The Journal of TRAUMA௡ Injury, Infection, and Critical Care High Rates of Acute Stress Disorder Impact Quality-of-Life Outcomes in Injured Adolescents: Mechanism and Gender Predict Acute Stress Disorder Risk Troy L. Holbrook, PhD, David B. Hoyt, MD, FACS, Raul Coimbra, MD, FACS, Bruce Potenza, MD, FACS, Michael Sise, MD, FACS, and John P. Anderson, PhD -p < 0.01; 6-month, ASD ,0.710 ؍ Background: Injury is the leading were enrolled in the study. The admis- score -vs. ASD 0.704 ؍ cause of death and functional disability sion criteria for patients were as follows: positive QWB score ;p < 0.001 ,0.742 ؍ in adolescent children. Little is known (1) age 12 to 19 years and (2) injury negative QWB score ؍ about quality of life and psychological diagnoses excluding severe traumatic 12-month: ASD-positive QWB score ؍ outcomes after trauma in adolescents. brain injury (TBI) or spinal cord injury. 0.718 vs. ASD-negative QWB score The Trauma Recovery Project in Ado- QoL after trauma was measured using 0.757, p < 0.01; 24-month, ASD-positive vs. ASD-negative 0.725 ؍ lescents is a prospective epidemiologic the Quality of Well-being (QWB) scale, QWB score p < 0.01. Female sex ,0.769 ؍ study designed to examine multiple out- a sensitive and well-validated functional QWB score op- and violent mechanism predicted ASD ؍ death to 1.000 ؍ comes after major trauma in adolescents index (range, 0 aged 12 to 19 years, including quality of timum functioning). ASD (before dis- risk (47% female vs. 36% male; odds ra- life (QoL) and psychological sequelae charge) was diagnosed with the Impact tio, 1.6; p < 0.05; violence 54% vs. 38%; .(such as acute stress disorder (ASD) and of Events Scale-Revised. Scores of 24؉ odds ratio, 1.9; p < 0.01 posttraumatic stress disorder (PTSD). were used to diagnose ASD. Patient out- Conclusions: Adolescent trauma The specific objectives of the present re- comes were assessed at discharge and at survivors have high rates of ASD. ASD port are to examine ASD rates and the 3, 6, 12, 18, and 24 months after dis- severely impacts QoL outcomes and is as- association of ASD with QoL outcomes charge. sociated with female sex and mechanism in injured adolescents. Results: ASD before discharge was of injury in adolescents. Early recognition Methods: Between April 26, 1999, diagnosed in 40% of adolescent trauma and treatment of ASD in seriously injured and November 13, 2002, 401 eligible survivors. ASD status was associated with adolescents will improve QoL outcomes. trauma patients aged 12 to 19 years tri- large QoL deficits during follow-up, as Key Words: Acute stress disorder, aged to five participating trauma center follows: 3-month, ASD-positive QWB Adolescents, Quality-of-life outcomes, .vs. ASD-negative QWB Posttraumatic stress disorder 0.667 ؍ hospitals in a regionalized trauma system score J Trauma. 2005;59:1126–1130. njury is not only the leading cause of death but notably the ability, return to work and usual activities, and psychological leading cause of preventable morbidity in individuals 19 sequelae such as posttraumatic stress disorder (PTSD).2–12 Iyears of age and younger.1 The establishment of mature Recently, the importance of PTSD as an outcome in trauma systems in the United States has led to an evolution in seriously injured trauma survivors has been demonstrated in trauma outcomes research, with studies directed toward several reports by our research team and by Michaels et al. short- and long-term quality of life (QoL) after injury, dis- and others.13–23 These studies have provided new and pro- vocative evidence that PTSD is both common and extremely detrimental in adult trauma patients. Little is known about Submitted for publication August 23, 2004. Accepted for publication January 13, 2005. psychological outcomes after serious injury in adolescents. In Copyright © 2005 by Lippincott Williams & Wilkins, Inc. adolescent children, the diagnostic symptomatology of acute From the Department of Family and Preventive Medicine (T.T.H., stress disorder (ASD), an early precursor of PTSD, and J.P.A.) and Division of Trauma, Department of Surgery (D.B.H., R.C., B.P.), PTSD, is similar to adults. The disorder is characterized by University of California, San Diego, and Mercy Hospital Trauma Center (M.S.), San Diego, California. recurrent flashbacks, reexperiencing of the traumatic event, 24 Supported by Agency for Health Research and Quality grant R01 HS hyperarousal, and avoidance. However, the severity of dis- 07611. ease, onset timing, duration, and response to treatment have Presented at the 34th Annual Meeting of the Western Trauma Association been postulated to be different than in adults.25 The Trauma Annual Meeting, February 22–28, 2004, Steamboat Springs, Colorado. Address for reprints: Troy L. Holbrook, PhD, University of California, Recovery Project in Adolescents (TRP-A) is a prospective San Diego Medical Center, 8896, 200 West Arbor Drive, San Diego, CA