Risk factors for PTSD symptoms following PICU admission for childhood septic shock.

ObjectivePaediatric intensive care unit (PICU) admission represents a traumatic event for many children. Follow-up studies have found post-traumatic stress disorder (PTSD) rates of 10-30%, with a particular prevalence following admission for sepsis. Dysregulated inflammatory responses are associated with PTSD. Sepsis involves a marked inflammatory response but the relationship between this and PTSD have not been clearly established. In this study we investigate associations between the inflammatory response, psychosocial risk factors, and PTS symptoms following PICU admission for septic shock.We investigate the outcomes for children aged > 3 years, discharged from one PICU following admission for septic shock between 2010 and 2017. The study was a retrospective analysis of PICU-specific PTS symptoms reported by parents at any time since discharge via the Trauma and Behavior Health screen. Demographics, pre-morbid health characteristics, and exposure to other traumatic events were assessed. Clinical characteristics and blood test results at admission and at 48 h were recorded from clinical records. Multiple linear regression was used to investigate relationships between PTS symptom scores and predictor variables.Data for 65 participants (48% male, median assessment age 8.0 years) was available. Median time since admission was 5.1 years. 30.8% children scored at risk of PTSD at any time since discharge Symptoms were significantly associated with acute CRP rise (p 0.03), other trauma exposures (p = 0.01), and female gender (p =0.04).PTS symptoms in children who have survived septic shock are prevalent. These findings support a possible contribution of acute inflammatory changes, cumulative traumatic exposure, and female gender in post-PICU PTSD development.

Commentary: Against the widespread use of other types of PD diagnosis - a commentary on the May 2022 debate (should CAMH professionals be diagnosing personality disorder in adolescence?).

Recent debate papers in Child and Adolescent Mental Health (Debate CAMH, May 2022) advocate a more widespread and appropriate use by CAMH clinicians of borderline personality disorder diagnoses. This paper makes the case against the widespread use of other types of PD diagnosis in children and young people. Nevertheless, it would be of interest to establish to what extent adult PDs have their roots in early neurodevelopmental anomalies, and ascertainment of personality traits can help clarify children's response to environmental or traumatic stresses in those presenting with problems such as at the interface between physical and mental health.

A new measure of excessive parental worries about children's health: Development of the Health Anxiety by Proxy Scale (HAPYS).

OBJECTIVE: Health anxiety by proxy is a newly introduced term to describe parents' experience of excessive and unpleasant worries about their child's health. This article describes the development of a new measure, the Health Anxiety by Proxy Scale (HAPYS), for systematic assessment of health anxiety by proxy. METHOD: The development of the HAPYS was performed over three phases. (1) Patients clinically assessed to have health anxiety by proxy participated in semi-structured interviews to elaborate their experience of worries regarding their child's health and their related behaviours, and to examine the face validity of items in an existing questionnaire: 'Illness Worry Scale - parent version'. (2) Based on the findings from Phase 1 the project group and a panel of experts selected and formulated questionnaire items and scoring formats. (3) The HAPYS was pilot-tested twice using cognitive interviewing with healthy parents and parents with health anxiety by proxy followed by further adjustments. RESULTS: The final version of HAPYS consists of 26 items characteristic of health anxiety by proxy and of an impact section with five items. CONCLUSION: Based on the pilot testing the HAPYS showed good face and content validity. It holds the potential to be a valid questionnaire to help clinicians across health care settings assess parents suffering from health anxiety by proxy.

Inflammation and psychopathology in children following PICU admission: an exploratory study.

BACKGROUND: Survivors of critical illness in childhood commonly display subsequent psychiatric symptoms including emotional and behavioural difficulties, and manifestations of post-traumatic stress disorder (PTSD). Anomalies in inflammatory profiles are an established finding in these childhood psychiatric conditions. OBJECTIVE: This exploratory study aimed to investigate whether abnormal peripheral blood inflammatory markers measured during paediatric intensive care unit (PICU) admission were associated with psychiatric symptoms after discharge. METHODS: We performed a prospective observational cohort study on 71 children with septic illness, meningoencephalitis and other critical disorders admitted to two PICUs between 2007 and 2010. 3-6 months following discharge, subjects were assessed for global psychiatric risk (ie, presence of emotional and behavioural difficulties on the parental Strengths and Difficulties Questionnaire (SDQ)), and for PTSD risk using the child-rated Impact of Events Scale (IES-8). Inflammatory and related biological markers were transcribed from PICU admission notes (white cell count, lymphocytes, neutrophils, C reactive protein (CRP), platelets, fibrinogen and lactate). FINDINGS: Global psychiatric risk at follow-up was associated with abnormal lymphocyte count during admission (χ2=6.757, p=0.014, n=48). In children with sepsis, partial correlation analyses controlling for age and gender highlighted associations between (i) SDQ scores and low lymphocyte count (r=-0.712; p=0.009, n=14), and (ii) IES-8 score and high CRP levels (r=0.823; p=0.006, n=11). These associations remained after correction for multiple comparisons. CONCLUSION: These results support the hypothesis that acute inflammation may play a role in determining the development of psychopathology following PICU admission. CLINICAL IMPLICATIONS: If the findings are replicated, they may help to better highlight which children are at risk of post-PICU psychopathology and appropriately target follow-up.

