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a School of Social Work
b Harborview Injury Prevention and Research Center
c Departments of Psychiatry and Behavioral Sciences
e Surgery
f Pediatrics, University of Washington, Seattle Washington
d Harborview Medical Center, Seattle, Washington
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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METHODS. This was a prospective cohort study of traumatically injured adolescents aged 12 to 18 who were admitted to a level I regional trauma center. Adolescents were screened for posttraumatic stress symptoms, depressive symptoms, and alcohol use on the surgical ward and 4 to 6 months postinjury. PCPs were contacted by telephone 4 to 6 months postinjury to assess follow-up care and the detection of emotional distress.
RESULTS. In the surgical ward, 39.4% of the adolescent patients or their parents reported no identifiable source of regular medical care. Only 24.3% of the patients had visited a PCP during the 4 to 6 months after injury. At 4 to 6 months postinjury, 30% of the adolescents were experiencing high posttraumatic stress symptom levels, 11% were experiencing high depressive symptom levels, and 17% had high levels of alcohol use. PCPs did not detect any new emotional distress or problem drinking during postinjury office visits.
CONCLUSIONS. Injured adolescents represent a high-risk pediatric population, a substantial number of whom develop mental health problems postinjury. Furthermore, almost 40% of adolescents in our study reported no source of primary care. These results suggest that referrals from trauma centers to PCPs are necessary and that an increase in awareness of and screening for adolescent emotional distress postinjury during follow-up appointments and at school should be routine components of postinjury care.
Key Words: adolescents • injury • primary care utilization • detection • posttraumatic stress • alcohol use • depression
Abbreviations: PTS—posttraumatic stress • DSM-IV—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition • PTSD—posttraumatic stress disorder • PCP—primary care provider • RI—University of California at Los Angeles Post-Traumatic Stress Disorder Reaction Index • ISS—injury severity score • OR—odds ratio • CI—confidence intervals
Injury is the leading cause of death and disability for children and adolescents in the United States.1 One quarter of children receive medical treatment in a hospital emergency department or are treated in private physicians' offices for injury annually.2 After a traumatic injury, adolescents are vulnerable to emotional distress. Children and adolescent patients and their parents may develop acute stress disorder and depressive and posttraumatic stress (PTS) symptoms after an injury. Although trauma centers rely on follow-up care in the community after discharge, little is known about how well-connected this high-risk population is to primary care and whether adolescents' emotional needs after injury are being met by community systems of care.
Adolescent patients who are admitted to surgical inpatient units frequently experience high levels of PTS symptoms and related comorbid conditions.3–7 Stallard et al8 found that 34.5% of children aged 5 to 18 years who were involved in traffic crashes and admitted to a hospital met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for posttraumatic stress disorder (PTSD) 1 month postinjury. In previously published results of this study population, Zatzick et al9 found that 
40% of the injured adolescents were experiencing high PTS symptom levels within 30 days after their acute care inpatient admission. Schreier et al7 found that 59% of the children were experiencing at least mild posttraumatic symptoms and that 30% met the diagnostic criteria for PTSD 6 months postinjury.
A child's or adolescent's vulnerability to PTS after injury is a highly individual response. Predictors or risk factors associated with increased risk for developing emotional distress after childhood injury have been identified and include the child's level of fear of death at the time of injury, history of previous trauma, parental emotional distress at the time of injury, prior parental psychopathology, and female gender.7, 8, 10–13 A series of investigations with youth and adults across trauma center sites has established that PTS and substance intoxication frequently go undetected in acute care inpatient settings.14–16
Primary care is often considered to be a potential site for detection and treatment of depression, PTS, acute stress symptoms, and drug and alcohol use after an injury. The degree to which this high-risk adolescent population is attached to primary care or has a usual source of care is unknown despite the assumption that adolescents will receive follow-up care postinjury from their primary care provider (PCP), including screening, treatment, and referral for emotional problems. Because the majority of adolescents under the age of 18 are enrolled in school, health professionals, teachers, and counselors in school represent an additional resource for the injured adolescent returning to the community after injury.17 Both PCPs and school professionals are in a position to identify emotional distress after traumatic injury and intervene with the resources at their disposal, but little is known about whether this occurs.
