that has been documented in youth injured by or exposed
to community violence.4-5 After
a traumatic event, such as a violent injury, many individuals experience acute
distress and a significant minority go on to develop the full clinical syndrome
of PTSD.6-9
Because traumatic exposure alone does not invariably result in persistent
traumatic stress symptoms (ie, not every person who experiences a traumatic
event develops PTSD), other predictors and screening assessments may be useful
in identifying individuals at greatest risk.
Often, the only point of medical contact for violently injured urban
youth is the emergency department (ED). It has been shown that self-reported
acute stress disorder (ASD) symptoms in the ED setting are fairly common in
children, adolescents, and young adults in the immediate aftermath of violent
injury.10 Acute stress disorder consists of
early posttraumatic symptoms, including dissociation, reexperiencing, avoidance,
and hyperarousal.3 A better understanding of
the relationship between early distress symptoms and persistent posttraumatic
distress in violently injured adolescents and young adults would enhance the
ability of pediatric clinicians to assess these youths' mental health and
emotional needs.
The objective of this study was to determine if symptoms of posttraumatic
stress, initially evaluated in the ED, persist over time, and whether the
degree of early distress is predictive of continued posttraumatic symptoms
weeks to months later. We hypothesized that there would be a moderate correlation
between acute stress symptom scores in the ED and posttraumatic stress symptoms
assessed on telephone follow-up.
PARTICIPANTS, MATERIALS, AND METHODS
We enrolled a convenience sample of adolescents and young adults between
the ages of 12 and 24 years who had come to the EDs of an urban children's
hospital and an urban adult hospital for treatment between September 1999
and April 2000. Participants were enrolled as part of the Violence Intervention
Project (VIP), an ongoing intervention study that surveys violently injured
youth (excluding victims of child abuse and domestic violence) residing in
the 8 ZIP codes surrounding the 2 hospitals. The median annual household income
in these ZIP codes ranges from $22 000 to $35 000. The racial/ethnic
background of residents in the neighborhoods encompassed by the 8 ZIP codes
is as follows: 70% black, 22% white, 6% Asian, and 2% Hispanic (personal communication,
University of Pennsylvania Health System Market Research Office, 2001 data).
The VIP also provided assessment and referral services to a subset of these
patients, when needed. Patients were excluded if they did not speak English,
were too ill or injured to answer a detailed questionnaire, or resided outside
the predetermined ZIP code areas. We reviewed all ED records during the enrollment
period at both hospitals to determine the proportion of eligible patients
successfully enrolled in the study.
Participants were enrolled in accordance with a study protocol approved
by the institutional review boards of both hospitals. Participants were recruited
only during the times that research assistants staffed the EDs, which includes
various shifts between the hours of 8 AM and midnight, 7 days per week. After
verbal consent was obtained, the research assistants administered a verbal
questionnaire to patients in treatment rooms during their ED visits. This
questionnaire asked about event circumstances, weapon use, and factors associated
with interpersonal violence, such as school attendance, alcohol use, drug
use, and weapon carrying. The patient was then asked to complete the Immediate
Stress Response Checklist (ISRC), as described in a previous report.10 Demographic and medical information were obtained
at the time of the visit or by review of the medical record. During routine
follow-up calls as part of the larger VIP study, the symptom checklist of
the Child and Adolescent Trauma Survey (CATS) was administered over the telephone.
Trained research assistants attempted telephone contact at least 6 times with
each youth during a 20-month period. Patients who were reached by telephone
and completed a follow-up assessment within 5 months of initial ISRC assessment
were included in the primary analysis. Each participant may have completed
more than 1 telephone follow-up assessment with the CATS during the course
of participation in the VIP study. Unless otherwise specified, the first follow-up
for each participant was used in each analysis presented. At the completion
of each telephone interview, the research assistant obtained consent for further
follow-up and offered general assistance with regard to the study and study-related
issues.
