prospective study of posttraumatic stress disorder in parents of children with newly diagnosed type...

Prospective Study of Posttraumatic Stress Disorderin Parents of Children With Newly Diagnosed

Type 1 Diabetes

MARKUS A. LANDOLT, PH.D., MARGARETE VOLLRATH, PH.D., JOSEPH LAIMBACHER, M.D.,

HANSPETER E. GNEHM, M.D., AND FELIX H. SENNHAUSER, M.D.

ABSTRACT

Objective: To determine the prevalence, course, and predictors of posttraumatic stress disorder (PTSD) in mothers and

fathers of children with newly diagnosed type 1 diabetes. Method: Forty-nine mothers and 48 fathers of 52 children (re-

sponse rate 65%) with newly diagnosed diabetes (age 6.5–15 years) were assessed at 6 weeks, 6 months, and 12 months

after the diagnosis with the Posttraumatic Diagnostic Scale. Results: The prevalence of current PTSD in mothers was

22.4% at 6 weeks, 16.3% at 6 months, and 20.4% at 12 months. In fathers, PTSD was found in 14.6%, 10.4%, and

8.3%, respectively. Mothers endorsed more symptoms of PTSD at all assessments. Multivariate analyses controlling

for demographics, metabolic control, and threat appraisals revealed that in mothers, the number of preceding life events

and PTSD symptoms at 6 months predicted PTSD at 12 months. In fathers, PTSD severity at 6 months was the only

significant predictor for PTSDat 12months.Conclusions: The results suggest that the diagnosis and treatment of diabetes

in their child constitute traumatic events for parents. The findings confirm the applicability of a posttraumatic stressmodel for

investigating the psychological impact of diabetes on parents. J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(7):682–689.

Key Words: chronic illness, childhood illness, diabetes mellitus, posttraumatic stress disorder, parental mental health.

Diagnosis and treatment of type 1 diabetes in a child areassociated with considerable stress in the parents. Thecomplex treatment regimen (insulin injection, dietarycontrol, exercise, monitoring of blood glucose) affectsalmost every aspect of daily living and places unique de-mands and emotional strains on the parents. It is there-fore not surprising that mothers and fathers of childrenwith diabetes are at risk of psychological dysfunction(Chaney et al., 1997; Hauenstein et al., 1989; Kovacset al., 1985; Northam et al., 1996; Thernlund et al.,

1996). Most studies show moderate to high initial psy-chological maladjustment in the first weeks after diag-nosis. Parental symptoms include depression, anxiety,grief reactions, and overall distress. This maladjustmentseems to diminish during the first year. However,Kovacs et al. (1990) found a slight increase in maternalsymptoms with illness duration. Moreover, parentalpsychological adjustment appears to be an importantpredictor of child metabolic control (Hesketh et al.,2004; Lernmark et al., 1999; Liss et al., 1998).

Surprisingly, there is only one pilot study on theprevalence of posttraumatic stress disorder (PTSD) inparents of children with newly diagnosed type 1 diabe-tes (Landolt et al., 2002). This is particularly strikingbecause learning that one’s child has a life-threateningdisease is a qualifying event for PTSD according to theDSM-IV (American Psychiatric Association, 1994).Moreover, high rates of posttraumatic stress symptomsand PTSD have been found in parents of children withother potentially life-threatening diseases such as cancer(Barakat et al., 1997; Kazak et al., 1998; Landolt et al.,2003; Pelcovitz et al., 1996).

Accepted February 3, 2005.Drs. Landolt and Sennhauser are with the University Children’s Hospital

Zurich, Switzerland. Dr. Vollrath is with the University of Oslo, Institute ofPsychology, Norway. Dr. Laimbacher is with the Children’s Hospital, St. Gallen;and Dr. Gnehm with the Children�s Hospital, Aarau, Switzerland.This study was funded by grants from the Gebert-Ruef-Foundation, the Hugo

and Elsa-Isler-Foundation, and Bayer Diagnostics.Correspondence to Dr. Markus A. Landolt, Department of Psychosomatics

and Psychiatry, University Children’s Hospital, Steinwiesstrasse 75, CH-8032Zurich, Switzerland; e-mail: [email protected]/05/4407–0682�2005 by the American Academy of Child

and Adolescent Psychiatry.

