Publications by authors named "Justin A Kenardy"

38 Publications

Topical Review: Medical Trauma During Early Childhood.

J Pediatr Psychol 2021 Aug;46(7):739-746

Department of Counseling and Clinical Psychology, Columbia University Teachers College.

Objective: Early childhood is a high-risk period for exposure to traumatic medical events due to injury/illness. It is also one of the most important and vulnerable periods due to rapid development in neurobiological systems, attachment relationships, cognitive and linguistic capacities, and emotion regulation. The aim of this topical review is to evaluate empirical literature on the psychological impact of medical trauma during early childhood (0-6 years) to inform models of clinical care for assessing, preventing, and treating traumatic stress following injury/illness.

Methods: Topical review of empirical and theoretical literature on pediatric medical traumatic stress (PMTS) during early childhood.

Results: There are important developmental factors that influence how infants and young children perceive and respond to medical events. The emerging literature indicates that up to 30% of young children experience PMTS within the first month of an acute illness/injury and between 3% and 10% develop posttraumatic stress disorder. However, significant knowledge gaps remain in our understanding of psychological outcomes for infants and young children, identification of risk-factors and availability of evidence-based interventions for medical trauma following illness.

Conclusions: This topical review on medical trauma during early childhood provides: (a) definitions of key medical trauma terminology, (b) discussion of important developmental considerations, (c) summary of the empirical literature on psychological outcomes, risk factors, and interventions, (d) introduction to a stepped-model-of-care framework to guide clinical practice, and (e) summary of limitations and directions for future research.
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http://dx.doi.org/10.1093/jpepsy/jsab045DOI Listing
August 2021

Accuracy of delirium assessments in critically ill children: A prospective, observational study during routine care.

Aust Crit Care 2021 05 21;34(3):226-234. Epub 2020 Oct 21.

Paediatric Critical Care Research Group, Centre for Children's Health Research, Brisbane, Australia; Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Australia; Menzies Health Institute Queensland, Griffith University, Australia.

Objectives: The objectives of this study was to explore the accuracy of the Cornell Assessment for Pediatric Delirium (CAP-D), Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM-ICU) when implemented in routine care as delirium screening tools, and to assess patient characteristics and clinical variables that may affect their validity.

Design: This is a prospective observational study.

Setting: The study was conducted in a 36-bed, mixed paediatric intensive care unit (PICU) at an Australian tertiary hospital.

Patients: The study included critically ill children developmentally aged 6 months to 17 years, with a PICU length of stay >18 h.

Interventions: No interventions were provided in the study.

Measurements And Main Results: Patients were screened for delirium by their bedside nurse (CAP-D and pCAM-ICU/psCAM-ICU) once daily, for up to 5 d. Delirium status identified using screening instruments was compared with delirium diagnosis using the diagnostic criteria for delirium (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). In this sample, the CAP-D retained its high sensitivity (91.3%) and good specificity (75.2%), whereas the psCAM-ICU and pCAM-ICU had moderate sensitivity (58.8% and 75.0%, respectively) and excellent specificity (89.8% and 84.9%, respectively). There was moderate agreement between the CAP-D and the psCAM-ICU (κ = 0.52, p < .001) and good agreement between the CAP-D and the pCAM-ICU (κ = 0.80, p < .01).

Conclusions: Although the CAP-D, psCAM-ICU, and pCAM-ICU all appear promising in their validation studies, when implemented in routine care, their performance can be variable. The CAP-D performed well in routine clinical practice, but follow-up diagnosis is required to confirm delirium. The psCAM-ICU and pCAM-ICU both provide valuable, objective assessments of delirium in critically ill children; however, further evaluation of their implementation in routine clinical practice is needed.
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http://dx.doi.org/10.1016/j.aucc.2020.07.012DOI Listing
May 2021

Development of an international data repository and research resource: the Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive.

Eur J Psychotraumatol 2020 10;11(1):1729025. Epub 2020 Mar 10.

Traumatic Stress Center, Summa Health System, Akron, OH, USA.

: Studies that identify children after acute trauma and prospectively track risk/protective factors and trauma responses over time are resource-intensive; small sample sizes often limit power and generalizability. The Prospective studies of Acute Child Trauma and Recovery (PACT/R) Data Archive was created to facilitate more robust integrative cross-study data analyses. : To (a) describe creation of this research resource, including harmonization of key variables; (b) describe key study- and participant-level variables; and (c) examine retention to follow-up across studies. : For the first 30 studies in the Archive, we described study-level (design factors, retention rates) and participant-level (demographic, event, traumatic stress) variables. We used Chi square or ANOVA to examine study- and participant-level variables potentially associated with retention. : These 30 prospective studies (N per study = 50 to 568; overall N = 5499) conducted by 15 research teams in 5 countries enrolled children exposed to injury (46%), disaster (24%), violence (13%), traffic accidents (10%), or other acute events. Participants were school-age or adolescent (97%), 60% were male, and approximately half were of minority ethnicity. Using harmonized data from 22 measures, 24% reported significant traumatic stress ≥1 month post-event. Other commonly assessed outcomes included depression (19 studies), internalizing/externalizing symptoms (19), and parent mental health (19). Studies involved 2 to 5 research assessments; 80% of participants were retained for ≥2 assessments. At the study level, greater retention was associated with more planned assessments. At the participant level, adolescents, minority youth, and those of lower socioeconomic status had lower retention rates. : This project demonstrates the feasibility and value of bringing together traumatic stress research data and making it available for re-use. As an ongoing research resource, the Archive can promote 'FAIR' data practices and facilitate integrated analyses to advance understanding of child traumatic stress.
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http://dx.doi.org/10.1080/20008198.2020.1729025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144287PMC
March 2020

The Course of Posttraumatic Stress in Children: Examination of Symptom Trajectories and Predictive Factors Following Admission to Pediatric Intensive Care.

Pediatr Crit Care Med 2020 07;21(7):e399-e406

Paediatric Intensive Care, Queensland Children's Hospital, Brisbane, Qld, Australia.

