CLINICAL AND LABORATORYOBSERVATIONS

POSTTRAUMATIC STRESS DISORDER AFTER DOG BITES IN CHILDREN

VINCENT PETERS, MD, MARTINE SOTTIAUX, MD, JOCELYNE APPELBOOM, MD, AND ANDRE KAHN, MD, PHD

Of 22 children who were victims of dog bite, 12 had symptoms of posttraumatic stress disorder 2 to 9 months after the bite.

Violent dog attacks inflicting multiple and/or deep wounds were associated with risk of posttraumatic stress disorder. (J Pediatr

2004;144:121-2)

Children who are victims of dog bites often require medical attention, but psychological support is rarely offered.1-3 Asposttraumatic stress disorder (PTSD) may develop after a stressful event,3-6 a study was conducted to evaluate whetherPTSD develops in children after a dog attack.

METHODSBetween April 2001 and February 2002, children who were victims of dog bites were consecutively enrolled at the

Emergency Department of the University Children’s Hospital. Inclusion criteria included children younger than 16 years who hadreceived a minor surgical treatment less than 48 hours after a dog bite and whose parents agreed to answer a questionnaire 2 to 9months after the bite.

The questionnaires included 60 items about the child’s sex and age, the circumstances of the accident, type of injury, type ofdog involved, and the child’s behavior before and after the accident. Semistructured comprehensive interviews were conducted bytelephone and 8 questionnaires were further completed during a home visit, following the suggestion of the parents.

PTSD was defined according to the 6 major criteria described under the 309.81 diagnostic definition of DSM-IV.4 Thenumber of items met for each criterion was computed and children were scored according to whether they met all criteria forPTSD (complete PTSD), had some symptoms of PTSD (partial PTSD), or had no symptom of PTSD.7

Statistical analyses were based on nonparametric tests (Wilcoxon rank test, Mann-Whitney U test) and v2 tests with Yatescorrection for small series. The statistical significance threshold was P < .05. The aim and the methodology of the study wereapproved by the university ethics committee and were explained to the parents, who gavetheir informed consent.

RESULTSTwenty-two of 26 children met inclusion criteria. The children had a median age of

7.5 years (range, 1-14 years); 12 were boys. For 14 children, the bite occurred at home; 9were bitten in the face. No child was hospitalized after the bite. The median delay betweenthe accident and the interview was 7 months (range, 2-9 months).

Among the 22 children,12 had symptoms of PTSD for more than 1 month: 5 had allDSM-IV criteria for PTSD; 7 children had some but not all criteria. PTSD symptomsincluded vivid reviviscence of the traumatic event (12 children), avoidance behavior ornumbing (7 children), and/or signs of increased arousal (6 children). Reviviscence includedfrequent questioning about dogs and/or intense fear reactions in the presence of a dog. Twochildren repeatedly played games, acting as aggressive dogs. Avoidance behavior was seenin the form of the child’s refusal to go out unaccompanied to a park, a street, or school.Three children had become shy and aggressive with siblings and peers. Psychologicalnumbing was manifest by a lack of interest in games and in school activities. Hypervigilancemanifestations occurred in the form of fear of potential accidents and fear of the dark,

See related article, p 17.

From University Children’s HospitalQueen Fabiola, Brussels, Belgium.Submitted for publication Jan 21, 2003;revision received Sept 3, 2003; acceptedOct 10, 2003.

Reprint requests: A. Kahn, HopitalUniversitaire des Enfants Reine Fabio-la, av. JJ Crocq 15, B-1020 Brussels,Belgium. E-mail: akahn@ulb.ac.be.0022-3476/$ - see front matter

Copyrightª 2004 Elsevier Inc. All rightsreserved.

10.1016/j.jpeds.2003.10.024PTSD Posttraumatic stress disorder

121

anxiety when left alone, difficulty going to bed and fallingasleep, frequent nightmares, agitated sleep, and nighttimearousal.

No difference was found between the 12 children witha complete or partial PTSD and the 10 children with noPTSD symptom for age, sex, time since the bite, type of dog,place of the accident, owner of the dog, child’s activity at thetime of the accident, or part of the child’s body bitten.

Six of the 12 children with PTSD but none of the 10children with no PTSD symptoms had multiple and deepwounds from violent dog bites. The children who had a minoraccidental bite by their pet had only one or no PTSD criteria.

DISCUSSIONOf the 22 child victims of dog bites, 12 had either partial

(7 children) or complete (5 children) PTSD, but none receivedpsychological support.

Some limitations must be considered in this survey.First, some differences could not have reached significancebecause of the limited number of subjects. This could con-tribute to the lack of differences between the children who didor did not have PTSD or the lack of sex susceptibility toPTSD.6-8 Second, in the absence of direct input from thechildren, it cannot be excluded that parents underreportedtheir children’s changes in behavior.5,7 Third, the frequency ofPTSD could be underevaluated because no validated question-naires for PTSD were used in the study.9 The frequency andtypes of PTSD symptoms were, however, comparable to thosereported in other surveys in children.4,6,7 Fourth, we have noinformation on factors known to favor the development ofPTSD, such as children’s intellectual or personality variables,8

past experience,6 parents’ responses,10 family history, presenceof a parent with PTSD symptoms,3,5,6,8 or social support.8

The reason why PTSD developed in some children onlyis not known. It could be related to the intensity and aggressive

122 Peters et al

character of the dog attack.3 Only the children who had severeand/or multiple bites had full PTSD symptoms; none of thechildren with an accidental bite from their pet did so.

Despite these limitations, this survey leads to theconclusion that child victims of dog bites should be consideredat risk for development of PTSD and need early psychologicalsupport. A prompt intervention is recommended to preventPTSD.5 Children who had violent and/or multiple dog bitesappeared to form a particularly important target for preventiveintervention.

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The Journal of Pediatrics � January 2004