DOI: 10.1097/01.chi.0000161645.98022.35

682 J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 44:7, JULY 2005

Several arguments support the notion that posttrau-matic stress may be a viable model for conceptualizingthe psychological impact of child diabetes on parents.First, the very onset of the disease may be traumatizingfor some parents (Thernlund et al., 1996). Some childrenbecome acutely ill and may be hospitalized in an inten-sive care unit, an experience that confronts parents withthe potential death of their child. Second, type 1 diabetesis still associated with significant morbidity, complica-tions, and shortened life expectancy despite remarkableimprovements in treatment regimens. Third, parentsmay be traumatized as a consequence of being responsi-ble for administering a treatment that involves a consid-erable amount of stress for the child. For example, thechild may experience the daily injections of insulin aspainful and as a threat to his or her physical integrity.Fourth, in a previous pilot study, the prevalence of PTSD6 weeks after child diagnosis of type 1 diabetes was foundto be 24% in mothers and 22% in fathers (Landolt et al.,2002). In sum, the diagnosis of diabetes may result ina psychological trauma with an acute phase (diagnosis,initial treatment) followed by subsequent chronic stres-sors (invasive treatment, threat of hypoglycemia, hyper-glycemia, and medical late effects).The purpose of the present study was twofold: (1) We

aimed to prospectively assess the prevalence and course ofPTSD in mothers and fathers of children with newly di-agnosed type 1 diabetes. Based on theoretical consider-ations and findings of a previous study (Landolt et al.,2002), we expected to find higher rates of PTSD in thisgroup than in the general population. Moreover, it washypothesized that prevalence of PTSDwould significantlydecrease within a year. (2)We aimed to investigate demo-graphic- and illness-related predictors of PTSD inparents of children with newly diagnosed diabetes. Also,the role of diabetes-related parental threat appraisals inpredicting PTSD was to be examined. We hypothesizedthat poorermetabolic control and higher threat appraisalswould increase the rates of parental PTSD.

METHOD

Participants

Mothers and fathers of 80 children (32 girls, 48 boys) with newlydiagnosed diabetes treated in four different children’s hospitals inthe German-speaking part of Switzerland were invited to participatein the study. Parents were consecutively recruited over a 36-monthperiod and asked to participate in the study within the first 2 weeksafter diagnosis if their child met all the following criteria: (1) new

diagnosis of type 1 diabetes, (2) no major systemic illness other thandiabetes, (3) sufficient command of the German language, and (4)no evidence of mental retardation. Parents were recruited only iftheir child was between 6.5 and 15 years of age at diagnosis becausethe children took part in a separate study on psychosocial issues indiabetes requiring an age restriction. Sixty-seven (83.8%) of 80 pa-rents whose children met the recruitment criteria agreed to partic-ipate. The main reason given for nonparticipation was that the studyseemed too time-consuming or that the parents felt overwhelmed.Due to incomplete data at one of the three assessments, 18 mothersand 19 fathers were excluded from further analyses. The final samplecomprised 49 mothers and 48 fathers of 52 families (response rate65% of eligible 80 families). There were no significant differencesbetween participating parents and parents who either did not par-ticipate or had incomplete data with regard to age (t = 1.42, p = .16)and gender of the child (x2 = 0.33, p = .57). The sample includes 30parents from a previous pilot study that reported on PTSD symp-toms 6 weeks after the child’s diagnosis of diabetes (Landolt et al.,2002).

