1. The Prevalence of Post-traumatic Stress Symptoms in Parents of Children Following Hurricane Ike and the Association with their Child’s Healthcare Utilization
Marcia Moreira, MD; Beth A. Auslander, PhD
RESULTS
ABSTRACT
SPECIFIC AIMS:
Determine the prevalence of post-traumatic stress symptoms (PTSS) depression/anxiety among parents of children and adolescents attending the UTMB pediatric primary care clinics following Hurricane Ike
Assess the relationship between parental PTSS/depression/anxiety and number of pediatric medical visits, including routine and sick visits
Assess the relationship between parental PTSS/depression/anxiety and parental report of child’s emotional or behavioral changes
Assess the prevalence of parents seeking mental health services for themselves and their child post-Hurricane Ike
METHODS:
Caregivers (n= 102) were recruited from the UTMB pediatric resident clinic and inpatient unit
Participants completed a questionnaire which included information regarding demographics, exposure to the hurricane, parents’ mental help seeking behavior, for themselves and their child, PTSD-checklist, and the Brief Symptom Inventory (BSI)-Depression/Anxiety
A retrospective medical chart review was conducted to assess the number of pediatric medical visits, including routine and sick visits from January 2009 – June 2009
RESULTS:
Study results showed 10 parents were above the recommended sum score of 44 for PTSS, 14 were above the recommended cutoff t-score of 63 for depression and 20 were above the recommended cutoff t-score of 63 for anxiety
Median number of pediatric medical visits was 2.0 (0-10), and sick visits of 1.0 (0-7). 39 participants had 1 or more routine medical visits
Simple correlations showed that PTSS, depression, and anxiety were all strongly related to each other (p < 0.001)
Predictive analysis showed that parental PTSS, depression, and anxiety were not related to total pediatric medical visits or sick visits. Parental anxiety was positively related to whether or not children attended routine visits, even when controlling for parent age
Parents with PTSS, depression, and anxiety were more likely to notice behavioral changes in their child post-Hurricane Ike
Although 15% of parents noticed changes in their child’s behavior, 30% of those parents did not seek mental health help
Parents with PTSS, depression, and anxiety sought mental health help for themselves (30%, 29%, 25% respectively)
CONCLUSIONS:
Our results suggest that even after a year post-disaster, healthcare providers should consider screening parents for PTSS, depression, and anxiety and children for emotional/behavioral problems so that they can provide appropriate mental health support/referrals. Routine visits may provide a good opportunity to conduct this screening
METHODS
EXPERIMENTAL DESIGN:
Recruitment
Parent participation was established from the UTMB pediatric resident clinic and inpatient unit
Parents were eligible if their child had had at least one medical visit in the UTMB electronic medical system since January 2009
Procedure
102 parents or legal guardians were recruited during August November 2009 (11-13 months post-disaster)
3 parents were dropped from the analysis due to excess missing data (n=99)
During their child’s visit, parents were offered to participate in a study regarding their reactions to Hurricane Ike by filling out a questionnaire
MEASURES:
Demographics
Questionnaires included information regarding parent/guardian’s age, gender, race/ethnicity; as well as questions with regard to their child’s age, gender, and race/ethnicity
Hurricane Exposure Items
Participants were asked whether they had evacuated in preparation for the hurricane (Yes or No), whether they sustained significant damage to their home (Yes or No), and whether their home damage had been fixed (Yes or No)
Parental PTSS
Participants were administered a PTSD-checklist, which was specific for Hurricane Ike
Based on prior research, a sum score > 44 was used as our cut-off
Parental Depression and Anxiety
Participants were administered the BSI subscales for depression and anxiety
The recommended cut-offs for each subscale was a t score > 63
OUTCOME MEASURES:
Medical Service Utilization
A retrospective medical chart review for one target child during January-June 2009 was conducted (start date was established given delay in patient care establishment following Hurricane Ike)
Review of electronic medical records provided data including total number of pediatric medical visits, as well as type of visit (routine healthcare versus sick)
Mental Health Utilization
Parents reported whether or not they noticed changes in their child’s behavioral or emotional functioning since Hurricane Ike
Parents were asked to report on their own mental healthcare utilization, as well as their child’s following Hurricane Ike (pediatrician, mental health provider, school, religious group/pastor)
STATISTICAL METHODS:
All data obtained from questionnaire and electronic medical record was entered into an Excel Spreadsheet and imported into SPSS and SAS for analysis
Descriptive statistics were performed on all variables
Predictive analysis was conducted to assess objectives #2, #3
Logistic regression was used for dichotomous outcomes (ex. child behavior changes, routine medical visits), and Poisson regression for count data (ex. total medical visits and sick visits) which revealed over dispersion; therefore, negative binomial was used
DESCRIPTIVE STATISTICS FOR DEMOGRAPHICS, MAIN OUTCOMES,
AND PREDICTORS (N=99)
CAREGIVERS WHO NOTICED CHANGES IN CHILD’S BEHAVIOR POST-HURRICANE IKE AND THE PERCENTAGES OF THOSE SEEKING HELP FOR CHILD BY PROVIDER
Variable
Median/Range
N (%)
Parent/Caregiver meeting criteria for PTSD (sum ≥ 44) No
Yes
89 (90)
10 (10)
Parent/Caregiver meeting criteria for Depression (t-score ≥63)
85 (86)
14 (14)
Parent/Caregiver meeting criteria for Anxiety (t-score ≥63)
79 (80)
20 (20)
Number of pediatric medical visits
Sick medical visits
Routine medical visits
1 or more
2.0 ( 0-10)
1.0 (0-7) 60 39
Parents who sought mental health for themselves following Hurricane Ike (n=95)