Objectives: This study investigated trauma symptom trajectories of children 2-16 years old following admission to pediatric intensive care and identified factors that predicted a child's trauma symptom trajectory.

Design: Prospective longitudinal design.

Setting: Two tertiary care PICUs in Brisbane, Qld, Australia.

Patients: Children 2-16 years old admitted to PICU for longer than 8 hours.

Measurements Main Results: Maternal reported child posttraumatic stress symptoms (n = 272) on the Trauma Symptom Checklist for Young Children were used to assess posttraumatic stress symptoms up to 12 months post admission. Semiparametric group-based trajectory analyses were completed to identify patterns over time. Age, gender, length of stay, premorbid functioning, maternal perceived threat to life, and maternal acute distress were assessed as potential risk factors. Three likely trajectory groups were identified. The majority of children were resilient (83.8%); however, a significant minority experienced chronic symptoms (12.9%) or elevated stress symptoms which resolved quickly (3.3%). After controlling for other variables, maternal report of premorbid internalizing behavior significantly predicted both chronic (odds ratio, 6.3) and recovery (odds ratio, 38.0) trajectories. Maternal acute distress significantly predicted child chronic symptom trajectories (odds ratio, 5.2).

Conclusions: Children with elevated trauma symptoms postintensive care need timely and effective intervention. The majority of children with high levels of acute symptoms will continue to have chronic, ongoing posttraumatic stress symptoms. In addition, acute maternal distress and preexisting internalizing child behavior predict ongoing psychologic distress after discharge from the PICU. Screening in the acute period post-PICU admission may identify children likely to experience ongoing chronic posttraumatic distress symptoms and enable targeted treatment of children at risk. This is the first study to examine symptom trajectories in children following pediatric intensive care admission and includes a sample of very young children.
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http://dx.doi.org/10.1097/PCC.0000000000002316DOI Listing
July 2020

Preventive intervention for trauma reactions in young injured children: results of a multi-site randomised controlled trial.

J Child Psychol Psychiatry 2020 09 8;61(9):988-997. Epub 2020 Jan 8.

School of Psychology, University of Queensland, Brisbane, QLD, Australia.

Background: Young children are at particular risk for injury. Ten per cent to twenty-five per cent develop posttraumatic stress disorder (PTSD). However, no empirically supported preventive interventions exist. Therefore, this study evaluated the efficacy of a standardised targeted preventive intervention for PTSD in young injured children.

Methods: Injured children (1-6 years) were enrolled in a multi-site parallel-group superiority prospective randomised controlled trial (RCT) in Australia and Switzerland. Screening for PTSD risk occurred 6-8 days postaccident. Parents of children who screened 'high-risk' were randomised to a 2-session CBT-based intervention or treatment-as-usual (TAU). Primary outcomes were PTSD symptom (PTSS) severity, and secondary outcomes were PTSD diagnosis, functional impairment and behavioural difficulties at 3 and 6 months postinjury using blinded assessments. Trials were registered with the Australian New Zealand Clinical Trials Registry (ACTRN12614000325606) and ClinicalTrials.gov (NCT02088814). Trial status is complete.

Results: One hundred and thirty-three children screened 'high-risk' were assigned to intervention (n = 62) or TAU (n = 71). Multilevel intention-to-treat analyses revealed a significant intervention effect on PTSS severity over time (b = 60.06, 95% CI: 21.30-98.56). At 3 months, intervention children (M = 11.02, SD = 10.42, range 0-47) showed an accelerated reduction in PTSS severity scores compared to control children (M = 17.30, SD = 13.94, range 0-52; mean difference -6.97, 95% CI: -14.02 to 0.08, p adj. = .055, d = 0.51). On secondary outcomes, multilevel analyses revealed significant treatment effects for PTSD diagnosis, functional impairment and behavioural difficulties.

Conclusions: This multi-site RCT provides promising preliminary evidence for the efficacy of a targeted preventive intervention for accelerating recovery from PTSS in young injured children. This has important clinical implications for the psychological support provided to young children and parents during the acute period following a single-event trauma.
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http://dx.doi.org/10.1111/jcpp.13193DOI Listing
September 2020

Large-Scale Dissemination of Internet-Based Cognitive Behavioral Therapy for Youth Anxiety: Feasibility and Acceptability Study.

J Med Internet Res 2018 07 4;20(7):e234. Epub 2018 Jul 4.

School of Psychology, University of Queensland, St Lucia, QLD, Australia.

Background: Internet-based cognitive behavioral therapy (iCBT) for child and adolescent anxiety has demonstrated efficacy in randomized controlled trials, but it has not yet been examined when disseminated as a public health intervention. If effective, iCBT programs could be a promising first-step, low-intensity intervention that can be easily accessed by young people.

Objective: The objective of our study was to examine the feasibility and acceptability of a publicly available online, self-help iCBT program (BRAVE Self-Help) through exploration of program adherence, satisfaction, and changes in anxiety.

Methods: This study was an open trial involving the analysis of data collected from 4425 children and adolescents aged 7-17 years who presented with elevated anxiety at registration (baseline) for the iCBT program that was delivered through an open-access portal with no professional support. We assessed the program satisfaction via a satisfaction scale and measured adherence via the number of completed sessions. In addition, anxiety severity was assessed via scores on the Children's Anxiety Scale, 8-item (CAS-8) at four time points: baseline, Session 4, Session 7, and Session 10.

Results: Participants reported moderate satisfaction with the program and 30% completed three or more sessions. Statistically significant reductions in anxiety were evident across all time points for both children and adolescents. For users who completed six or more sessions, there was an average 4-point improvement in CAS-8 scores (Cohen d=0.87, children; Cohen d=0.81, adolescents), indicating a moderate to large effect size. Among participants who completed nine sessions, 57.7% (94/163) achieved recovery into nonelevated levels of anxiety and 54.6% (89/163) achieved statistically reliable reductions in anxiety.