Measures

Posttraumatic Diagnostic Scale (PDS) (Foa et al., 1997). Thiswidely used self-report measure of PTSD yields both a diagnosisaccording to DSM-IV criteria and a rating of PTSD symptom se-verity. Parents were asked to rate the presence of each of the 17symptoms of PTSD on a 4-point Likert scale ranging from ‘‘notat all’’ (0) to ‘‘very much’’ (3). To ensure assessment of diabetes-related PTSD, items were worded such that the symptoms wereclearly related to the diabetes of the child. For example, item 1 askedwhether the parents had intrusive images related to the onset andtreatment of their child’s diabetes. Total symptom severity scoresrange from 0 to 51, with higher scores representing greater severity.In addition, for each of theDSM-IV criterion clusters, the PDS pro-vides dichotomous and continuous data. Both the number of symp-toms and symptom severity are endorsed. The questionnaireincludes nine items assessing impairment caused by the traumain different areas of life, using a yes/no format. In its original Englishversion, the PDS has demonstrated high internal consistency (a =.92) and good test-retest reliability (k = 0.74) (Foa et al., 1997).Agreement between PTSD diagnoses obtained from the PDS andthe Structured Clinical Interview for DSM-III-R PTSD modulewas 82%. The sensitivity of the PDS was 0.89 and its specificitywas 0.75. The present study used the German version of thePDS, which has been validated previously (Steil and Ehlers,2000). In the present sample, internal consistency at initial assess-ment was a = .81 for fathers and a = .77 for mothers. In accordancewith the DSM-IV, PTSD was diagnosed if participants reported atleast one re-experiencing symptom, three avoidance symptoms, twoarousal symptoms, and impairment in at least one life area. A symp-tom was rated as present if the respective item was scored 1 or greater(Foa et al., 1997). Partial PTSD was defined restrictively: partici-pants were required to have at least one symptom in each of the threePTSD symptom clusters (Stein et al., 1997).

Socioeconomic status (SES) was calculated by means of a scorereflecting both paternal occupation and maternal education (range2–12 points).

Three social classes were defined as follows: SES scores 2–5, lowerclass; SES scores 6–8, middle class; and SES scores 9–12, upper class.This measure has been shown to be a reliable and valid indicator ofSES in our community (Landolt et al., 2003).

PARENTAL PTSD IN CHILDREN WITH DIABETES

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 44:7, JULY 2005 683

Life Events. The occurrence of 12 major life events, such as changeof domicile, unemployment, or parental separation, was assessed byusing the mothers as informants. Appropriate events for our samplewere selected from previously published life event scales (Paykel,1983). A life events sum score was computed by counting the num-ber of life events. Life events were assessed at 6 weeks for the previous12 months, at 6 months for the time since diagnosis, and at 12months for the time between the 6- and the 12-month assessment.Metabolic Control. Quality of metabolic control at 6 and 12

months was assessed by measuring glycosylated hemoglobin(HbA1c). The HbA1c assay is an index of the mean concentrationof blood glucose attached to hemoglobin for the 6- to 10-week pe-riod preceding the day of blood sampling. According to the DiabetesControl and Complications Trial guidelines (Diabetes Control andComplications Trial Research Group, 1993), glycemic control isconsidered ‘‘good to excellent’’ with HbA1c £8.0%, ‘‘fair’’ withHbA1c 8.1%–10.0%, and ‘‘poor’’ with HbA1c >10.0%. In addi-tion, number of episodes of severe hypoglycemia (defined accordingto the Diabetes Control and Complications Trial guidelines) duringthe study period was assessed for each patient. Such episodes arelife threatening and require immediate medical intervention. Also,at 6 weeks and 6 and 12 months, endocrinologists were asked torate patient compliance with the treatment regimen using a 3-pointLikert scale ranging from poor (0) to good (2).

Procedure

The study was approved by the research ethics committees of allinvolved hospitals. After obtaining informed written consent fromthe parents, questionnaires were mailed to mothers and fathers6 weeks and 6 and 12 months after diagnosis of diabetes in theirchild. Parents were asked to complete their questionnaires separatelyand not to consult each other. Demographic and medical data wereretrieved from the patients’ hospital records.

Statistical Analyses

Data were analyzed using the statistical package SPSS, release 11(SPSS Inc., Chicago, IL). All analyses were performed with two-sidedtests; p < .05 was considered significant. Repeated measures analysisof variance and Cochran Q test were used to examine the course ofPTSD over time. Because of potential dependencies between thedata collected for mothers and fathers in the same family, meansof symptom severity and number of symptoms were comparedby paired t tests. Pearson correlation coefficients were computedto examine the relationship of overall PTSD symptom severity withdemographic and illness-related variables. Two linear regressionmodels were set up for mothers and fathers using PTSD symptomseverity at 12 months as a dependent variable. Independent variableswere chosen based on previous knowledge and statistical importanceof the variables in this study.