The aim of this investigation was to determine adolescents' level of attachment and contact with primary care and school 4 to 6 months postinjury; assess injured adolescents' postinjury symptoms of PTS, depression, and alcohol; determine continuity of care between trauma center and PCPs; and examine the level of these community providers' detection of adolescent emotional distress 4 to 6 months after a traumatic injury. On the basis of our and others' previous investigations, we hypothesized that a substantial percentage of adolescents would not have a usual source of primary care at the time of the index-injury admission; that adolescents would have high levels of PTS symptoms, depressive symptoms, and alcohol use 4 to 6 months postinjury; that care linkage between the trauma center and the community, in many cases, would be incomplete; and that we would observe low rates of PCP detection of adolescent emotional distress and at-risk alcohol consumption 4 to 6 months postinjury.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Recruitment
All eligible patients were approached by research assistants in the surgical ward in the order dictated by the random-number assignments.
Data Collection
Adolescent Interviews
As part of the larger longitudinal study, adolescents were interviewed at the time of the initial hospitalization and by telephone 4 to 6 months postinjury. Self-report was used to assess all adolescent symptoms. During the initial ward interview, patients were asked to identify their PCP and their school (if still in school).
Chart Review
A research associate blinded to patient symptom status conducted a chart review for all patients in the study to assess documentation of referrals made for patients and linkage between trauma center and community systems of care. The senior investigators (D.F.Z. and F.P.R.) audited the chart-review process by screening a sample of the chart reviews. The trauma registry was used to obtain injury diagnoses and treatment data.
PCP Interviews
At 4 to 6 months postinjury, we attempted to interview the adolescent's PCP by telephone to assess the adolescent's connection to primary care and determine detection by their PCP of emotional distress after injury. We first called the physician's office and asked to speak with the medical records department to confirm that they had received the consent for release of information and that the patient had been seen by the physician during the 4 to 6 months after the injury. If the answer was "yes" to both questions, we scheduled a telephone appointment with the physician after he/she had time to review the medical records. The researcher spoke directly with the physician, who reviewed the patient's chart and responded with information from chart notes as well as from personal recall. The physician was asked how many visits the patient had during the 4 to 6 months postinjury, the reason for the patient's visit(s), and whether a new emotional, behavioral, or school problem had been detected during the visit. For 2 instances in which the physician was no longer available, a nurse reviewed the medical chart and answered the researcher's questions. The range of total telephone attempts needed to complete an interview ranged from 2 to 13.
School Counselor Interviews
School counselors were contacted by telephone by the researcher 4 to 6 months postinjury. First, school receipt of parent consent and patient assent was confirmed. The school counselor then was asked if he/she was aware of the adolescent's injury. The counselor was asked about a range of services available to students in that school and whether the injured adolescent needed special accommodations at school after the injury (ie, an excusal from participating in gym class or sports, help with carrying books, or extensions on school work). We asked the counselor whether the patient had emotional difficulties or behavior problems that affected school work or limited activities with friends for the 4 weeks before the injury and 4 weeks before the time of the 4- to 6-month interview. These issues are ones that fall in the domain of the school counselor's role. The counselor either knew the patient well enough to answer from memory or consulted school records and teacher reports to answer the questions.
Measures
Adolescent PTSD Symptoms
The University of California at Los Angeles Post-Traumatic Stress Disorder Reaction Index (RI) for DSM-IV18 was used to assess adolescent PTSD. The RI includes 20 items that assess the DSM-IV B (intrusion), C (avoidance), and D (arousal) PTSD symptom clusters during the month before the interview. A cutoff of 38 on the RI has a sensitivity of 0.93 and specificity of 0.87 for PTSD when compared with the child and adolescent version of the clinician-administered PTSD scale18; this cutoff was used in the current investigation to assess for high PTS symptom levels.
Adolescent Depressive Symptoms
The Center for Epidemiologic Studies Depression Scale was used to assess adolescent and parent depressive symptoms.19 The measure assesses depressive symptoms over the week before the interview. A score of 
27 has been suggested as a conservative indicator of high levels of depressive symptoms; this cutoff was used in the current investigation to assess for high levels of depressive symptoms.
Adolescent Alcohol Use
Alcohol consumption in the year before the injury and again 4 to 6 months postinjury was assessed with the Alcohol Use Disorders Identification Test (AUDIT), a 10 item self-report screening measure used for early identification of problem drinking in the acute care setting.20 We defined high levels of alcohol consumption as scores of >5 on the first 3 items of the AUDIT that assess the quantity and frequency of alcohol consumption.21
Adolescent Preinjury Trauma
We screened for traumatic life events that predated the adolescent's index-injury admission by using a modified 10-item version of the RI trauma-history screen.18 Examples of these questions are "Were you ever in a big earthquake that badly damaged the building you were in?" and "Were you ever beat up, shot at, or threatened to be hurt badly in your town?"
