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    Dog bites in children: Focus on posttraumatic stress disorder

    Learn how to recognize the signs of posttraumatic stress disorder in wounded children and when to refer them for psychotherapy.

    The memories of the pain a child suffers from a vicious dog bite will eventually fade. The fear and emotional damage, however, could last a lifetime. Learn how to recognize the signs of posttraumatic stress disorder in wounded children and when to refer them for psychotherapy.

    I have vivid memories of the family of a 9-year-old son of an emergency department (ED) physician whom I saw more than a decade ago. The parents made an appointment for their son on the advice of their attorney to determine whether residual psychological symptoms persisted from a dog bite he had sustained 1 year earlier.

    Mark (not the boy's name) was playing at the neighbor's house. Two children were in the kitchen when the neighbor heard screams and crying. She rushed in to find Mark with blood flowing over the side of his face and head. She placed a towel over the bleeding, which appeared to be the result of a dog bite. A quick call found the boy's father at home. He immediately arrived, tenderly carried his son to his car, and drove to the ED where Mark's wounds were repaired without incident.

    During their only visit to my office, I met with the parents and the child together. Mark made an initial and lasting impression as a fine boy. At my invitation, he sat in a chair near me while his parents sat a bit farther back, yet easily within his view. I began by asking Mark to tell me about the dog bite. After only a few sentences he became tense and tearful. He told a clear story as he struggled through his tears and gasps to complete it.

    A child's perspective

    For an adult to appreciate the experience of a child bitten by a dog, especially if it is at the shoulders or higher, imagine being attacked by an angry, opened-mouthed, growling bear near your face. Your immediate shock and emotional overload would be similar to that of a dog-bitten child. There is, however, one striking, important difference.

    On hearing their son tell his story with such strong emotion, the parents' faces reflected surprise and sadness. They had no idea that he had silently carried such a heavy emotional burden during the year since the attack.

    Here is the important difference of this kind of trauma to a child versus an adult. The adult victim of a bear attack might speak of the bear attack easily and often. Sensitive and intelligent children, however, quickly notice that any time the dog bite attack comes up, no matter the source, their parents' faces express guilt and sadness. Consequently, these children stay silent about the trauma and work to bury their feelings. That combination can lead to posttraumatic stress disorder (PTSD) after a dog bite, as it may with any overwhelming trauma.

    Symptoms of PTSD in dog-bitten children

    I used the remainder of our appointment to promote a discussion between the boy and his parents to begin to resolve their emotions. I suggested that they be alert to any indications of PTSD symptoms, including changes in typical daily functioning.

    Research over the past decade about the psychological sequelae of a dog bite confirms that PTSD occurs in a high percentage of young children attacked by dogs.1-4 Signs and symptoms of PTSD include excessive anxiety, irritability, decreased school performance, sleep disturbance, reduced creativity, withdrawal, altered appetite, depression, physical complaints, pronounced startle responses, and behavior problems.5 Any one of these can impede the expected social, academic, and emotional growth of a child.

    These symptoms can occur any time and may exacerbate with seeing or being near a dog to the point of total avoidance or excessive fear.

    Dog-bite statistics and fatalities

    Even after decades of education about dog-bite prevention, more than 4 million dog bites are reported annually in the United States.6 That is 1,000 dog bites per day, most of them involving children.7

    In 2010, the ED at Rady Children's Hospital in San Diego cared for 225 dog-bitten children (conversation with Kay Thompson, RN, BSN, CPEN-KA). That is a rate of 4 per week.

    Nationally, annual child fatalities from dog attacks from 2007 to 2010 ranged from 28 to 33.8 California leads with 7 in 2010. These wounds receive appropriate debridement and repair, but complete care should not end there because clinicians also could reduce the emotional loads of these young victims.

    Traumatic stress prevention strategies


    SAMPLE EMERGENCY DEPARTMENT HANDOUT
    By the time the wound is closed and dressed, parents usually have developed a strong bond to the physician. Physical closeness heightens their attachment while their anxiety subsides. Typically, the family will remember anything the physician recommends for a long time. This presents an excellent opportunity to begin modulation of any PTSD that may be developing.

    A handout should be provided to instruct the family on how to discuss everyone's feelings about the dog attack.9 It should include a list of local mental health professionals and clinics available to assist the family should professional assistance be desired (see, "Sample Emergency Department Handout"). A list of helpful Web sites could include: AACAP.org; www.doggonesafe.com/dog_bite_victim_support; and www.helpguide.org/mental/post_traumatic_stress_disorder_symptoms_treatment.htm.

    The ED staff will communicate with the child's primary care physician to ensure appropriate follow-up for the physical wound.9-13 The staff also should inform the physician about the possibility of the child's developing PTSD. The parents can be encouraged to give their child's physician a copy of the same information handout they received in the ED, because it contains suggestions for assisting the parents and physician in identifying and reducing PTSD symptoms if present.

    Current evidence-based effective treatment for PTSD in children recommends early diagnosis followed by trauma-focused cognitive behavioral therapy. A study of preschool children demonstrated predictive validity for the alternative method of diagnosing PTSD.14 The unremitting course of PTSD symptomatology in preschool children and rates of impairment that are higher than rates of diagnosis indicate the need for efficacious treatment.