MEASURES
The ISRC10 is a 26-item, verbal questionnaire
designed to evaluate the key features of acute stress responses in the immediate
posttrauma period (dissociation, reexperiencing, avoidance, and hyperarousal).
The ISRC is not intended to provide a diagnosis of ASD because this is not
possible to accomplish in an immediate fashion (the diagnosis requires a 2-day
minimum duration of symptoms). Respondents rate each item on a 3-point scale:
0 = "not true," 1 = "somewhat or sometimes true," or 2 = "very or often true."
Item ratings on the ISRC were summed to form a total acute stress symptom
severity score (ISRC score). In addition, we computed a dichotomous score
for "broad acute stress responses" that was positive if the individual reported
at least 1 symptom in every one of the symptom subcategories that compose
the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) criteria for ASD (peritrauma or posttrauma
dissociation, reexperiencing, avoidance, and hyperarousal). Symptoms are counted
as present only when rated by the respondent as "very or often true" (an item
rating of 2). Psychometric analyses indicate that the ISRC has strong internal
consistency ( = .86), and that in adolescents, the ISRC correlates
strongly with an adult measure of ASD and moderately with parent reports of
adolescents' acute stress reactions (J.A.F. and N.K.A., unpublished data,
2002).
The symptom checklist of the CATS11 is
a 12-item tool designed as a brief measure of posttraumatic stress symptom
severity in children and youth. Items are rated on a 4-point Likert-type scale
(scored as 0, 1, 2, and 3) and address the core symptom categories of PTSD
(reexperiencing, avoidance, and hyperarousal). The CATS is not intended to
provide a formal PTSD diagnosis but does serve as a useful indicator of the
severity of PTSD symptoms. The summed total score of 12 items forms a symptom
severity score (CATS score). In addition, we computed a dichotomous score
for "significant posttraumatic stress responses" that was positive if the
individual reported at least 1 symptom in every symptom category included
in the DSM-IV criteria for PTSD (reexperiencing,
avoidance, and hyperarousal). Symptoms were counted as present only when rated
by the respondent as occurring "often" (an item rating of 3). The CATS score
correlates highly with other measures of PTSD and with clinician assessment,
and a CATS score of 27 or higher has been associated with the presence of
diagnostic PTSD.11 The instrument was selected
as a brief measure with excellent psychometric properties. It is also practical
for use in telephone follow-up assessment to give an indication of posttraumatic
stress outcome.
STATISTICAL ANALYSES
Descriptive statistics were computed for the frequency of various demographic
and injury circumstance characteristics. Characteristics of participants and
nonparticipants (those patients who completed an acute stress assessment but
could not be reached for follow-up) were compared using  2
tests for categorical variables and an independent-sample t test for age. Prevalence rates and 95% confidence intervals were
computed for broad acute stress responses, significant later posttraumatic
stress responses, and for the prevalence of each symptom category. The relationship
between ISRC and CATS scores was explored using nonparametric correlations
(Spearman  ), first for the sample as a whole and then separately for
those assessed before or after their 1-month postinjury date.
In secondary analyses, we examined the relationship between severity
of posttraumatic stress responses and a range of potential demographic or
situational correlates. We also explored the potential that acute stress symptoms
in the ED may usefully predict longer-term posttraumatic stress, by examining
the correlation between acute symptoms and posttraumatic stress more than
5 months postinjury. These analyses included only the participants with a
follow-up assessment later than 5 months and used the latest CATS assessment
available for each participant. An independent-sample t test or analysis of variance was used to assess variation in mean
ISRC and CATS scores on categorical variables (sex, injury type, and inclusion
in the assessment/referral or the control conditions of the larger VIP study).
Nonparametric correlations were used to compare the association of symptom
severity with age and with time since injury. SPSS 10.0 (SPSS Inc, Chicago,
Ill) was used for all analyses. Sample size calculations were based on the
study's primary objective of estimating the correlation between ISRC and CATS
scores. A sample size of 69 is adequate to detect a correlation of 0.30 or
greater (setting at P<.05), with 80% power.