Post-traumatic stress after PICU and corticosteroid use.

AIM: To examine the association between corticosteroid use in paediatric intensive care units (PICU) and subsequent symptoms of post-traumatic stress disorder (PTSD). METHODS: The subjects were children aged 8-16 years admitted to PICU with sepsis, meningoencephalitis (ME) and other disorders. Illness information was extracted from case notes; 3-6 months post discharge children completed a PTSD symptom questionnaire (eight-item Impact of Events Scale (IES-8)) assessing intrusion and avoidance symptoms. Saliva samples were also collected for cortisol profile analysis. RESULTS: 53 children completed the IES-8 questionnaires. 33 provided saliva samples. 19 (36%) received corticosteroids. In children with sepsis (n=15), corticosteroid use was associated with significantly lower PTSD intrusion symptom scores. There was a trend towards an association between corticosteroid use and lower evening cortisol levels. There was a comparable but weaker trend in children with ME. DISCUSSION: Corticosteroid use may be associated with fewer PTSD symptoms and lower evening cortisol levels following PICU admission in children with sepsis.

Stress hormones and posttraumatic stress symptoms following paediatric critical illness: an exploratory study.

In this exploratory case-control study, we investigated basal cortisol regulation in 5-16-year-old children, 3-6 months following PICU (paediatric intensive care) admission. This was nested within a study of child psychological and cognitive function; 47 children were assessed alongside 56 healthy controls. Saliva samples were collected three times per day (immediately after waking, waking +30 min, and waking +12 h) over two consecutive weekdays. In addition, data on posttraumatic stress symptoms were ascertained from 33 PICU admitted children using the Impact of Events Scale-8 (IES-8). Primary analysis revealed no significant differences in basal cortisol concentrations between PICU discharged children and healthy controls (p > 0.05). Secondary analysis in the PICU group identified a significant positive association between posttraumatic stress symptoms and evening (waking +12 h) cortisol concentrations (p = 0.004). However, when subject to multivariate analysis, evening cortisol was a modest independent predictor of IES-8 scores, relative to the presence of septic illness and poor pre-morbid health. We conclude that paediatric critical illness does not appear to result in marked perturbations to basal cortisol at 3-6 month following discharge. There was evidence of a link between evening cortisol and symptoms of PTSD, but this was not a robust effect and requires further elucidation.

Research into hallucinations and psychotic-like symptoms in children: implications for child psychiatric practice.

There is a growing research interest in childhood hallucinations as predictors of psychotic states. This work appears to have limited direct relevance for clinical child psychiatric practice, but it highlights the continuing relevance of research into precursors of psychotic states and into the determinants of clinically relevant hallucinations in children.

What is special about a Paediatric Liaison Child and Adolescent Mental Health service?

BACKGROUND: The paediatric population is known to be at high risk for psychiatric problems. Paediatric liaison child/adolescent mental health services (PL-CAMHS) have been developed to help increase recognition and management of psychiatric morbidity in the paediatric setting. This report describes clinical activity by a psychological medicine PL-CAMHS and considers specificity by comparing this with community/general CAMHS activity. METHOD: Clinical information was obtained on consecutive patients seen by a PL-CAMHS in a UK tertiary specialist hospital. Where feasible this was compared with published data on national/community CAMHS work. RESULTS: Data was obtained on 800 patients (mean age 11.9, SD 3.8). Most referrals came from a variety of paediatric teams, nearly two-thirds were for psychosomatic problems or difficulties adjusting to physical illness. The majority had an ICD-10 psychiatric diagnosis (mostly adjustment, mood and anxiety, and somatoform disorders); problems were often complex and in about half, family difficulties were also noted; one-third had received prior mental health treatment. Virtually all children were seen by the PL service within a month of referral and only 2% of families failed to attend for assessment. Some level of clinical improvement was noted for the majority. There were indications of differences from national/community CAMHS work in referral source, take up rates and psychiatric diagnoses. CONCLUSIONS: Paediatric liaison child and adolescent mental health services users commonly have characteristic psychiatric problems, interventions appear potentially effective and the work is specific and complementary of community CAMHS. Thus PL-CAMHS make a distinct contribution to the provision of truly comprehensive CAMHS.

