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Journal of Child & Adolescent Trauma logoLink to Journal of Child & Adolescent Trauma
. 2024 Mar 12;17(4):1013–1018. doi: 10.1007/s40653-024-00619-4

Prevalence of psychosocial interventions for pediatric dog bite injury: Is the bark actually worse than the bite?

Kelli N Patterson 1, Tran Bourgeois 1, LeeAnn Wurster 2, Sarah N VerLee 3, Lindsay A Gil 1, Kyle Z Horvath 1, Peter C Minneci 5, Katherine J Deans 5, Rajan K Thakkar 2,4, Dana Schwartz 2,4,✉
PMCID: PMC11646243  PMID: 39686930

Abstract

Purpose

Long-term psychological effects may occur after childhood dog bite injuries. We performed a national survey to assess psychosocial interventions for children presenting with dog bite injuries to pediatric trauma centers.

Methods

A 26-question, online survey was administered to Pediatric Trauma Program Managers in the United States (n = 83). The survey queried whether institutions provide directed psychosocial interventions to pediatric dog bite injury patients in the Emergency Department, inpatient, or outpatient settings and the types of interventions being used. Descriptive statistics were performed to demonstrate survey results.

Results

In total, 28 American College of Surgeons or State-verified Pediatric Trauma Centers responded to the survey (n = 28/83, 34%). Of the respondents, 18 (64.3%) did not have any interventions in place to address the psychosocial effects of pediatric patients’ dog bite injuries. Of the 10 (35.7%) institutions with interventions in place, the types of psychosocial resources offered included: automated order sets within the electronic medical record, specialized teams that assess the patient while hospitalized or outpatient, child psychology referrals initiated at discharge, pet therapy, and trauma resiliency programs.

Conclusion

Most institutions surveyed did not have protocols or interventions in place to address psychosocial disturbances in children with dog bite injuries. We provide the example of our institution’s practice, in which automatic psychology consults are placed for every child who is admitted with a dog bite injury. Performing caregiver education in the emergency department, providing caregivers with regional psychosocial resources, and communicating with a child’s pediatrician may promote the necessary standardized psychological screening and/or follow up of these patients.

Keywords: Child, Pediatrics, Wounds and injuries, Bites and stings, Psychology

Introduction

Pediatric dog bite injury is a leading cause of Emergency Department (ED) visits, with many severe injuries requiring hospital admission or operative repair (Basco et al., 2020; Huang et al., 2017; McLoughlin et al., 2020). Dogs remain extremely popular pets, with an estimated 89.7 million total pet dogs owned in the United States in 2018 and at least 50% of US households reporting owning one or more dogs in 2020 (Cook et al., 2020). The predisposition for dogs to bite is known to be due to a confluence of factors including training, genetics, socialization to people, quality of supervision, victim behavior, and previous maltreatment. As there are few major coordinated efforts to support prevention, education, and policy change, pediatric dog bites remain an important public health concern (Guidelines, 1987).

The physical and psychological integrity of a child is threatened when sustaining trauma, and this requires directed medical intervention (Kassam-Adams, 2006). Extensive research has demonstrated that children can suffer impairing acute and long-lasting psychological burdens following trauma, especially when sustaining a physical injury (Abdullah et al., 1994; Anderson, 1980; Caffo, 2003; Kassam-Adams, 2006; Pillemer, 1988; Winston et al., 2002). The psychosocial sequelae of trauma are well-documented following motor vehicle collisions, for example (Caffo, 2003; Winston, 2002). Psychological symptoms consistent with acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) have also been described as a result of burns, fractures, and spinal cord injuries, irrespective of injury severity (Abdullah et al., 1994; Anderson, 1980; Pillemer, 1988). These symptoms disrupt not only a child’s physical health, but also their social and educational development, making directed intervention to address psychological distress an integral component of caring for these children as a whole (Seng et al., 2005).

Psychosocial disturbances have also been demonstrated, in more limited research, to occur in children following a dog bite injury (Boat et al., 2012; Ji, 2010; Peters et al., 2004). The objective of this study was to survey pediatric trauma programs nationally to determine whether institutions are currently providing psychosocial interventions to children presenting or being admitted to their facility with dog bite injuries.

