Relation between parental psychopathology symptoms and posttraumatic growth after a child's admission to intensive care: Two faces of the same coin?

ContentslistsavailableatScienceDirect

Intensive

and

Critical

Care

Nursing

jo u r n al ho m e p a g e :w w w . e l s e v i e r . c o m / i c c n

Original

article

Relation

between

parental

psychopathology

and

posttraumatic

growth

after

a

child’s

admission

to

intensive

care:

Two

faces

of

the

same

coin?

Rocío

Rodríguez-Rey

_,

_Jesús

_Alonso-Tapia

a_{EuropeanUniversityofMadrid,SchoolofBiomedicalSciences,DepartmentofPsychology} b_{UniversidadAutónomadeMadrid,DepartmentofBiologicalandHealthPsychology,Spain}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Accepted5August2017

Keywords:

Posttraumaticstress Anxiety

Depression Posttraumaticgrowth Paediatricintensivecare

a

b

s

t

r

a

c

t

Objectives:Confrontedwiththepotentially traumaticexperienceof achild’sadmissiontoa paedi-atricintensivecareunit,parentsmayexperiencepsychopathologicalpost-traumasymptomsaswell asposttraumaticgrowth.Theaimofthiscross-sectionalstudywastoexploretherelationbetween psy-chopathologysymptoms,namely,posttraumaticstressdisorder),anxietyanddepression,aswellaspost traumaticgrowthinparentsfollowingtheirchild’shospitalisationinapaediatricintensivecareunit.

Methods:Sixmonths aftertheirchild’sdischarge,143 parentscompletedthequestionnaire,which assessedposttraumaticgrowth(PosttraumaticGrowthInventory),posttraumaticstressdisorder( David-sonTraumaScale),depressionandanxiety(HospitalAnxietyandDepressionScale).

Results:Ofthe143parents,23.1%reportedsymptomsofposttraumaticstressdisorder,21%reported symptomsofmoderatetosevereanxiety,9.1%reportedsymptomsofmoderatetoseveredepression and37.1%reportedatleastamediumdegreeofposttraumaticgrowth.Therewasamoderate,direct associationbetweenposttraumaticstressdisorder,depressionandanxietywithposttraumaticgrowth. Higherscoresinanxiety,depressionandposttraumaticstressdisorderwereassociatedwithhigher levelsofposttraumaticgrowth,contradictingthenotionofaninvertedU-shapedrelationshipbetween psychopathologysymptomsandposttraumaticgrowth.

Conclusions:Giventhatpositiveandnegativeoutcomesafterachild’scriticaladmissiontendtoco-occur, itissurmisedthatparentswhoindicateposttraumaticgrowthdonotdenythedifficulties.Whilenot negatingthenegativeimpactonthementalhealthofaparentwithachildadmittedtointensivecare, includingtheassessmentofposttraumaticgrowthasanoutcomefollowingthiseventhasimportant implicationsforresearchandclinicalpractice.

©2017ElsevierLtd.Allrightsreserved.

Implicationsforclinicalpractice

•Parentswhohaveexperiencedthehospitalisationoftheirchildinapaediatric intensivecareunitdisplaysignificantlevelsof posttraumaticstress,anxiety,depressionandposttraumaticgrowthsixmonthspost-discharge.

•Aspositiveandnegativeoutcomesfollowingachild’sadmissiontothePICUtendtoco-occur,parentswhoindicateposttraumatic growthtendnottodenythedifficulties.

•Notconsideringthepossibilityofbothpositiveandnegativepsychologicalconsequencesofthisexperiencewouldprovidean incompleteviewofthepsychologicalimpactonparentsoftheircriticallyillchild’shospitalization.

•InterventionstofacilitatethepsychologicaladaptationofthefamilyfollowingtheadmissionofachildtothePICUshouldaimat preventingpsychopathologicalsymptomsandhelpingfamiliesfindgrowthandmeaningfollowingtheevent.

∗Correspondingauthors.

E-mailaddresses:[email protected](R.Rodríguez-Rey),[email protected](J.Alonso-Tapia).

http://dx.doi.org/10.1016/j.iccn.2017.08.005 0964-3397/©2017ElsevierLtd.Allrightsreserved.

