Pediatric traffic injuries:
Financial support by the Stichting Achmea Slachtoffer en Samenleving is gratefully acknowledged.
Publication of this thesis was also supported by the Dutch Trauma Association/Nederlandse Vereniging voor Traumatologie.
Cover by W.M. Sturms
Printed by Stichting Drukkerij C. Regenboog, Groningen, The Netherlands
Sturms, Leontien M.
Pediatric traffic injuries: consequences for the child and the parents.
Thesis University of Groningen, the Netherlands - With ref. - With summary in Dutch.
ISBN-nummer: 9077113118
Copyright 2003: L.M. Sturms, Groningen, the Netherlands. All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without the prior written premission of the copyright owner.
RIJKSUNIVERSITEIT GRONINGEN
Pediatric traffic injuries:
consequences for the child and the parents
Proefschrift
ter verkrijging van het doctoraat in de Medische Wetenschappen aan de Rijksuniversiteit Groningen
op gezag van de
Rector Magnificus, dr.F. Zwarts, in het openbaar te verdedigen op
woensdag 16 april 2003 om 16.00 uur
door
Leontien Marianne Sturms
geboren op 5 maart 1974 te Nairobi, Kenia
Promotores: Prof. drs. W.H. Eisma Prof. dr. H.J. ten Duis Prof. dr. J.W. Groothoff
Co-promotor: Dr. C.K. van der Sluis
Beoordelingscommissie: Prof. dr. A.J.H. Prevo Prof. dr. D. Post Prof. dr. O.F. Brouwer
Paranimfen: Fabiënne Schasfoort Matthijs Sturms
List of abbreviations
AIS Abbreviated injury scale AN(C)OVA Analysis of (co)variance BC Bonferroni correction CHQ Child health questionnaire
CF Child form
CI Confidence interval FSII Functional status II
HRQoL Health-related quality of life KvL Kwaliteit van leven
ICC Intra-class correlation coefficient ICD International classification of diseases IES Impact of event scale
ISS Injury severity score
MAIS Maximum AIS
MCID Minimal clinically important difference MV Motor vehicle
N Number
OR Odds ratio
PF Parent form
PTSD Post-traumatic stress disorder
RLOG Registratie letsels en ongevallen Groningen SD Standard deviation
SES Socioeconomic status SVL Schokverwerkingslijst
TACQOL TNO-AZL children’s quality of life questionnaire
TAPQOL TNO-AZL preschool children’s quality of life questionnaire TBI Traumatic brain injury
Contents
Introduction 1
Chapter 1 Characteristics of injured children attending the emergency department: patients potentially in need of rehabilitation
Clinical Rehabilitation 2002;16:46-54
17
Chapter 2 The health-related quality of life of pediatric traffic victims and the impact on the parents and families: a prospective study
Submitted
33
Chapter 3 A prospective study on pediatric traffic injuries: health-related quality of life and post-traumatic stress
Submitted
51
Chapter 4 The health-related quality of life of pediatric traffic victims
The Journal of Trauma 2002;52:88-94
69
Chapter 5 Young traffic victims’ long-term health-related quality of life: child self-reports and parental reports
Archives of Physical Medicine and Rehabilitation, in press
85
Chapter 6 Bicycle-spoke injuries among children: accident details and consequences
Nederlands Tijdschrift voor Geneeskunde. 2002; 146 (36): 1691-1696.
101
Discussion 113
Summary 129
Samenvatting 137 Northern Centre for Healthcare research and previous dissertations 145
Dankwoord 153
1
Introduction
Introduction
3
Introduction
Injuries are among the leading causes of death and disability in the world and constitute a world-wide health problem.1,2 Injuries affect mostly young people.2,3 In the Netherlands, the highest number of injuries requiring medical treatment per year per 1000 persons has been evaluated for children and young adults.3 Severe and fatal injuries are particularly associated with traffic accidents.2,3 This thesis focuses on children injured in traffic accidents.