Conclusions: Participant feedback was positive, and the program was acceptable to most young people. Furthermore, significant and meaningful reductions in anxiety symptoms were achieved by many children and adolescents participating in this completely open-access and self-directed iCBT program. Our results suggest that online self-help CBT may offer a feasible and acceptable first step for service delivery to children and adolescents with anxiety.
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http://dx.doi.org/10.2196/jmir.9211DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6053603PMC
July 2018

Cognitive/affective factors are associated with children's acute posttraumatic stress following pediatric intensive care.

Psychol Trauma 2019 Jan 7;11(1):55-63. Epub 2018 May 7.

Centre of National Research on Disability and Rehabilitation Medicine (CONROD), The University of Queensland.

This study aimed to explore children's experiences and memories of the pediatric intensive care unit (PICU) and identify the relative importance of premorbid, trauma, and cognitive/affective variables associated with acute posttraumatic stress symptoms (PTSS). Participants were 95 children aged 6-16 years admitted to the PICU and their parents. Children completed questionnaires and an interview assessing PTSS, peritrauma affect, and their memory of the admission 3 weeks following discharge. Medical data were extracted from patient charts. Premorbid and demographic data were provided by parent questionnaire. Most children remembered some aspects of their admission. Younger age, admission for traumatic injury (rather than non-injury-related reasons), and cognitive/affective factors including confusion, peritrauma panic, and sensory memory quality were associated with acute PTSS. Age and traumatic injury accounted for 18% of the variance in PTSS (p < .01). The addition of cognitive/affective variables increased the explained variance to 38% (p < .001). Child age did not moderate the effect of cognitive/affective variables on PTSS. This study demonstrates that objective indicators of disease severity do not adequately explain the high prevalence of PTSS in children following PICU admission. It also suggests that subjective, cognitive factors such as the way children process and remember a PICU admission are very important in the onset of PTSS. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000349DOI Listing
January 2019

Delirium in the Critically Ill Child: Assessment and Sequelae.

Dev Neuropsychol 2017 26;42(6):387-403. Epub 2017 Sep 26.

c Paediatric Critical Care Research Group, Mater Research Institute, University of Queensland , Brisbane , QLD , Australia.

Delirium is a common and serious neuropsychiatric complication in critically ill patients of all ages. In the context of critical illness, delirium may emerge as a result of a cascade of underlying pathophysiologic mechanisms and signals organ failure of the brain. Awareness of the clinical importance of delirium in adults is growing as emerging research demonstrates that delirium represents a serious medical problem with significant sequelae. However, our understanding of delirium in children lags significantly behind the adult literature. In particular, our knowledge of how to assess delirium is complicated by challenges in recognizing symptoms of delirium in pediatric patients especially in critical and intensive care settings, and our understanding of its impact on acute and long-term functioning remains in its infancy. This paper focuses on (a) the challenges associated with assessing delirium in critically ill children, (b) the current literature on the outcomes of delirium including morbidity following discharge from PICU, and care-giver well-being, and (c) the importance of assessment in determining impact of delirium on outcome. Current evidence suggests that delirium is a diagnostic challenge for clinicians and may play a detrimental role in a child's recovery after discharge from the pediatric intensive care unit (PICU). Recommendations are proposed for how our knowledge and assessment of delirium in children could be improved.
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http://dx.doi.org/10.1080/87565641.2017.1374961DOI Listing
February 2018

Predictors of non-return to work 2 years post-injury in road traffic crash survivors: Results from the UQ SuPPORT study.

Injury 2017 Jun 16;48(6):1120-1128. Epub 2017 Mar 16.

Recover Injury Research Centre, The University of Queensland, Brisbane, Australia; School of Psychology, The University of Queensland, Brisbane, Australia.

Purpose: Individuals who have sustained an injury from a road traffic crash (RTC) are at increased risk for long lasting health problems and non-return to work (NRTW). Determining the predictors of NRTW is necessary to develop screening tools to identify at-risk individuals and to provide early targeted intervention for successful return to work (RTW). The aim of this study was to identify factors that can predict which individuals will not RTW following minor or moderate injuries sustained from a RTC.

Method: Participants were 194 claimants (63.4% female) within a common-law "fault-based" system from the UQ SuPPORT cohort who were working prior to their RTC. Participants were assessed at 6 months on a variety of physical and mental health measures and RTW status was determined at 2 years post-RTC. RTW rate was 78.4%.

Results: Univariate predictors of NRTW included being the driver or passenger, having a prior psychiatric diagnosis, high disability level, low mental or physical quality of life, predicted non-recovery, high pain, low function, high expectations of pain persistency, low expectations about RTW, having a psychiatric diagnosis, elevated depression or anxiety. The final multivariable logistic regression model included only two variables: disability level and expectations about RTW. Seventy-five percent of individuals who will not RTW by 2 years can be identified accurately at an early stage, using only these two predictors.

Conclusion: The results are promising, because they suggest that having information about two factors, which are easily obtainable, can predict with accuracy those who will require additional support to facilitate RTW.
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http://dx.doi.org/10.1016/j.injury.2017.03.012DOI Listing
June 2017

Generic versus disorder specific cognitive behavior therapy for social anxiety disorder in youth: A randomized controlled trial using internet delivery.

Behav Res Ther 2017 03 8;90:41-57. Epub 2016 Dec 8.

School of Applied Psychology and the Menzies Health Institute Queensland, Griffith University, Mount Gravatt Campus, QLD, 4122, Australia.