RESULTS

Characteristics of the Sample

Descriptive information about the sample is con-tained in Table 1. Boys were slightly overrepresentedamong our patients. Most families were from the upperor middle class, probably as a result of the language

requirement (many non-Swiss nationals are from thelower class). Overall, metabolic control and treatmentcompliance of the children were excellent. At 6 months,92.2% of the children had HbA1c levels of £8%; at 12months, this was the case for 84% of the children. Threepatients had an episode of severe hypoglycemia duringthe study period. At 6 weeks and 6 months, 90.4% ofthe children were rated as perfectly compliant. At 12months, this was true for 76.9%. None of the patientsshowed poor compliance during the study period.

Prevalence of PTSD

PTSD symptoms in parents at 6 weeks and 6 and 12months after diagnosis of diabetes in their child arelisted in Table 2. Prevalence of current PTSD amongmothers was 22.4% at 6 weeks, 16.3% at 6 months,and 20.4% at 12 months. In fathers, PTSD was foundin 14.6% at 6 weeks, in 10.4% at 6 months, andin 8.3% at 12 months. In addition, between 32.7%and 79.6% of mothers and 29.2% and 56.3% of fathersmet criteria for partial PTSD at one of the three as-sessment points. In both parents, symptoms of re-experiencing and hyperarousal were reported most oftenat all assessments than symptoms of avoidance and psy-chic numbing. At 6 weeks, intrusive images (PDS item 1)

TABLE 1Patient Characteristics

No. 52 (100%)Gender

Female 22 (42.3%)Male 30 (57.7%)

Age at diagnosis (yr)

Mean (SD) 10.5 (2.7)Living with both biological parents 45 (86.5%)Socioeconomic statusLower 2 (3.9%)

Middle 39 (75.0%)Upper 9 (17.3%)Unknown 2 (3.9%)

No. of life eventsMean preceding 12 mo (SD) 1.4 (1.7)Mean at 6 mo (SD) 0.8 (0.9)

Mean at 12 mo (SD) 1.0 (1.4)Days in hospitalMean (SD) 14.3 (7.6)

Range 3–36HbA1c (%)Mean at 6 mo (SD) 6.8 (0.9)Mean at 12 mo (SD) 7.3 (1.1)

LANDOLT ET AL.


were the most prevalent symptom among parents(85.7% of mothers, 87.5% of fathers). Parents reportedto repeatedly re-experience the situation in which theywere informed of the diagnosis by the physician. Also,some parents had intrusive images and thoughts aboutthe poor condition of their child at diagnosis and thechild’s reaction to the medical treatment. Notably,intrusive images continued to be the most prevalentsymptom at 6 and 12 months.

Repeated-measures analysis of variance showed sig-nificant differences in the number and severity of symp-toms among allDSM-IV symptom clusters for mothers.In fathers, the decrease of symptomatology withinthe first year was also significant for symptoms of re-experiencing and hyperarousal but not for avoidanceand psychic numbing. Symptom decrease occurredmainlybetween 6 weeks and 6 months after diagnosis of dia-betes. Interestingly, in both parents, the rates of PTSD

TABLE 2PTSD Symptoms and Diagnosis in Mothers and Fathers at 6 Weeks and 6 and 12 Months

6 Wk 6 Mo 12 Mo F Q p

Mothers (n = 49)Reexperiencing% who met DSM-IV criteria 93.9 67.3 65.3 16.63 <.0005

Mean no. of symptoms (SD) 2.7* (1.5) 1.7 (1.6) 1.6 (1.6) 14.53 <.001Mean symptom severity (SD) 5.0* (3.7) 2.1 (2.3) 2.3 (3.0) 18.66 <.001

Avoidance/psychic numbing

% who met DSM-IV criteria 22.4 18.4 22.4 0.73 .70Mean no. of symptoms (SD) 1.7* (1.4) 1.1 (1.7) 1.2 (1.7) 3.40 .04Mean symptom severity (SD) 2.8* (2.3) 1.4 (2.1) 1.7* (2.5) 9.25 <.001

