Injured Children Show Marked Increase in Mental Health Diagnoses

By Hillary Eames
Friday, January 18, 2019

Children who are hospitalized for injuries may subsequently be more likely to be diagnosed with mental health issues, recent research suggests.

Authors of A study in The Journal of Pediatrics found that children treated for serious injuries were 63 percent more likely to be diagnosed with a mental health condition after their injury. They were also 155 percent more likely to be prescribed medication to treat mental illness.

Researchers observed more than 2,200 children who had been hospitalized for unintentional injuries at Nationwide Children’s Hospital in Columbus, Ohio, from June 2005 to May 2015. The children, who were 18 years of age or younger, were enrolled in the facility’s managed-Medicaid program, allowing them to receive a baseline mental health evaluation.

Mental health diagnosis rates varied considerably by injury type. Children who experienced head injuries were up to five times as likely to have a mental health diagnosis one year after their injury, according to the study. Children age 4 or younger who suffered burns were eight times as likely to be diagnosed with a mental health condition post-injury.

Increases in diagnoses were especially noteworthy for stress-related conditions, such as learning, eating, sleep and adjustment disorders.

Mounting Evidence

The findings reinforce earlier research that suggests pediatric injuries have a connection to mental health conditions.

A similar study in the Canadian Medical Association Journal found that major physical trauma was associated with a 40 percent higher rate of hospitalization for mental health diagnoses. The study also found that children under age 18 who suffered a major injury had the largest increased risk of hospitalization for mental health diagnoses. The researchers concluded that mental health services should be part of the traumatic-injury recovery process for injured children.

Another study, published in PM&R, the journal of the American Academy of Physical Medicine and Rehabilitation, found adolescents who suffered a traumatic brain injury were three times as likely to receive mental health services as their uninjured peers.

“We expect children to show a certain amount of stress and discomfort as a result of spending time in the hospital for an injury ...,” Julie Leonard, MD, MPH, Associate Professor of Pediatrics at Nationwide Children’s and Ohio State University College of Medicine, Associate Director of the Center for Pediatric Trauma Research at Nationwide Children’s, and Principal Investigator in the Center for Injury Research and Policy, says in a news release about the most recent study. “[I]t’s clear that there are often serious mental health concerns after children go home. We, as healthcare providers, need to do a better job assessing children for mental health needs, identifying high-risk children and referring them to mental health providers before sending them home.”

Correlation vs. Causation

Experts caution that the findings do not necessarily demonstrate that injuries cause mental health issues in children.

“There is not a direct correlation between an injury and an emotional response, except in cases of trauma-related injuries such as abuse, assault and neglect,” says David Adams, PhD, ABPP, FAACP, Director of Atlanta Medical Psychology. “Children, like adults, are variable in their response to physical and emotional demands. Some weather this period with appreciable optimism and strength. Others become dependent, feel helpless in a healthcare environment and lack the resources to cope without psychological intervention.”

Questions about Causation

There are some limitations regarding interpretation of the findings of the National Children’s Hospital study linking childhood injuries and mental health issues.

For example, children observed in the study may have had pre-existing mental health conditions that were diagnosed only after extended time spent with healthcare providers, Julie Leonard, MD, MPH, Associate Professor of Pediatrics at Nationwide Children’s and Ohio State University College of Medicine, Associate Director of the Center for Pediatric Trauma Research at Nationwide Children’s, and Principal Investigator in the Center for Injury Research and Policy, explains in a HealthDay article about the study.

Moreover, an injury could simply have exacerbated existing mental health issues, Reshma Naidoo, PhD, PSA Director of Cognitive Neuroscience at Nicklaus Children’s Hospital in Miami, pediatric neuropsychologist and neurorehabilitation specialist, tells MD News. And regardless of age or mental health, Naidoo says, an injury causes some level of stress, and providers may have difficulty differentiating between a pre-existing condition and a predictable response to physical trauma.

“You probably would be looking at diagnostic criteria, severity and the length of the problem,” Naidoo says. “The expected amount of stress, I would say, is difficult to know ... [but] the stress is situational. Mental health [issues] tend to be of longer duration and tend to be pervasive and debilitating across environments. Stress tends to be situation-limited and time-limited, unless the stressor is chronic.”

Naidoo suggests mental health screenings should be part of an injured child’s course of treatment. As a follow-up, children who seem to have a mental health condition should receive behavioral therapy, as should their parents or caretakers.

“It’s a very effective way to provide tools and mechanisms to the child and the family to decrease stressors before they become insurmountable,” Naidoo says. “It becomes something in the parents’ toolkit that they can forever draw on, teaching parents how to handle anxiety [in a way] that’s ... more functional.”