The impact of traffic accidents on children has long been illustrated by mortality statistics. Mortality reflects the seriousness of the incident and fatalities are often well documented. In high-income countries, road traffic injuries are the leading cause of death in children aged 5-14 years, and in adolescents and adults aged 15-44 years.2 However, a far larger group of children survive their injuries. According to recent estimates in the Netherlands, almost 150,000 traffic victims aged 0-24 years receive medical treatment annually.3 To characterize the impact of traffic incidents in children more accurately, the outcomes of non-fatally injured children also needs to be addressed. The consequences of the injuries suffered by these children and their parents, siblings and extended family members are not yet fully known. A better understanding of the nonfatal outcomes is essential in order to provide the appropriate care and information for the patients and their families. Furthermore, insight into these outcomes is also important for policy makers who may need to compare traffic injuries with other health problems in order to choose priorities.
This thesis aims to extend the limited knowledge concerning the nonfatal outcomes of pediatric traffic injuries. This introductory chapter begins with a review of the literature in order to provide insight into current understanding of the nonfatal outcomes of childhood injuries, including traffic injuries. Furthermore, the problems and current limitations of our knowledge that still have to be addressed by further studies are highlighted and the objectives and outline are presented.
Pediatric injuries: functional outcomes
The majority of studies regarding the functional outcomes of pediatric injuries have focused on hospitalized and severely injured children. A scoring system often used to indicate the severity of multiple injuries is the Injury Severity Score (ISS).4 The ISS values range from 0 to 75 with higher scores reflecting more severe injuries. Table 1 shows the results of studies on the functional outcomes of samples of children with moderate to severe injuries at different follow-up assessments. A number of these studies determine the
4
child’s functional status with the physical health scales from the Rand Health Insurance Study. These scales measure physical activities, role activities, mobility and self-care activities. At discharge, 68-98% of the injured children were found to experience one or more functional limitations in these scales.5-7 Six months and one year following the injury, these percentages were 48-79% and 45-67% respectively.5-8 According to Hu et al., recovery rates for functional status were similar at the six-month and one year follow-ups.7 At one year post-injury, the most limiting factors for the children were in their physical and role activities.7,8 The longer-term impact of childhood injuries on the child’s functional status has been illustrated by Valadka et al.9 This study indicated that even after an average of 4 years following the injury (range, 1-7 years), 47% of injured children suffered functional status restrictions as measured by the Rand scales. This study argues that limitations existing one year after discharge tend to be long-term and possibly permanent.
In addition to the Rand health status scales, other measures, including the Functional Independence Measure and the disability scale developed by Gofin et al.,13 have been applied in pediatric outcome studies. The latter scale for children aged 4-17 years consists of 25 items derived from the International Classification of Impairments, Disabilities and Handicaps (ICIDH). Immediately after injury, the presence of at least one disability on this scale was high (58%).12 Six months post-injury about one in three children still presented at least one disability. Furthermore, after six months a proportion of the children had limitations, particularly in the area of leisure time activities (14%), sport activities (19%) and to a lesser degree in daily activities (8%) and school activities (8%).12
The Functional Independence Measure (FIM) is a widely applied instrument in adult outcome studies. The FIM has been used by Van der Sluis et al.10 in order to examine the long-term functional outcomes of severely injured children. In general, these children had good long-term outcomes (7-11 years follow-up). Those patients who did not have maximum FIM scores particularly failed to record maximum scores for the social cognition and communication domains. Additionally, the FIM has been used to assess the functional outcome of 13,649 injured children who did not have significant head injuries.11 At the time of hospital discharge, 26% of the children had some disability. Most of the affected children were limited in their motor functions, including basic activities of daily living such as bathing, dressing or walking.
6
In contrast to the findings presented by Van der Sluis et al.,10 few children demonstrated limitations in communication and social/cognitive categories of functioning. However, the submaximum scores for the ‘cognitive’ domains in the study by Van der Sluis et al.10 were most likely attributable to the effects of severe brain injuries that had not been included in the study by Aitken et al.11 Further analyses of the results of Aitken et al.11 showed that children with lower extremity fractures in particular were likely to be discharged with functional limitations. The relationship between lower extremity fractures and a high risk of functional limitations has been affirmed in a later study in which hospitalized children with lower extremity fractures were shown to experience more functional limitations compared with hospitalized children with upper extremity fractures at one month and six months post-injury.14
The functional outcome studies described above were predominantly restricted to hospitalized children with moderate to severe injuries. The functional limitations experienced by nonhospitalized children with, in general, minor injuries, has received far less attention.15,16 The study carried out by Rivara et al. is one of the few studies that has examined the functional outcome of injured children not requiring hospitalization.15 In this study, using the Rand physical health status scales, 55% of the children were reported to have limitations in their usual activities within the first week after injury. At the end of one week, and one month post-injury, respectively, 17% and 4% of the children were not yet back to all normal activities. After four months nearly all patients had returned to normal activities.