Hyperarousal% who met DSM-IV criteria 75.5 44.9 38.8 20.67 <.0005Mean no. of symptoms (SD) 2.5*** (1.4) 1.7*** (1.7) 1.4* (1.6) 10.93 <.001Mean symptom severity (SD) 4.2*** (3.0) 2.3*** (2.5) 2.0** (2.5) 14.37 <.001

All three symptom clusters% who met DSM-IV criteriafor full PTSD

22.4 16.3 20.4 1.40 .50

% who met criteria for partial PTSD 79.6 38.8 32.7 32.35 <.0005Mean PTSD total symptom severity

(SD) 11.9*** (7.4) 5.8* (6.1) 6.0* (6.8) 17.32 <.001

Fathers (n = 48)Reexperiencing% who met DSM-IV criteria 93.8 77.1 72.9 10.50 <.01

Mean no. of symptoms (SD) 2.4 (1.3) 1.5 (1.2) 1.5 (1.3) 8.15 <.001Mean symptom severity (SD) 4.0 (2.7) 2.1 (1.8) 2.0 (2.0) 10.22 <.001

Avoidance/psychic numbing% who met DSM-IV criteria 16.7 12.5 12.5 0.50 .78

Mean no. of symptoms (SD) 1.2 (1.3) 0.9 (1.1) 0.8 (1.3) 1.33 .28Mean symptom severity (SD) 1.9 (2.7) 1.0 (1.3) 0.9 (1.4) 2.74 .08

Hyperarousal

% who met DSM-IV criteria 52.1 31.3 25.0 11.12 <.01Mean no. of symptoms (SD) 1.7 (1.2) 0.9 (1.0) 0.9 (1.2) 9.51 <.001Mean symptom severity (SD) 2.5 (2.0) 1.0 (1.2) 0.9 (1.3) 13.84 <.001

All three symptom clusters% who met DSM-IV criteria for

full PTSD 14.6 10.4 8.3 1.08 .58% who met criteria for partial PTSD 56.3 41.7 29.2 9.41 <.01

Mean PTSD total symptom severity(SD) 8.4 (6.2) 4.1 (3.5) 3.8 (4.0) 11.10 <.001

Note: Significant differences between mothers and fathers (paired t tests; *p < .05; **p < .01; ***p < .001). PTSD = posttraumatic stress

disorder.



diagnoses did not change significantly over time. Nota-bly, four mothers and six fathers showed delayed onsetof PTSD, i.e., meeting criteria for diagnosis only at 6or 12 months but not at 6 weeks. Considering delayedonset in some parents and recovery in other parents, 15mothers (30.6%) and 13 fathers (27%) had PTSD atone time during the study period.

Comparison of Mothers and Fathers

Table 2 shows that mothers reported a significantlyhigher number and greater severity of symptoms in allsymptom clusters at 6 weeks than fathers. Moreover, thepercentage of mothers with full or partial PTSD at 6weeks was higher than among fathers. At 6 and 12months, mothers and fathers differed only in numberand severity of hyperarousal symptoms. However, thepercentage of full and partial PTSD as well as PTSDtotal symptom severity remained higher in mothersat 6 and 12 months. Overall, mothers showed or tendedto show more symptoms at all times.

Predictors of Posttraumatic Stress Symptomatology

In Table 3, the correlations between demographic andmedical variables and parents’ PTSD severity at 6 weeksand 6 and 12 months are presented. Notably, at all time

points, demographic variables such as child age, child gen-der, SES, and family structure (one versus two parent fam-ilies) were not significantly associated with the parentalPDS total scores. The same was true for life events occur-ring after the diagnosis of diabetes. Parental threat apprais-als at 6 weeks were significantly correlated with symptomsof PTSD at 6weeks. Inmothers, preceding life events weresignificantly related with PDS scores at 6 and 12 months.With regard to illness-related variables, length of hospitalstay predicted fathers’ PDS scores at 6 weeks. In addition,poorer metabolic control at 6 and 12 months was associ-ated with parental PTSD. Notably, all mothers but noneof the fathers of our three patients with an episode of se-vere hypoglycemia showed full PTSD at 12 months. Pa-tient compliance at 6 weeks was positively related to PTSDseverity inmothers at 6 weeks. Finally, inmothers, severityof PTSD at 6 weeks and 6months was significantly relatedto the symptomatology at follow-up. Interestingly, infathers, only PTSD symptoms at 6 months predictedPTSD symptoms at 12 months.