88 (93)
7 (7)
Parents who noticed behavioral changes in their child following Hurricane Ike
84 (85)
15 (15)
DISCUSSION
Our study found that the prevalence of PTSS in parents after months following Hurricane Ike was 10%. This is consistent with adult studies that have shown that even after 9 months following a disaster, symptoms of PTSS are evident. Although previous research has found an association between PTSS and adult medical visits, our study found that both PTSS and depression were unrelated to pediatric medical visits (total, sick, and routine). It could be that we were unable to detect a relationship because of the low number of parents reporting PTSS. Since previous studies have shown that the number of adults reporting PTSS after a natural disaster decreases over time, it may be helpful to evaluate the relationship between parental PTSS and children’s healthcare utilization earlier than 11 months post-disaster. Parental anxiety was positively related to whether or not children attended routine medical visits. It could be that parents with anxiety perceive their child’s illness as more severe and perceive their child at risk for negative outcomes, thereby making them more likely to attend routine visits than parents without anxiety. Overall, our findings suggest that caregivers with PTSS, depression, and anxiety are more likely to report changes in their child’s behavior post-disaster. It could be that when parents are aware of their own PTSS, depression, and anxiety, they are more attuned to their child’s symptoms or more likely to project their symptoms onto their child than parents without such symptoms. It also could be that when parents experience PTSS, depression, and anxiety, their parenting behaviors become less warm, less consistent, and less accepting which in turn result in child emotional/behavior problems. Future longitudinal research that includes both parent and child report of symptoms following a disaster is needed to explore this relationship further. Of concern is that the majority of parents reporting symptoms of PTSS, depression, and anxiety did not seek help for themselves and 30% of the parents noticing behavioral changes in their child did not seek help for their child. These findings suggest that healthcare providers should consider screening parents for PTSS/depression/anxiety and children for emotional and behavioral problems, even up to a year post a natural disaster, so that appropriate mental health referrals can be provided.
CORRELATIONS BETWEEN PREDICTOR VARIABLES
PTSD-Checklist
BSI-Depression
0.74 
BSI-Anxiety
0.70 
0.88 
 p <0.001
Predictive Analyses
The only demographic variable related to outcome was parent age, which was negatively related to routine visits.
LOGISTIC REGRESSIONS AND NEGATIVE BINOMIALS ASSESSING PREDICTOR VARIABLES, MEDICAL VISITS AND CHILD BEHAVIOR CHANGE (OR, (CI))
Predictor
Variables
Total Medical
Visits
Routine
Sick
Child Behavior
Change
PTSD- Checklist
0.79 (0.38,1.61)
0.35 (0.07, 1.75)
1.11 (0.57, 2.18)
7.90 (1.94, 32.1)*
BSI-Depression
1.3 (0.78, 2.43)
1.6 (0.53, 5.16)
1.09 (0.61, 1.96)
14.86 (4.01, 55.11)*
BSI-Anxiety
1.5 (0.92, 2.44)
3.79 (1.35, 10.62)*
1.17 (0.71, 1.94)
9.96 (2.96, 33.45)*
LIMITATIONS
There was a 11 month gap between Hurricane Ike and our study recruitment
This study was based on self report, instead of a clinical interview
Parents/caregivers may have answered the questions based on previous symptoms following the hurricane, and not on their current symptoms
Results were based on a small sample
DESCRIPTIVE STATISTICS FOR DEMOGRAPHICS, MAIN OUTCOMES, AND PREDICTORS (N=99)
Variable
Mean ± SD
N (%)
Parent/Caregiver Age (n=98)
32.9 ± 10.1
Child Age
5.88 ± 4.4
Parent/Caregiver Gender
Male
Female
6 (6)
93 (94)
Child Gender (n=97)
54 (56)
43 (44)
Race
White
Hispanic
African-American
Other
13 (13)
48 (49)
35 (35)
3 (3)
Evacuated for Hurricane Ike (n=97) No
Yes
84 (87)
Home Damage following Hurricane Ike
55 (56)
44 (44)
BACKGROUND
On September 12, 2008, Hurricane Ike devastated Galveston, Texas and surrounding areas by causing wide-spread flooding and damaging winds. It is estimated that 45,000 islanders fled for the storm, while 20,000 stayed behind to protect their belongings. In the immediate aftermath, the city had limited drinking water, few working sewers, limited electricity, and minimal medical facilities. Many of the affected families were forced to move into shelters or crowded homes with distant relatives.  
Natural disasters can have devastating effects on communities and can place individuals at risk for mental health problems. Previous research with adults and children suggests that PTSS can be prevalent after hurricanes and that PTSS are associated with increased health care usage in adults. Little is known about the role PTSS in parents play in children’s healthcare utilization. We extended previous research by determining the prevalence of PTSS, depression, and anxiety among parents of children attending UTMB pediatric clinics at 11 to 13 months post-Hurricane Ike (Objective 1). We assessed the relationship between parental PTSS/depression/anxiety and number of pediatric medical visits, including sick and routine visits (Objective 2). In addition, we examined the relationship between PTSS/depression/anxiety and parent report of child emotional/behavioral changes (Objective 3). Finally, we inquired about parent’s mental health seeking behavior for themselves and for their child (Objective 4).
CONCLUSIONS
Our results suggest that even after a year post-disaster, healthcare providers should consider screening parents for PTSS, depression, and anxiety and children for emotional/behavioral problems so that they can provide appropriate mental health support/referrals. Routine visits may provide a good opportunity to conduct this screening.
* p < 0.05
In the final logistic regression model, controlling for parent age, parent anxiety was related to routine medical visits (OR= 4.43 ;CI= 1.50, 13.09)
PARENTS WITH PTSS, DEPRESSION, AND ANXIETY:
MENTAL HEALTH HELP-SEEKING FOR THEMSELVES