Injury Severity
Injury severity was abstracted from surgical records by using a conversion software program (ICD-MAP) that transforms recognized International Classification of Diseases, Ninth Revision, Clinical Modification codes into the abbreviated injury scale and subsequently an injury severity score (ISS). Injury severity was categorized as mild (ISS: <9), moderate (ISS: 9–16), or severe (ISS: >16).22
Health Service Use
Preinjury mental health visits, diagnoses, and medication were recorded at the initial interview through adolescent and parent self-report by using the following criteria: having a mental health diagnosis, use of psychiatric medication, or having had a mental health visit in the year before injury.9
Data Analysis
We first assessed the demographic, clinical, and injury characteristics of the adolescent cohort. We derived high PTS, depressive, and alcohol symptom levels by using previously described scale cutoffs. We compared provider presence/absence, postinjury visits, and symptoms in patients with and without high symptom levels by using odds ratios (ORs) and 95% confidence intervals (CIs). We compared high and low levels of PTS symptoms, depressive symptoms, and alcohol use with trauma center care data and primary care use and detection of symptoms by using ORs with 95% CIs.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Of 105 patients, 34.3% were female; the mean age was 15.9 years (SD: 1.89 years), and 26.7% were nonwhite. The median trauma center length of stay was 3 days, the mean length of stay was 5.2 days (SD: 5.77 days), and 28.6% of the patients were hospitalized for 7 days. Mild injury (ISS: <9) accounted for 41.9% of the sample, moderate injury (ISS: 9–16) accounted for 38.1%, and 20.0% had injuries that were severe (ISS: >16). Intentional injuries resulting from nonfamily interpersonal violence accounted for 10.5% of the cases. Twenty-one percent were insured through public insurance.
High levels of preinjury alcohol use were reported by 13.6% of the patients. A portion of the patients (12.4%) reported experiencing psychological concerns before the injury, as measured by use of any psychiatric medication or having had a psychiatric diagnosis or an office visit for mental health in the year before the injury. Thirty percent of the adolescent patients reported 4 previous trauma events in their lives before the injury.
Of the 105 adolescent participants who were interviewed during the ward interview, 4 refused to provide information about a source of primary care, and information was missing for 2 of the patients. Of the remaining 99 participants, 39 (39.4%) reported that they did not have an identifiable usual source of primary care at the time of surgical ward hospitalization, which confirmed our hypothesis that a substantial percentage of adolescents would not have a usual source of care. Only 22 (36.6%) of the 60 patients who did identify a PCP were seen for at least 1 office visit during the 4 to 6 months after the trauma center discharge. Reasons for the visit, reported by the physician during the 4- to 6-month interview, included removal of stitches, acute illness, pain management related to injury, routine health maintenance, and reproductive health. School enrollment for this patient sample at the time of injury was 86.7% (n = 91), with 3 of those patients reporting home schooling.
Patients who had a PCP were less likely to have an intentional injury (OR: 0.2: 95% CI: 0.1 to 0.8) and were less likely to have public insurance (OR: 0.4; 95% CI: 0.2 to 1.1). There were no significant differences between the group that identified a PCP and the group that did not in age, gender, race, injury severity, or prior mental health problems (Table 1).
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1 measure 4 to 6 months postinjury. Although referral to acute care or surgical care providers for postinjury follow-up was made for 84.8% (n = 89) of the patients, the number of referrals to a PCP or mental health counselor was low. These results support our hypothesis that linkage between trauma center and community care would be incomplete (Table 2). During the adolescents' hospitalization, trauma center staff contact with PCPs was recorded in the medical chart for 4 patients, documentation of a referral to the PCP by trauma center staff was found for 7 patients, and 6 patients were referred to mental health care at discharge. Trauma center staff contact with a PCP during inpatient hospitalization was documented for only 7.4% of patients who developed PTS symptoms 4 to 6 months postinjury, for 0 patients who developed depressive symptoms, and for 6.7% of patients who subsequently measured high for alcohol use.
