Behavioral
Changes in Pediatric Intensive Care Units
Stacie McHan Jones, MD; Debra
Henry Fiser, MD; Richard Lee Livingston,
Objective. \p=m-\Thepurposes of this study were to compare the frequency and severity of manifestations of anxiety, depression, delirium, and withdrawal in pediatric patients hospitalized in intensive care unit vs ward settings and to evaluate the impact of preexisting psychopathologic disorders on the expression of these symptoms. Research Design. \p=m-\Prospectivepatient series. \s=b\
Setting.\p=m-\Tertiary care pediatric center. Patients.\p=m-\Forty-three subjects aged 6 to 17 years hospitalized in either the pediatric or cardiovascular intensive care unit (n 18) or on the general wards (n 25) were recruited to participate. Subjects were excluded if their parents were unavailable for diagnostic interview or if they could not answer interview questions themselves. Selection Procedures.\p=m-\Consecutive sample. =
=
Interventions. \p=m-\None. Measurements and Results.\p=m-\The Hospital Observed Behavior Scale, developed for this study, was used to describe objectively subjects' manifestations of anxiety, depression, delirium, and withdrawal. The Diagnostic Interview for
(ICU) syndrome, defined Thetype of organic brain syndrome, has been described of manifestations, intensive
care
unit
as a
includ¬ and delir¬ ing fear, anxiety, depression, hallucinations, ium. These manifestations occur frequently in patients unable to adapt to stressful situations or with premorbid psychopathology.1 Other contributing factors include sensory overload or monotony, sleep deprivation, and
in adult patients, with a variety
medications.1"6 A child's
capacity
to our
Children and Adolescents and Diagnostic Interview for Children and Adolescents-Parents were used to determine the presence of preexisting psychopathologic disorders. As measured by the Hospital Observed Behavior Scale, subjects in the intensive care unit exhibited apprehension, anxiety, detachment, sadness, and weeping more often than did patients in the ward. Behavior was also significantly influenced by severity of illness, duration of hospitalization, number of previous hospitalizations, and presence of a preexisting anxiety or mood disorder. We found the Hospital Observed Behavior Scale to have good interrater reliability. Conclusions.\p=m-\Ourdata indicate that critically ill children in the intensive care unit, children with prolonged or repeated hospitalizations, and children with preexisting anxiety and mood disorders are at greater risk than other hospitalized pediatric patients for psychological trauma and/or behavior problems that may warrant psychiatric intervention. The Hospital Observed Behavior Scale is a reliable tool to quantitate behaviors in hospitalized children.
(AJDC. 1992;146:375-379)
likely to be manifested in hospitalized children when the children have preexisting psychopathology. more
SUBJECTS AND METHODS
Subjects
Subjects were inpatients at Arkansas Children's Hospital, Lit¬ tle Rock, between the ages of 6 and 17 years (n 43). Subjects in the ICU (n 18) were in either the pediatrie ICU or cardiovascu¬ lar ICU, and subjects in wards (n 25) were in private or semiprivate ward rooms. On enlistment to the study, informed con¬ sent was obtained as required by the Human Research Advisory Committees of the hospital and the University of Arkansas for Medical Sciences. Subjects were consecutively selected for study based on the following criteria: ages 6 to 17 years, parent avail¬ ability for interview, and subject ability to communicate. Ex¬ cluded subjects were those whose parents were unavailable for diagnostic interview or those who could not answer interview questions themselves. A small number of subjects were excluded due to parental refusal to consent. Two additional subjects withdrew from the study during the interview. Each subject was examined within 48 hours of admission or within 48 hours of the time that the subject was able to commu¬ nicate verbally (for those subjects who were in neurologically compromised condition or those whose tracheas were intubated on admission). =
=
=
to
cope with
a
catastrophic
event is
limited when there is preexisting psychopathology in the child or parent.7 In the ICU environment, children exhibit withdrawal and passive behavior, anxiety, egocentricity, and negative, demanding behavior subjectively.6,8"10 The behaviors of children in the ICU have not been measured
objectively,
MD
knowledge.
