Thank you so much to Dr. Tasker and the Board of Pediatric Critical Care and SCCM for the ability to present this article today. So as Dr. Tasker said, I would be presenting on PICU-associated parental post-traumatic stress beyond the first year. And this is my team, without whom this work would not be possible. So this all started with the question, where do we go from here? If we look at PICS or PICS-P, we see that there are long-term effects after a child is admitted to the ICU, that we're trying to discern how that relates to their reintroduction into society. And our thought as a team was, if a parent is affected, how does that affect a child's reintroduction after critical care? So we started with the question that has been answered by many colleagues before, what is medical traumatic stress? And here we look at DSM-V5 to really give us the thought on acute and post-traumatic stress, where we have a traumatic incident. In this case, we look at the PICU admission as our traumatic incident. And then we look at symptoms associated with post-traumatic stress disorder as a whole. And we say for acute post-traumatic stress, acute traumatic stress, sorry, we're looking at two to four weeks after a child's been admitted to the ICU. And then for post-traumatic stress, we add the tincture of time to, they say, greater than four weeks after admission to the ICU. And so why study traumatic stress? A lot of times we look at a child in the ICU and we look at outcomes related to that child. But parental traumatic stress in particular, when we look at acute stress, we're looking at one out of three parents meeting DSM criteria. And when we're looking at acute stress symptoms that don't meet criteria for death disorder, up to 70 to 80 percent, it's quite a large number. For post-traumatic stress, we're looking at one out of five parents. And then for post-traumatic stress symptom, a very broad range from the multiple articles that have been published in this area of 20 to 80 percent. So then not only can we say, okay, our parents may be affected by their child being admitted to the ICU, but how does that relate to the family and to the child themselves? And here we see increased child psychiatric behavioral disorders and parent and spouse psychiatric issues. Something called multigenerational or intergenerational trauma, where you can have either psychological or sometimes even physical change in how family members respond to trauma. Increased parental substance abuse and deficits of head of household abilities. And increased financial stress for the family. And this data is not only seen in the pediatric ICU population, but in post-traumatic stress in parents throughout many different niches. So then we said, well, what do we not know? We've had multiple articles that have been presented that say, yes, we have post-traumatic parental stress from the ICU. But really those articles have focused within the 12-month period, with one article going out to 18 months. And so our question was, what really happens to these parents outside of that range? And so we wanted to evaluate the percentage of parents meeting PTSD diagnosis at about two years post-discharge. And then what are the risk factors for these particular parents, and how do they compare to risk factors for acute traumatic stress and for short-term post-traumatic stress, which we define in our study as less than 18 months. And then the effects of post-traumatic stress and PTSD symptoms on how a child and family does from a psychosocial and economic sense. This is a two-center perspective cohort study. And we enrolled from July of 2016 and finished our follow-up in January of 2020. So our inclusion criteria were parents of children 0 to 17 years who had been admitted to the PICU unexpectedly and admitted for greater than 48 hours. And then for our exclusion criteria, on the basis from our psychiatric and psychology colleagues, we decided to exclude parents who had recently, within the last two years, been admitted for a psychiatric disorder, or parents who were suspected of their child dying in the ICU imminently, or who died during the study period. And the reason for this was we felt that it would be difficult to differentiate grief and other psychiatric disorders from post-traumatic stress disorder related to the ICU, and also felt that if anything, we would underestimate how many parents were meeting criteria versus overestimate because there had already been evidence that mental health disorders and grief potentially can lead to increased levels of PTSD. We also decided to exclude parents of children who were suspected or confirmed of physical or sexual child abuse during that admission, and non-English-speaking parents, simply because our study tools were not validated in other languages. So talking about study tools used, we decided to use the post-traumatic symptom scale interview version for DSM-V5 because it allowed us to get a deeper sense of what exactly, which symptoms were bothering our parents, because it is an interview scale. And we did use the cutoff point of greater than or equal to 23 as our cutoff for a probable PTSD diagnosis that has been validated by the developers. For acute stress disorder, we used the acute stress disorder scale for DSM-V5. For prior psychiatric illnesses, which we tested when a parent came into the ICU, we used the PHQ. And then we had internal questionnaires which looked at demographics, previous history of both parent and child from a psychologic perspective, medical perspective, and socioeconomic perspective. So when looking at the assessment timeline, we approached parents during the admission, within three to 14 days of their PICU admission. And this is where we established the PHQ and additional questionnaires looking at their demographics and socioeconomic standing. And then we looked at a child's functional status. We again repeated a discharge of functional status, and this was to evaluate whether there was a substantial change in a child's functioning while they were in the ICU. And we also did the acute stress disorder scale to evaluate the acute stress that was experienced by the PICU admission as a whole. At three to nine months, we assessed parents with the PSSI-5 and also additional questionnaires to evaluate things that had changed from the discharge date, whether it be medical, socioeconomic standing, and additional