Pediatric injuries: psychosocial outcomes
In addition to functional limitations, childhood injuries can also result in impaired psychosocial functioning. Children have been shown to display changes in behavior, emotions, and cognitive functioning. Although all injured children may be at risk of these sequelae, head injuries have been particularly associated with psychobehavioral symptoms. This is illustrated by the study by Stancin et al.,17 in which 70% of the group of children hospitalized for traumatic fractures and moderate to severe traumatic brain injuries showed affective/behavioral symptoms approximately one month following injury. Within the group of children who had only incurred fractures, 28% displayed these symptoms, including moodiness, anger and depressed mood.
Long-term psychobehavioral effects among children with multiple injuries, with or without minor head injury, have been investigated by Basson et al.18 The parents reported a range of psychobehavioral changes. Behavioral
Introduction
7 changes included hyperactivity, substantial scholastic difficulties and rage
attacks. The emotional changes included depression, social withdrawal and phobias. The Child Behavioral Checklist that was used to identify abnormal behavior after the trauma episode, revealed that substantial psychobehavioral changes were found in 28% and 35% of children with and without head injuries, respectively. These percentages did not differ significantly. This may be surprising with respect to the expected association between a head injury and behavioral problems. Basson et al.,18 however, only included minor head injuries. Almost all the injured children had developed the symptoms within one month of the injury. Two thirds of parents reported that their children had returned to ‘normal’ after displaying symptoms for an average of 19 months (range, 3 months-6 years).
Wesson et al.6 also investigated the psychological effects of pediatric injuries. The children were divided into two groups: those who had sustained minor trauma (ISS<16) and those who had sustained major trauma (ISS≥16). A comparison was made of the pre-injury and post-injury behavioral disturbances. The proportion of children who had pre-injury behavioral disturbances was 14%; however, an increased proportion of the major trauma group displayed behavioral problems at six months and one year following discharge (41%). This was not the case for the minor trauma group, in which 38% of the children had pre-injury behavioral disturbances and a comparable proportion of 39% of the children showed behavioral problems at six months and one year post-injury. In general, behavioral problems tended to be more common among the children with persistent physical limitations as measured by the Rand physical health status scales.
In addition to the behavioral and emotional changes described above, injured children may also suffer cognitive problems. Harris et al.19 indicated that half of their sample of severely injured children were described by their parents as having deficits in attention, memory or learning. Traumatic brain injuries play an important role in impaired cognitive functioning. In the study by Stancin et al.,17 70% of the children with accompanying moderate to severe head injuries displayed cognitive problems one month after injury. These problems were almost absent in the group of children hospitalized for fractures only. Furthermore, six months after injury, Gofin et al.12 indicated that the children who suffered severe head injuries presented higher percentages of limitations in school activities than other children hospitalized for injuries. Lower academic performance has also been reported for children with head injuries compared with children without head injuries.6 As a result of diminished cognitive abilities, mainly due to severe brain injuries, children
8
may need to move to a school offering a lower standard of education, including special education.10,19
Post-traumatic stress reactions
It is noticeable that an increasing number of studies have focused on the injury-related psychological stress reactions in children following injury. Injuries may involve the threat of serious injury or death and evoke feelings of intense fear, helplessness or horror.20 Consequently, injuries can be traumatic experiences resulting in post-traumatic stress symptoms and even in the diagnosis of post-traumatic stress disorder (PTSD). For the diagnosis of PTSD, a number of criteria need to be met including the presentation of symptoms indicating that the traumatic event is regularly re-experienced, trauma-related stimuli are avoided, and that the individual has experienced a measurable increase in arousal.21
Approximately one month following the injury, 13-23% of children hospitalized for injuries were found to be suffering from the criteria mentioned above and were diagnosed as having PTSD.20,22 Higher percentages of injured children suffer a number of post-traumatic stress symptoms but fail to meet all the criteria for the diagnosis of PTSD. At six months and one year post-injury, children have also been found to experience post-traumatic stress symptoms.23,24
Children injured in traffic accidents have been found to have a relatively high risk of developing PTSD compared with children who sustained injuries due to falls, sport or leisure activities.25-27 The reported prevalence rates of PTSD in children injured in traffic accidents ranges from 34-45% at 4-7 weeks post-injury, to 14-25% at 6-12 months post-injury.26,28-30
Pediatric injuries: family outcomes
Studies have been carried out to assess the consequences of pediatric injuries on the family, particularly the impact of severe pediatric injuries. These studies have shown that pediatric trauma can have a profound effect on the family. For example, Hu et al.31 revealed that six months and one year following severe pediatric injury, 45% and 23% of the parents, respectively, found that their family life had not yet returned to normal.