The study examined whether the efficacy of cognitive behavioral treatment for Social Anxiety Disorder for children and adolescents is increased if intervention addresses specific cognitive and behavioral factors linked to the development and maintenance of SAD in young people, over and above the traditional generic CBT approach. Participants were 125 youth, aged 8-17 years, with a primary diagnosis of SAD, who were randomly assigned to generic CBT (CBT-GEN), social anxiety specific CBT (CBT-SAD) or a wait list control (WLC). Intervention was delivered using a therapist-supported online program. After 12-weeks, participants who received treatment (CBT-SAD or CBT-GEN) showed significantly greater reduction in social anxiety and post-event processing, and greater improvement in global functioning than the WLC but there was no significant difference between CBT-SAD and CBT-GEN on any outcome variable at 12-weeks or 6-month follow-up. Despite significant reductions in anxiety, the majority in both treatment conditions continued to meet diagnostic criteria for SAD at 6-month follow-up. Decreases in social anxiety were associated with decreases in post-event processing. Future research should continue to investigate disorder-specific interventions for SAD in young people, drawing on evidence regarding causal or maintaining factors, in order to enhance treatment outcomes for this debilitating condition.
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http://dx.doi.org/10.1016/j.brat.2016.12.003DOI Listing
March 2017

Coping with Accident Reactions (CARE) early intervention programme for preventing traumatic stress reactions in young injured children: study protocol for two randomised controlled trials.

Trials 2016 07 28;17:362. Epub 2016 Jul 28.

Department of Psychosomatics and Psychiatry and Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland.

Background: Accidental injury represents the most common type of traumatic event experienced by children under the age of 6 years. Around 10-30 % of young injured children will go on to develop post-traumatic stress disorder (PTSD) and other co-morbid conditions. Parents of injured children are also at risk of PTSD, and this is associated with short- and long-term consequences for their children's physical and psychological recovery. Despite the significance of this problem, to date, the mental health needs of injured young children have been neglected. One reason for this is due to the uncertainty and considerable debate around how to best provide early psychological intervention to traumatised children and adults. To address these gaps, researchers and psychologists in Australia and Switzerland have developed the Coping with Accident Reactions (CARE) programme, which is a two-session early intervention designed to prevent persistent PTSD reactions in young injured children screened as 'at risk'. Two separate international studies are being conducted to evaluate the effectiveness and feasibility of this programme.

Methods/design: The study design for the two proposed studies will employ a randomised controlled trial design and children (aged 1-6 years) who are screened as at risk for PTSD 1 week after an unintentional injury, and their parents will be randomised to either (1) CARE intervention or (2) treatment as usual. Assessment will be completed at baseline (2 weeks) and 3 and 6 months post-injury.

Discussion: This international collaboration provides an excellent opportunity to test the benefit of screening and providing early intervention to young children in two different countries and settings. It is expected that outcomes from this research will lead to significant original contributions to the scientific evidence base and clinical treatment and recovery of very young injured children.

Trial Registration: The Australian study was registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12614000325606 ) on 26 March 2014. The Swiss study was registered with ClinicalTrials.gov ( NCT02088814 ) on 12 March 2014.
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http://dx.doi.org/10.1186/s13063-016-1490-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4964020PMC
July 2016

Early Maternal Reflective Functioning and Infant Emotional Regulation in a Preterm Infant Sample at 6 Months Corrected Age.

J Pediatr Psychol 2016 Sep 24;41(8):906-14. Epub 2016 Jan 24.

School of Nursing, Midwifery and Paramedicine, Australian Catholic University.

Objective: This study investigated the influence of maternal reflective functioning (RF) on 6-month-old infants' emotional self-regulating abilities in preterm infant-mother dyads.

Methods: 25 preterm (gestational age 28-34.5 weeks) infants' affect, gaze toward mother, and self-soothing behaviors (thumb-sucking and playing with clothing) were measured during the still-face procedure at 6 months corrected age. Maternal RF was measured at 7-15 days post-delivery using the Parent Development Interview.

Results: Infants with high RF mothers showed the most negative affect during the still-face episode (M = 21.33s, SE = 5.44), whereas infants with low RF mothers showed the most negative affect in the reunion episode (M = 18.14s, SE = 3.69). Infants with high RF mothers showed significantly more self-soothing behaviors when distressed (Ms > 14.5s) than infants with low RF mothers (Ms < 1s), p's < .01.

Conclusion: Maternal RF was associated with infants' self-regulating behavior, providing preliminary evidence for the regulatory role of maternal RF in preterm infants' emotion regulation capacity.
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http://dx.doi.org/10.1093/jpepsy/jsv169DOI Listing
September 2016

Physical Therapist-Delivered Pain Coping Skills Training and Exercise for Knee Osteoarthritis: Randomized Controlled Trial.

Arthritis Care Res (Hoboken) 2016 05;68(5):590-602

Duke University, Durham, North Carolina.

Objective: To investigate whether a 12-week physical therapist-delivered combined pain coping skills training (PCST) and exercise (PCST/exercise) is more efficacious and cost effective than either treatment alone for knee osteoarthritis (OA).

Methods: This was an assessor-blinded, 3-arm randomized controlled trial in 222 people (73 PCST/exercise, 75 exercise, and 74 PCST) ages ≥50 years with knee OA. All participants received 10 treatments over 12 weeks plus a home program. PCST covered pain education and training in cognitive and behavioral pain coping skills, exercise comprised strengthening exercises, and PCST/exercise integrated both. Primary outcomes were self-reported average knee pain (visual analog scale, range 0-100 mm) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, range 0-68) at week 12. Secondary outcomes included other pain measures, global change, physical performance, psychological health, physical activity, quality of life, and cost effectiveness. Analyses were by intent-to-treat methodology with multiple imputation for missing data.

Results: A total of 201 participants (91%), 181 participants (82%), and 186 participants (84%) completed week 12, 32, and 52 measurements, respectively. At week 12, there were no significant between-group differences for reductions in pain comparing PCST/exercise versus exercise (mean difference 5.8 mm [95% confidence interval (95% CI) -1.4, 13.0]) and PCST/exercise versus PCST (6.7 mm [95% CI -0.6, 14.1]). Significantly greater improvements in function were found for PCST/exercise versus exercise (3.7 units [95% CI 0.4, 7.0]) and PCST/exercise versus PCST (7.9 units [95% CI 4.7, 11.2]). These differences persisted at weeks 32 (both) and 52 (PCST). Benefits favoring PCST/exercise were seen on several secondary outcomes. Cost effectiveness of PCST/exercise was not demonstrated.