Introduction

The existing literature on parental reactions after a child’s admissiontoa paediatricintensivecareunit(PICU) hasfocused on exploring the presence and severity of psychopathological reactions,primarilyposttraumaticstressdisorder(PTSD)andless frequently,anxietyanddepression(Bronneretal.,2008;Bronner

etal.,2010;ColvilleandGracey,2006;ColvilleandPierce,2012;

Faumanetal.,2011).However,overthepasttwodecades,there

hasbeenincreasingacknowledgementthatfacingtraumaticevents cancausetheindividualtofunctionatahigherlevelthanbefore,an eventtermedposttraumaticgrowth(PTG)(TedeschiandCalhoun, 1996).Asinglestudyhasexploredthisphenomenonamongparents ofcriticallyillchildrenandfoundmoderatelevelsofPTGamongthis group(ColvilleandCream,2009).

Thus,theevidencesuggeststhatfacingtheexperienceofhaving achildundergointensivecaretreatmentmayproducebothpositive andnegativeconsequencesforparents.However,aquestionthat hasemergedfromtheliteratureiswhetherPTGisrelatedtoahigher orlowerlevelofpsychopathologicalsymptomsfollowinga trau-maticevent.Understandingtherelationbetweentheseopposing consequencesofatraumaticeventwouldprovidevaluable infor-mationfordevelopinginterventionstrategies.Toourknowledge, onlyonestudy(ColvilleandCream,2009)hasexploredboththe positiveandnegativeoutcomesofhavingachildundergo inten-sivecaretreatment.Usingasampleof50parentsfourmonthsafter theirchild’sdischargefromaPICU,theyfoundaninvertedU-shape relationbetweenPTGandPTSD,withhigherlevelsofPTG corre-spondingtomediumlevelsofPTSDsymptoms.Theyalsofound thatPTGwasunrelatedtosymptomsofanxietyanddepression.

PreviousstudiesaimedatexploringtherelationbetweenPTSD symptomsandPTGwithavarietyoftrauma-exposedpopulations haveyieldedinconsistentresults.Tedeschi(2011)reportsthat facil-itatingPTGmayprovideopportunitiestoreducePTSDsymptoms amongcombatveteransandtheirfamilies.Consistentwiththis, somestudiessuggestthatPTGfollowingtraumaisassociatedwith lowerPTSDsymptomsovertime(Frazieretal.,2004;Ullrichand

Lutgendorf,2002).Conversely,otherstudieshavefoundthatPTSD

symptoms are positivelyassociated withPTG scores(Helgeson

etal.,2006;Levine etal.,2009;Morriset al.,2005;Takuetal.,

2007;Jinetal.,2014),andagain,otherstudieshavefoundthat

thesevariableswereuncorrelated(Powelletal.,2003).Barakatetal.

(2006)findapositiverelationbetweenposttraumaticstress

symp-tomsandPTG,whereas,consistentwiththeresultsbyColvilleand

Cream(2009),KleimandEhlers(2009)findacurvilinear

relation-shipbetweenPTGandpost-traumadepressionandPTSD.Although therelationbetweenPTGand depressionand anxietyhasbeen much less studied,the meta-analyticreview of Helgeson et al.

(2006)concludesthatPTGissignificantlyassociatedwithlower

depressionandunrelatedtoanxiety.

Thepicturethatemergesfromtheliteratureisthattherelation betweenpositiveandnegativeoutcomesaftertraumaisunclear. Inaddition,toourknowledge,onlythestudyofColvilleandCream

(2009)hasexploredthepositiveandnegativeoutcomesin

par-entsafterachild’sadmissiontothePICU.Therefore,inthisstudy, weaimtogatherevidenceabouttheassociationbetweenPTGand thesymptomsofpsychopathology,i.e.,symptomsofdepression, anxietyandPTSD,amongparentsofcriticallyillchildren.

Method

Setting

Data were collected from a PICU located in a tertiary level hospitalwith16beds,eightphysiciansand49nursingstaff.The

nurse-to-patientratiois2:1.Regardingpsychosocialservices pro-videdinthePICU,asocialworkerattendstofamiliesuponrequest, andapsychologistfromanon-governmentalorganisationprovides psychologicalsupporttwiceaweektothechildrenwithheart con-ditionsandtheirfamilies.