questions about the child's medical health as well. And then we repeated this at 18 to 30 months. When we look at the enrollment demographics, we had a total of 265 parents. And of a female gender, we had 58%, which we were lucky to enroll 42% of fathers or male genders because this is quite large for this niche of study. And then we had a pretty even split of 55% slightly more enrollees at Murray Ferrari's Children's Hospital. Interestingly to us that I want to highlight is that we found with the PHQ that 24% of our parents screened for active psychiatric disorder at time of admission. And also that almost 50% of our parents had experienced either themselves or another close family member outside of the child who had been admitted to an ICU in the past. When looking at the children, we had 188 children that were enrolled. And history of chronic disease was quite prevalent, so about 50%. And then also history of previous NICU or PICU admission was 57%. Most of our children were expected to survive to discharge with a median PRISM score of 3. And then also wanted to highlight outside of length of stay that was about a week that we had about a 30% significant change in functional status for this cohort of children from the start of their ICU admission to the end. So in looking at our retention, we were able to retain 73% for our 3 to 9 month cohort and 66% for our 18 to 30 month cohort. And both of these timeframes were chosen, one, to kind of match the existing data that is usually around 3 to 9 months post-discharge. And we wanted to look at the period at around 2 years post-discharge, so that explains that kind of wide timeframe for the final assessment. So in the first primary report of our results, at 3 to 9 months, we had about 15% of our parents meeting criteria for probable PTSD. And at 18 to 30 months, we had about 13%, which was less of a drop than we expected, to be honest. And then looking at post-traumatic stress symptoms, we had 75 subjects at 3 to 9 months or 38% and about 34% at 18 to 30 months post-discharge. So our big question was whether or not this was trajectory of post-traumatic stress disorder or were we evaluating parents who had newly met diagnosis for PTSD at 18 to 30 months. So about 60% of our participants completed both T2 and T3 assessments. And out of those 160 parents, 11 met criteria for PTSD at both time points. We have another 11 or 7% meeting PTSD criteria only at T2 or 3 to 9 months. And at 18 to 30 months, we had new onset parents who were now qualifying for PTSD criteria who had not done so previously. So looking at the 22 parents that met PTSD criteria at T2, you had 11 that continued, as we talked about previously, to have PTSD at 18 to 30 months. And of the 11 who had resolution of their PTSD, 64% of them still met criteria for significant post-traumatic stress symptoms at 18 to 30 months. And of the 19 parents that met criteria for PTSD at 18 to 30 months, you had 8 who were newly developed at 18 to 30 months, as we discussed previously. And of these 8, 63% had met criteria for significant post-traumatic stress symptoms at T2. So in looking at the results where we examined the risk factors for post-traumatic stress disorder, we looked at the parents that met criteria at 3 to 9 months and found that parental concerns of injury during the admission and meeting acute stress disorder at discharge were highly associated with meeting criteria for post-traumatic stress disorder. And then, interestingly, the more knowledgeable a parent was about their child's illness was also significantly associated with parental post-traumatic stress. And then how affected a child was, so the higher their POPC score in terms of how they were functioning was also significant for post-traumatic stress. In looking at our primary outcome for risk factors, which is PTSD at 18 to 30 months, again, acute stress disorder at discharge was highly significant. We have parental concerns not so much about what happened in the ICU, but now an overall concern that their child is now more susceptible to death after discharge being significant as well. You had a history of self or family member admitted to the ICU, which we were interesting to find that this showed up in our multivariable analysis at 18 to 30 months, because as you note, it was not part of the analysis at 3 to 9 months. And then our most interesting outcome, at least from our perspective, was there was a decrease in family income that was measurable and significant between T2 and T3, so 3 to 9 months to 18 to 30 months. So we thought to ourselves, looking at the overall trends, for short-term post-traumatic stress disorder, you had pre-admission factors being mainly highly associated with post-traumatic stress disorder in our parents, and admission factors, such as parental concerns, whereas for long-term post-traumatic stress, we had a lot of post-admission factors. And it kind of begged the question, can we put all of these parents together, or do we need to have multiple time points in which we are evaluating parents and possibly extending the knowledge branch of treatment or mitigation factors? Then we thought to ourselves, and I would like to preface that this data has not been confirmed by other studies, and so this is our group just looking at our data and thinking through strategies, is if you look at admission discharge and post-discharge, are there time points for screening and interventions? And from previous studies, and ours as well, we looked at social determinants of healthcare and mental health status as an intervention time point, if we screen for this at admission, and then at discharge, acute stress disorder being the main one. And post-discharge, whether it be in ICU clinics or in our pediatric clinics, whether screening for post-traumatic stress disorder and offering intervention would be helpful. And next steps for us would be using our data to try and create a prediction model. We recently had publications looking at post-traumatic assessment scales that has been used for adults, and then the evaluation of qualitative themes, which we also collected data for in this study, and overall would be planning and testing interventions on targeted patient populations and increasing feasibility of those interventions. Thank you so much for your attention.

pediatric ICU admissions

parents

post-traumatic stress disorder

PTSD

long-term effects