A supported psychoeducational intervention to improve family mental health following discharge from paediatric intensive care: feasibility and pilot randomised controlled trial.

OBJECTIVE: To assess feasibility and pilot a supported psychoeducational tool to improve parent and child mental health following discharge from a paediatric intensive care unit (PICU), in preparation for a large randomised controlled trial (RCT). DESIGN: Feasibility assessment and single-centre, parallel group, pilot RCT. A concealed computer generated list was used to randomise participants, with an allocation of 2:1 in favour of the intervention. SETTING: A PICU in an acute care hospital in London, UK. PARTICIPANTS: 31 parents of children aged 4-16 years-old admitted to PICU. INTERVENTION: Parents received a psychoeducational tool supported by a telephone call. The psychoeducational tool outlined the possible psychological reactions in children and parents alongside management advice. The telephone call addressed each family's postdischarge experience, reinforced the psychoeducational material and encouraged parents to put into practice the advice given. MAIN OUTCOME MEASURES: The primary outcome was the number of feasibility criteria successfully met (linked to the intervention and the study design). Secondary outcomes were questionnaire data collected at 3-6-month follow-up assessing mental health in parents and children. RESULTS: 31 parents were randomised (intervention n=22; treatment as usual, TAU n=9). 23 parents were included in the analysis of secondary outcomes (intervention n=17; TAU n=6). 3 (of 6) intervention and 1 (of 6) study design feasibility criteria were fully met. All unmet criteria could be addressed with minor or significant modifications to the protocol. At follow-up there was a tendency for parents who received the intervention to report lower post-traumatic stress symptoms in themselves and fewer emotional and behavioural difficulties in their children than TAU parents. This needs to be explored in a fully powered trial. CONCLUSIONS: This feasibility and pilot RCT provided valuable information on the intervention and trial design for a full RCT. TRIALS REGISTRATION NUMBER: NCT01737021; Results.

Persistence of Neuropsychological Deficits Following Pediatric Critical Illness.

OBJECTIVE: To study 12-month persistence of neuropsychological deficits in PICU survivors. DESIGN: Prospective follow-up study. SETTING: Two PICUs. PARTICIPANTS: Children 5-16 years old with neuropsychological deficits 3-6 months following PICU care for meningoencephalitis, sepsis, and other critical illnesses (excluding other primary neurological disorders). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Neuropsychological function was assessed using the Cambridge Neuropsychological Test Automated Battery, the Children's Memory Scale, and the Wechsler Abbreviated Scale of Intelligence or Wide Range Intelligence Test. Forty-seven of 88 PICU admitted children (53%) were identified as neuropsychologically impaired 3-6 months after discharge; of these, 23 provided 12-month follow-up data. In spite of significant improvements in measures of memory, there was little change in intelligence quotient and visual attention over the study period, and children's educational progress remained below expectation. CONCLUSIONS: We found persistently reduced neuropsychological function following PICU admission in the critical illnesses under study.

Fifteen minute consultation on children 'hearing voices': when to worry and when to refer.

Auditory hallucinations are uncommon paediatric presentations, but they can be alarming and lead to emergency consultations. This review outlines the phenomenology of auditory hallucinations, their assessment and clinical significance. Auditory hallucinations are seen in the course of acute medical disorders, often together with decreased levels of consciousness, as in febrile illness and in toxic, neurologically compromised states; they can also be a feature of episodic neurological conditions such as migraine and temporal lobe epilepsy. Auditory hallucinations are key symptoms in psychiatric disorders such as schizophrenic and other psychotic states, but they can also present with depressive and anxiety disorders, and in the context of virtually every psychiatric disorder of childhood. In fact hallucinations--usually simple and transient--are common in the general child populations. Auditory hallucinations become clinically significant when they occur as part of a medical disorder or in the context of acute psychotic states and schizophrenia, when they are frequent, complex, distressing and cause impairment. The treatment of clinically relevant hallucinations is that of the primary medical or psychiatric disorder. Occasionally they require treatment in their own right with psychological treatments, and only when these have been tried and fail, a careful trial of antipsychotic medication may be appropriate.

Mental and physical well-being following admission to pediatric intensive care.