RESULTS
During the enrollment period, 396 patients aged 12 to 24 years were
seen in the 2 EDs for treatment of a violence-related injury. Two hundred
three patients were eligible for the study because they were seen during the
hours staffed by research assistants. We recruited 112 (55%) of the 203 patients
into the current study during their ED visit. Forty-two patients refused participation
and 9 were unable to be enrolled because of severity of illness. Forty patients
were recruited into the larger violence intervention study but were not included
in the current study analyses because they did not complete the acute stress
assessment while in the ED. Sixty-nine (62%) of the 112 enrolled patients
were subsequently reached by telephone to complete a CATS assessment within
5 months of the initial event. When the 69 participants were compared with
the 43 eligible youths who were assessed in the ED but did not complete a
follow-up assessment within 5 months, there were no significant differences
in age, sex, injury type, or degree of acute stress symptom severity in the
ED (initial ISRC score). There was a statistically significant difference
in the distribution of race/ethnicity between the 2 groups since only 1 of
7 white patients initially assessed in the ED completed a follow-up assessment.
Participants ranged in age from 12 to 24 years (mean [SD] age, 15.1
[2.8] years). Sixty-three (91%) were adolescents (aged 12-17 years), and 6
(9%) were young adults (aged 18-24 years). Forty-seven (68%) of the 69 participants
were male. Sixty-two (90%) of the participants in this study were black, 3
(4%) were Asian, and 1 participant (1%) was white. Race or ethnicity was undeclared
for 3 (4%) of the participants. The most significant type of injury sustained
by study participants was contusion (43 patients, [62%]), laceration (8 [12%]),
fracture (6 [9%]), bite injury (6 [9%]), and cavitation including gunshot
(3 [4%]). Type of injury was undetermined in 2 [3%] and listed as "other"
in 1 [1%] of participants. The most common "weapons" causing injury to participants
were fists, feet, or hands (42 patients [61%]), followed by blunt objects
(6 [9%]), teeth (5 [7%]), guns (4 [6%]), and knives or other piercing objects
(3 [4%]). For 3 (4%) of participants, the weapon was not identified and 6
(9%) of participants reported that no weapon was involved (eg, pushing, shoving).
Each violent incident was categorized on the basis of participant-reported
event characteristics. The incidents were categorized as "assault/mugging"
of the patient (29 patients [42%]) or a "fight/argument" in which the patient
was involved (40 [58%]). Follow-up CATS data were obtained during routine
follow-up calls, ranging from 11 days to 5 months after the ISRC. Of the 69
participants, 25 were first surveyed with the CATS within 1 month of the violent
injury and 44 between 1 and 5 months after the injury (31 of these between
1 and 2 months postinjury, 8 between 2 and 3 months, 3 between 3 and 4 months,
and 2 between 4 and 5 months).
ACUTE POSTTRAUMATIC STRESS SYMPTOMS
In the ED, each type of acute stress symptom was reported (at the moderate
to severe level) by a fairly large percentage of patients (Table 1). The 69 patients in this sample endorsed between 0 and
23 acute stress symptoms during the ED visit (mean [SD], 9.2 [5.5]). Seventeen
patients (25%) reported broad acute stress responses, with at least 1 significant
symptom in every category (dissociation, reexperiencing, avoidance, and arousal).
Age (r = 0.08, P = .50),
sex (t = .05, P = .96),
type of injury (analysis of variance: F = .44, P
= .82), and assignment to the assessment/referral or control group (t = 1.12, P = .27) were not associated
with the degree of acute stress symptom severity as reported in the ED.
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Individuals Reporting at Least 1 Moderate-to-Severe Symptom, by Symptom
Category*
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POSTTRAUMATIC STRESS SYMPTOMS AT FOLLOW-UP
On telephone follow-up, each type of posttraumatic stress symptom was
reported (at the moderate to severe level) by a smaller but still substantial
percentage of youth (Table 1).
Four (6%) of the 69 patients scored 27 or higher on the CATS. All of the patients
meeting this cutoff were among those assessed more than 1 month postinjury,
suggesting that they may have met diagnostic criteria for PTSD.
