When Is Our Job Done? Evaluation of Long-Term Psychological Outcomes in Pediatric Critical Care.

Pediatric Critical Care Medicine www.pccmjournal. org 1099 Survivors of pediatric critical care leave the PICU when their care can safely be handed to the pediatric ward, to a rehabilitation hospital, or to the child’s family. But is their PICU experience really done, or does the legacy of that ICU stay remain with them as they grow and develop? In this issue of Pediatric Critical Care Medicine, report by Kyösti et al (1) of an observational cohort adds to our understanding of the residual consequences of PICU stay. This report describes the long-term follow-up of Finnish infants and children admitted for intensive care during 2009–2010. Parents of younger patients and older patients themselves were asked to complete the Strengths and Difficulties Psychological Questionnaire (SDQ). Limited data on post-ICU care needs and persistent illnesses were also collected. The principal findings are that 7.2% and 7.6% of children had borderline or abnormal psychological health scores, respectively, at a mean of 6.3 years post-ICU stay. These percentages reflect a prevalence of dysfunction that is typical of the reference population (British children); however, the multivariable regression analysis points to a possible vulnerable population—that is, those with chronic illness or/ and need for ongoing therapy. These results add to findings of an earlier cohort study of Canadian children from two PICUs followed at 6 weeks and 6 months (2). In that study of postPICU behavior and psychological measures (impact of events, self-control, and medical fears), survivors demonstrated fears about medical situations, a sense of loss of control, and ongoing posttraumatic stress disorder (PTSD) at 6 months postdischarge (2). Although the results of the report may not be entirely surprising—that psychological dysfunction may endure for some and that those, perhaps, most at risk may have the greatest burden of long-term clinical disease—this report affirms the suspicions of many clinicians about lives that may be affected well beyond PICU stays. Consensus is forming around such understanding. In a 2010 Society of Critical Care Medicine Stakeholders’ Conference the term “Post-Intensive Care Syndrome “(PICS) was coined (3). For adult survivors, issues of 1) mental health including PTSD, depression, and anxiety; 2) cognitive impairment; and 3) physical impairment were seen as important domains of dysfunction. Research gaps and areas for focused efforts centered on: 1) identifying the mechanisms of PICS morbidities, 2) exploring the PICS epidemiology, and 3) focused research on specific subgroups—three of which were children and patients with preexisting or post-ICU chronic illnesses (3). Similar comments have been made about PICS in pediatric patients (4). Several cohort studies demonstrate that 17% to 62% of PICU survivors had PTSD at a few months to up to 1-year post-discharge (2, 5–11), whereas other studies found recall for some events and procedures of PICU stay (12, 13). Current efforts to describe this field for the pediatric critical care community include work on a scoping review of the literature by a group of Pediatric Acute Lung Injury and Sepsis Investigators (personal experience). As the authors and others (8) point out, assessment of a child’s psychological well-being should incorporate the child’s own sense of internal well-being. A multifaceted assessment of psychological functioning is possible for school-aged children where validated measures exist for parent, teacher, and self-report (the last as performed in the study by Kyösti et al [1]). However for infants and younger children, evaluation of psychological health is solely accessible in parent reports. The use of parent reports introduces the confounder of parental/ family functioning into the assessment. There is increased understanding that family dysfunction may, itself, be an outcome of PICU stay (7, 14). Furthermore, family functioning postPICU may confound that outcome via an effect on the way the family fills out the questionnaire or even as to whether they fill it out at all. In the study by Kyösti et al (1), young age, along with the other factors already mentioned, was associated with abnormal SDQ scores. Assessment of the younger subjects was limited, by necessity, to parent report—parents whose own resiliency for the situation may be adversely affected by the stress of the child’s continuing dysfunction. This is supported by the finding that the impact supplement domain (reported by parents for children of all ages) had the highest percentage of abnormal scores (1). It is reasonable to temper conclusions about associations between young age and later psychological dysfunctions with the knowledge that the reporters may face stress of their own. Furthermore, direct assessment of family *See also p. e496.