(1) that some hospi¬ talized children demonstrate measurable anxiety, depres¬ sion, delirium, and withdrawal; (2) that children in the ICU exhibit these responses more frequently than children hos¬ pitalized on general wards; and (3) that these responses are We tested the following hypotheses:
Accepted for publication October 21, 1991. From the Departments of Pediatrics (Drs Jones and Fiser), Psychiatry (Drs Fiser and Livingston), and Anesthesiology (Dr Fiser), Arkansas Children's Hospital, and the University of Arkansas for
Medical Sciences, Little Rock. Presented in part at the Southern Society for Pediatric Research, New Orleans, La, January 30, 1987, the Society of Critical Care Medicine, Anaheim, Calif, May 28, 1987, and the American Academy of Child and Adolescent Psychiatry, Seattle, Wash, October 29, 1988.
Reprint requests to Arkansas Children's Hospital, 800 Marshall St, Little Rock, AR 72202-3591.
Data Collection The following data were collected from the medical record of each subject: demographic information, diagnosis, duration of hospital stay and ICU stay, number of previous hospital and ICU admissions, and medications. Duration of parental visitation and sleep were recorded hourly by the patient's nurse on bed¬ side data sheets. The Pediatrie Risk of Mortality Scale (PRISM), developed and validated in a multi-institutional study by Pollack et al,11 is a
Downloaded From: http://archpedi.jamanetwork.com/ by a Monash University Library User on 06/16/2015
Table
of Subjects in the Ward and 1.—Comparison for HOBS Behaviors*
ICU
Behavior Exhibited on Day, No. of Subjects
Worst
Ward (n = 25)
HOBS Item
Apprehensive toward staff, including physician 2. Apprehensive about routine, nonpainful procedures (eg, changing intravenous bag) 3. Startles easily 1.
4. Anxious/worried expression 5. Overreacts 6. Complains or whines 7.
excessively (relative to age and expected distress) Appears preoccupied
8. Inattentive, distractible 9. Detached/standoffish with family and visitors 10. Detached/standoffish with staff 11. Appears to hallucinate 12. Motor agitation when awake (not just fidgeting) 13. Misbehaves, disobeys 14. Mannerisms (ie, tapping,
16 9
10 17 11 9
15 14
11
18 11 9
18.
Tearful, weeping Appears confused
disoriented 19. Statements of
(spontaneous, to
or
anxiety/worry
Ward (n 25)
No. of white
14
17
NSt
No. of
10
9
NSt
ICU =
=
NS
12.2±3.8
NSt
Changes in Pediatric Intensive Care Units
Stacie McHan Jones, MD; Debra
Henry Fiser, MD; Richard Lee Livingston,
Objective. \p=m-\Thepurposes of this study were to compare the frequency and severity of manifestations of anxiety, depression, delirium, and withdrawal in pediatric patients hospitalized in intensive care unit vs ward settings and to evaluate the impact of preexisting psychopathologic disorders on the expression of these symptoms. Research Design. \p=m-\Prospectivepatient series. \s=b\
Setting.\p=m-\Tertiary care pediatric center. Patients.\p=m-\Forty-three subjects aged 6 to 17 years hospitalized in either the pediatric or cardiovascular intensive care unit (n 18) or on the general wards (n 25) were recruited to participate. Subjects were excluded if their parents were unavailable for diagnostic interview or if they could not answer interview questions themselves. Selection Procedures.\p=m-\Consecutive sample. =
=
Interventions. \p=m-\None. Measurements and Results.\p=m-\The Hospital Observed Behavior Scale, developed for this study, was used to describe objectively subjects' manifestations of anxiety, depression, delirium, and withdrawal. The Diagnostic Interview for
(ICU) syndrome, defined Thetype of organic brain syndrome, has been described of manifestations, intensive
care
unit
as a
includ¬ and delir¬ ing fear, anxiety, depression, hallucinations, ium. These manifestations occur frequently in patients unable to adapt to stressful situations or with premorbid psychopathology.1 Other contributing factors include sensory overload or monotony, sleep deprivation, and
in adult patients, with a variety
medications.1"6 A child's
capacity
to our
Children and Adolescents and Diagnostic Interview for Children and Adolescents-Parents were used to determine the presence of preexisting psychopathologic disorders. As measured by the Hospital Observed Behavior Scale, subjects in the intensive care unit exhibited apprehension, anxiety, detachment, sadness, and weeping more often than did patients in the ward. Behavior was also significantly influenced by severity of illness, duration of hospitalization, number of previous hospitalizations, and presence of a preexisting anxiety or mood disorder. We found the Hospital Observed Behavior Scale to have good interrater reliability. Conclusions.\p=m-\Ourdata indicate that critically ill children in the intensive care unit, children with prolonged or repeated hospitalizations, and children with preexisting anxiety and mood disorders are at greater risk than other hospitalized pediatric patients for psychological trauma and/or behavior problems that may warrant psychiatric intervention. The Hospital Observed Behavior Scale is a reliable tool to quantitate behaviors in hospitalized children.