Conclusion: This model of care could improve access to psychological treatment and augment patient outcomes from exercise in knee OA, although it did not appear to be cost effective.
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http://dx.doi.org/10.1002/acr.22744DOI Listing
May 2016

A Web-Based Early Intervention Can Prevent Long-Term PTS Reactions in Children With High Initial Distress Following Accidental Injury.

J Trauma Stress 2015 Aug;28(4):366-9

School of Psychology, The University of Queensland, Brisbane, Queensland, Australia.

The present study explored the targeting of a preventative information provision intervention delivered to children following accidental injury by assessing the impact of initial traumatic distress on response to treatment. Analyses were based on baseline and 6-month outcome of child traumatic stress in a control (n = 28) and an intervention group (n = 31). Moderation of treatment outcome by initial levels of child traumatic stress was assessed through multiple hierarchical regression analyses. Results indicated the interaction between treatment provision and initial level of posttraumatic stress significantly predicted 6-month outcome (β = -.42, p = .019). When initial distress was high, children in the control group demonstrated an increase in trauma symptoms, and had significantly higher trauma symptoms at follow-up than those in the treatment group (d = 0.94, p = .008). When initial distress was not elevated, no significant differences were noted between the groups. These results indicate that a preventative early intervention may be best targeted at children presenting with the specific risk factor of high initial distress.
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http://dx.doi.org/10.1002/jts.22025DOI Listing
August 2015

A new method for assessing content validity in model-based creation and iteration of eHealth interventions.

J Med Internet Res 2015 Apr 15;17(4):e95. Epub 2015 Apr 15.

Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, PA, United States.

Background: The advent of eHealth interventions to address psychological concerns and health behaviors has created new opportunities, including the ability to optimize the effectiveness of intervention activities and then deliver these activities consistently to a large number of individuals in need. Given that eHealth interventions grounded in a well-delineated theoretical model for change are more likely to be effective and that eHealth interventions can be costly to develop, assuring the match of final intervention content and activities to the underlying model is a key step. We propose to apply the concept of "content validity" as a crucial checkpoint to evaluate the extent to which proposed intervention activities in an eHealth intervention program are valid (eg, relevant and likely to be effective) for the specific mechanism of change that each is intended to target and the intended target population for the intervention.

Objective: The aims of this paper are to define content validity as it applies to model-based eHealth intervention development, to present a feasible method for assessing content validity in this context, and to describe the implementation of this new method during the development of a Web-based intervention for children.

Methods: We designed a practical 5-step method for assessing content validity in eHealth interventions that includes defining key intervention targets, delineating intervention activity-target pairings, identifying experts and using a survey tool to gather expert ratings of the relevance of each activity to its intended target, its likely effectiveness in achieving the intended target, and its appropriateness with a specific intended audience, and then using quantitative and qualitative results to identify intervention activities that may need modification. We applied this method during our development of the Coping Coach Web-based intervention for school-age children.

Results: In the evaluation of Coping Coach content validity, 15 experts from five countries rated each of 15 intervention activity-target pairings. Based on quantitative indices, content validity was excellent for relevance and good for likely effectiveness and age-appropriateness. Two intervention activities had item-level indicators that suggested the need for further review and potential revision by the development team.

Conclusions: This project demonstrated that assessment of content validity can be straightforward and feasible to implement and that results of this assessment provide useful information for ongoing development and iterations of new eHealth interventions, complementing other sources of information (eg, user feedback, effectiveness evaluations). This approach can be utilized at one or more points during the development process to guide ongoing optimization of eHealth interventions.
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http://dx.doi.org/10.2196/jmir.3811DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414959PMC
April 2015

Feasibility of a screening program for at-risk children following accidental injury.

J Trauma Stress 2015 Feb;28(1):34-40

School of Psychology, Counselling and Community, University of Southern Queensland, Springfield, Queensland, Australia; School of Psychology, University of Queensland, St Lucia, Queensland, Australia.

Screening is recommended as a simple method for identifying those who should be monitored for risk following trauma. Effective methods for implementing large-scale screening programs are yet to be established. This study tested the feasibility and utility of a screening program with hospitalized youth exposed to injury in 3 Australian hospitals. Eligible families (N = 1,134) were contacted and 546 children (48.0%) screened for risk of posttraumatic stress disorder (PTSD) at 1-2 weeks postinjury. There were 95 (17.4%) children whose screen result was at risk. A rescreening phase was introduced during the study, with 68 children completing the rescreen at 4-6 weeks postinjury, and 26 (38.2% of those rescreened) still at risk. Of those initially screened, 29 (5.3%) completed diagnostic assessments, 21 (3.8%) were diagnosed with partial or full PTSD, and 17 (3.1%) commenced treatment. Screening was successful at identifying and reaching children with PTSD, but the response rate was lower than expected, which limited the utility of the program. The addition of a rescreening phase demonstrated that not all at-risk children required intervention. These findings replicate previous studies that have shown natural remission in PTSD symptoms and highlight the potential for rescreening as part of a watchful waiting approach.
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http://dx.doi.org/10.1002/jts.21981DOI Listing
February 2015

PTSD perpetuates pain in children with traumatic brain injury.

J Pediatr Psychol 2014 Jun 11;39(5):512-20. Epub 2014 Apr 11.

Centre of National Research on Disability and Rehabilitation Medicine (CONROD), School of Medicine, The University of Queensland, Brisbane, Australia.

Objective: This study tested theoretical models of the relationship between pain and posttraumatic stress disorder (PTSD) in children with traumatic brain injury (TBI).

Methods: Participants consisted of 195 children aged 6-15 years presenting to 1 of 3 Australian hospitals following a mild-severe TBI. Children were assessed at 3, 6, and 18 months after their accident for PTSD (via the Clinician-Administered PTSD Scale for Children and Adolescents [CAPS-CA] clinical interview) as well as physical pain (via the Child Health Questionnaire, 50-item version [CHQ-PF50]). Trained clinicians administered the CAPS-CA at home visits, and the CHQ-PF50 was collected through questionnaires.

