Abstract
OBJECTIVE: Dogs are important members of many families in many countries. However, posttraumatic stress disorder (PTSD) in children after animal attacks has always been underestimated, and a more-detailed study of PTSD in children after animal attacks is needed.
METHODS: The charts and follow-up data for 358 children after animal-induced injuries were reviewed. Family Apgar Scale assessment and PTSD screening were performed at emergency department admission. On week 1 after the emergency department admission, the patient underwent evaluation for acute stress disorder (ASD) diagnosis, by using the Child Acute Stress Questionnaire. PTSD screening and interim history-taking were performed 3 months after the emergency department admission, by telephone or in face-to-face interviews, by using the Clinician-Administered PTSD Scale for Children and Adolescents. P values of <.05 were considered significant.
RESULTS: A total of 19 patients developed PTSD, including 10 patients with severe injuries, 8 patients with moderate injuries, and 1 patient with a mild injury (χ2=48.104; P=.000). No significant differences in PTSD occurrence according to gender and age were observed. Family Apgar Scale scores were not significantly related to PTSD (P=.781). ASD and PTSD symptom severity scores were significantly associated (r=0.51; P < .005).
CONCLUSIONS: Child victims of severe animal attacks should be considered at risk for the development of PTSD, family support was not correlated with posttraumatic stress symptoms in school-aged children after animal attacks, and ASD seems to be an early predictive indicator of PTSD.
WHAT'S KNOWN ON THIS SUBJECT:
ASD and PTSD in children after animal attacks are poorly understood.
WHAT THIS STUDY ADDS:
Child victims of severe animal attacks should be considered at risk for the development of PTSD. Family support was not correlated with posttraumatic stress symptoms in school-aged children after animal attacks.
Dogs are important members of many families in many countries. Although the majority of dogs live peaceably with their adoptive families, a significant number of people are bitten by dogs every year. China, as the most populous country in the world, has numerous animal-induced injuries every day. The best estimates available note that nearly 14 million bites occur each year and 1 in 7 patients, or 2 million bite victims, require medical attention. Children, because they tend to underestimate the danger arising from dogs, are exposed frequently to bite accidents. A US study found that 46% of schoolchildren had been bitten by a dog by the time they reached grade 12.1The aesthetic and psychological consequences of bite accidents may influence negatively the quality of life of children and their families.2,3
Posttraumatic stress disorder (PTSD) describes the clustering of symptoms that develop after exposure to traumatic events. Substantial evidence shows that exposure to traumatic experiences may affect brain function in several ways and may have long-lasting consequences.4 Rates of PTSD and PTSD symptoms may vary according to traumatic exposure; 60% of children exposed to a sniper attack met PTSD criteria 1 year after the incident,5 and studies of urban youths exposed to community violence reported PTSD rates of 24% to 34.5%.6 For most animal-induced injuries, children seem to be unharmed or only transiently affected. However, severe dog bites/scratches and multiple injuries may bring tremendous harm to children, both physically and psychologically. PTSD in children after animal-induced injury is common but is a neglected condition for clinical pediatricians. Pediatric patients with PTSD are at risk for social, learning, and developmental disorders.7 Therefore, there is urgency for PTSD screening for children after animal attacks, to reduce the psychological impact for children.
The primary objective of this study was to analyze the incidence of and predictive factors for PTSD in children after animal-induced injuries. We evaluated retrospectively the charts and follow-up data for 358 children who sought medical assistance in the emergency department because of animal-induced injuries.
METHODS
The study was conducted in accordance with the guidelines of the Helsinki Declaration. Data for this study were gathered by using a questionnaire, and formal ethics approval was obtained from the ethics committee of Peking University People's Hospital.
The emergency department at Peking University People's Hospital is one of the few rabies prevention centers in Beijing, treating ∼500 pediatric patients with animal-induced injuries each year. This study included children who were 5 to 17 years of age, were willing to participate in the study, and sought medical attention after an animal injury between May 1, 2006, and July 31, 2009. Subject enrollment began after informed consent was obtained from both the child and his or her parents. The exclusion criteria included cognitive impairments, psychotic diseases, speech disorders, and retardation. The standard medical treatment for animal injuries at the emergency department consisted of postexposure vaccine prophylaxis for rabies and/or rabies immunoglobulin treatment, meticulous wound cleaning, and closure of gaping wounds (if needed). Intradermal sutures were used for facial wounds, to achieve better aesthetic results. In the case of deep lacerations, wound drainage and/or systemic antibiotic treatment were used. Patients with complicated, severe, or multiple wounds were admitted to the hospital for further treatment.
