Posttraumatic Stress Disorder (PTSD), Dog bites & Children

Post-traumatic stress disorder, or PTSD, is frequent consequence of dog bite injury. Studies have shown that approximately 40% of dog bite victims, particularly children, will be afflicted with this kind of psychological injury following a dog bite incident.

PTSD is a consequence of a dog bite attack and has been researched in a number of peer reviewed epidemiological studies. The likelihood that PTSD will happen to a dog bite victim increases substantially when the injuries are inflicted to the face of a child or when the dog bite injuries are severe.

In this post, I presented a summary of research findings on PTSD and dog bites, presented from my perspective as dog bite expert. This review supplements an article previously posted on this website entitled “Post-traumatic stress disorder in children”.

Post-traumatic Stress Disorder in children: Research findings

PTSD is a recognized psychiatric condition classified by the American Psychiatric Association in the 5th edition of their Diagnostic and Statistical Manual of Mental Disorders. The incidence of PTSD in the general population, as a result of any serious trauma, including the trauma of being bitten by a dog, is remarkably high.  For example, data from Canada show prevalence rates ranging from 1.3% to 37.4%. The prevalence rate of lifetime PTSD was estimated to be 9.2%. ^[1]Ameringen M. et. al. Post-traumatic stress disorder in Canada. CNS Neurosci. Ther. 2008, 14, 171.

In the United States, the past year and lifetime prevalences were 4.7% and 6.1% respectfully. ^[2]Goldstein R. et. al. The epidemiology of DSM-5 post=traumatic stress disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Psychiatric … Continue reading The telltale signs of PTSD in a dog bite victim are acute-anxiety,  generalized fear, social withdrawal, bedwetting (in children), anger, nightmares, irritability, altered appetite and depression.

An early study substantiating that PTSD occurs in children as a result of being attacked by a dog was published in 2004.  In this study, the psychological adjustment of 57 children (3 to 12 years) who suffered disfiguring injuries to the face or extremities as a result of a dog bite was analyzed. Results showed that within five days of the traumatic event, 98 percent of the children were symptomatic for post-traumatic stress disorder, depression, or anxiety. One month after the injury,82 percent continued to display symptoms, and 42% of the children continued to report symptoms at 12-month follow-ups. Persistent symptoms typically included flashbacks, fear of re-injury, mood disorders, body-image changes, sleep disturbances, and anxiety. ^[3]Peters, V. et. al. Post-traumatic stress disorder after dog bites in children. J. Pediatrics, 2004, 144, 121-122.

A subsequent study also provides proof that post-traumatic stress disorder can happen as a result of the dog bite injury. In this study, the medical records for 358 children treated in an emergency room for dog bite injury were reviewed. Victims underwent evaluation for acute stress disorder (ASD) diagnosis.   A total of 19 patients developed PTSD, including ten patients with severe injuries, eight patients with moderate injuries, and one patient with a mild injury. ASD and PTSD symptom severity scores were significantly associated. The authors concluded that “child victims of severe animal attacks should be considered at risk for the development of PTSD. Post-traumatic stress disorder in children after animal attacks has always been underestimated, and a more detailed study of PTSD in children after animal attacks is needed.” ^[4]Rusch, M., et. al. Psychological adjustment in children after traumatic disfiguring injuries: a 12-month follow-up. Plastic Reconstructive Surgery 2000,106,1451-458

Researchers in another study assessed the ongoing needs of 34 children and their families one month after receiving care in a pediatric emergency department for a dog bite. More than 70% of the parents noted at least one new concerning behavior in their child, and more than 85% of the parents were also concerned about their own reactions. Half of the parents believed that their children might benefit from interventions to help with post-bite fears, and nearly three-quarters of the families felt that they would benefit from education regarding dog bite prevention. ^[5]Boat B, et.al.  Pediatric dog bite victims: a need for a continuum of care. Clinical Pediatr  2012 ,51, 473-477.