(AJDC. 1992;146:375-379)
likely to be manifested in hospitalized children when the children have preexisting psychopathology. more
SUBJECTS AND METHODS
Subjects
Subjects were inpatients at Arkansas Children's Hospital, Lit¬ tle Rock, between the ages of 6 and 17 years (n 43). Subjects in the ICU (n 18) were in either the pediatrie ICU or cardiovascu¬ lar ICU, and subjects in wards (n 25) were in private or semiprivate ward rooms. On enlistment to the study, informed con¬ sent was obtained as required by the Human Research Advisory Committees of the hospital and the University of Arkansas for Medical Sciences. Subjects were consecutively selected for study based on the following criteria: ages 6 to 17 years, parent avail¬ ability for interview, and subject ability to communicate. Ex¬ cluded subjects were those whose parents were unavailable for diagnostic interview or those who could not answer interview questions themselves. A small number of subjects were excluded due to parental refusal to consent. Two additional subjects withdrew from the study during the interview. Each subject was examined within 48 hours of admission or within 48 hours of the time that the subject was able to commu¬ nicate verbally (for those subjects who were in neurologically compromised condition or those whose tracheas were intubated on admission). =
=
=
to
cope with
a
catastrophic
event is
limited when there is preexisting psychopathology in the child or parent.7 In the ICU environment, children exhibit withdrawal and passive behavior, anxiety, egocentricity, and negative, demanding behavior subjectively.6,8"10 The behaviors of children in the ICU have not been measured
objectively,
MD
knowledge.
(1) that some hospi¬ talized children demonstrate measurable anxiety, depres¬ sion, delirium, and withdrawal; (2) that children in the ICU exhibit these responses more frequently than children hos¬ pitalized on general wards; and (3) that these responses are We tested the following hypotheses:
Accepted for publication October 21, 1991. From the Departments of Pediatrics (Drs Jones and Fiser), Psychiatry (Drs Fiser and Livingston), and Anesthesiology (Dr Fiser), Arkansas Children's Hospital, and the University of Arkansas for
Medical Sciences, Little Rock. Presented in part at the Southern Society for Pediatric Research, New Orleans, La, January 30, 1987, the Society of Critical Care Medicine, Anaheim, Calif, May 28, 1987, and the American Academy of Child and Adolescent Psychiatry, Seattle, Wash, October 29, 1988.
Reprint requests to Arkansas Children's Hospital, 800 Marshall St, Little Rock, AR 72202-3591.
Data Collection The following data were collected from the medical record of each subject: demographic information, diagnosis, duration of hospital stay and ICU stay, number of previous hospital and ICU admissions, and medications. Duration of parental visitation and sleep were recorded hourly by the patient's nurse on bed¬ side data sheets. The Pediatrie Risk of Mortality Scale (PRISM), developed and validated in a multi-institutional study by Pollack et al,11 is a
Downloaded From: http://archpedi.jamanetwork.com/ by a Monash University Library User on 06/16/2015
Table
of Subjects in the Ward and 1.—Comparison for HOBS Behaviors*
ICU
Behavior Exhibited on Day, No. of Subjects
Worst
Ward (n = 25)
HOBS Item
Apprehensive toward staff, including physician 2. Apprehensive about routine, nonpainful procedures (eg, changing intravenous bag) 3. Startles easily 1.
4. Anxious/worried expression 5. Overreacts 6. Complains or whines 7.
excessively (relative to age and expected distress) Appears preoccupied
8. Inattentive, distractible 9. Detached/standoffish with family and visitors 10. Detached/standoffish with staff 11. Appears to hallucinate 12. Motor agitation when awake (not just fidgeting) 13. Misbehaves, disobeys 14. Mannerisms (ie, tapping,
16 9
10 17 11 9
15 14
11
18 11 9
18.
Tearful, weeping Appears confused
disoriented 19. Statements of
(spontaneous, to
or
anxiety/worry
Ward (n 25)
No. of white
14
17
NSt
No. of
10
9
NSt
ICU =
=
NS
12.2±3.8
NSt