Ethicalapproval

The study was approved by the institutional review board (approvalnumber 13/015)ofthehospitalwhere thestudy was conducted.Allparticipantssignedaninformedconsentformthat guaranteedconfidentialityanddescribedthestudy,includingits purposes,potentialrisksandbenefits.

Participants

Theparentsofchildrenwhohadbeenadmittedformorethan 12hourstoa16-bedPICUinatertiaryhospitalinMadrid,Spain, wereaskedtoparticipateinthestudysixmonthspost-discharge oftheirchild.Exclusioncriteriaweretheinabilitytospeaksufficient Spanishtocompletethequestionnaireandthedeathofthechild duringtheadmissionorwithinthesixmonthfollow-upperiod.

Datacollection

Procedure

Thisstudywaspartof aseriesof studiesdesignedtoassess thepsychologicaloutcomesofhavingachildadmittedtoaPICU. TheparentsofeverychildthathadbeenadmittedtothePICUfor morethan12hourswerecontactedbyemail,postortelephonesix monthsafterthechild’sdischargefromthePICUandwereasked tocompleteandreturntheincludedquestionnaires.

Instruments

Medicaldata. DatatocompletethePaediatricIndexofMortalityII (PIM2;Slateretal.,2003),whichpredictsthemortalityriskinthe PICUduringthefirst24hoursofadmission,wereobtainedfrom thechild’smedicalrecords.Todeterminetheseverityofthechild’s conditionasperceivedbytheparent,theparentswereaskedto respond,usinganeight-pointLikertscalethatrangedfrom0to 7,tothefollowingquestion:Howseveredoyouthinkyourchild’s conditionwasatthetimeofyourchild’sadmissiontothePICU?

Davidson trauma scale (DTS; Davidson et al., 1997).The DTS is a 17-item self-report measure that assesses the 17 symptoms of PTSD as defined in the DSM-IV-TR (Diagnostic and Statisti-calManualofMentalDisorders-FourthEdition-TextRevision)and includedundercriteriaB:re-experiencing;C:avoidance/numbing andD:hyperarousal(AmericanPsychiatricAssociation.,2011).The DTSyieldsatotalscorerangingfrom0to136.Acut-offof40is recommendedforclassificationofthosewithPTSD,witha diag-nostic accuracy of 83% (Davidson et al., 1997). A more recent study(McDonaldetal.,2009)hasfoundthattheDTShasadequate internalconsistency(␣=0.97)andconcurrent,convergentand dis-criminantvalidity.TheSpanishversionhasdemonstratedadequate internalconsistency(␣=0.90)andtest-retestreliability(ICC=0.87)

(Bobes et al., 2000).The three DTS subscales (re-experiencing,

avoidance/numbing,andhyperarousal)werecomputedbyadding allsubscaleitemsanddividingbythetotalnumberusedinthescale

(McDonaldetal.,2009),resultinginapossiblerangeof0–4.

Hospitalanxiety anddepressionscale(HADS;ZigmondandSnaith, 1983). TheHADSisa14-item,self-reportingscreeningscalewith two7-itemLikertsubscales,oneforanxietyandonefor depres-sion.Forbothsubscales,ascoreof8–10indicatesamildcaseanda score≥11indicatesamoderatetoseverecase.Aliteraturereview

(Bjellandetal.,2002)findsthatCronbach’salphaforanxietyvaried from0.68to0.93(mean0.83)andfrom0.67to0.90(mean0.82) fordepression.Inthisstudy,weusedtheSpanishversion(Quintana etal.,2003).Arecentreviewaimedatexploringthepsychometric propertiesoftheSpanishHADS(Terol-Cantero&Cabrera-Perona, 2015)confirmsthetwo-factorstructureofthisscaleandreveals thatbothsubscaleshaveadequateinternalconsistency(␣ranging from0.80to0.87).