Table 4 summarizes statistics for the regression modelpredicting PTSD symptom severity at 12 months inmothers. The selected variables accounted for 52% ofthe variance in the PDS scores. The number of preced-ing life events and symptomatology at 6 months

TABLE 3Correlations Between Demographic and Medical Variables and Parental PTSD Severity (PDS Total Score)

Mothers Fathers

6 Wk 6 Mo 12 Mo 6 Wk 6 Mo 12 Mo

Child age –0.06 –0.01 –0.07 0.23 –0.14 –0.14

Gender (0 = m; 1 = f) –0.12 –0.21 –0.26 –0.24 –0.06 0.00Socioeconomic status 0.18 0.07 –0.13 –0.04 –0.04 0.00Living with both biological

parents –0.21 –0.26 –0.16 –0.10 0.11 0.07Threat appraisal at 6 wk 0.34* 0.20 0.17 0.51*** 0.00 0.08Life events in preceding 12 mo 0.15 0.29* 0.38** 0.02 0.00 0.00

Life events at 6 mo 0.16 0.15 –0.15 –0.17Life events at 12 mo 0.07 –0.01Days in hospital 0.05 0.13 0.00 0.31* 0.00 –0.14HbA1c at 6 mo 0.31* 0.30* 0.16 0.32*

HbA1c at 12 mo 0.50*** 0.21Patient compliance at 6 wk 0.37** 0.14 0.12 0.18 –0.02 0.08Patient compliance at 6 mo 0.08 0.12 0.00 0.06

Patient compliance at 12 mo –0.11 –0.17PDS total score at 6 wk 0.45*** 0.30* 0.21 0.13PDS total score at 6 mo 0.71*** 0.72***

Note: *p < .05; **p < .01; ***p < .001; Pearson correlations.PTSD = posttraumatic stress disorder; PDS = posttraumatic diagnostic scale.

LANDOLT ET AL.


contributed with significant b weights. Child age, childgender, threat appraisals at 6 weeks, metabolic controlat 6 months, and PTSD symptomatology at 6 weeksdid not contribute significantly to the prediction of PTSDat 12 months.In Table 5, statistics for the regression model predict-

ing PDS scores in fathers at 12 months are presented.Overall, the highly significant model explained 42% ofthe variance. The strongest predictor of PTSD at 12months was the symptomatology at 6 months. Thus,fathers with more severe PTSD symptoms at 6 monthswere at greatest risk of PTSD at 12 months. In addition,metabolic control at 6 months predicted PDS scores at12 months nearly significantly (p = .07).

DISCUSSION

To our knowledge, this is the first study to prospec-tively examine the course of PTSD in mothers and fa-thers of children with newly diagnosed type 1 diabetes.Supporting earlier findings of a pilot study (Landoltet al., 2002), our results showed remarkable rates of

parental PTSD at 6 weeks and 6 and 12 months afterdiagnosis of diabetes. Specifically, between 16% and22% of the mothers and 8% and 14% of the fathershad a current PTSD diagnosis. In addition, a significantgroup of parents met criteria for partial PTSD. Rates ofPTSD were significantly higher than those reportedfrom community samples in the United States (Kessleret al., 1995; Stein et al., 1997) and inGermany, a societythat is similar to Switzerland (1% in men, 2.2% inwomen [Perkonigg et al., 2000]). Interestingly, ratesof PTSD in this study were similar to those previouslyfound in mothers of children with cancer (Pelcovitzet al., 1996). This supports our notion that the elevatedrates of PTSD among parents in our sample are a con-sequence of their child’s diabetes.Consistent with previous longitudinal studies using