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We compared high/low levels of PTS symptoms, high/low levels of depressive symptoms, and high/low levels of alcohol use reported at 4 to 6 months postinjury and found no significant difference between the level of problems and injury severity or whether patients identified having a PCP. Although a majority of the adolescents in the study identified a PCP during the surgical ward interview, almost 40% did not. We examined primary care utilization at 4 to 6 months postinjury and found that 40% (n = 24) of those who identified a PCP had at least 1 primary care visit in the 4 to 6 months after injury. We compared the high/low-symptom groups for PTS symptoms, depressive symptoms, and alcohol use and whether the patients had seen their PCP during the 4 to 6 months after the injury and found no significant difference between the groups who did and did not have an office visit (Table 3). Of those adolescents with no provider, 42.3% reported high PTS symptoms, 50% reported high depressive symptoms, and 50% reported high alcohol use at 4 to 6 months postinjury.
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School Counselors
Before the injury, 86.7% of the patients were enrolled in school, 3 of whom reported receiving home schooling. All 33 schools that we contacted had at least 1 designated school counselor whose role was to provide academic, emotional, and resource support. Most schools had a school nurse employed at least part-time (84.8%) and had some form of on-site mental health services (72.7%). Academic support services were available in most schools (72.7%) and consisted of services such as organized tutoring, study clubs, teachers staying after school to help students, peer tutoring, and study hall. Injury-prevention education was reported as a routine part of the school curriculum in 54% of schools. School counselors' awareness of the student's injury was variable, with 63.6% reporting being aware that the student had sustained an injury. Sixty percent of the counselors had met with the patient in the 4 to 6 months after the injury: 55% for academic reasons, 10% specifically because of the injury, and 35% for other reasons. Counselors reported that 27% of the students received emotional support at school after the injury. Five of the schools responded to the patient's injury by providing education or support to the patient's peers regarding the injury.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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To our knowledge, this is the first investigation to prospectively follow a cohort of injured adolescents and assess linkage between trauma center and primary care, injured adolescent attachment to primary care services, and primary care detection of emotional and substance-related symptoms postinjury. We found that although 39.3% of the adolescent patients had high PTS, depressive, or alcohol-related symptoms 4 to 6 months after the injury, almost 40% of the adolescent patients reported no usual source of primary care. There was no significant difference between the age, gender, race, injury severity, or prior mental health problems of the adolescents in our study who did and did not identify a usual source of care, which suggests that there is a need to make certain that all hospitalized injured adolescents are connected to a source of primary care in their community.
Pediatric guidelines and recommendations for postinjury adolescent care offer recommendations for screening for emotional problems after injury that are often aimed at the adolescent's pediatrician or PCP. The assumption is often made that the patient is connected to a routine source of care in the community, but this was not the case for many of the patients in our study. Furthermore, >40% of the patients with high levels of distress who did have a PCP were not seen by their PCP in the 4 to 6 months after the injury. When patients were seen, PTS symptoms, depressive symptoms, and alcohol-related disorders were not detected by the providers. This seems to be a missed opportunity for intervention with this group of adolescents.
The rate of adolescent connection to primary care in our study is consistent with other studies. Yu et al26 reported that 32% of adolescents had not had a physical examination in the past year. The Commonwealth Fund's quality of health care report found that 34% of adolescents aged 15 to 17 did not receive recommended preventive care.27 Medical Expenditure Panel Survey data28 showed that 37.8% of 13- to 17-year-olds and 44.4% of 18- to 21-year-olds had no medical office-based expenditures for the year 1999.
Whether a child is treated in a pediatric-only trauma center or an adult-focused center may influence trauma center linkage of injured children to primary care, although this seems to be unstudied. Very few injured children and adolescents are treated in pediatric-only trauma centers.29 Acute care linkage to community care providers requires intensive follow-up by staff. In our study, the number of telephone attempts needed to complete an interview with the PCP ranged from 2 to 13. Pediatric-only trauma centers may have systems and staff designated to maintain close contact with community care providers, but other hospital settings may not.
To accomplish the goal of inpatient-outpatient continuity of care, promising interventions have been studied including face-to-face contact with a social worker or nurse, intensive telephone follow-up, offering vouchers for transportation to primary care, scheduling a PCP follow-up appointment before discharge, and implementing a dedicated role for the purpose of continuity of care between the acute care facility and community primary care.30–35 In real-world adult trauma and adult-pediatric trauma center settings, this level of intensive intervention is not likely to occur unless at least some personnel time is dedicated to that role. Connecting an injured adolescent at high risk for emotional distress postinjury to a routine source of community medical care before hospital discharge may be the first component toward intervention with this population.4 Rushton et al36 reported that 16% of children with existing psychosocial problems were referred to a mental health provider at an initial primary care visit.