    The Journal of the American Academy of Child and Adolescent Psychiatry practice parameter for the assessment and treatment of children and adolescents with PTSD recommends trauma-focused psychotherapies be considered first-line treatments.15 Among its recommendations is that, among psychotherapies, there is convincing evidence that trauma-focused therapies are superior to nonspecific or nondirective therapies in resolving PTSD symptoms. The importance of directly addressing the child's traumatic experiences in therapy makes sense because avoidance of talking about trauma-related topics would be an expected occurrence.

    PTSD in other traumatic bites and stings

    This examination of PTSD after a child suffers a dog bite may raise interest in other bites commonly sustained by children. These include stings and bites by bees, wasps, spiders, snakes, and scorpions.

    Consideration of a few points will support the position that PTSD follows such accidents to a significantly lesser degree than occurs with dog bites. In comparison, dog bite wounds typically are larger, bloodier, and easily visible to all observers compared with insect stings and snakebites. Dog bites typically come from a known, usually-assumed-to-be-friendly and larger animal.

    Additionally, the literature, with the possible exceptions of the small minority of cases that lead to serious complications, mentions nothing about any emotional aftermath from insect stings and snakebites. This is not to ignore the rarer PTSD that may follow some stings and bites; however, dog bites in children much more commonly lead to PTSD.

    What the ED should do in cases of dog bites in children

    An ED can follow these steps to reduce or prevent the development of PTSD in dog-bitten children:

    1. Immediate and consistent staff recognition of the potential for PTSD.

    2. Specific support of the physician closing and dressing the wounds with parents to discuss the event in an age-appropriate way.

    3. Provide a handout to parents to read and carry to their primary physician. This will include urging them and the patient to discuss their feelings about the attack on a regular basis. The handout may include a list of mental health clinics, professionals, and online contacts for additional support.

    The recognition and care for the potential of emerging PTSD symptoms after dog bites should be a priority in the ED and the offices of primary care physicians.

    The author acknowledges significant editing assistance from Elizabeth P. Schmitt, LCSW; William W. Baak, MD; and Martin T. Stein, MD.

    DR SCHMITT is a child and adolescent psychiatrist, Department of Psychiatry and Department of Family and Preventive Medicine, University of California, San Diego, School of Medicine. The author has nothing to disclose regarding affiliation with, or financial interests in, any organization that may have an interest in any part of this article.

    REFERENCES

    1. American Psychological Association. Children and trauma: update for mental health professionals. www.apa.org/pi/families/resources/children-trauma-update.aspx. Accessed June 30, 2011.

    2. Ji L, Xiaowei Z, Chuanlin W, Wei L. Investigation of posttraumatic stress disorder in children after animal-induced injury in China. Pediatrics. 2010;126(2):e320-e324.

    3. Schalamon J, Ainoedhofer H, Singer G, et al. Analysis of dog bites in children who are younger than 17 years. Pediatrics. 2006;117(3):e374-e379.

    4. Scheeringa MS, Wright MJ, Hunt JP, Zeanah CH. Factors affecting the diagnosis and prediction of PTSD symptomatology in children and adolescents. Am J Psychiatry. 2006;163(4):644-651.

    5. Blank M. Posttraumatic stress disorder in infants, toddlers, and preschoolers. BCMJ. 2007;49(3):133-138.

    6. Nonfatal dog bite-related injuries treated in hospital emergency departments—United States, 2001. DogsBite.org Web site. www.dogsbite.org/bite-study-nonfatal-emergency-2001.htm. Accessed July 5, 2011.

    7. Dog bite statistics. DogsBite.org Web site. www.dogsbite.org/bite-statistics.htm. Accessed July 5, 2011.

    8. Dog bite fatalities. DogsBite.org Web site. www.dogsbite.org/bite-statistics-fatalities.htm. Accessed July 5, 2011.

    9. Berkowitz SJ, Stover CS, Marans SR. The Child and Family Traumatic Stress Intervention: secondary prevention for youth at risk of developing PTSD. J Child Psychol Psychiatry. 2011;52(6):676-685.

    10. Ziegler MF. Mental health consequences of trauma: the unseen scars. Clin Pediatr Emerg Med. 2010;11(1):57-64.

    11. Spates CR, Samaraweera N, Plaisier B, Souza T, Otsui K. Psychological impact of trauma on developing children and youth. Prim Care. 2007;34(2):387-405.

    12. Hon KL, Fu CC, Chor CM, et al. Issues associated with dog bite injuries in children and adolescents assessed at the emergency department. Pediatr Emerg Care. 2007;23(7):445-449.

    13. Kenardy JA, Spence SH, Macleod AC. Screening for posttraumatic stress disorder in children after accidental injury. Pediatrics. 2006;118(3):1002-1009.

    14. Scheeringa MS, Zeanah CH, Myers L, Putnam FW. Predictive validity in a prospective follow-up of PTSD in preschool children. J Am Acad Child Adolesc Psychiatry. 2005;44(9):899-906.

    15. Cohen JA, Bukstein O, Walter H, et al; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. J Am Acad Child Adolesc Psychiatry. 2010;49(4):414-430.

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