measures of general psychopathology (Kovacs et al.,1985, 1990; Northam et al., 1996; Thernlund et al.,1996) and in agreement with our hypothesis, we founda significant decrease in the number and severity ofparental PTSD symptoms over a period of 12 monthsafter diagnosis of diabetes in their child. Notably, thereduction occurred mainly between 6 weeks and 6months after the diagnosis. This is in line with findingsby Kovacs et al. (1985). However, symptoms did notdisappear entirely, and parental morbidity remainedelevated at 6 and 12 months. Specifically, the prevalenceof PTSD diagnoses according to DSM-IV did not sig-nificantly decrease over time. This is consistent withstudies among parents of pediatric cancer survivors thatfound PTSD symptoms to persist for many years(Kazak et al., 1997; Pelcovitz et al., 1996). In mothers,our findings even suggest that symptoms of PTSDslowly increased again during the 6- to 12-monthperiod after diagnosis. Again, this is in line with thefindings of Kovacs et al. (1990) who found a slightincrease in maternal depression and anxiety with illnessduration. Overall, our results show that the onset andinitial treatment of diabetes in a child is associated withconsiderable acute and ongoing traumatic stress for theparents.In this sample, both mothers and fathers were af-

fected by the illness of their child, although motherswere more likely to endorse symptoms of PTSD atall assessments. This corresponds with previous studiesof traumatized and community samples that have con-sistently found women to have a higher risk of PTSD(Stein et al., 1997). Also, this is consistent with findings

TABLE 4Regression Analysis Predicting PTSD Severity (PDS Total Score)

at 12 Months in Mothers

Variable b Significance b Partial r

Child age –.02 .83 –0.04Child gender –.09 .42 –0.13

Preceding life events .23 .04 0.32Threat appraisal at 6 wk .05 .66 0.07HbA1c at 6 mo .10 .39 0.14

PDS total score at 6 wk –.09 .46 –0.12PDS total score at 6 mo .64 <.0005 0.62

Note: F = 8.09; p < .0005; R 2 = 0.60, R 2 adjusted = 0.52.

TABLE 5Regression Analysis Predicting PTSD Severity (PDS Total Score)

at 12 Months in Fathers

Variable b Significance b Partial r

Child age .01 .91 0.02Child gender .07 .55 0.10

Preceding life events .01 .91 0.02Threat appraisal at 6 wk –.09 .51 –0.11HbA1c at 6 mo .23 .07 0.30PDS total score at 6 wk .03 .83 0.04

PDS total score at 6 mo .63 <.0005 0.65

Note: F = 5.38; p < .0005; R 2 = 0.51, R 2 adjusted = 0.42.



by Kovacs et al. (1985). Although data on fathers wereless complete in their study, Kovacs et al. found higherrates of depression and anxiety in mothers than in fa-thers. Probably the higher rates of PTSD and othersymptoms of psychological maladjustment amongmothers result from their carrying most of the respon-sibility and burden of diabetes care.In both parents, the best predictor of PTSD severity

at 12 months was PTSD severity at 6 months, whereasPTSD severity at 6 weeks was not predictive, when thePTSD level at 6 months was controlled. Perhaps, theresponse at 6 weeks is part of an acute stress reactionthat is not related to the long-term risk of PTSD. Thisis in contrast to findings by Kovacs et al. (1990) andThernlund et al. (1996) who found the degree of theinitial emotional reaction in the first weeks to be thebest predictor of subsequent symptomatology amongmothers. However, these studies assessed general psy-chopathology and not PTSD.Interestingly, in mothers, the number of preceding life

events was found to be a significant predictor of PTSD atfollow-up. This indicates a possible long-lasting negativeeffect of stressful events on the long-term psychologicaladjustment ofmothers. From a clinical point of view, thisfinding underlines the necessity of a careful evaluation ofthe parental history. Whereas metabolic control was nota significant predictor of PTSD in the regression analyses,significant associations between HbA1c and parentalPTSD at follow-up were found in bivariate analyses,indicating that poorer metabolic control was related tomore PTSD symptoms. Also, the mothers of childrenwith an episode of severe hypoglycemia all had PTSD.These associations suggest that an unfavorable courseof the disease may contribute to maternal traumatic ex-periences. A similar pattern was found in fathers in whomthe predictive value ofHbA1cwith regard to PTSD symp-toms at follow-up barely missed statistical significance.With regard to the etiology of parental PTSD, this