Linking an injured adolescent to primary care does not ensure that emotional distress after an injury will be detected by the PCP. In our study, PCPs did not detect any new emotional problems although 45.2% of the patients seen by their PCP in the 4 to 6 months postinjury demonstrated at least 1 symptom of psychological distress. This detection finding is consistent with studies that have examined screening for emotional problems in pediatric primary care. Wren et al37 found that screening and diagnosis of mood and anxiety symptoms is not a part of routine child and adolescent primary care; mood and anxiety symptoms were found in only 3.3% of children aged 4 to 15 despite estimated prevalence rates of between 8% and 15%. Williams et al38 found that many pediatric providers listed anxiety and depression as diagnoses that they made infrequently and that none used instruments to routinely screen for behavioral health problems. Gardner et al39 found that clinicians used DSM-criteria screening of child mental health problems in only 23% of visits in which a mental health problem was found. Wilson et al40 found that providers' clinical impressions of adolescents' substance use underestimated actual problem behavior.
Lack of time in primary care visits, physician perceptions of available referral resources, and lack of brief screening tools and targeted mental health diagnostic training hinder pediatric providers' ability to detect and treat mental health problems.38, 41 Because screening for emotional distress after injury falls within the domain of preventive pediatric primary care, inpatient adolescent trauma care should place a renewed focus on assessing primary care attachment and linking patients to primary care. In addition, information about the high risk for psychological distress and the need to screen for psychological problems after adolescent injury needs to be made available to PCPs. There is a need to increase awareness among PCPs of the prevalence of and risk factors for emotional distress that often follows injury.
Most of the adolescents in our study attended school. School health professionals are in a unique position, because they may be the single-most available health professional in adolescents' lives.42 School counselors, school nurses, mental health specialists, and teachers are in a position to identify emotional distress after injury and to refer these students to community- or school-based mental health professionals. Future design of interventions for injured adolescents who experience PTS symptoms, depressive symptoms, and substance use after injury may want to take into account the high rate of school attendance among adolescents and the universal presence of school health professionals in adolescents' daily environment and consider delivery of these services in school.
There are some limitations of our study to consider. The number of subjects in this study may not have been large enough to achieve statistical significance in some of the analyses. The study relied on adolescent self-report rather than clinical observation to determine the patients' level of emotional distress after injury. Although the majority of subjects consented and assented verbally to the school counselor interview procedures, only approximately one half of the adolescents and parents returned the written consent and assent forms, although we sent 3 mailings. Despite these limitations, this seems to be the first study to examine traumatically injured adolescent attachment to primary care, trauma center linkage to adolescent primary care, the number of primary care visits 4 to 6 months postinjury, and PCP detection of adolescents' emotional distress after a traumatic injury.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Intervention design needs to take real-world care environments into account when developing interventions aimed at detecting and treating adolescent emotional distress after injury. The first step in intervention design should be using a case manager in the trauma center who is dedicated to the integration of acute care and primary care systems; screening for risk of postinjury emotional distress; and referral to appropriate community care. There is a need to increase awareness among primary care providers and school health professionals of the risk for emotional distress after adolescent injury. Because many injured adolescents require follow-up visits with acute/surgical care, screening for emotional problems in the months after injury during acute/surgical care follow-up visits may be useful. Development of brief screening tools to detect adolescent PTS symptoms, depressive symptoms, and substance use for use in busy pediatric/adolescent primary care and school settings is recommended.
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ACKNOWLEDGMENTS |
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We thank Joan Russo, PhD, for statistical consultation and Angela Ghesquiere, MSW, for research-assistant support.
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FOOTNOTES |
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Address correspondence to Janice A. Sabin, MSW, PhC, School of Social Work, University of Washington, 4101 15th Ave NE, Seattle, WA 98105-6299. E-mail: sabinja{at}u.washington.edu
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This article has been cited by other articles:
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 D. Zatzick Collaborative Treatment of Traumatized Children and Teens: The Trauma Systems Therapy Approach Arch Pediatr Adolesc Med, September 1, 2007; 161(9): 914 - 915. [Full Text] [PDF]
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