OBJECTIVE: To assess mental and physical well-being in school-aged children following admission to pediatric intensive care and to examine risk factors for worse outcome. DESIGN: A prospective cohort study. SETTING: Two PICUs. SUBJECTS: A consecutive sample of 88 patients 5-16 years old (median age, 10.00 yr; interquartile range, 6.00-13.00 yr) admitted to PICU from 2007 to 2010 with septic illness, meningoencephalitis, or other critical illnesses were assessed a median of 5 months following discharge and outcomes compared with 100 healthy controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Parents completed questionnaires documenting child mental and physical well-being, including the Strengths and Difficulties Questionnaires, Chalder Fatigue Scale, and Child Sleep Habits Questionnaire. Children over 8 years completed the Impact of Event Scale -8. The children admitted to PICU scored worse on all measures in comparison with the healthy controls, with 20% scoring at risk for psychiatric disorder, 34% with high levels of post-traumatic stress symptoms, 38% at risk for fatigue disorder, and 80% scoring at risk for sleep disturbance. In the PICU group, multivariable regression analyses identified septic illness as an independent predictor of post-traumatic stress symptoms and family status, past child health problems, and PICU length of stay as predictors of reduced general mental well-being. CONCLUSIONS: Our findings indicate that a significant minority of school-aged children admitted to PICU are at risk for reduced mental and physical well-being in the short term. Symptoms of poor mental well-being were linked to both vulnerability factors and critical illness factors.

Testing the feasibility of therapeutic identification of depression in young people in British general practice.

PURPOSE: Depression in young people attending primary care is common and is associated with impairment and recurrence into adulthood. However, it remains under-recognized. This study evaluated the feasibility of training primary care practitioners (PCPs) in screening and therapeutic identification of adolescent depression, and assessed its effects on practitioner knowledge, attitudes, screening, and management. METHODS: We trained PCPs in therapeutic identification of adolescent depression during general practice consultations. To assess changes in knowledge and attitudes, PCPs completed questionnaires before and after training. We ascertained changes in depression screening and identification rates in the 16 weeks before and after training from electronic medical records of young people aged 13-17 years. Post-training management of depression was recorded on a checklist. RESULTS: Aspects of practitioner knowledge (of depression prevalence and treatment guidelines) and confidence (regarding depression identification and management) increased significantly (all p < .04). Overall screening rates were enhanced from .7% to 20% after the intervention and depression identification rates from .5% before training to 2% thereafter (29-fold and fourfold increases, respectively). Identification was significantly associated with PCP knowledge of prior mental health problems (Fisher's exact test, p = .026; odds ratio, 4.884 [95% confidence interval, 1.171-20.52]) and of psychosocial stressors (Fisher's exact test, p = .001; odds ratio, 17.45 [95% confidence interval, 2.055-148.2]). CONCLUSIONS: The Therapeutic Identification of Depression in Young People program is a feasible approach to improving primary care screening for adolescent depression, with promising evidence of effectiveness. Further evaluation in a randomized trial is required to test practitioner accuracy, clinical impact, and cost benefit.

Neuropsychologic function three to six months following admission to the PICU with meningoencephalitis, sepsis, and other disorders: a prospective study of school-aged children.

OBJECTIVE: To assess short-term neuropsychological function and academic performance in school children following admission to intensive care and to explore the role of critical neurologic and systemic infection. DESIGN: A prospective observational case-control study. SETTING: Two PICUs. SUBJECTS: A consecutive sample of 88 children aged 5-16 years (median age=10.00, interquartile range=6.00-13.00) who were admitted to intensive care between 2007 and 2010 with meningoencephalitis, septic illness, or other critical illnesses. They were assessed 3 to 6 months following discharge, and their performance was compared with that of 100 healthy controls. Patients were without prior neurologic or neurodevelopmental disorder. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data encompassing demographic and critical illness details were obtained, and children were assessed using tests of intellectual function, memory, and attention. Questionnaires addressing academic performance were returned by teachers. After adjusting for covariates, the children admitted to PICUs significantly underperformed on neuropsychological measures in comparison to healthy controls (p<0.02). Teachers deemed more children admitted to PICUs than controls as performing educationally worse and having problems with school work (ps=0.001), as well as performing below average on aspects of executive function and attention (ps<0.04). Analysis of the effect of illness type on outcome revealed that aspects of neuropsychological function, such as memory function, and teacher-rated academic performance were most reduced in children with meningoencephalitis and septic illness. In the PICU group, multivariable linear regression revealed that worse performance on a composite score of neuropsychologic impairment was more prevalent when children were younger, from a lower social class, and had experienced seizures during their admission (ps<0.02). CONCLUSIONS: Admission to intensive care is followed by deficits in neuropsychologic performance and educational difficulties, with more severe difficulties noted following meningoencephalitis and septic illness. These results highlight the importance of future studies on cognition and educational outcome incorporating type of illness as a moderating factor.