Screening for post-traumatic stress disorder after injury in the pediatric emergency department - a systematic review protocol

Pediatric injury is highly prevalent and has significant impact. Injuries are the largest cause of morbidity and mortality among children in the United States and Canada, and are the leading cause of emergency department (ED) visits for children greater than 1 year of age [1–3]. Injury-related ED visits in the United States are estimated to range from 63 to 165 per 1,000 children [4]. The vast majority of pediatric injuries are treated acutely in EDs with a strong focus on physical trauma.

The prevalence of stress disorders such as acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) following injury is high. Some children with sub-clinical features suffer as much distress and impairment as those diagnosed with full PTSD, and the risk factors to identify those children at greatest risk for subsequent development of PTSD have been outlined [5]. Recent research has demonstrated that up to 68% of all children experience potentially traumatic events, with more than half of these children experiencing multiple events [6]. A recent systematic review of 21 single-center cohort studies reported the prevalence of PTSD among pediatric survivors of motor vehicle accidents (MVA) to be between 12% and 46% at 4 months post-MVA and 13 to 25% at 12 months post-MVA [7]. A prospective cohort study of children experiencing orthopedic trauma including bone fractures secondary to falls, sporting injuries or MVAs found that 33% of the cohort experienced PTSD at 1 year follow-up [8]. Historically it was thought that PTSD symptoms would only develop after experiencing trauma resulting in severe injury. It has recently been discovered, through cohort studies in children, that these considerably high rates of ASD and PTSD do not seem to depend on the nature or the severity of the injury sustained [7] and even mild trauma can have long-lasting effects [8–10]. Explanations for this are variable, multifactorial and complex, but biological plausibility for this effect is present [11]. Some individuals may be identifiably at higher risk for the development of subsequent stress disorders because of key pre-traumatic, peri-traumatic, and post-traumatic factors that are individually specific but that over a population are identifiable.

The consequences of failing to recognize and treat children at risk for PTSD are stark and prevail into adult life. PTSD is linked to changes in neurobiology [12, 13] during development and highly correlated with poor quality of life [14]. Long-term consequences of unrecognized and untreated ASD and PTSD include increased lifetime risk of poor school performance, impaired development, aggression, risk-taking behaviors, depression, suicidal ideation, increased adult mental illness and increased adult physical illness [15–19].

The ED is usually the first and is often the only point of medical care for children experiencing a physical trauma. Thus, the ED visit may be the best opportunity to screen for PTSD vulnerability and to connect patients to resources for future interventions or treatments [20, 21]. Such screening, however, is not current practice in this setting. In 2008, the American Academy of Pediatrics (AAP) released a position statement on the management of pediatric trauma stating that psychological support is a vital component of pediatric trauma care [22]. The AAP has also recently released a report describing the importance of the role of ED healthcare professionals in the stabilization and discovery of pediatric mental health, and advocating for improved recognition and treatment of mental health needs [23]. Despite these strong recommendations, psychological support as a component of follow-up for pediatric trauma is lacking or absent [24, 25]. Reasons for this are variable, but time pressures and lack of awareness of appropriate screening tools are key contributors. This review aims to address this deficiency by conducting a comprehensive review in order to identify PTSD screening tools that are suitable for use in the pediatric ED setting. Specific research objectives are to: (1) identify, describe, and critically evaluate instruments available to screen for PTSD in children and adolescents; (2) review and synthesize the test-performance characteristics of these tools; and (3) describe the clinical utility of these tools with particular focus on suitability for ED use. A broad systematic synthesis of the evidence regarding the availability and performance of available tools applicable to this very important setting does not yet exist.

The systematic review protocol has been registered with the PROSPERO systematic review database (registration number CRD42013004893) and has been designed based on the PRISMA statement and guidelines established in the Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0.

The ED is a unique environment. The pace, range of conditions and stress is high. Healthcare providers have multiple competing care duties and the chances of successfully implementing a screening tool into clinical care pathways for pediatric traumatic events will be maximized if the tool is carefully selected to suit the environment while maintaining accuracy in diagnosis to ensure improved outcomes. Given that pediatric injury is so prevalent and that EDs support the vast majority of these injuries acutely, it is logical for clinicians familiar with this unique environment and its patients to review and select the most suitable tool possible. To date, we are unaware of the availability of any such comprehensive review pertaining to the use of such tools in the acute-care ED. This review will address this deficiency by identifying, describing and evaluating such tools and comparing their features in a concise table. We will make screening recommendations based on the tools described and provide a foundation for the development of future practice guidelines in the psychological management of pediatric injury.