Several more patients were experiencing clinically significant (albeit
subsyndromal) PTSD symptoms at follow-up: 10 participants (15%) reported significant
posttraumatic stress responses, with at least 1 significant symptom in every
symptom category (reexperiencing, avoidance, and arousal) (Table 1). Age (r = -0.09, P = .48), time since injury (r = 0.13, P = .30), sex (t = -1.36, P = .17), type of injury (analysis of variance: F = 0.43, P = .83), and assignment to the assessment/referral or
control group (t = 1.71, P
= .09) were not associated with the degree of posttraumatic stress symptom
severity at follow-up.
RELATIONSHIP BETWEEN ACUTE AND LATER POSTTRAUMATIC STRESS SYMPTOMS
The ISRC score (acute stress symptom severity) in the ED was strongly
associated with the CATS score (posttraumatic stress symptom severity) at
follow-up (r = 0.55, P<.001).
The association between the ISRC and CATS scores was comparably strong in
the 25 patients who were assessed within 1 month of injury (r = 0.64, P = .001) and in those who were
assessed between 1 and 5 months of injury (r = 0.50, P = .001). Secondary analysis of the 42 participants whose
latest follow-up assessment was more than 5 months postinjury (range, 5.5-20
months) revealed that the length of time between injury and assessment was
not associated with the CATS score. Participants' ISRC score and their latest
CATS score showed a moderate association (r = 0.39, P = .01).
COMMENT
Acute stress symptoms seem to be common among urban youth seen in the
ED for violent injury, with more than 80% reporting some symptoms and about
one third reporting significant acute posttraumatic distress.10
Our prospective study investigated whether symptoms reported by youth in the
immediate aftermath of a violent injury persist over time, and whether the
severity of early symptoms is predictive of continued posttraumatic stress
symptoms. This study demonstrates that symptoms of acute stress reported by
violently injured urban patients in the ED correlate with future reporting
of posttraumatic stress weeks to months after the event. Variables such as
demographic and event circumstances did not affect these results. Not surprisingly,
correlations were higher for posttraumatic stress symptoms reported closer
to the time of injury, but the association with acute symptom severity persisted
even when posttraumatic symptoms were assessed more than 5 months later. This
substantiates the discovery of acute stress in the immediate postinjury period
as a marker for continued emotional and psychological distress in a substantial
proportion of violently injured adolescents and young adults.
Approximately two thirds of urban youths report victimization by physical
violence, and almost 90% of these youths report witnessing such events in
their home, school, or neighborhood.12 The
prevalence of these experiences is substantially lower, but still of concern,
for suburban youths.5, 12 Studies
have demonstrated that a single and sudden traumatic event, such as a motor
vehicle crash, pedestrian injury, or violent crime can lead to PTSD in a significant
number of cases.8, 13-14
Although individuals whose symptoms merit a formal diagnosis of PTSD are of
greatest concern, the risk of persistent subsyndromal but significant posttraumatic
symptoms also warrants attention.15
Several studies of adults injured by violence and those injured in motor
vehicle crashes have suggested a link between acute distress, assessed within
the first month of injury, and posttraumatic stress symptoms 6 months to 2
years later.8, 16-17
Our study extends this work to a younger age group and examines the utility
of assessing acute stress symptoms in the ED. The latter is an especially
practical investigation for identification and treatment of posttraumatic
psychological sequelae in urban youth, as the ED visit is often the only point
of contact for young people who sustain a violent injury.