Methods

The Institutional Review Board (IRB) determined that this study did not perform research involving human subjects as defined by Department of Health and Human Services and Federal Drug Administration regulations and did not require IRB review and approval. A 26-question, online survey was sent to pediatric Trauma Program Managers around the country. A listserv for both the Pediatric Trauma Society Trauma Nurse Leadership group and/or the COVID Pediatric Trauma Society group was utilized to contact Trauma Program Managers at their respective institutions. Ultimately, 83 institutions were sent the online survey to complete.

Responses to this survey determined whether institutions were providing any psychosocial interventions to children sustaining a dog bite injury in the Emergency Department (ED), inpatient, or outpatient settings. A positive response was followed up by a series of questions that focused on describing the specific types of interventions being implemented at each of these institutions. Institutions were de-identified and classified based on the level of their trauma center, type of verification (American College of Surgeons (ACS)-verified, State-verified, or both), and range of annual emergency department visits. Study data were collected and managed using REDCap (Research Electronic Data Capture) electronic data capture tools hosted at Nationwide Children’s Hospital (Harris et al., 2009; 2019). Descriptive statistics were performed to demonstrate survey results.

Results

Twenty-eight institutions, which are either ACS or State-Verified Pediatric Trauma Centers, responded to our survey (n = 28/83, 34%). Characteristics of the responding institutions based on whether they have a psychosocial intervention for dog bite injuries are detailed in Table 1. Most responding institutions had an annual emergency department volume of < 50,000 patients (10/28; 35.7%), followed by a volume of 50,000–74,999 patients (9/28; 32.1%). Of the 28 responders, 18 (64.3%) stated that they do not have interventions in place to address the psychosocial consequences of dog bite injuries in their pediatric population. Of the 10 (35.7%) institutions that do have interventions in place, 1 (10%) provides intervention while the patient is in the ED, 10 (100%) to admitted patients, and 5 (50%) in the outpatient setting. The types of psychosocial interventions offered by these institutions are summarized in Table 2.

Table 1.

Description of trauma centers and existence of current psychosocial intervention

Variable Characteristic Total N (%) No (n = 18)
N (%)		 Yes (n = 10)
N (%)
Trauma Center Level
Level 1 Pediatric - Freestanding center 8 (28.6) 5 (27.8) 3 (30.0)
Level 1 Pediatric - Associated with adult center 8 (28.6) 5 (27.8) 3 (30.0)
Level 2 Pediatric 8 (28.6) 6 (33.3) 2 (20.0)
Other 4 (14.3) 2 (11.1) 2 (20.0)
Verification
State verified 10 (35.7) 7 (38.9) 3 (30.0)
Both ACS and state verified 10 (35.7) 7 (38.9) 3 (30.0)
ACS verified 8 (28.6) 4 (22.2) 4 (40.0)
Neither ACS nor state verified 0 (0.0) 0 (0.0) 0 (0.0)
Annual Emergency Department volume
< 50,000 10 (35.7) 7 (38.9) 3 (30.0)
50,000–74,999 9 (32.1) 5 (27.8) 4 (40.0)
75,000–99,999 4 (14.3) 2 (11.1) 2 (20.0)
100,000–124,999 4 (14.3) 4 (22.2) 0 (0.0)
125,000+ 1 (3.4) 0 (0.0) 1 (10.0)
Intervention
No 18 (64.3) – –
Yes 10 (35.7) – –
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Table 2.

