Elsevier

Journal of Critical Care

Volume 45, June 2018, Pages 149-155
Journal of Critical Care

Outcomes/Predictions
Prediction of parental posttraumatic stress, anxiety and depression after a child's critical hospitalization

https://doi.org/10.1016/j.jcrc.2018.02.006Get rights and content

Highlights

  • Having a child under intensive care treatment impairs parental mental health.

  • Parental rates of psychopathology did not decline over time, suggesting chronicity.

  • Resilience is a strong indirect protective factor for parental mental health.

  • The effect of resilience in parental mental health is mediated by perceived stress.

  • Interventions to prevent/reduce parental distress in the PICU should be implemented.

Abstract

Objective

To study the role of parental resilience, emotions accessed during admission and perceived stress in predicting the degree of parental posttraumatic stress disorder (PTSD), anxiety and depression symptoms after a child's treatment in intensive care.

Methods

This was prospective longitudinal cohort study. A total of 196 parents of pediatric intensive care survivors completed questionnaires assessing resilience, perceived stress, emotions experienced during admission, 48 h post-discharge (T0). Sociodemographic and medical data were also collected. Main outcomes were anxiety, depression and PTSD, three (T1) and six (T2) months later.

Results

At T2, 23% of parents reported clinically significant levels of symptoms of PTSD, 21% reported moderate-severe anxiety, and 9% reported moderate-severe depression. These rates were not statistically different to rates at T1. Path analyses indicated that 47% of the variance in psychopathology symptoms at T2 could be predicted from the variables assessed at T0. Resilience was a strong negative predictor of psychopathology symptoms, but this effect was mostly indirect, mediated by the stress that parents perceive during their child's critical hospitalization.

Conclusions

Mobilizing coping in order to maintain resilience and to decrease their perceived stress levels could improve parents' mental health outcomes following their child's intensive care treatment.

Introduction

In keeping with the principles of family-centered care, it is acknowledged that multidisciplinary teams in intensive care units should include attention to the needs of parents and caretakers [1,2]. Having a child admitted to a pediatric intensive care unit (PICU) is an extremely difficult experience for parents, as these children are, by definition, at increased risk of death. Research examining the psychological impact of having a child on PICU have found that psychopathological reactions are common, with rates of posttraumatic stress disorder (PTSD) around 20–30%, rates of anxiety around 20% and rates of depression around 15% [[3], [4], [5], [6], [7], [8]]. This impairment in parental mental health can have devastating consequences for family structure and functioning, and patient and sibling quality of life [9], which underlines the importance of finding ways to prevent and treat psychopathology symptoms in this population.

However, as Bronner et al. [4] have pointed out, although many parents experience psychopathological reactions, most of them do not; the majority of parents are resilient and recover without any significant stress symptoms in the long term. As not every individual who is exposed to this potentially traumatic event will develop significant distress, it is important to identify associated risk and protective factors at the time of the child's admission [5].

The main objective of this study was to develop a comprehensive predictive model of parental psychopathology symptoms after a child's PICU admission, from psychological variables assessed at the time of child's discharge. It was hoped that such a model would facilitate the detection of high-risk parents and also potentially suggest elements that might usefully be included in early preventive psychological interventions in the future.

Fig. 1 shows the model that summarizes our main hypotheses. On the basis of relevant findings in the literature, the main study hypotheses were that, as has been found in the parents of children with cancer [9] parental resilience would be associated with lower levels of subsequent psychopathology symptoms. Resilience is defined as positive adaptation or recovery despite experiences of significant adversity [10], and it can be measured as one's perceived ability to cope with stress [11]. As Fig. 1 shows, the relation between resilience and psychopathology was expected to be mediated through the experience of more positive emotions [12] and fewer negative emotions [13] in the peri-trauma period, and lower perceived stress during the admission [6,14]. As for positive emotions, a prospective study conducted on college students by Fredrickson et al. [12], showed that experiencing positive emotions in the aftermath of a traumatic experience (the 9/11 terrorist attacks) fully mediated the relation between pre-event ego resilience, and post-event psychopathology. Additionally, parents with higher resilience use more adaptive coping strategies, such as positive thinking or task-oriented coping [[15], [16], [17]], which is associated to more positive emotions [18], and also with less negative emotions and perceived stress [19]. With regards to the direct effect of perceived stress in psychopathology symptoms, it has been found that acute stress disorder is the best predictor of PTSD in parents of critically ill children [3], thus we expect a positive relation between these variables.

Finally, the contribution of sociodemographic and medical variables (such as parents' age or gender, or child's illness severity) some of which have been shown to be associated with parental adaptation after having a child admitted to a PICU [13,20], was also examined. Unexpected admission [3,7] or subsequent hospital admissions in the time of the following-up have been found associated to higher distress [3]. Additionally, previous studies found that parents belonging to ethical minorities, and unemployed parents reported higher distress [3,5]. Also, most of literature agrees that mothers report higher distress than fathers [4,5,8]. These variables are not included in the model presented in Fig. 1, but their association to parental psychopathology symptoms will be studied through correlations or mean comparisons.

Section snippets

Participants and procedures

Participants were parents whose child had been recently discharged from a 16-bed PICU, located in a tertiary hospital in Spain. Ethical permission for this prospective longitudinal cohort study was granted by the ethics committee. Exclusion criteria were being admitted for less than 12 h and not speaking Spanish well enough to complete the questionnaires. All parents of consecutive admitted children meeting inclusion criteria were asked for participation in the study. Parents were asked to

Baseline psychological measures

The mean for perceived stress was 23.65 (SD = 8.65). Regarding resilience, the mean was 19.28 (SD = 4.91). Overall, parents reported experiencing positive emotions, such as gratitude (M = 23.63; SD = 6.88) significantly more often than negative ones such as guilt (M = 9.88; SD = 6.14) during admission (t = 15.74; p < 0.001). Although the objective probability of the risk of death (PIM2) was 6%, 37 parents (26%) believed their child could die during admission.

Associations between socio-demographic/medical variables and psychological variables at T0

As for the associations between demographic and

Discussion

In life, few experiences can be considered more difficult than that of a parent facing the real possibility that their child could die or become severely disabled. The results of this study confirm that having a child under intensive care treatment can negatively affect parental mental health in the mid-to long-term, and are consistent with previous studies [3,5,7,8].

Data on the evolution of parental psychopathology symptoms showed that rates of PTSD, anxiety and depression did not decline over

Conclusion

This study highlights the need for a trauma-informed care framework in the PICU and suggests that parental risk and protective factors could usefully be assessed at discharge to identify those most likely to require further support. Interventions aiming to decrease parental PTSD, anxiety and depression rates should be focused at mobilizing adaptive coping [14] in order to maintain resilience and to decrease their perceived stress levels during admission [[15], [16], [17]]. These interventions

Acknowledgments

The authors would like to acknowledge all physicians and nursing staff of the PICU of Hospital 12 de Octubre, and specially Lidia Casanueva, Victoria Ramos, Alba Palacios, Ana Llorente, Silvia Belda, Marta Olmedilla, Olga Ordóñez, Raquel Vinagre and Eva Val for their help with the data collection.

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    Authors do not have any conflict of interest and no external funding was obtained for this study.

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