Hip Dysplasia and Stress

A child with hip dysplasia raises anxiety levels and causes stress for the child and family. Adolescents and adults with hip dysplasia are also at risk for stress-related problems, but these are addressed in a separate commentary.

There is much to learn about the effects of stress, so physicians and psychologists are taking a greater interest in the psycho-social effects of treatment for children and adults with hip dysplasia, or similar conditions. Stress is a part of modern-day life and sometimes this leads to unusual behaviors or emotional problems. Stress may also contribute to physical ailments such as heart attacks, asthma, obesity, and gastrointestinal problems.

Managing stress can help diminish some of these common problems that affect many people. However, traumatic events may lead to Post Traumatic Stress Disorder (PTSD). This is a psychiatric disorder with specific diagnostic criteria. Thankfully, most people who have a traumatic event do not develop post-traumatic stress disorder (PTSD). The psychological criteria to consider a diagnosis of PTSD in children younger than six can be found elsewhere [https://www.verywellmind.com/dsm-5-ptsd-criteria-for-children-2797288]

There are some reports that major surgery, or repeated surgery increases the risk of PTSD symptoms for children and their parents. Repeated or prolonged general anesthesia for major congenital problems may also increase the risk of memory or behavioral disorders. These problems are more common with increased severity and frequency of treatment. Brief episodes of treatment for a curable condition are less likely to cause PTSD. Factors such as coping skills, parental involvement, marital strife, pre-treatment preparation and outcomes of treatment also influence the development of stress-related disorders. Nonetheless, there is increased risk for psychosocial problems when children undergo surgery for major congenital problems.

Many families experience stress during treatment. One study showed that 75% of parents providing care for infants who had surgery for hip dysplasia experienced social problems and 65% reported psychological problems in addition to the usual problems of physically caring for the child (Orthop Nurs. 2015;34(5):280-6). However, a long-term study of 19 children who were successfully treated for hip dysplasia showed that four years later, the hip dysplasia children had slightly lower physical scores, but similar psychosocial scores to age-matched children who had no prior treatments (Unal VS, Saudi Med J. 2006;27(8):1212-6). In spite of this encouraging study, there haven’t been any other detailed studies of children treated with casts or surgery for hip dysplasia.

Much more is needed because of the growing awareness of the potential long-term psychosocial consequences of anesthesia and major surgical interventions in children. Since 1999, the FDA has been studying effects of general anesthesia in brain development. However, the answers remain uncertain. The FDA has advised parents and physicians to consider brain development for children younger than three when recommending procedures that last longer than 3 hours or require multiple general anesthetics. Until, we have good alternatives to general anesthesia in young children, preventive measures for stress along with improved parental preparation may help considerably.

The International Hip Dysplasia Institute is working hard to find new methods for early diagnosis to avoid general anesthesia. The IHDI is also exploring non-surgical methods that may be appropriate for older children to avoid anesthesia and surgery. This along with studies to document the effects of current treatments would go a long way to advance our understanding of hip dysplasia and the psychosocial effects of treatment. We can only do this with your support and involvement.

If you suspect that your child has behavioral or cognitive effects from treatment for hip dysplasia, then psychological evaluation is appropriate. There are effective interventions including play therapy, eye-movement desensitization and reprocessing (EMDR), and other methods that can help minimize the consequences of surgical or non-surgical interventions.

Criteria for PTSD in Children Younger than 6 Years of Age includes one of each of the following:

The presence of at least one of the following intrusive symptoms that are associated with the traumatic event and began after the event occurred:
1. Recurring, spontaneous, and intrusive upsetting memories of the traumatic event.
2. Recurring and upsetting dreams about the event.
3. Flashbacks or some other dissociative response where the child feels or acts as if the event were happening again.
4. Strong and long-lasting emotional distress after being reminded of the event or after encountering trauma-related cues.
5. Strong physical reactions, like increased heart rate or sweating, to trauma-related reminders.

The child exhibits at least one of the following avoidance symptoms or changes in his or her thoughts and mood. These symptoms must begin or worsen after the experience of the traumatic event.
1. Avoidance of or the attempted avoidance of activities, places, or reminders that bring up thoughts about the traumatic event.
2. Avoidance of or the attempted avoidance of people, conversations, or interpersonal situations that serve as reminders of the traumatic event.
3. More frequent negative emotional states, such as fear, shame, or sadness.
4. Increased lack of interest in activities that used to be meaningful or pleasurable.
5. Social withdrawal.
6. Long-standing reduction in the expression of positive emotions.

The child experiences at least one of the below changes in his or her arousal or reactivity, and these changes began or worsened after the traumatic event:
1. Increased irritable behavior or angry outbursts. This may include extreme temper tantrums.
2. Hypervigilance, which consists of being on guard all the time and unable to relax.
3. Exaggerated startle response.
4. Difficulties concentrating.
5. Problems with sleeping.

In addition to the above criteria, these symptoms need to have lasted at least one month and result in considerable distress or difficulties in relationships or with school behavior. The symptoms also cannot be better attributed to ingestion of a substance or to some other medical condition.

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