Results: Structural equation modeling found the data supported the mutual maintenance model and also the nested perpetual avoidance model.

Conclusions: Both models indicate PTSD is driving the presence of pain, and not vice versa. A fourth model stating this was proposed. Therefore, it may be useful to address PTSD symptoms in treating child pain for expediting recovery.
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http://dx.doi.org/10.1093/jpepsy/jsu014DOI Listing
June 2014

Prospective evaluation of parent distress following pediatric burns and identification of risk factors for young child and parent posttraumatic stress disorder.

J Child Adolesc Psychopharmacol 2014 Feb 4;24(1):9-17. Epub 2014 Feb 4.

1 Centre of National Research on Disability and Rehabilitation Medicine and School of Psychology, University of Queensland , Herston, Queensland, Australia .

Objective: Early childhood is a high-risk time for exposure to potentially traumatic medical events. We have previously reported that 10% of young children continue to have posttraumatic stress disorder (PTSD) 6 months after burn injury. This study aimed to 1) document the prevalence and prospective change in parental psychological distress over 6 months following their child's burn injury and 2) identify risk factors for posttraumatic stress symptoms (PTSS) in young children and their parents.

Methods: Participants were 120 parents of 1-6-year-old children with unintentional burn injuries. Data were collected within 2 weeks, 1 month, and 6 months of burn injury using developmentally sensitive diagnostic interviews and questionnaires.

Results: Within the first month, ∼ 25% of parents had a probable PTSD diagnosis, and moderate to extremely severe levels of depression, anxiety, and stress. Distress levels decreased significantly over time; however, 5% of parents still had probable PTSD at 6 months. Hierarchical multiple regression and path analyses indicated that parent posttraumatic stress reactions contributed significantly to the development and maintenance of child PTSS. Other risk factors for child PTSS included premorbid emotional and behavioral difficulties and larger burn size. Risk factors identified for parent PTSS included prior trauma history, acute distress, greater number of child invasive procedures, guilt, and child PTSS.

Conclusions: The findings from this study suggest that parents' responses to a traumatic event may play a particularly important role in a young child's psychological recovery. However, further research is needed to confirm the direction of the relationship between child and parent distress. This study identified variables that could be incorporated into screening tools or targeted by early intervention protocols to prevent the development of persistent child and parent PTSS following medical trauma.
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http://dx.doi.org/10.1089/cap.2013.0066DOI Listing
February 2014

The use of diaries in psychological recovery from intensive care.

Crit Care 2013 Dec 18;17(6):253. Epub 2013 Dec 18.

Intensive care patients frequently experience memory loss, nightmares, and delusional memories and some may develop symptoms of anxiety, depression, and post-traumatic stress. The use of diaries is emerging as a putative tool to 'fill the memory gaps' and promote psychological recovery. In this review, we critically analyze the available literature regarding the use and impact of diaries for intensive care patients specifically to examine the impact of diaries on intensive care patients' recovery. Diversity of practice in regard to the structure, content, and process elements of diaries for intensive care patients exists and emphasizes the lack of an underpinning psychological conceptualization. The use of diaries as an intervention to aid psychological recovery in intensive care patients has been examined in 11 studies, including two randomized controlled trials. Inconsistencies exist in sample characteristics, study outcomes, study methods, and the diary intervention itself, limiting the amount of comparison that is possible between studies. Measurement of the impact of the diary intervention on patient outcomes has been limited in both scope and time frame. Furthermore, an underpinning conceptualization or rationale for diaries as an intervention has not been articulated or tested. Given these significant limitations, although findings tend to be positive, implementation as routine clinical practice should not occur until a body of evidence is developed to inform methodological considerations and confirm proposed benefits.
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http://dx.doi.org/10.1186/cc13164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056894PMC
December 2013

The diagnosis of posttraumatic stress disorder in school-aged children and adolescents following pediatric intensive care unit admission.

J Child Adolesc Psychopharmacol 2013 Nov;23(9):614-9

1 The University of Queensland , Brisbane, Australia .

Objectives: This study explored the diagnosis of posttraumatic stress disorder (PTSD) in children and adolescents following pediatric intensive care unit (PICU) admission. Specifically, the study aimed to describe the presentation and prevalence of PTSD symptoms 6 months postdischarge, explore the validity of the DSM-IV PTSD algorithm and alternative PTSD algorithm (PTSD-AA) in school-aged children and adolescents, and examine the diagnostic utility of Criterion C3 (inability to recall aspects of a trauma) in this cohort.

Methods: Participants were 59 children aged 6-16, admitted to PICU for at least 8 hours. PTSD was assessed via diagnostic interview (Children's PTSD Inventory) 6 months following PICU discharge.

Results: The PTSD-AA was found to provide the most valid measure of PTSD at 6 months. Removing Criterion C3 improved the validity of Criterion C.

Conclusions: This study supports the use of the PTSD-AA excluding Criterion C3 for identifying highly traumatized children and adolescents following PICU admission.
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http://dx.doi.org/10.1089/cap.2013.0044DOI Listing
November 2013

Predictors of child post-concussion symptoms at 6 and 18 months following mild traumatic brain injury.

Brain Inj 2013 ;27(2):145-57

Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia.

Background: A proportion of children will experience persistent post-concussion symptoms (PCS) following a mild traumatic brain injury (mTBI). As persistent PCS may be maintained by pathological and psychological factors, this study aimed to describe and evaluate potential pre- and post-injury parent and child predictors of persistent PCS.

Methods: A total of 150 children with mTBI and their parents participated. Parents completed measures of their own distress and children's PCS and health-related quality-of-life (HRQoL) at baseline (reflecting pre-injury function). These measures, as well as measures of children's distress and cognitive function were administered at 6 and 18 months post-injury.

Results: Children's PCS at 6 months post-injury were predicted by both pre-injury parent distress and children's pre-injury PCS. At 18 months post-injury, children's PCS were predicted by higher levels of parent distress and child PCS at 6 months post-injury, as well as poorer post-injury cognitive functioning. Change in PCS between 6-18 months post-injury was predicted by parent's pre-injury anxiety and children's HRQoL.