Following childhood injuries, parents have reported injury-related financial and work problems, as well as a worsening in their martial relationship, alterations in the relationship with their child and changes in the composition of the family unit.12,19,32 Furthermore, parents have found that
Introduction
9 they experience psychological distress of clinical significance due to the
child’s injury,6,14 especially with pediatric traumatic brain injury.17,33
The effect of the injured child on other siblings has rarely been addressed. In a study by Basson et al.,18 none of the siblings of injured children demonstrated significant psychological changes; however, other studies have reported adverse outcomes, including significant levels of psychological distress, school problems or aggressive personality changes.19,34
Issues requiring attention
The studies described above have illustrated the extensive impact of pediatric injuries on the child and the family. Despite this knowledge, several issues regarding the outcomes of pediatric injuries need to be studied or require further clarification. A number of these issues constitute the background of this thesis and are described below.
Health-related quality of life
The implications of childhood injuries on quality of life, remarkably, had not yet been considered when we started our study. Quality of life is increasingly recognized as an outcome of interest in monitoring the outcome of medical care and intervention.35,36 The current emphasis on quality of life largely reflects the view that traditional outcome measures used in medicine, especially survival or reduction of symptoms, are limited and do not capture the total impact of illness or treatment of a patient.37
Quality of life theoretically incorporates all aspects of an individual’s life.38 In general, the concepts covered by various quality of life definitions include a combination of non-health-related elements, such as family, friends, life circumstances and health-related factors.39 In medicine, the emphasis is often concentrated on the health-related aspects of quality of life. To differentiate health from more general social and environmental issues, the more specific concept of health-related quality of life (HRQoL) has been defined.37 HRQoL refers to the impact of dysfunction associated with an illness or injury, medical treatment and health care policy.40 The terms ‘quality of life’ and ‘HRQoL’ provide independent information and should not be used synonymously.41
Although there is not yet a uniform definition of HRQoL, it is generally acknowledged that HRQoL is a multidimensional construct. The idea that HRQoL encompasses several domains is largely based on the definition of health as described by the World Health Organization42 as ‘a state of complete physical, mental and social well being and not merely the absence
10
of disease or infirmity’. In the literature, the identified dimensions in the definition of health have been expanded to four ‘core’ HRQoL domains: physical symptoms, functional status, psychological functioning and social functioning.40 In addition to the multidimensionality of the HRQoL concept, there is consensus that HRQoL is a reflection of the way that patients perceive their health status. Differences in appraisal of the health status account for the fact that individuals with the same objective health status can report very different subjective HRQoL.43
The measurement of HRQoL should ideally be derived from the individual’s perspective as HRQoL concerns the patients’ values. In pediatric HRQoL assessments, parents, doctors and teachers have usually been used as informants, mainly due to the uncertainty regarding the child’s ability to rate his or her HRQoL, or because of practical reasons. However, it is increasingly suggested that children themselves can provide reliable information concerning their HRQoL.44
The measurement of HRQoL would appear to be of critical interest in the area of pediatric injuries. Some pediatric injuries can be managed but not cured, as is the case in chronic diseases. The literature has shown that childhood injuries are likely to result in temporary or permanent physical and/or psychosocial restrictions. The degree to which these children suffer a reduced HRQoL, i.e. perceive these limitations as disturbing, is unknown. Knowledge of the HRQoL of these children, and especially which domains of HRQoL are affected, provides complementary information for medical professionals.
Outcomes of nonhospitalized injuries
Although the vast majority of injuries receiving medical care are minor in severity, the emphasis of the outcome studies has been on hospitalized and severely injured children. It is possible to argue that the more severe injuries will logically result in more disabilities. However, before excluding patients with minor injuries for research goals, this idea needs to be proven by studies that systematically assess and compare the outcomes of minor and nonhospitalized injuries with severe and hospitalized injuries.