epidemiologic study designed to examine multiple outcomes 92103-8896; email: [email protected]. after major trauma in adolescents aged 12 to 19 years, in- DOI: 10.1097/01.ta.0000196433.61423.f2 cluding quality of life (QoL) and psychological sequelae such 1126 November 2005 Acute Stress Disorder in Injured Adolescents as depression, ASD, and PTSD. The specific objectives of the ranges from 0 for death to 1.0 for asymptomatic full func- present report are to examine ASD rates and the association tioning. The QWB scale includes a symptom scale and three of ASD with QoL outcomes in injured adolescents. A sec- scales of function: mobility, physical activity, and social ondary objective was to investigate the association of injury activity. Each symptom and step on these scales has its own event-related factors such as perceived threat to life and associated preference weight. The overall QWB score is mechanism of injury with ASD onset. based on a preference-weighted average of functioning in the previous 6 days with respect to symptoms and the three PATIENTS AND METHODS function scales. Individual subscale and symptom scores are Source of Study Population not routinely reported because of both the preference weigh- Between April 26, 1999, and November 13, 2002, 401 ing and the greater utility and generalizability of a summary eligible trauma patients triaged to five participating trauma score. Typically, the QWB score is reported as a decimal with center hospitals in the San Diego Regionalized Trauma Sys- three significant digits. Normal healthy adolescent children tem were enrolled in the TRP-A study. The admission criteria usually score in the range of 0.900 to 0.950, with 1.000 for patients were as follows: (1) age 12 to 19 years and (2) representing asymptomatic full function. The mean QWB injury diagnoses excluding severe traumatic brain injury or score in a population sample of healthy children in San Diego spinal cord injury. Enrollment criteria also included a current County was 0.910. address in California, Arizona, Utah, or Oregon; correspond- The validity of the measure is well established, and both ing telephone number(s) for follow-up contact; and English the sensitivity and predictive value independent of the mea- or Spanish as the primary language spoken. sure have been estimated to be at above 0.90.30,31 Earlier Patient outcomes were assessed at discharge and at 3, 6, reports from the adult Trauma Recovery Project have docu- 12, 18, and 24 months after discharge by a trained inter- mented the high sensitivity of the index to the well end of the viewer. Institutional review board approval for the study was functioning continuum.7,8 Thus, differences as small as 1% to granted by all participating hospitals, and informed consent 2% are clinically significant. for the discharge and follow-up interviews was obtained from each enrolled patient. The questionnaire is designed to collect Statistical Analysis information on sociodemographic and injury-event character- QoL as measured by the QWB scale was considered as istics and includes several standardized survey instruments the primary outcome variable. For the functional outcome designed to measure functional status before and after injury. analysis, the Student’s t test was used to examine the differ- Follow-up interviews are complete through the 12-month ence in QWB score by ASD status at each follow-up time follow-up time point. Follow-up rates for each follow-up time point. Comparisons by ASD status were made using ␹2 anal- point are as follows: 3-month, 96%; 6-month, 90%; 12- ysis and the association of ASD with injury-event related month, 90%; 18-month, 90%; and 24-month, 88%. factors and mechanism were quantified using the odds ratio.32 Ͻ Injury Event-Related Questions Statistical significance was attributed to p 0.05. As part of the primary discharge interview, injury event- related questions were asked of each study participant. Per- RESULTS ceived threat to life was assessed with the following question: The mean age of TRP-A adolescents was 15.0 Ϯ 2.3 “Did you feel during this event that your life was in danger?” years, and 62% (n ϭ 246) were male patients. In Table 1, the Respondents answered either yes or no to this dichotomous distribution of mechanism of injury in the TRP-A cohort is question. shown. The most common mechanism was motor vehicle crash (22%), followed by recreational (16% [all-terrain vehi- Acute Stress Disorder cle, skateboard, team sport]), bike (13%), intentional injuries Each patient was assessed at discharge for early symp- (13% [assaults, gunshot wounds, stab wounds]), falls (12%), toms of ASD using the Impact of Events Scale-Revised, a and pedestrian struck (10%), a distribution similar to that validated scale developed to assess psychological morbidity observed among all adolescent patients admitted to trauma related to ASD onset.24 A score of greater than 24 on the centers in San Diego County.