Rebecca S. Bernard

The Relationship Between Acute Stress Disorder and Posttraumatic Stress Disorder in the Neonatal Intensive Care Unit

BACKGROUND Having an infant hospitalized in the neonatal intensive care unit (NICU) is a highly stressful event for parents. Researchers have proposed posttraumatic stress disorder (PTSD) as a model to explain the psychological reaction of parents to their NICU experience. OBJECTIVE The authors sought to examine the prevalence of PTSD in parents 4 months after the birth of their premature or sick infants and the relationship of PTSD and symptoms of acute stress disorder (ASD) immediately after their infants birth. METHOD Eighteen parents completed a self-report measure of ASD at baseline in addition to self-report measures of PTSD and depression at a 4-month follow-up assessment. RESULTS In the sample, 33% of fathers and 9% of mothers met criteria for PTSD. ASD symptoms were significantly correlated with both PTSD and depression. Fathers showed a more delayed onset in their PTSD symptoms, but, by 4 months, were at even greater risk than mothers. DISCUSSION The relatively high levels of psychological distress experienced by parents coupled with the potential negative outcomes on the parent and infant suggest that it is important to try to prepare parents for the expected psychological reactions that may occur in the event of a NICU hospitalization and also to support parents during the transition to home care.

Brief cognitive–behavioral intervention for maternal depression and trauma in the neonatal intensive care unit: A pilot study†

Parents of hospitalized premature infants are at risk for developing psychological symptoms. This randomized controlled pilot study examined the effectiveness of a brief cognitive-behavioral intervention in reducing traumatic and depressive symptoms in mothers 1 month after their infants discharge from the hospital. Fifty-six mothers were randomly assigned to the intervention or control group. Results showed that mothers experienced high levels of symptoms initially and at follow-up. At follow-up, there was a trend for mothers in the intervention group to report lower levels of depression (p = .06; Cohens f = .318), but levels of traumatic symptoms were similar for both groups. Brief psychological interventions may reduce depressive symptoms in this population. Estimates of the effect sizes can be used to inform future intervention studies.

A Token Economy for Exercise Adherence in Pediatric Cystic Fibrosis: A Single-Subject Analysis

OBJECTIVE In cystic fibrosis (CF), adherence to airway clearance techniques (e.g., chest physiotherapy and exercise) is poor. Exercise is important because pulmonary difficulties are associated with the highest mortality rate. Despite this, very little research has focused on exercise adherence in CF. This study examined a token economy for increasing exercise in children with CF. METHODS An ABAB single-subject design evaluated a token economy for increasing and maintaining exercise in three children with CF. Patient report, parent report, and physiological measures were used to assess treatment integrity, medical stability, and changes in exercise. RESULTS Measures suggested that treatment integrity was strong. Results indicated strong treatment effects for all participants without negative medical side effects. Follow-up of 1 and 3 months supported continued exercise for all participants. CONCLUSIONS A token economy effectively increased exercise in children with CF, and the single-subject design highlighted some of the intricacies of individualized treatment of adherence. Implications and recommendations for further research are discussed.

Parent Anxiety and Infant Pain During Pediatric Immunizations

Infants’ procedural pain and parents’ treatment room anxiety has been largely ignored in the research and clinical domains. To understand and manage infant procedural pain, it is essential to examine the correlates and potential predictors of this pain. Given that parent anxiety is a strong predictor of preschoolers’ procedural anxiety and pain, it is likely that parents play a role in infants’ distress during medical procedures. The purpose of this study was to thoroughly examine parent anxiety and its effects on infant procedural pain for 37 parent-infant dyads. Results demonstrated that only parent self-report measures were intercorrelated and several measures of parent distress correlated with measures of infant distress. Treatment implications and recommendations for future research are discussed.

Topical Anesthesia Versus Distraction for Infants' Immunization Distress: Evaluation With 6-Month Follow-Up

Topical anesthetic and distraction are effective pain management techniques, yet they have not been fully evaluated for infants. Eighty-four 1-year-olds undergoing immunizations were randomized to distraction, topical anesthetic, or control. The 42 infants who returned for their 18-month injections were evaluated for long-term treatment gains. An observational scale revealed that infants demonstrated lower distress with distraction than topical anesthetic or control during the recovery phase of the injection at 12 months, and parents and nurses rated infants as more distressed at 12 than 18 months. Distress measures were positively associated across time.

Comparison of Short-Term Psychological Outcomes of Respiratory Failure Treated by Either Invasive or Non-Invasive Ventilation

Background There is now widespread recognition of the development of symptoms of posttraumatic stress disorder (PTSD) in individuals subjected to treatment in the hospital intensive care unit (ICU). Objective The authors sought to investigate traumatic aspects of the ICU hospitalization experience. Method A group of 20 adult pulmonary patients requiring ventilation in the ICU were compared with 20 patients treated without ventilation. Subjects completed a semistructured interview about their hospital experience and were given self-report measures to assess PTSD and coping style. Results Subjects requiring invasive ventilation were significantly more likely to endorse symptoms of PTSD. There was a strong correlation between symptoms of PTSD and recall of memories of traumatic medical events. Symptoms of PTSD were positively associated with habitual experiences of distress and negatively associated with the use of denial of distress. Conclusion Specific traumatic aspects of a patients treatment, in this case the experience of intubation and mechanical ventilation, may be an additive risk factor for the development of PTSD.

Inter-rater reliability of the Pediatric Transplant Rating Instrument (P-TRI): Challenges to reliably identifying adherence risk factors during pediatric pre-transplant evaluations

Fisher M, Storfer‐Isser A, Shaw RJ, Bernard RS, Drury S, Ularntinon S, Horwitz SM. Inter‐rater reliability of the Pediatric Transplant Rating Instrument (P‐TRI): Challenges to reliably identifying adherence risk factors during pediatric pre‐transplant evaluations.
Pediatr Transplantation 2011: 15:142–147.

Traumatic Stress Reactions in Parents in Pediatric Intensive Care: A Review

Recent advances in pediatric therapeutic technology have led to a significant increase in the number of children receiving treatment in pediatric intensive care units (PICU). Similarly, preterm births, which now represent 12-13% of all live births in the United States and which have increased by 31% since 1981, have resulted in increased numbers of hospitalizations in neonatal intensive care units (NICU). While sophisticated use of technology has been a major factor in improving survival rates in the pediatric population, the admission of a child to an intensive care unit is often a stressful event in the lives of their parents. Recently, researchers have identified post traumatic stress disorder (PTSD) as a model to describe and explain the psychological reaction of parents to their PICU and NICU experiences. This model is useful in helping interpret parental reactions and in informing potential preventative and treatment interventions. The current review presents a comprehensive overview of parental traumatic stress reactions and intervention studies in the ICU setting.