Parental outcomes
It is increasingly recognized that the parents and families of injured children also experience a range of consequences, including work and financial problems, problematic family functioning, and parental psychological distress. The psychological wellbeing of the parents is of importance for the
Introduction
11 child’s recovery and wellbeing. Parents who are preoccupied with their own
problems or feelings may not adequately support their child, or are unable to identify problems for which medical care should be sought. The knowledge of the parental psychological impact following pediatric trauma needs to be extended as the current understanding stems only from a small number of studies that have focused on hospitalized, severely injured children or children suffering from head injuries. Moreover, recent suggestions that the parents of pediatric traffic victims also carry a risk of developing post-traumatic stress symptoms29,45-47 need further investigation and confirmation.
Risk groups
Another concern that needs further attention is the question of which children and families carry the highest risk of adverse outcomes. To our knowledge, there is little systematic evidence or consensus about the relationship between injury-related, accident-related and sociodemographic variables and child outcomes. Head injuries and lower extremity fractures may comprise an exception. Studies have consistently reported that children with particularly severe head injuries have a higher risk of psychobehavioral and cognitive symptoms, and lower extremity fractures have systematically shown that they are associated with functional limitations. Far less consensus exists regarding the predictive value of trauma scales, such as the ISS. According to a number of studies, the ISS and the Modified Injury Severity Score (MISS) are significantly related to the functional limitations experienced by injured children at the time of discharge from hospital,11 at six months post-injury,5,12 one year after the incident,14 and at an average of four years post-injury.9 In contrast, Hu et al.7 and Wesson et al.6 failed to find a correlation between the ISS and functional status at comparable follow-up assessments. Behavioral problems have, and have not, been associated with the ISS.6,14,18 Clearly, more studies are required to further investigate the relationship between injury severity indicators and child outcomes. Furthermore, sociodemographic factors, including the child’s age, gender and the family’s socioeconomic status, need to be considered also. This applies also to parental and family outcomes. Knowledge regarding the predictors of adverse outcomes is essential for the identification of children, parents and families at highest risk of residual effects.
12
Objectives
The purpose of this thesis is to address the aforementioned unresolved issues regarding the outcomes of childhood injuries, and specifically pediatric traffic injuries. For this thesis the following three main objectives are defined:
- To examine the short-term and long-term HRQoL of pediatric traffic victims as reported by the children themselves and their parents. This aim applies not only to severely injured patients but also to young traffic victims with minor injuries.
- To explore the degree to which children and their parents experience post-traumatic stress reactions after pediatric traffic injuries.
- To investigate which sociodemographic, injury or accident-related factors are associated with adverse child and parent outcomes.
Outline
Epidemiology
For the interpretation of the outcomes of pediatric traffic injuries, insight into the magnitude and severity of pediatric injuries in general, and specifically pediatric traffic injuries, is important. Chapter 1, therefore provides an epidemiological overview of the characteristics of a cohort of injured children who attended the Department of Traumatology at University Hospital Groningen, The Netherlands. This overview drew our attention to a group of young children who needed treatment for bicycle-spoke injuries. We found it remarkable that even though these injuries are preventable they are still frequently seen. Chapter 6 presents a study of the accident details of bicycle-spoke injuries and the effects of these injuries on the physical and psychosocial functioning of children.
Short-term outcomes: HRQoL, parent/family impact, post-traumatic stress Chapter 2 presents the findings of a prospective study on the short-term
HRQoL of pediatric traffic victims and the impact of the incident on the parents and family. In this study the parents of pediatric traffic victims were asked to participate in three assessments. The first measurement took place shortly after the child’s injury to assess pre-injury data. Post-injury data was gathered during two follow-up assessments, at three months and six months after the incident.
Chapter 3 addresses the young traffic victims’ own point of view of their
short-term HRQoL at the time of the same three assessments. Furthermore, this chapter explores the degree of post-traumatic stress symptoms
Introduction
13 experienced by the children and their parents. Finally, Chapters 2 and 3 both
include analyses to identify subgroups of children and parents/families at high risk of suffering short-term adverse effects.
Long-term outcomes: HRQoL
Chapter 4 evaluates the HRQoL of young traffic victims 1.5-3.4 years
post-injury. For this purpose, the parental reports of the young traffic victims’ HRQoL were compared with the HRQoL reported by parents of contemporaries in the general Dutch population. To identify those traffic victims at high risk of a reduced long-term HRQoL, the relationship between the children’s HRQoL and injury, accident and sociodemographic characteristics was also investigated.
