Psychosocial and Neurocognitive Outcomes of Children in and Beyond the Pediatric Intensive Care Unit

Abstract

Children who survive critical illness often experience psychosocial and cognitive sequelae that persist long after hospital discharge. Across three complementary studies, this dissertation examines neurocognitive and psychosocial processes that occur on a continuum before and after pediatric critical illness. Study 1 examines pediatric intensive care unit (PICU) delirium and its relationship to cognitive dysfunction during and beyond PICU admission. The literature shows a high incidence of delirium in the pediatric intensive care unit (PICU). Children have high rates of cognitive dysfunction following PICU admission. Delirium has been linked to declines in academic performance. The primary objective of this investigation was to examine the incidence of delirium in children admitted to the PICU and the relationship between delirium and long-term cognitive dysfunction. A prospective observational design was employed at an urban, academic children’s hospital. Participants were children aged 5-17 with an expected PICU stay exceeding 24 hours. Delirium screening was conducted daily during PICU admission. Children’s cognitive functioning was assessed using the Children’s Memory Scale (CMS) during hospitalization and at three-month follow-up. Parents completed the Behavior Rating Inventory of Executive Function (BRIEF-2) to evaluate pre-hospital and post-discharge executive functioning. A total of 146 children were enrolled. A subset of 103 completed in-hospital and/or three-month CMS (mean age = 11.0 years). Approximately one-third of children exhibited cognitive dysfunction at three-months. During admission, 37.3% of children screened positive for delirium, but results demonstrated no relation between delirium burden and cognitive dysfunction at either time point. However, children exhibited sustained deficits from hospitalization to follow-up. This investigation is a novel evaluation of the influence of pediatric delirium on later cognitive function. Children admitted to the PICU demonstrated high rates of cognitive dysfunction during hospitalization and at three-month follow-up. While in-hospital cognitive dysfunction was associated with later cognitive dysfunction, delirium burden was not associated with cognitive dysfunction at either time point. Study 2 investigates the relationship between posttraumatic stress symptoms (PTS) and cognitive function from pre-hospitalization through post-discharge, examining how pre-existing trauma and in-hospital cognitive dysfunction relate to later PTS in PICU survivors. To conduct exploratory analyses of pre-existing posttraumatic stress (PTS), in-hospital cognitive function, and later PTS and cognitive function at post-hospitalization follow-up in pediatric critical care survivors. This study employed a prospective, observational design in a pediatric ICU (PICU) and general care inpatient floor at an urban, academic, children’s hospital. Children aged eight to 17 years-old without developmental delay, severe psychiatric disorder, or traumatic brain injury were included. Children’s prehospitalization trauma history was assessed with the University of California Los Angeles-Reaction Index (UCLA-RI). PTS was present if children had four of the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for posttraumatic stress disorder. Chi-squared tests compared presence or absence of pre-hospitalization PTS and in-hospital cognitive function, along with PTS and cognitive function at follow-up. Over half of children reported that, prior to their PICU hospitalization, they had been exposed to trauma. Children also had high rates of PTS related to their PICU stay when assessed three-months following their PICU admission. There was a significant association between the presence of pre-hospitalization PTS and the presence of in-hospital learning/encoding deficits, χ²(1, N = 41) = 4.985, p = .026. There were no significant relations between PTS and number of cognitive deficits at either time point. However, given the limited power of the current study, findings should be interpreted with caution. These data highlight the need for increased awareness amongst mental health providers of the high incidence of PTS in children following PICU admission, and integration of proactive screening and deployment of resources for children with trauma exposure prior to hospitalization. Study 3 examined posttraumatic growth among children following PICU admission and evaluated associations with PTS and family functioning. Data from two prospective cohort studies at a large, urban children’s hospital were combined using integrative analyses. The sample had N = 121 children (ages 8-17) assessed three-months following PICU admission. PTG was measured with the Posttraumatic Growth Inventory for Children-Revised (PTGI-C-R); PTS with the UCLA PTSD Reaction Index (UCLA-RI); and family functioning (cohesion and flexibility) with the Family Adaptability and Cohesion Evaluation Scales-IV (FACES-IV). Demographic and medical covariates were collected. Group comparisons and hierarchical linear regression evaluated predictors of PTG. Children with PTS had higher PTG scores than those without PTS (t(116) = −3.61, p < .001, d = −0.67). In multivariable models, PTS remained the only significant predictor of PTG (B = 5.11, SE = 1.42, β = .33, p < .001; R² = .107). Parent education showed an inverse univariate association with PTG; family cohesion (lower) correlated with higher PTG univariately, but family cohesion/flexibility were not significant in adjusted models. Following PICU admission, children commonly report PTG, which co-occurs with distress. Findings underscore the importance of recovery approaches that both mitigate PTS and promote PTG, and they motivate research on cultural/family contexts and longitudinal trajectories beyond three months. Collectively, findings advance a multidimensional model of post–intensive care outcomes in children, emphasizing that cognitive and psychosocial functioning are interdependent domains of recovery. This work highlights the need for integrative screening and follow-up care in pediatric critical care that focus on long-term neuropsychological and emotional health beyond mere survival of life-threatening illness.