Specific psychosocial interventions and populations they are available to at institutions with current practices

Variable Characteristic N %
Patient population that interventions are available to (n = 10) Patients seen in Emergency Department 1 10
Admitted patients 10 100
Patients who are followed in outpatient surgery clinics 5 50
Program / institution has automated order sets or flags which are triggered in the *EMR when pediatric dog bite injury is seen. (n = 10) No 9 90
Yes 1 10
Presence of special teams / providers available to see patient while in the hospital / clinic (n = 10) Social worker 8 80
Psychology 8 80
Case management 3 30
Specialized nursing team 1 10
Other 4 40
Nursing team (n = 1) Trauma Resiliency and Recovery program with coordinator who is a nurse 1 100
Other (n = 4) Child psychology and referral process initiated to trauma clinic after discharge 1 25
Injury prevention team, pet therapy 1 25
Injury prevention 1 25
Trauma Resiliency and Recover Program consulted for all admitted traumas regardless of method of injury 1 25
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EMR = Electronic medical record

One center utilizes an automatic order set within the electronic medical record (EMR) system which includes a consult to social work. All 10 centers have a special team or providers who are available to see patients during their hospitalization or after discharge. These teams include members from social work (n = 8), psychology (n = 8), case management (n = 3), and nurses with specialized training (described as a Trauma Resiliency and Recovery program nurse coordinator (n = 1)). Four centers listed “other” for the presence of specialized teams or providers, and this included: child psychology and referral process being initiated after discharge, injury prevention team/pet therapy, and consultation to the Trauma Resiliency and Recover Program for all admitted trauma patients.

Discussion

Overall, most institutions surveyed do not have standardized protocols or interventions in place regarding the psychosocial management of children presenting with pediatric dog bite injuries. Of the 10 centers with interventions in place, automated EMR order sets and special teams/providers were among the resources used for inpatient evaluation or evaluation after discharge. Four institutions specifically mentioned additional programs or therapies they have in place for outpatient treatment and follow-up, such as injury prevention teams, pet therapy, and child psychology referrals.

Dog bite injuries during childhood may have lifelong psychosocial effects. The link between trauma inflicted during childhood and long-term mental health effects is well-documented in the literature (Oh et al., 2018). In a scoping review of dog bite-related sequelae, Dhillon et al. (2019) identified three articles that focused on PTSD from 1985 to 2015. Boat et al. (2012) showed that over 70% of children bitten by a dog began to demonstrate at least one new concerning behavior in the weeks following a bite. Among these behaviors mentioned were talking more frequently about the incident, being fearful of and avoiding dogs, being anxious about going to the hospital, and having nightmares. Parents are also affected by their child’s dog bite injury, with over 86% endorsing concerns following the bite, ranging from feeling guilty about the accident, worrying about their child’s scars, and being angry or fearful for their child’s safety (Boat et al., 2012). Peters et al. (2004) performed formal PTSD evaluations in children one month after an aggressive encounter with a dog and 55% (12/22) showed evidence of partial or complete PTSD (Peters et al., 2004). In China, Ji et al. (2010) studied 358 children with animal bite injuries and found that 5% developed PTSD within 3 months of initial presentation. Half of patients also demonstrated symptoms of ASD during their initial presentation, and a significant association was found between wound severity and the development of PTSD (Ji, 2010). These studies demonstrate the substantial impact of a child being bitten by a dog and, given the increasing frequency of dog ownership, substantiate the need for robust efforts toward standardized evaluation and/or follow-up of psychological effects (Cook et al., 2020; McLoughlin et al., 2020).

Our tertiary pediatric trauma center has implemented a program to address and evaluate the potential psychosocial impact of dog bites. Every patient admitted to our hospital following a dog bite injury automatically receives a psychology consult. The psychologist completes a clinical interview, screens the patient and caregiver for acute traumatic stress symptoms within 24 h of admission, and provides related psychoeducation and intervention during the hospital stay. Psychology provides continuity of care for these patients during their outpatient trauma follow-up appointments, as well as services to patients who were treated and discharged directly from ED. A psychologist meets with each patient and caregiver during their initial trauma surgery clinic visit, with focus on continued monitoring of traumatic stress symptoms and providing interventions to promote health coping and adjustment. Behavioral health referrals are provided to patients and caregivers who require additional psychological treatment for acute and posttraumatic stress symptoms.