study does not allow any definite conclusions. Evenso, the comparison with community samples, thediabetes-related wording of PDS items, the specificsymptoms reported by the parents, and the high threatappraisals at 6 weeks strongly suggest that high rates ofparental PTSD in our sample are the result of the child’sdiabetes. Two possible etiologic factors may be consid-ered: the shock of the diagnosis and traumatic aspects ofmedical treatment. Elevated initial PTSD symptom lev-els and high parental threat appraisals at 6 weeks suggest

that the shock of the child’s diagnosis may be important.The findings that child metabolic control and numberof episodes of severe hyperglycemia were related toPTSD and that a number of parents showed delayedonset of PTSD support the hypothesis that treatment-related stressors may be crucial as well. However, thisstudy was not able to identify any additional demographicor medical predictors of PTSD. Specifically, parentaldistress was not related to SES or the gender of thechild. In addition, contradicting our hypothesis, threatappraisals at baseline were not related to PTSD at12 months.

Limitations

Some limitations of this study merit note. First, nocontrol group and no data on premorbid parental ad-justment were assessed. However, as mentioned above,there are several arguments that strongly suggest thatparental PTSD is a consequence of the illness of theirchildren. Second, this study examined a middle to up-per class sample. Thus, generalization of our findings toother groups of parents should be done judiciously.Third, 35% of parents eligible for this study refusedto participate or provided incomplete data. Possibly,some of those did so because of avoidance characteristicsof PTSD or because they were well adjusted and thequestionnaire was not relevant to them. Both caseswould affect prevalence estimates of PTSD. Althoughcomparison of study completers and dropouts revealedno differences with regard to PTSD severity at 6 weeks(mothers: t = 0.18, p = .86; fathers: t = 0.88, p = .38), it isstill possible that parents who had experienced fewersymptoms at 6 and 12 months may have droppedout more likely. Fourth, only one self-report question-naire of PTSD has been used. Different rates of PTSDmight have been found if structured clinical interviewshad been administered. However, the reported sensitiv-ity and specificity of the PDS are high. Finally, ourmeasure aimed only at PTSD. Because of possiblecomorbidity, inclusion of standardized instrumentsassessing depression and anxiety in parents would havebeen useful. Despite these limitations, this study is theonly prospective study of PTSD in parents of childrenwith newly diagnosed diabetes so far. It provides prelim-inary evidence that a sizable group of mothers andfathers has PTSD symptoms that are related to the onsetand treatment of diabetes in their child.

LANDOLT ET AL.


Implications

This study suggests several possible issues for futureresearch activities. Our findings support the applicabilityof a posttraumatic stress model for investigating the psy-chological impact of child diabetes on parents. Becauseour sample size was limited, our findings need to be rep-licated in larger samples and, if possible, in other coun-tries. More knowledge is needed regarding the extent towhich illness-related demands versus routine daily stres-sors contribute to parental PTSD. Future studies shouldassess this in more detail. Because the relationship be-tween parental and child adjustment is well docu-mented in childhood chronic diseases (Frank et al.,1991), future studies should investigate the influenceof parental PTSD on child adjustment and metaboliccontrol. Possibly parental PTSD impairs parental func-tioning and thereby affects the psychological adjustmentand metabolic control of the child with diabetes.There are also clinical implications that can be drawn

from this study.Our findings confirm the need for carefulevaluation of PTSD in parents of children with diabetes.Although most mothers and fathers adjust well, a signif-icant minority continues to have full or partial PTSD.Early identification of these individuals would provideopportunities for psychological interventions that havebeen found to be effective in treating PTSD, thus en-hancing the quality of life of families with children withnewly diagnosed diabetes. In addition, the findings of thisstudy highlight the specific vulnerability of mothers.Clinical interventions have to consider the specific situ-ation of mothers and should help to minimize their dis-tress, particularly during the first months after diagnosis.

Disclosure: Dr. Landolt obtained a research grant for this study fromBayer Diagnostics. The other authors have no financial relationshipsto disclose.

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