In another study, a total of 19 children developed PTSD within three months of initial presentation at an emergency room department for a dog bite injury. Findings also showed an association between the severity of the bite injury and the development of PTSD. For example, PTSD happened in 10 patients with severe injuries, eight patients with moderate injuries, and one patient with a mild dog bite injury. Moreover, at the time of initial admission to the emergency department, half of the children were symptomatic for acute stress disorder (ASD). This finding was noteworthy because ASD and PTSD symptom severity scores were significantly associated. The authors of the study concluded that pediatric dog bite victims should be considered at risk for the development of PTSD, and ASD seems to be an early predictive indicator of PTSD. ^[6]Ji L, et.al. Investigation of posttraumatic stress disorder in children after animal-induced injury in China. Pediatrics. 2010;126, 320–e324.

Another study sought to identify predictors of PTSD and adaptive functioning of children exposed to a single and repetitive adverse events that varied in severity. Eighty-six parents and their children, aged 4 to 9 years, were interviewed after three types of adverse experiences: repetitive exposure to parental violence, a dog attack, or a milder stressor. Results showed that trauma symptoms were more significant for the first two groups.  Within the dog attack group, boys were found to report more PTSD symptoms than girls, and overall, younger children were at higher risk for PTSD symptomology. The authors concluded “Children appear to experience elevated post-traumatic stress disorder symptomatology after both single and repetitive adverse events that are potentially life-threatening” ^[7]Rossman, B. et. al Symptomatology and adaptive functioning for children exposed to normative stressors, dog attack, and parental violence. J Am Acad Child Adolesc Psychiatry. 1997, 36, 1089-97.

In another study, a meta-analysis of the literature was made to determine the various sequelae to dog bite injury. In this study, 693 cases over 30 years were analyzed.  As expected, much of the literature focused on rabies. However, the study also uncovered other sequelae resulting from dog bite injury. For example, analysis showed that the sequelae from dog bites result in anxiety around dogs and PTSD. The authors concluded, “While a lot of focus in the literature is on rabies as a sequela to dog bites, the impacts of anxiety and PTSD are not as well articulated. While dramatic long-term impacts of dog bites such as permanent scarring and disfigurement, infection, and pain are important, other sequelae such as post-traumatic stress or anxiety and economic costs should not be overlooked.” ^[8]Dhillon, J. et. al Scoping decades of dog evidence: a scoping review of dog bite-related sequelae. Can J Public Health. 2019, 110, 364-375.

Another study describes a case for a 4-year-old girl. The child was hospitalized for surgical repair and intravenous antibiotic therapy due to extensive lesions caused by a single dog bite. The investigators found that this single traumatic dog bite triggered the onset of an unusual psychological response, selective mutism, and acute post-traumatic stress disorder. The authors note “There is limited literature discussing the psychological effect of dog bites in children. Parents and physicians involved in pediatric physical trauma need to be more familiar with post-traumatic behavioral reactions. ^[9]Dimitrios A. et.al. Selective mutism due to a dog bite trauma in a 4-year-old girl: A case report. J Med Case Rep. 2009, 3:100.

Finally, neurological impairment may happen in an adolescence as a result of PTSD. Specifically, damage to the hippocampus may occur. The hippocampus is the central part of the brain dealing with memory. In one study, children between the ages of 10 and 17 with a confirmed diagnosis of post-traumatic stress disorder were compared with a group of children with no post-traumatic stress disorder. Brain scans were taken when subjects completed a test for verbal memory. The test consisted of having subjects read a list of words from one list, then read an additional set of words from another list, and then remember which words were on the original list. Compared with subjects without post-traumatic stress disorder, those with PTSD did poorly on this test. The conclusion is that the memory of a child may be compromised as result of PTSD. ^[10]Carrión, G et. al.  Reduced Hippocampal Activity in Youth with Post-traumatic Stress Symptoms: An MRI Study. Pediatric Psychol. 2010, 35, 559–569.

Conclusions

PTSD resulting from dog bite injury is a type of injury that should be taken into consideration by attorneys negotiating settlements in dog bite lawsuits. How to value of this type of injury remains elusive, particularly when trying to take into account long-term effects on the child. Further research is needed to find associations if any, between the severity of the dog bite injury and lasting effects into the early adult years of the victim.

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Richard Polsky, PhD, is a California-based animal behavior expert witness. He welcomes inquiries from attorneys seeking expert opinion about the consequences of dog bite injury, like post-traumatic stress disorder.