Posttraumaticgrowthinventory(PTGI;TedeschiandCalhoun,1996). ThePTGIisthebest-knownmeasuretoassessPTG.Itconsistsof21 itemswitha6-pointLikertresponseformatrangingfrom0(“Idid notexperiencethischangeasaresultofmycrisis”)to5(“Iexperienced thischangetoaverygreatdegreeasaresultofmycrisis”). Reliabil-ityofthePTGIwashighfortheoriginalversion(␣=0.90)andthe Spanishversion(␣=0.95)(WeissandBerger,2006).Toensurethat parents’responsesreferredtotheexperienceoftheirchild’s hos-pitalization,insteadofusingthephrase“asaresultofmycrisis”,we rewordedtheresponsestoread“asaresultofmychild’sadmission tothePICU”.AlthoughaccordingtoTedeschiandCalhoun(1996), thePTGIincludesfivedomains(appreciationoflife,interpersonal relationships, personal strength, new possibilities and spiritual PTG),theliteraturehasyieldedinconsistentresultsregardingthis factorstructure (Costa-RequenaandGil Moncayo,2007;Powell

etal.,2003;Hoetal.,2004;Takuetal.,2007).Consequently,the

PTGIfactor structure wasexamined in oursample, and it was foundthatathree-factormodelwithapersonal,aninterpersonal andatranspersonaldimensionfitourdatabetter(Rodríguez-Rey,

Alonso-Tapia,Kassam-Adams&Garrido-Hernansaiz,2016).Thus,

thisfactorstructurewasusedtoguidetheinterpretationofthe PTGIscoresinthepresentstudy.Toprovideresultscomparableto previousstudies,wealsocalculatedthescoresforthefiveoriginal factors

Dataanalysis

Descriptiveanalyseswereconductedtoestablishtheprevalence ofsymptomsofPTSD,anxiety,depressionandPTG.Next,bivariate Pearson’scorrelationanalyseswereconductedtoexplorethe rela-tionbetweenPTSDanditssubscales,anxiety,depressionandPTG anditssubscales.ToexplorethepossibilityofU-inverseshaped relationshipsbetweenanxiety,depressionandPTSDwithPTG,we calculatedaquadraticsolutionandcomparedittoalinearsolution. Ifthequadraticsolutionfitthedatabetterthanthelinearsolution, therelationbetweenpsychopathologysymptomsandPTGmaybe curvilinear.Asonlyparentswhocompletedthe21itemsofthePTGI wereincludedinthestudy,therearenomissingdatainthepresent study.

Results

Sampledescriptivedata

Atotalof158parentswereaskedtoparticipateinthestudy6 monthsaftertheirchild’sdischargefromthePICUofwhich143 parents(90.5%)of100childrenagreedtoparticipate.Descriptive dataofthesamplearesummarizedinTable1.

Levelofpsychopathologyandposttraumaticgrowth

OntheDTS,33parentsofthe143participants(23.1%)reported PTSDsymptomsoverthecutoffof40.Regardingthescoresonthe threeDTSsubscales,themostcommonPTSDsymptomwas hyper-arousal(M=0.96,SD=0.99),followedbyre-experiencing(M=0.71, SD=0.78),andavoidance/numbing(M=0.57,SD=0.74).

Table1

Socio-demographicandmedicalcharacteristicsforthechildrenandtheparents.

Socio-demographicdata

Children(n=99) Mean(SD)orn/% Parents(n=143) Mean(SD)orn/%

Age(months) 59.56(61.77) Age(years) 38.24(6.31)

Male 59/59.6 Male 52/36.4

Female 40/40.4 Female 91/63.6

Medicaldataofthechildren Mean(SD)orn/%

Illnessseverity(PIM2) 5.69(9.44) Parentalperceptionofseverityofthechild’scondition(0–7) 4.08(1.97)

Diagnosis

Heartdisease 29/29.3

Oncologicaldisease 18/18.2 Respiratorycondition 8/8.08

Others 44/44.44

ReasonsforPICUadmission

Recoveryafterplannedsurgery 68/68.7 Emergencymedicaltreatment 15/15.2 Relapseofachronicdisease 4/4 Accidentalinjury/emergencysurgery 12/12.1

Note.PICU=PediatricIntensiveCareUnit;PIM=aPediatricIndexofMortality.

