Risk factors for the development of medical stress syndrome following surgical intervention Amichai Ben-Ari a, b, ⁎, Fortu Benarroch b , Yaron Sela c , Daniella Margalit a a Department of Behavioral Sciences, Ariel University, Israel b Herman Dana Division of Child and Adolescent Psychiatry, Hadassah-Hebrew University Medical Center, Jerusalem, Israel c School of Psychological Sciences, Tel Aviv University abstract article info Article history: Received 17 August 2019 Received in revised form 9 November 2019 Accepted 19 November 2019 Available online xxxx Key words: PTSD PTSS pediatric surgery Screening Risk factors Background: Pediatric surgical procedures involve traumatic stress that may cause psychological distress, leading to decreased adherence to continued surgical follow-up and delayed physical recovery. Risk factors for pediatric medical trauma, however, have not been studied enough. We aim to define the risk factors detectable during hos- pitalization in pediatric surgery and characterize children at risk of developing PTSD, in order to focus preventive interventions on these children. Methods: The participants in this prospective study were parents of 235 children aged 1–13 years hospitalized in a pediatric surgical ward, who form a representative sample of patients of this age in the ward. They completed questionnaires measuring symptoms of psychological distress, 3–5 months after discharge. Results: Higher parental stress, parental concerns regarding family social support, and parental concerns regard- ing sibling problems had a significant positive correlation with the children’s emotional distress measured 3–5 months after hospitalization. Among children aged 1–5 years, emergency (as opposed to elective) operation and a higher number of invasive procedures were also positively correlated with the children’s PTSS. Conclusions: There is a need to develop measurements for identifying children at high risk for developing post- traumatic stress following surgical intervention; guidelines for developing such a screening instrument are outlined. Type of study: Prognosis study (level of evidence – 1). © 2019 Published by Elsevier Inc. 1. Introduction Children in medical care who undergo surgical interventions may experience fear, uncertainty, helplessness, and sometimes even a sense of threat to life [1]. Studies in the field show that illnesses, hospi- talization and medical interventions are significant stressors for chil- dren that may lead to the development of symptoms of posttraumatic stress disorder (PTSD), such as hyper-arousal, re-experiencing the event, and avoidance patterns. These symptoms can lead to significant changes, such as impairment in social and scholastic functioning, diffi- culties in self-regulation and in sleep, mood disturbances and develop- mental problems [2–6]. Most studies examining the development of posttraumatic symp- toms following medical intervention among children focused on the population of cancer and diabetic patients [7, 8] and on children hospi- talized in intensive care units [5, 9, 10]. Few studies concentrated on the development of posttraumatic symptoms in children who underwent surgical interventions. In a study of children aged 1–6 who were hospitalized for various surgical interventions, 28.6% of the parents re- ported that their children suffered from distress that impaired their functioning and caused them difficulties in adaptation, and 10.39% of the children were diagnosed with PTSD [2]. In another study of children aged 6–13 who were similarly hospitalized for various surgical inter- ventions, 26.4% had partial PTSD and 10.2% had PTSD [11]. However, many of the children who developed posttraumatic stress symptoms (PTSS) after surgery have not been diagnosed and are inadequately treated due to lack of awareness among medical staff of the psycholog- ical implications of a medical event on children [9, 12]. Identifying risk factors is of great importance because it can enable the early identification of children at risk of developing medical trauma and allow their referral to preventive intervention. Indeed, early pre- ventive interventions have been shown to be effective in children at risk of developing PTSD [13–17]. In the absence of early detection, de- veloping PTSS will cause not only emotional distress and dysfunction but also decreased adherence to continued surgical follow-up and de- layed physical recovery after surgery [18]. At the public level, moreover, the development of PTSD among children following a medical event leads to increased expenses for public health institutions. Early detec- tion can enable the effective concentration of resources of the public health system, focusing on a smaller number of children who are at Journal of Pediatric Surgery xxx (xxxx) xxx ⁎ Corresponding author at: Ben Zakai 36/8, Jerusalem, Israel. Tel.: +972 29978901; fax: +972 2 5324844. E-mail address: baamichai@gmail.com (A. Ben-Ari). YJPSU-59500; No of Pages 6 https://doi.org/10.1016/j.jpedsurg.2019.11.011 0022-3468/© 2019 Published by Elsevier Inc. Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg Please cite this article as: A. Ben-Ari, F. Benarroch, Y. Sela, et al., Risk factors for the development of medical stress syndrome following surgical intervention, Journal of Pediatric Surgery, https://doi.org/10.1016/j.jpedsurg.2019.11.011