Conclusions: Children at risk of persistent PCS can be identified by higher levels of pre- and post-injury PCS, parent distress and poorer post-injury cognition. These factors should be addressed by interventions aimed at minimizing the occurrence and impact of child PCS.
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http://dx.doi.org/10.3109/02699052.2012.729286DOI Listing
August 2013

The utility of the Children's Revised Impact of Event Scale in screening for concurrent PTSD following admission to intensive care.

J Trauma Stress 2012 Oct 9;25(5):602-5. Epub 2012 Oct 9.

School of Psychology, University of Queensland & Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland, Brisbane, Queensland, Australia.

Although there is some information available regarding the utility of the Children's Revised Impact of Event Scale (CRIES) in screening for posttraumatic stress disorder (PTSD), data are scarce and limited to studies sampling children predominantly injured in road traffic accidents. This study investigated the utility of 2 versions, the CRIES-8 and CRIES-13, in identifying those children meeting criteria for PTSD following admission to a pediatric intensive care unit (PICU). The Children's PTSD Inventory (CPTSDI), a diagnostic interview, and the CRIES-13 were administered to 55 children, aged 6-16 years, 6 months following admission to the PICU. Of the 55, 14 (25%) met criteria on the CPTSDI. Cutoff scores of 14.5 on the CRIES-8 and 22.5 on the CRIES-13 maximized sensitivity and specificity and correctly classified 78%-86% of children. Both cutoff scores were lower than those reported in other samples. The CRIES-13 appeared to offer greater utility than the CRIES-8, also in contrast to previous findings. Methodological or sampling differences may account for the discrepancy with prior studies. The proposed cutoffs are recommended specifically for use with PICU patients and replication and further validation of the CRIES with other samples is warranted.
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http://dx.doi.org/10.1002/jts.21742DOI Listing
October 2012

Prevalence, comorbidity and course of trauma reactions in young burn-injured children.

J Child Psychol Psychiatry 2012 Jan 14;53(1):56-63. Epub 2011 Jun 14.

School of Psychology and Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland, Herston, Qld, Australia.

Background: Infants, toddlers and preschoolers are the highest risk group for burn injury. However, to date this population has been largely neglected. This study examined the prevalence, onset, comorbidity and recovery patterns of posttrauma reactions in young children with burns.

Methods: Parents of 130 unintentionally burned children (1-6 years) participated in the study. The Diagnostic Infant Preschool Assessment was conducted with parents at 1 and 6 months postinjury.

Results: The majority of children were resilient. However, 35% were diagnosed with at least one psychological disorder, there was a high rate of comorbidity with posttraumatic stress disorder, and 8% of children did not experience recovery in distress levels over the course of 6 months.

Conclusions: These outcomes are likely to have serious repercussions for a young child's medical and psychosocial recovery as well as their normal developmental trajectories. It is recommended that screening, prevention and early intervention resources are incorporated into paediatric health care settings to optimise children's psychological adjustment following burn injury.
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http://dx.doi.org/10.1111/j.1469-7610.2011.02431.xDOI Listing
January 2012

Diagnosis of posttraumatic stress disorder in preschool children.

J Clin Child Adolesc Psychol 2011 ;40(3):375-84

School of Psychology and Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland, Herston, QLD, Australia.

This study investigated the existing diagnostic algorithms for posttraumatic stress disorder (PTSD) to determine the most developmentally sensitive and valid approach for diagnosing this disorder in preschoolers. Participants were 130 parents of unintentionally burned children (1-6 years). Diagnostic interviews were conducted with parents to assess for PTSD in their child at 1 and 6 months postinjury and the Child Behavior Checklist for 1.5-5 was also completed. The proposed algorithm for PTSD in preschool children for the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) provided the most developmentally sensitive and valid measure of PTSD. The rate of PTSD diagnosis was 25% at 1 month and 10% at 6 months. The predictive utility of Criterion A was not demonstrated. These findings provide support for the inclusion of the proposed algorithm for PTSD in preschool children.
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http://dx.doi.org/10.1080/15374416.2011.563474DOI Listing
August 2011

Trauma in early childhood: a neglected population.

Clin Child Fam Psychol Rev 2011 Sep;14(3):231-50

School of Psychology, University of Queensland, Brisbane, QLD, Australia.

Infants, toddlers and preschoolers are a high risk group for exposure to trauma. Young children are also vulnerable to experiencing adverse outcomes as they are undergoing a rapid developmental period, have limited coping skills and are strongly dependent on their primary caregiver to protect them physically and emotionally. However, although millions of young children experience trauma each year, this population has been largely neglected. Fortunately, over the last 2 decades there has been a growing appreciation of the magnitude of the problem with a small but expanding number of dedicated researchers and clinicians working with this population. This review examines the empirical literature on trauma in young children with regards to the following factors: (1) how trauma reactions typically manifest in young children; (2) history and diagnostic validity of posttraumatic stress disorder (PTSD) in preschoolers; (3) prevalence, comorbidity and course of trauma reactions; (4) developmental considerations; (5) risk and protective factors; and (6) treatment. The review highlights that there are unique developmental differences in the rate and manifestation of trauma symptomatology, the current Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV-TR) PTSD criteria is not developmentally sensitive and the impact of trauma must be considered within the context of the parent-child relationship. Recommendations for future research with this population are also discussed.
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http://dx.doi.org/10.1007/s10567-011-0094-3DOI Listing
September 2011

Parental response to child injury: examination of parental posttraumatic stress symptom trajectories following child accidental injury.

J Pediatr Psychol 2010 Jul 25;35(6):646-55. Epub 2010 Apr 25.

Centre of National Research on Disability and Rehabilitation, The Medical School, University of Queensland, Herston Road, Herston 4006, Queensland, Australia.

Objective: Trajectory analyses were used to empirically differentiate patterns of posttraumatic stress symptoms in parents following child accidental injury and explore the relationship between parent and child recovery patterns.