Table2

PercentofSampleEndorsingPosttraumaticGrowth(PTG)inthefiveoriginal dimen-sionsofthePTGI,inthethreedimensionsofthePTGIthatemergedinoursample andinthetotalPTGIatleastinamediumdegree*.

%

Totalgrowth 37.1

Threefactorstructure

Personalgrowth 44.8

Interpersonalgrowth 54.5 Transpersonalgrowth 21 Five-factorstructure

Appreciationforlife 54.5 Perceivedstrength 46.2 Relatingtoothers 40.6 NewPossibilities 29.4 Spiritualchange 25.9

Note:PTGI:Posttraumaticgrowthinventory.*Atleastinamediumdegreemeans thattheaveragescoreis≥3.

OntheHADS,30parents(21%)reportedmoderate-severe anx-iety symptoms (scores ≥11), and 13 reported moderate-severe symptomsofdepression(9.1%).

TheaveragescoreonthePTGIwas47.40(SD=26.74).To deter-minethepercentageof thesamplewho experiencedsignificant PTG,we calculated thenumber of parentswho obtainedmean scoresofatleast3(“Ihaveexperiencedthischangetoamedium degree”)inthePTGItotalscore.Basedonthiscriterion,53parents (37.1%)experiencedpositivechangeatleasttoamediumdegree.

InTable2weareincludingthepercentageofparentswhoreported

PTGinthePTGIdimensionsoftheoriginalfive-factorstructureas wellasthethree-factorstructurethatemergedinoursample.

Relationbetweenpsychopathologyandposttraumaticgrowth

Table3presentsthecorrelationcoefficientsforPTGscoresand

symptomsofPTSD,anxietyanddepression.

AlthoughPTSDsymptomsweremoderatelyandpositively cor-relatedwithPTG,thesignificantcorrelationsbetweensymptoms ofanxietyanddepressionwithPTGwereweaker.Moreover,while interpersonalPTGwasmoderatelyandpositivelycorrelatedwith symptomsofPTSDandanxiety,itscorrelationwithdepressionwas significantalbeitweaker.TranspersonalPTG,however,was posi-tivelycorrelatedwithsymptomsofPTSD,anxietyanddepression.

Table3

CorrelationcoefficientsofthePTGI,theDTSandtheHADStotalscoresandsubscales.

PTGPers. PTGInterp. PTGTransp. DTS Intr. Avoid. Hyper. HADS-A HADS-D PIM2 PerceivedSeverity

PTG 0.911*** _0.825*** _0.754*** _0.277*** _0.269*** _0.215** _0.271*** _0.218** _0.200* _{0.060 0.207}*

PTGPersonal. 0.648*** _0.565*** _{0.151 0.157 0.128 0.158 0.075 0.081 0.041 0.159}

PTGInterpersonal 0.552*** _0.317*** _0.321*** _0.268*** _0.298*** _0.224** _0.167* _{0.081 0.185}*

PTGTranspersonal 0.306*** _0.289*** _0.179* _0.294*** _0.285*** _0.311*** _{−0.006 0.113}

DTS 0.863*** _0.759*** _0.924*** _0.673*** _0.677*** _{−0.050 0.151}

Intrusion 0.676*** _0.681*** _0.468*** _0.442*** _{0.022 0.281}

Avoidance 0.668*** _0.492*** _0.479*** _{−0.078 0.136}

Hyperarousal 0.736*** _.722*** _{−0.051 0.038}

HADS-A 0.835*** _{−0.091 −0.055}

HADS-D −0.084 −0.081

PIM2 0.363***

Note:PTGI=posttraumaticgrowthinventory;PTG=posttraumaticgrowth;DTS=DavidsonTraumaScale;HADS=HospitalAnxietyandDepressionScale;Pers.=personal; Interp.=interpersonal;Trans.=transpersonal;Intr.=intrusion;Avoid.=avoidance;Hyper.=hyperactivation;HADS-A=HospitalAnxietyandDepressionScale,subscale anx-iety;HADS-D=HospitalAnxietyandDepressionScale,subscaledepression;PIM2=paediatricindexofmortality2.