Numerous long-term consequences have been described as resulting from untreated stress symptoms including functional disabilities, cortical changes, sleep disturbances, self-medicating tendencies, and additional psychiatric conditions (Chae et al., 2004; Ehlert et al., 2001; Gold et al., 2008; Kuhne et al., 1986; Lavie, 2001; Marshall, 2002; Trief et al., 2006). Therefore, the prevention of psychological distress following a dog bite injury becomes extremely important to avoid such disruptions in a child’s mental, social, and physical development. Some institutions may not have 24-hour access to psychology services, for example, those smaller institutions with an emergency department visit rate of < 50,000 patients annually; however, there are still feasible and innovative ways to provide patients and their caregivers necessary psychosocial screening and resources. Implementing standardized dog bite injury policies and procedures within hospital systems or automated EMR order sets could lead to more at-risk children being identified, contacted, screened, and/or followed by psychology services. When caregivers present to the emergency department with their child, it would ideally be standard of care to provide them with education about the psychosocial disturbances that may occur following a dog bite injury, empowering the caregiver to recognize these issues and seek out additional treatment when appropriate. Fliers or infographics could be provided to caregivers via email, text messaging, or in paper form, with regional psychosocial resources listed. Communication and continuity of care could also be improved by automatically sending a letter to the child’s pediatrician following their presentation to the ED or urgent care for a dog bite injury. This letter would explain the risk of psychosocial distress after a dog bite to primary care providers (PCPs), alert them about the need for proactively screening for symptoms of ASD or PTSD, and facilitate placement of a referral for psychological services if needed.

As dog ownership rates continue to grow, it is nearly inevitable that a child who has suffered a dog bite injury will again be in close proximity to dogs (Cook et al., 2020). In addition to identifying and clinically treating patients for psychosocial distress, the specialized trauma resiliency programs and dog therapy programs mentioned by a few of the responding trauma centers in our study could be utilized to help children adjust long-term. Hospitals could partner with these programs or establish their own infrastructure to create more normalcy for children returning to daily life. Overall, promoting awareness of the psychosocial distress children face following dog bites, standardizing the identification of patients at-risk, improving communication between providers, and providing families with the education and resources needed to cope with psychological symptoms are vital to the prevention of mental health disturbances.

This study has several limitations. First, survey response rates were low (n = 28/83), which decreases the sample size and power of the study, potentially introducing bias. However, there is no consensus on acceptable minimal response rates in the literature, and regarding survey data, a 34% response rate is still reasonable. The generalizability of this study is limited due survey respondents including just Level 1 Pediatric Trauma Centers, Level 1 Pediatric Trauma Centers associated with an Adult Trauma Center, and Level 2 Pediatric Trauma Centers. Hospitals without a pediatric association, non-trauma centers, and those without ACS and/or state verification are not represented in our results. The conclusions drawn from this study may not be applicable to these hospitals, though most moderate to severe pediatric dog bite injuries will be transferred to an ACS and/or State-verified Level 1 or Level 2 Trauma Center for their care. Furthermore, we did not ask for data regarding hospital location, so the geographical clustering of responding hospitals, available resources, or differences in the psychosocial management of pediatric dog bites could affect our results.

Conclusion

In addition to upstream prevention efforts, we must focus on how we can alleviate the significant psychosocial disturbances which occur after a child is bitten by a dog. By implementing standardized psychological screening and evaluation of these patients and their caregivers when they present with a dog bite injury, we can identify those who warrant further treatment. Complete care of this injury pattern should include intervention to prevent the development of the lasting psychosocial effects, which have been linked to ASD and PTSD in children.

Author contribution

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Kelli Patterson, Tran Bourgeois, LeeAnn Wurster, Sarah VerLee, Lindsay Gil, Kyle Horvath, Peter Minneci, Katherine Deans, Rajan Thakkar, and Dana Schwartz. The first draft of the manuscript was written by Kelli Patterson, Tran Bourgeois, Sarah VerLee, Kyle Horvath, Lindsay Gil, Rajan Thakkar, and Dana Schwartz and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

No funds, grants, or other support was received.

Declarations

Conflict of interest

All authors have no conflicts of interest to declare. The authors have no commercial associations or sources of support that might pose a conflict of interest.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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