university of pennsylvania school of medicine the children’s hospital of philadelphia effect of...

University of Pennsylvania School of Medicine

The Children’s Hospital of Philadelphia

Effect of Parental Depression on

School Attendance and Emergency

Room Use

James Guevara, MD, MPH

David Mandell, ScD

Thomas Crowder

Shooshan Danagoulian, MA, MSc

Jacqueline Reyner, BA

Susmita Pati, MD, MPH

The Children’s Hospital of PhiladelphiaUniversity of Pennsylvania School of MedicineUniversity of California, Berkeley

The Children's Hospital of Philadelphia


Background

• Asthma and ADHD are each associated with increases in emergency department (ED) visits and school absences

• Parental depression results in parenting behaviors that have been associated with increases in ED visits and may increase school absences

• Not clear whether effects of parental depression are independent of child chronic health conditions



Study Aims

1. To estimate the prevalence of parental depression in a nationally representative population of children

2. To determine the independent association of parental depression and school attendance/ED use among children with and without chronic health conditions



Study Design• Secondary analysis of 1997-2004 National Health

Interview Survey (NHIS)

• NHIS employs multistage probability sampling scheme to provide nationally representative data on civilian non-institutionalized population in U.S.

• NHIS comprised of 4 core components: Household, Family, Sample Adult, and Sample Child

• Household, Sample Adult, and Sample Child components were merged for each year using unique family reference and child identifiers



Main Independent Variables

•ADHD and asthma were identified by parent report of health conditions

-“Have you ever been told your child has…”

•Parental depression was measured by 3 questions assessing sadness, hopelessness, or worthlessness among adult household members over past 30 days

-Responses of “All” or “Most of the time” to any of 3 questions were categorized as depression



Main Outcomes

•School absences and ED visits reported by adult respondents

•School absences: days of school missed due to illness or injury in past 12 months

•ED visits: number of visits to a hospital ER for child’s health in past 12 months



Potential Confounding Variables•Child: age, sex, race, insurance status

•Family: maternal education status, parents present in household, family income category

•Survey: survey year



Analysis

•Data were weighted to reflect complex sampling design

•Bivariate analyses of outcomes with independent main and potential confounding variables

•Multivariate weighted regression models were estimated for each outcome controlling for independent and confounding variables



Results

• 220,141 children <18 years old in survey over all 8 years

• Of these, 104,930 children had data available on all child and family variables

• This sample weighted to represent 58,000,000 children in U.S.



Prevalence of Health Conditions

0

2

4

6

8

10

12

14

Pro

po

rtio

n (

%)

Asthma ADHD Parental Depression



Demographic Characteristics of Sample

Characteristic Asthma N=12.0%

ADHD N=5.3%

Depression N=1.8%

Full Sample N=100%

Mean Age (SE) 9.8 (0.1) 11.6 (0.1) 9.1 (0.1) 8.5 (0.1) Male (%) 60.0 73.4 48.7 51.2 Non-white (%) 40.1 25.8 54.0 37.5 Single Parent Family (%) 35.4 37.6 67.6 27.7 Maternal Education ≤ High School

44.9

44.3

67.6

44.9

Family Income <100% FPL

19.9

17.9

50.3

16.9

Insurance Public None

28.8 8.3

29.7 8.6

51.9 17.6

22.9 10.7



Prevalence of Parental Depression

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Pro

po

rtio

n (

%)

Asthma ADHD Neither



Adjusted increase in ED visits and School Absences

Asthma N=12.0%

ADHD N=5.3%

Depression N=1.8%

School Absences/yr (95% CI)

2.4 (2.1-2.6) 1.1 (0.8-1.4) 1.8 (0.6-2.9)

ED Visits/yr (95% CI)

0.28 (0.26-0.30) 0.08 (0.05-0.11) 0.09 (0.03-0.14)

*Adjusted for age, sex, race, parent status, maternal education level, poverty status, insurance status, and year



Conclusions• Parental depression was low in this sample using

available measures

• Depression was more common among parents of children with chronic health conditions than those of children without

• Depression was more common among single, poor, and minority parents

• Children of depressed parents have similar increases in school absences and ED use as children with common chronic health conditions



Limitations

•Adult respondent report of school absences and ED visits may reflect recall bias

•Lack of validated depression measure in survey may underestimate parental depression



Implications

•Strategies to improve recognition and treatment of parental depression in pediatric health settings should be disseminated

•Strategies should target those at greatest risk: minorities, single parents, impoverished, or have children with chronic health conditions

•Future research using nationally representative surveys may benefit from inclusion of validated measures of depression



Acknowledgments

• This study was funded by NIH grants MH065696 and HD047655

• The authors have no conflicts of interest to declare

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