There are some limitations to this study. The convenience sampling allows
for the possibility that the 112 patients enrolled and assessed in the ED
do not adequately represent the population of young patients who come to the
ED for violent injuries. It is encouraging that those enrolled in the VIP
study were selected only because of research assistant availability and the
ability to complete a lengthy questionnaire in the ED and not necessarily
for reasons that would likely affect the main outcome measures. Importantly,
the 61% of initially enrolled patients who completed a follow-up assessment
were similar in almost all measured demographic and event-related characteristics
to those enrolled patients who did not complete a follow-up assessment. Because
the measures used in this study do not provide for a formal diagnosis of ASD
or PTSD, these results should be interpreted as reflecting general posttraumatic
stress symptom severity rather than the presence or absence of either of these
psychiatric disorders. It should also be noted that this study did not measure
prior or ongoing traumatic experiences or pre-event levels of distress symptoms,
which can affect the severity of event-related stress reactions.18
It is possible that the assessment of acute stress reactions in the ED captured
symptoms that were present prior to the index violent event. Although detailed
information on a patient's exposure to prior traumatic events is rarely discovered
in the acute care setting, it may be worthwhile to investigate how this exposure
affects acute stress responses and how knowledge of prior trauma exposure
can supplement other data, such as acute stress scores or physiologic indicators
to better predict PTSD development.19 Although
1 month's duration of symptoms is required to fit the present criteria for
diagnosis of PTSD, for some participants in our study, the only available
follow-up assessment was performed earlier than 1 month. Future investigations,
using larger and more varied samples of youths in various clinical settings
and follow-up measures that comprehensively assess PTSD symptoms and provide
a reliable and valid formal diagnosis of PTSD, are needed to further generalize
our findings and to determine if there are distinct subtypes of self-reported
symptoms or other indicators that can more accurately predict the development
of PTSD in these patients.
Extending studies of injured adults, the results of this study support
the link between acute stress symptoms after violent injury and posttraumatic
stress many weeks or months later. Although the best therapies for prevention
and treatment of posttraumatic stress symptoms are still being investigated,
early detection in the immediate postinjury period offers physicians the opportunity
to connect high-risk youth with family, community, and professional support
that may prevent long-term psychological ramifications.20-21
| What This Study Adds
This prospective study demonstrates that symptoms of acute stress reported
by violently injured urban youth in the ED are associated with future reporting
of posttraumatic stress weeks to months after the event. Correlations were
higher for posttraumatic stress symptoms reported closer to the time of injury
but the association with acute symptom severity persisted even when posttraumatic
symptoms were assessed more than 5 months later. This substantiates the evaluation
of acute stress in the immediate postinjury period as a possible indicator
of longer-term emotional distress experienced by violently injured youth.
Early detection in the immediate postinjury period may offer clinicians the
opportunity to connect high-risk youth with family, community, and professional
support that may prevent long-term psychological ramifications.
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AUTHOR INFORMATION
Accepted for publication May 1, 2002.
This study was funded by a Special Projects Grant from the Ambulatory
Pediatrics Association, McLean, Va. The Violence Intervention Project is funded
by the William Penn Foundation, Philadelphia, Pa.
We thank Jennifer Cohn, MD, and Marisa Turner for their assistance with
data entry, the Academic Associates Program at the University of Pennsylvania
(Philadelphia) for assistance with survey administration, the doctors and
nurses in the EDs at the Children's Hospital of Philadelphia (Philadelphia)
and the Hospital of the University of Pennsylvania for their participation
in this project, and Pat Parkinson for her assistance in the preparation of
the manuscript.
Corresponding author and reprints: Joel A. Fein, MD, Division of
Emergency Medicine, The Children's Hospital of Philadelphia, 34th St &
Civic Center Boulevard, Philadelphia, PA 19104 (e-mail: fein{at}e-mail.chop.edu).
From the Divisions of Emergency Medicine (Dr Fein, Mss Gavin and Blanchard,
and Mr Huang) and General Pediatrics (Dr Kassam-Adams), the Children's Hospital
of Philadelphia, Emergency Department (Dr Datner), the Hospital of the University
of Pennsylvania, and Departments of Pediatrics (Dr Fein, Mss Gavin and Blanchard,
and Mr Huang), Child and Adolescent Psychiatry (Dr Kassam-Adams), and Emergency
Medicine (Dr Datner), the University of Pennsylvania School of Medicine, Philadelphia.
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