* _p≤.05. ** _p≤.01. ***_p≤.001.

Table4

LinearandquadraticrelationsbetweenPTG(DV)andPTSD,anxietyanddepression symptoms(IVs)(N=143).

IV Model R2 _p

PTSD Linear_Quadratic 0.077_0.093 0.001_0.001

Anxiety Linear 0.048 0.009

Quadratic 0.074 0.005

Depression Linear 0.040 0.017

Quadratic 0.040 0.057

AspresentedinTable3,onlyinterpersonalPTGexhibiteda sig-nificantcorrelationwithperceivedseverityofthechild’scondition, whilenoneofthefactorswascorrelatedwiththechild’sprobability todiewithinthefirst24hoursofadmissiontothePICU(PIM2).

Table4indicatestheadjustmentoflinearandquadratic

rela-tionsbetweenPTGandPTSD,anxietyanddepression.Aquadratic solutionbetweenPTSDandPTGdidnotfitthedatabetterthana linearsolution.Regardinganxiety,aquadraticsolutionfitthedata slightlybetterthanalinearsolution.AsubsequentANOVA con-ductedafterdividingthesampleintothreegroups,namely, low anxiety,mediumanxietyandhighanxiety,withapproximately33% oftheparentsineachgroup,revealedthattheparentsinthelowest anxietygroupreportedsignificantlylowerlevelsofPTGthanthose inthemediumandhighanxietygroups(p=0.002andp=0.038, respectively).However,thedifferencesbetweenthemediumand highanxietygroupsinPTGwerenotsignificant(p=0.412).With regardstodepression,thelinearsolutionfitthedatabetterthan thequadraticsolution.

Discussion

Thefindingsofthisstudyindicatetheextenttowhichparents sufferfromsymptomsof PTSD,anxiety,depression andPTGsix monthsaftertheirchild’sdischargefromPICU andidentifythe relationbetweenPTGandpsychopathologysymptoms.Ourfirst findingisthatbothpositiveandnegativepsychologicaloutcomes arefrequentinparentsfollowingtheirchild’sadmission.Our sec-ondfindingisthathigheranxiety,depressionandPTSDscoresare relatedtohigherPTGscores.Thus,consistentwithprevious

stud-ies(Helgesonetal.,2006;Levineetal.,2009;Morrisetal.,2005;

Takuetal.,2007;Jinetal.,2014),asourstudysupportsthepremise

thatpositiveandnegativeeffectsoftraumaticeventscoexistinthe sameperson,thosewhoperceivebenefitsdonotdeny experienc-ingdifficulties.Accordingly,PTGandpainareinextricablylinked

aspartofthepost-traumarecoveryprocess,similartotwosidesof thesamecoin.

Onepossibleexplanationforthepositiverelationbetween psy-chopathologyandPTGisthatforPTGtooccur,theeventmustbe upsettingenoughtocauseconsiderabledisruptiontoan individu-alsassumptionabouthowtheworldoperatesandhowtheyfitinto thatworld(Janoff-Bulman,2004).Thus,itislikelythatindividuals whohavebeenmorenegativelyimpactedbythetraumatic experi-encealsohavegreateropportunityforPTG.Thisissupportedbythe factthat,inourstudyhigher,perceivedseverityofthechild’s medi-calconditionisrelatedtohigherintrusionthoughtsandhigherPTG, thussuggestingthatparentswhoperceivetheirchild’ssituationas moresevereexperiencethedeepestchanges,bothpositivelyand negatively.ThisiscoherentwithHelgesonetal.(2006),whosuggest thatexperiencingintrusivethoughtsreflectscognitiveprocessing aimedatunderstandingandprocessingthetraumaticeventrather thanservingasamarkerofmentalhealth.Thus,experiencing intru-sivethoughtsmaybeasignalthatpeopleareworkingthroughthe implicationsofthestressorintheirlives,whichthencouldleadto PTG.