For each patient, the following information was recorded: victim's name, age, gender, race, and contact information; date of injury; breed of dog; anatomic location of the injury; number of wounds; circumstances of the injury; relationship of the patient to the dog; hospital admission; need for operation; Family Apgar Scale scores; and PTSD screen results. Detailed medical, psychiatric, and social histories also were obtained. One week after the emergency department admission, the patients underwent assessment for acute stress disorder (ASD) diagnosis, by using the Child Acute Stress Questionnaire.8 PTSD screening and interim history-taking were performed 3 months after the emergency department admission, by telephone or in face-to-face interviews, by using the Clinician-Administered PTSD Scale for Children and Adolescents.9 Interviewers who conducted assessments at month 3 were not aware of the children's ASD status at week 1. ASD and PTSD were defined according to the diagnostic definitions of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.10
Abbreviated Injury Scale scores, Injury Severity Scores, and Glasgow Coma Scale scores were not used in this study because animal attack wounds differ from wounds attributable to traffic accidents, which mainly involve organ damage, cranial damage, and bone fractures. Therefore, to classify wound severity, we divided the cases into 3 groups on the basis of whether sutures and hospitalization were needed. Mild injuries required only simple medical treatment, moderate injuries required sutures in the emergency department, and severe injuries required hospitalization. The Family Apgar Scale was used to evaluate family support and function.11 The Family Apgar Scale consists of 5 questions, each addressing one of the following constructs regarding family support and functioning: adaptability, partnership, growth, affection, and resolve. Test-retest reliability was reported as r=0.83,11 and internal consistency in the prestudy was 0.87.
Descriptive analyses summarized subject characteristics and the prevalence of ASD and PTSD, expressed as means and SDs. ASD or PTSD status was described separately for children in 2 age groups (5–11 years and 12–17 years). The χ2 test was used to compare the prevalence of ASD and PTSD according to gender, age group, and injury severity. For groups with significantly different rates of PTSD, odds ratios (with 95% confidence intervals [CIs]) were calculated. Prediction of PTSD from independent variables, such as ASD scores and family support, was based on correlations (Spearman ρ, 2-tailed). Analyses were conducted by using SPSS 11.5 (SPSS Inc, Chicago, IL). P values of <.05 were considered significant.
RESULTS
Demographic Characteristics
In this study, 358 pediatric patients were interviewed, accounting for 36.7% of all pediatric patients with animal injuries during the study period. There were 201 boys and 157 girls. The mean age of the subjects was 9.4 ± 2.8 years. All of the patients were Asian, specifically Chinese. Of the 358 patients, 38 were hospitalized (severe injuries), 81 received sutures in the emergency department (moderate injuries), and the other 239 received only simple treatment (mild injuries) (Table 1).
Demographic Characteristics of Subjects
Animal Attacks
Most of the patients were injured by dogs (294 children [82.1%]); other victims were bitten by cats (25 children [7.0%]), rabbits (19 children [5.3%]), guinea pigs (12 children [3.4%]), and rats (8 children [2.2%]). The majority of victims were injured by a dog known to them, that is, their family pet (112 of 358 children [31.3%]) or a dog known to them but not owned by them (171 of 358 children [47.8%]). Unknown dogs were responsible for 20.9% of injuries (75 of 358 children). Bites to the lower leg, foot, and arm were most common. The majority of children (276 children [77.1%]) received 1 bite during the attack.
ASD and PTSD
A total of 38 victims met the symptom criteria for ASD, including 17 in the severe injury group, 13 in the moderate injury group, and 8 in the mild injury group. ASD occurrence was significantly higher in the severe injury group than the other 2 groups (χ2=62.458; P=.000). Of the 38 patients, 16 were male. There were no statistically significant differences in the occurrence of ASD according to gender (χ2=3.403; P=.065). Twenty-eight patients were 5 to 11 years of age, and the other 10 were 12 to 17 years of age. Children 5 to 11 years of age were more likely than those 12 to 17 years of age to have ASD (χ2=7.665; P=.006; odds ratio: 2.765 [95% CI: 1.300–5.881]). Table 2 presents the prevalence of each ASD symptom category and ASD among children within each wound severity group. Although 10.4%, 38.3%, and 63.4% of the children in the mild, moderate, and severe injury groups, respectively, developed reexperiencing symptoms, only 3.3%, 16%, and 44.7% of the children were diagnosed as having ASD.
ASD Among Injured Children
No child in any wound severity group had PTSD at the admission assessment. A total of 19 patients developed PTSD. Ten patients from the severe injury group met the diagnostic criteria for PTSD, 8 patients from the moderate injury group developed PTSD, and 1 patient from the mild injury group developed PTSD (χ2=48.104; P=.000). No significant difference was observed on the basis of gender (χ2=0.628; P=.428) or age group (χ2=1.966; P=.161; odds ratio: 0.498 [95% CI: 0.185–1.342]). Table 3 presents the prevalence of each PTSD symptom category and PTSD among children within each age category.
PTSD Among Injured Children
Family Apgar Scale scores, as a hypothesized indicator of PTSD, were not significantly related to PTSD (P=.781). ASD and PTSD symptom severity scores were significantly associated (r=0.51; P < .005). Furthermore, among the 19 children who developed PTSD, 14 patients were diagnosed as having ASD and the other 5 patients had partial ASD symptoms.