In Chapter 5, the long-term HRQoL reported by the young traffic victims themselves is presented, and the degree of concordance between child and parent reports on the child’s long-term HRQoL is investigated.
In the final chapter, the main findings of the studies presented in this thesis are discussed, general conclusions are presented and recommendations for future research are suggested.
References
1. Meyer AA. Death and disability from injury: a global challenge. J Trauma 1998;44:1-12.
2. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000;90:523-6.
3. Hertog den PC, Geurts JJM, Hendriks HMH, Hutten JM, van Kampen LTB, Schmikli SL, et al. Ongevallen in Nederland 1997/1998. Amsterdam: Stichting Consument en Veiligheid; 2000.
4. Baker SP, O'Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187-96.
5. Wesson DE, Williams JI, Spence LJ, Filler RM, Armstrong PF, Pearl RH. Functional outcome in pediatric trauma. J Trauma 1989;29:589-92.
6. Wesson DE, Scorpio RJ, Spence LJ, Kenney BD, Chipman ML, Netley CT, et al. The physical, psychological and socioeconomic costs of pediatric trauma. J Trauma 1992;33:252-5.
7. Hu X, Wesson DE, Logsetty S, Spence LJ. Functional limitations and recovery in children with severe trauma: a one-year follow-up. J Trauma 1994;37:209-13.
8. Greenspan AI, MacKenzie EJ. Functional outcome after pediatric head injury. Pediatrics 1994;94:425-32.
9. Valadka S, Poenaru D, Dueck A. Long-term disability after trauma in children. J Pediatr Surg 2000;35:684-7.
14
10. Van der Sluis CK, Kingma J, Eisma WH, ten Duis HJ. Pediatric polytrauma: short-term and long-short-term outcomes. J Trauma 1997;43:501-6.
11. Aitken ME, Jaffe KM, DiScala C, Rivara FP. Functional outcome in children with multiple trauma without significant head injury. Arch Phys Med Rehabil 1999;80:889-95.
12. Gofin R, Adler B, Hass T. Incidence and impact of childhood and adolescent injuries: a population-based study. J Trauma 1999;47:15-21.
13. Gofin R, Hass T, Adler B. The development of disability scales for childhood and adolescent injuries. J Clin Epidemiol 1995;48:977-84.
14. Stancin T, Kaugars AS, Thompson GH, Taylor HG, Yeates KO, Wade SL, et al. Child and family functioning 6 and 12 months after a serious pediatric fracture. J Trauma 2001;51:69-76.
15. Rivara FP, Thompson RS, Thompson DC, Calonge N. Injuries to children and adolescents: impact on physical health. Pediatrics 1991;88:783-8.
16. Alexander BH, Rivara FP, Thompson D, Thompson RS. Measurement of severity for nonhospitalized injuries in the pediatric age group. Pediatr Emerg Care 1992;8:148-51.
17. Stancin T, Taylor HG, Thompson GH, Wade S, Drotar D, Yeates KO. Acute psychosocial impact of pediatric orthopedic trauma with and without accompanying brain injuries. J Trauma 1998;45:1031-8.
18. Basson MD, Guinn JE, McElligott J, Vitale R, Brown W, Fielding LP. Behavioral disturbances in children after trauma. J Trauma 1991;31:1363-8.
19. Harris BH, Schwaitzberg SD, Seman TM, Herrmann C. The hidden morbidity of pediatric trauma. J Pediatr Surg 1989;24:103-5.
20. Aaron J, Zaglul H, Emery RE. Post-traumatic stress in children following acute physical injury. J Pediatr Psychol 1999;24:335-43.
21. American Psychiatric Association. Diagnostic and statistical manual of mental disorders- fourth edition (DSM-IV). Washington, DC: APA; 1994.
22. Daviss WB, Mooney D, Racusin R, Ford JD, Fleischer A, McHugo GJ. Predicting post-traumatic stress after hospitalization for pediatric injury. J Am Acad Child Adolesc Psychiatry 2000;39:576-83.
23. Rusch MD, Grunert BK, Sanger JR, Dzwierzynski WW, Matloub HS. Psychological adjustment in children after traumatic disfiguring injuries: a 12-month follow-up. Plast Reconstr Surg 2000;106:1451-8.