Asecondpossibility toexplain theassociationbetween psy-chopathology and PTG is that PTG takes time to emerge and therefore,measuresofPTGtakensoonaftertheeventreflecta cog-nitivestrategytofacedistressmorethanactualPTG(McFarland

andAlvaro,2000).Eventhough,inourstudy,PTGwasmeasured

sixmonthspostdischarge,thereisapossibilitythatthistimelapse hasnotbeenlongenoughforsomeparentstoexperiencerealPTG. Ifthisisso,moreseverelydistressedparentsmaybe compensat-ingfortheirsymptomsofpsychopathologybydrawingonillusory PTG.Thisiscoherentwithdatafromameta-analyticreviewthat indicatedthefindingofbenefitsismorestronglyrelatedtobetter outcomeswhenmorethantwoyearshaselapsedsincethe trau-maticevent(Helgesonetal.,2006).Toexplorewhetherthisistrue forparentsofcriticallyillchildren,newstudiesthatincreasethe timebetweendischargeassessmentshouldbeconductedtoassess therelationshipofPTGandsymptomsofpsychopathology.

Additionally,ourdatacontradictthenotionthat therelation betweenPTSDandPTGhasaninvertedU-shape,asfoundinthe studybyColvilleandCream(2009).Althoughaquadraticsolution adjustedbettertotherelationbetweenanxietyandPTG,anANOVA indicatedthatnotonlymediumbutalsohighlevelsofanxietywere relatedtohigherPTGscores.Asonlythementionedstudyandthe presentstudyhaveexploredtheassociationofPTSD withPTSD, depressionandanxietyinthiscontextandastheresultsare non-convergent,moreevidenceisneededbeforefurtherconclusions aredrawn.

Limitations

This study presents with certain limitations. First, as all questionnaires used are screening instruments and no clinical interviewshave beenconducted,we can refer onlytoparental psychopathologysymptoms, not topsychopathology diagnoses. Furthermore,anoteofcautionisaddedregardingtheuseofthe HADS.Althoughithasbeenusedinresearchwithparentsof

chil-dreninthePICU(ColvilleandCream,2009;Reesetal.,2004),some

authorshavenoteditslimitationsandadvisedresearchersagainst

itsuse(CoyneandvanSonderen,2012;Coscoetal.,2012).

Sec-ond,asmostofthechildrenwereadmittedelectivelytothePICU, theresultsmaynotgeneralizetoapopulationofparentswhose childrenhaveexperiencedurgentPICUadmissions.Third,although specialeffortsweremadetoengageandretainfathersinourstudy, thisgroupconstitutesonlyone-thirdofthesample.Futurestudies shouldinvestineffortstoengagefathers(Board,2004).

Conclusion

Whilenotnegatingthenegativeimpactonmentalhealthofthe adverseortraumaticexperienceofhavingachildwhoiscritically ill,includingtheassessmentofPTGasanoutcomehasimportant implications.First,notconsideringthepossibilityofbothpositive andnegativepsychologicalconsequencesofthisexperiencewould provideanincompleteviewofthepsychologicalimpactonthe parentsoftheircriticallyillchild’shospitalization.Second, inter-ventionstofacilitatefamilies’psychologicaladaptationafterPICU shouldnotbeaimedonlyatpreventingpsychopathology,butalso athelpingthemgrowandfindmeaningfromtheexperience, nei-therofwhichisnotincompatiblewiththesufferingofthenegative sequelaeof trauma.Thisrepresentsa challengefor researchers andhealthcareproviderswhoshouldevaluatewhether interven-tionstopreventpsychopathologyaffectparentalPTGandwhether afocusonPTGenhancestheeffectivenessofpsychological inter-ventionsforthesefamilies.

Conflictofinterest

Theauthorsdeclarethatthereisnoconflictofinterestregarding thepublicationofthispaper.

Fundingsource

ThisworkwassupportedbyUniversidadAutónomadeMadrid underaFPI-UAMfellowship.

Ethicalstatement

Thestudywasapprovedbytheinstitutionalreviewboardofthe hospitalwherethestudywasconducted.Allparticipantssigned an informed consent form that guaranteed confidentiality and describedthestudy,includingitspurposes,potentialrisksand ben-efits.

Acknowledgments

Theauthorswouldliketoacknowledgeallphysiciansand nurs-ingstaffofthePICUofHospital12deOctubrefortheirhelpwith thedatacollection.

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