Method: Parent (n = 189) self-reported symptoms from acute to 2 years post accident were examined to (1) identify distinct parent symptom trajectories; (2) identify risk factors; and (3) explore the patterns of children and parents together.

Results: Analysis revealed three distinct symptom trajectory groups for parents: resilient (78%); clinical level acute symptoms that declined to below clinical level by 6 months (recovery 8%); and chronic subclinical (14%). Children of resilient parents were most likely to be resilient. Half of the children of parents with chronic subclinical trajectories were likely to have chronic trajectories.

Conclusion: Clinicians cannot rely only on clinical level symptoms in parents to identify high risk families but include families where the parent has subclinical level symptoms.
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http://dx.doi.org/10.1093/jpepsy/jsq035DOI Listing
July 2010

A randomized controlled trial of a web-based early intervention for children and their parents following unintentional injury.

J Pediatr Psychol 2010 Jul 11;35(6):581-92. Epub 2009 Nov 11.

Centre of National Research on Disability and Rehabilitation Medicine, Herston, Queensland, Australia 4006.

Objective: The aim of this article was to evaluate the effectiveness of an information provision web-based early intervention via a randomized controlled trial for children and their parents following pediatric unintentional injury.

Method: Participants were randomly assigned to an intervention (n = 29) or a control group (n = 27) following baseline measurements. Further assessment was taken at 4-6 weeks and 6 months post-trauma event.

Results: Analyses revealed that children within the intervention group reported improved anxiety, in comparison to a worsening of symptoms for children in the control group. Furthermore, children who had higher baseline trauma scores reported the intervention to be helpful.

Conclusions: The intervention showed promising results in its ability to aid child recovery.
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http://dx.doi.org/10.1093/jpepsy/jsp095DOI Listing
July 2010

The course of posttraumatic stress in children: examination of recovery trajectories following traumatic injury.

J Pediatr Psychol 2010 Jul 17;35(6):637-45. Epub 2009 Jun 17.

Centre of National Research on Disability and Rehabilitation, Medical School, The University of Queensland, Herston Road, Herston 4006, Queensland, Australia.

Objective: Group-based trajectory modeling was used to identify patterns of posttraumatic stress symptom (PTSS) in children 6-16 years following accidental injury. The aims were to: (a) identify probable groups of children following distinct trajectories, and (b) identify risk factors affecting the probability of group membership.

Method: Children's Impact of Events Scale (n = 190) was used to assess PTSS up to 2 years post injury. Age, gender, type of injury, and preinjury behavior were assessed as risk factors.

Results: Three distinct trajectory groups were identified: resilient (57%), elevated stress symptoms which recovered quickly (33%), and chronic (10%). Younger children were more likely to be in the recovery group. Those with serious injuries were more likely to be in the chronic group. Preinjury child behavior problems were predictive of recovery and high chronic symptoms.

Conclusion: Identification of distinct PTSS trajectory groups has implications for understanding the course and treatment of PTSS in children.
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http://dx.doi.org/10.1093/jpepsy/jsp050DOI Listing
July 2010

The influence of pre-injury behaviour on children's type of accident, type of injury and severity of injury.

Brain Inj 2008 Jul;22(7-8):595-602

Centre of National Research on Disability and Rehabilitation Medicine, University of Queensland, Australia.

Primary Objective: To investigate the relationship between children's pre-injury behaviour and accident type (high vs. low risk), injury type (traumatic brain injury (TBI), fractures/dislocations and other injuries) and TBI severity.

Research Design: Cross-sectional comparison of 205 children with TBI aged 6-14 years, with 101 children aged 7-14 years with non-TBI injuries.

Methods And Procedures: Pre-injury behavioural data were collected via parental report with the Child Behaviour Checklist. Information on children's accident type and TBI severity was obtained from medical records.

Main Outcomes And Results: The pre-injury behaviour of children involved in high or low risk accidents did not differ. Pre-injury behavioural differences were observed among children with TBI, fractures/dislocations, other injuries and normative samples. The involvement of children in high and low risk accidents differed depending on the severity of TBI. Pre-injury behaviour of children with mild or moderate/severe TBI was similar.

Conclusions: Pre-injury behaviour does not appear to influence children's involvement in high vs. low risk accidents or the severity of their TBI. However pre-injury behaviour increases children's differential risk for types of accidental injuries.
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http://dx.doi.org/10.1080/02699050802132453DOI Listing
July 2008

Predicting children's post-traumatic stress symptoms following hospitalization for accidental injury: combining the Child Trauma Screening Questionnaire and heart rate.

J Anxiety Disord 2008 Dec 2;22(8):1447-53. Epub 2008 Mar 2.

Centre of National Research on Disability and Rehabilitation Medicine (CONROD), University of Queensland, Australia.

This study investigated the utility of combining the Child Trauma Screening Questionnaire (CTSQ) [Kenardy, J. A., Spence, S. H., & Macleod, A. C. (2006). Screening for post-traumatic stress disorder in children after accidental injury. Pediatrics, 118, 1002-1009] and children's heart rate (HR; emergency department and 24-h post-admission) to identify children likely to develop post-traumatic stress disorder (PTSD) symptoms at 1 and 6 months post-injury. Children completed the CTSQ within 2 weeks of injury. PTSD symptoms were assessed with the Anxiety Disorders Interview Schedule for DSM-IV [Silverman, W. K., & Albano, A. M. (1996). Anxiety Disorders Interview Schedule for DSM-IV, Child Version, Parent Interview Schedule. Orlando, Florida: The Psychological Corporation], for 79 children aged 7-16 years. A combination of the CTSQ plus HR (CTSQ-HR) was better than the CTSQ alone or HR alone at identifying children likely to develop PTSD symptoms. These findings suggest that the CTSQ-HR screen may increase identification of children who are likely to develop PTSD symptoms, enabling development of targeted prevention programs.
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http://dx.doi.org/10.1016/j.janxdis.2008.02.007DOI Listing
December 2008
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