24. Levi RB, Drotar D, Yeates KO, Taylor HG. Post-traumatic stress symptoms in children following orthopedic or traumatic brain injury. J Clin Child Psychol 1999;28:232-43.
25. Canterbury J, Yule W. The effects on children of road accidents. In: Mitchell M, editor. The aftermath of road accidents. London: Routledge; 1997. p 59-69.
26. Stallard P, Velleman R, Baldwin S. Prospective study of post-traumatic stress disorder in children involved in road traffic accidents. BMJ 1998;317:1619-23.
27. Gill AC. Risk factors for pediatric post-traumatic stress disorder after traumatic injury. Arch Psychiatr Nurs 2002;16:168-75.
28. Mirza KA, Bhadrinath BR, Goodyer IM, Gilmour C. Post-traumatic stress disorder in children and adolescents following road traffic accidents. Br J Psychiatry 1998;172:443-7.
Introduction
15
29. De Vries AP, Kassam AN, Cnaan A, Sherman SE, Gallagher PR, Winston FK. Looking beyond the physical injury: post-traumatic stress disorder in children and parents after pediatric traffic injury. Pediatrics 1999;104:1293-9.
30. Keppel-Benson JM, Ollendick TH, Benson MJ. Post-traumatic stress in children following motor vehicle accidents. J Child Psychol Psychiatry 2002;43:203-12. 31. Hu X, Wesson DE, Kenney BD, Chipman ML, Spence LJ. Risk factors for extended
disruption of family function after severe injury to a child. CMAJ 1993;149:421-7. 32. Osberg JS, Kahn P, Rowe K, Brooke MM. Pediatric trauma: impact on work and
family finances. Pediatrics 1996;98:890-7.
33. Wade SL, Taylor HG, Drotar D, Stancin T, Yeates KO. Family burden and adaptation during the initial year after traumatic brain injury in children. Pediatrics 1998;102:110-6.
34. Orsillo SM, McCaffrey RJ, Fisher JM. Siblings of head-injured individuals: A population at risk. J Head Trauma Rehabil 1993;8:102-15.
35. Quality of life and clinical trials. Lancet 1995;346:1-2.
36. Leplege A, Hunt S. The problem of quality of life in medicine. JAMA 1997;278:47-50.
37. Eiser C, Mohay H, Morse R. The measurement of quality of life in young children. Child Care Health Dev 2000;26:401-14.
38. Bowling A. Health-related quality of life: a discussion of the concept, its use and measurement. In: Bowling A, editor. Measuring disease. Buckingham: Open University Press; 1995. p 1-19.
39. Loonen HJ, Derkx BH, Otley AR. Measuring health-related quality of life of pediatric patients. J Pediatr Gastroenterol Nutr 2001;32:523-6.
40. Spieth LE, Harris CV. Assessment of health-related quality of life in children and adolescents: an integrative review. J Pediatr Psychol 1996;21:175-93.
41. Feldman BM, Grundland B, McCullough L, Wright V. Distinction of quality of life, health related quality of life and health status in children referred for rheumatologic care. J Rheumatol 2000;27:226-33.
42. World Health Organization. Constitution of the World Health Organization. Geneva, 1948.
43. Eiser C, Morse R. A review of measures of quality of life for children with chronic illness. Arch Dis Child 2001;84:205-11.
44. Feeny D, Jupiner EF, Ferrie PJ, Griffith LE, Guyatt GH. Why not just ask the kids? Health-related quality of life in children with asthma. In: Drotar D, editor. Measuring health-related quality of life in children and adolescents. Mahway, New Jersey: Lawrence Erlbaum Associates; 1998. p 171-86.
45. Landolt MA, Boehler U, Schwager C, Schallberger U, Nuessli R. Post-traumatic stress disorder in paediatric patients and their parents: an exploratory study. J Paediatr Child Health 1998;34:539-43.
46. McDermott BM, Cvitanovich A. Post-traumatic stress disorder and emotional problems in children following motor vehicle accidents: an extended case series. Aust N Z J Psychiatry 2000;34:446-52.
47. Winston FK, Kassam-Adams N, Vivarelli-O'Neill C, Ford J, Newman E, Baxt C, et al. Acute stress disorder symptoms in children and their parents after pediatric traffic injury. Pediatrics 2002;109:e90