DISCUSSION
Animal-induced injuries are very common, especially among children. With the development of rabies vaccines and antibiotics, rabies occurrence and wound infection rates have been reduced significantly. For animal-induced injuries, however, children may need more care from physicians, not only medical/surgical interventions but also psychological interventions. Little is known about the normal range of acute psychological responses of children in the immediate aftermath of animal attacks, which makes the identification of adverse child responses extremely difficult. Peters12 demonstrated that 12 of 22 pediatric patients developed PTSD symptoms after dog bites, but no detailed data and analyses were provided. Some studies involving PTSD in children were related to acute physical injuries,13,–,15 such as traffic accidents, which are generally different from the trauma of animal attacks. This study investigated PTSD occurrence in children after animal attacks and indicated possible predictive indicators.
The reason why PTSD developed in some children is not known. However, it could be related to the intensity and aggressive character of the animal attack.16 Our study also leads to the conclusion that child victims of severe animal attacks should be considered to be at risk for PTSD and may need early psychological support. In the severe injury group, 26.3% of the children developed PTSD, compared with 9.9% and 0.4% in the moderate and mild injury groups, respectively. No significant differences in PTSD occurrence according to gender and age were observed, although girls seemed to be more vulnerable and younger children seemed to be more likely to develop PTSD. In this study, we included only patients who fully met the criteria for ASD/PTSD, excluding patients who might have symptoms but did not meet the criteria for ASD/PTSD diagnosis. For example, 63.4% and 57.9% of the children in the severe injury group developed reexperiencing and avoidance symptoms, respectively, but only 44.7% of the children had confirmed ASD. The situation was similar for PTSD diagnosis. Additional study may be needed specifically for children with ASD/PTSD symptoms but without a specific diagnosis.
We hypothesized that less family support would contribute to posttraumatic stress symptoms in children after animal attacks. However, the study results do not support this hypothesis. ASD symptoms seem to be possible predictive indicators of PTSD. There have been numerous studies on the relationship between ASD and PTSD in adults, which revealed that 63% to 83% of patients diagnosed as having ASD develop PTSD.17,–,19 Kassam-Adams and Winston20 examined the utility of ASD as a predictor of PTSD among 8- to 17-year-old youths after traffic accidents and found a positive relationship. Furthermore, PTSD severity was found to be strongly associated with self-reported ASD symptom severity among youths and young adults who were assessed within hours after a violent injury.21 Our study findings regarding the ASD-PTSD relationship indicated that ASD symptoms may be used as possible predictive parameters for PTSD in children after animal attacks. However, further investigation of the sensitivity and specificity may be needed.
Previous studies examined factors related to the development of PTSD in children, such as demographic variables (eg, age and gender), previous psychopathologic conditions, injury severity, and physiologic factors (eg, heart rate and physiologic arousal). One study of 401 adolescents 12 to 19 years of age demonstrated that female gender, perceived threat to life, and violence-related mechanisms of injury were predictive of ASD, as measured with the Impact of Events Scale-Revised.22 In addition, another study found that the acute heart rate near the time of injury might be related to the development of PTSD in children after traffic-related physical injuries.23 However, many possible predictive indicators were not included in that study. Additional studies may take into account possible related parameters for an overall evaluation of PTSD risk factors.
There are some limitations to this study. Firstly, we evaluated urban and suburban populations, and rural areas were not covered. Therefore, a bias might have been generated through population selection. Because dogs in rural areas are more ferocious and more-severe wounds may be more common, cases of children experiencing PTSD may be more prevalent. Secondly, this study enrolled only a Chinese population, and other races and ethnicities were not included. Therefore, similar studies among children in rural settings and in other ethnic populations would be useful. Thirdly, because no existing appropriate instrument could be used for evaluation of animal attack wounds, we divided the cases into 3 groups on the basis of gross wound severity. This triage was based mainly on the judgment of the physicians in the emergency department, and systematic differences in grouping might have occurred. Future studies might adopt a wound evaluation instrument to achieve better wound severity grouping. Lastly, this study enrolled only patients >5 years of age. Future studies should develop a more patient-friendly, easier questionnaire for PTSD evaluation in younger patients.
Given previous research findings that linked untreated PTSD with poorer health and functional outcomes, all of the 19 children with PTSD and their parents were referred for psychological care. Finally, we propose that physicians in emergency departments dealing with pediatric patients after animal attacks should be encouraged to instruct the children's parents to observe the children closely after the injury, for psychological effects.
Footnotes
- Accepted April 26, 2010.
- Address correspondence to Li Ji, MD, Peking Union Medical College Hospital, Department of Pediatrics, Beijing, China, 100730. E-mail: lijiatpumh{at}126.com
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- PTSD =
- posttraumatic stress disorder •
- ASD =
- acute stress disorder •
- CI =
- confidence interval
REFERENCES
- Copyright © 2010 by the American Academy of Pediatrics
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