Cognitive and non-cognitive

factors associated with

posttraumatic stress in mothers
of children with T1DM
Antje Horsch
University Hospital Lausanne, Switzerland
antje.horsch@chuv.ch

Illness as Traumatic Stressor

Learning that an ones child has a life-threatening illness can trigger
PTSD.
Parents of children with cancer/leukemia, with severe burn injuries,
with paediatric spinal cord injury, organ transplantation,
hematopietic stem cell transplantation, meningitis and those
undergoing bone marrow transplantation.
In these studies, up to 71% of parents were found to report
significant levels of posttraumatic stress symptoms.
So far, only a few studies have investigated the occurrence of PTSD
in relation to a diagnosis of a chronic illness, such as diabetes.
e.g. Best et al. (2011); Taieb et al. (2003); Kazak et al. (1998); Manne et al. (2000, 2004);
Young et al. (2003); Shears et al. (2005)

Diabetes as Traumatic Stressor

T1DM has much in common with other chronic
conditions
Parental PTSD higher if child diagnosed with
chronic illness compared with child having been
involved in accident
Immediacy and degree of life threat can vary
considerably
Potential for recurring traumatic events
Horsch et al. (2007); Landolt et al. (2003)

Diabetes as Traumatic Stressor

1.The very onset may be traumatising in some cases. Parents may be
confronted with the threatened death of their child.
2. Previous research has demonstrated that parents of children with diabetes
show moderate to high distress in the first months after diagnosis.

3. Diabetes may be associated with morbidity, such as episodes of hypo- or

hyperglycemia.
4. Administering the injections that are painful for the child and may be
perceived as a threat to the childs physical integrity.
5. Witnessing ones child undergoing aversive medical procedures can result in
parental PTSD.
Horsch et al. (2007); Landolt et al. (2002); Boman et al. (2004); Streisand et al. (2005)

Posttraumatic Stress Disorder

(A) Exposure to traumatic event (A1) which caused intense
distress (A2)
(B) Persistent re-experiencing (e.g. intrusive memories,
flashbacks, nightmares)
(C) Avoidance of stimuli associated with trauma, and numbing
of general responsiveness
(D) Hyper-arousal (e.g. irritability, increased startle response,
sleep difficulties)
(E) Duration of disturbance is more than one month
DSM-IV (APA, 1994)
5

PTSD and treatment adherence

Relationship between PTSD and non-adherence in
paediatric liver transplant recipients and survivors
of a myocardial infarction
Trauma-focused intervention successfully treated
non-adherence
No evidence of a link between PTSD and T1DM
in adults
Shemesh et al (2000, 2001, 2004, 2006); Myers et al. (2007)

Research Questions
(1) What aspects of the childs illness are perceived as

traumatic?
(2) How common are PTSD symptoms/diagnosis in mothers
in response to their childs recently diagnosed type I
diabetes?
(3) What are the predictors of mothers PTSD symptoms?
(4) Do mothers who experience PTSD symptoms struggle to
adhere to their childs treatment regime?

Measures

Structured Clinical Interview DSM-IV-PTSD module (First et

al., 1995)
Distressing aspects of your childs diabetes scale (Horsch et
al., 2007)
The Posttraumatic Diagnostic Scale (Foa et al., 1997)
Posttraumatic Cognitions Inventory (Foa et al., 1999)
Memories of Your Childs Illness Questionnaire (Ehlers, 2004)
The Hospital Anxiety and Depression Scale (Zigmond & Snaith,
1983)
Social Provisions Scale (Russell & Cutrona, 1984)
Family Responsibility Questionnaire (La Greca et al., 1990)
Adherence and IDDM Interview (Hanson et al., 1987)

Sample
60 mothers of children with diabetes who attended diabetes
clinics in the South East of England.
Majority of mothers was of Caucasian origin, in employment
and married and attended an average of 13.5 (2.7) years in
education
Children were under the age of 16 and had been diagnosed with
type I diabetes at least 1 month and up to 5 years before
assessment took place.
Mean age of the child with diabetes:10.3 years (SD = 4.14).
Of the children with diabetes, 31 (51.7%) were female.
Mean number of months since diagnosis of diabetes: 35.2
months (SD = 16.61).
38% family history of diabetes

(1) What aspects of the childs illness

are perceived as traumatic?

 finding out that child has diabetes (55%)

child having a bad hypo (hypoglycaemia) (16.7%)
administering the first injection (6.7%)
child being ill before diagnosis was made (6.7%)
initial hospital stay (6.7%)
child refusing treatment (3.3%)
child having seizures due to diabetes (3.3%)
sudden weight loss due to diabetes (1.7%)
Horsch et al. (2007)

Distressing aspects of diabetes

Child being ill

Child being rushed into hospital
Finding out that child has diabetes
Getting to grips with treatment
regime
Administering injections
Attending clinic appointments
Having to control what child eats
Worrying about hypo
Worrying about child becoming ill
Worrying about childs future
Worrying about childs health being
permanently damaged
Worrying about child dying
Horsch et al. (2007)

Mean rating
(SD)

Number (%) of
participants who
rated as very
severely distressing

2.72 (2.01)
4.34 (3.09)
3.57 (0.72)
2.55 (1.06)

19 (31.7)
16 (26.7)
39 (65.0)
12 (20.0)

3.77 (2.51)
1.01 (1.17)
1.77 (1.11)
2.65 (1.20)
1.88 (1.40)
2.58 (1.16)
3.00 (1.01)

24 (40.0)
2 (3.3)
6 (10.0)
21 (35.0)
11 (18.3)
17 (28.3)
25 (41.7)

2.83 (2.26)

23 (38.3)

(2) How common are PTSD

symptoms/diagnosis in mothers?

Prevalence rates of maternal PTSD symptoms

Type I Diabetes mellitus

Current PTSD symptoms

Criterion B
Criterion C
Criterion D
Meet criteria for partial
PTSD diagnosis
Meet full criteria for PTSD
diagnosis
PTSD symptoms since
traumatic stressor
occurred
Criterion B
Criterion C
Criterion D
Meet criteria for partial
PTSD diagnosis
Meet full criteria for PTSD
diagnosis

SCID (N = 60,
%)

PDS (N = 60,
%)

29 (48.3)
6 (10)
21 (35)
9 (15)

38 (63.3)
38 (63.3)
35 (58.3)
n/a

6 (10)

Anorexia nervosa
SCID (N = 31,
%)

PDS (N =
31,%)

10 (32.3)
5 (16.1)
4 (12.9)
5 (16.1)

22 (71.0)
16 (51.6)
16 (58.1)
20 (64.5)

n/a

2 (6.5)

n/a

46 (76.7)
10 (16.7)
30 (50)
19 (31.7)

n/a
n/a
n/a
n/a

15 (48.8)
6 (19.4)
6 (19.4)
6 (19.4)

n/a
n/a
n/a
n/a

19 (16.7)

n/a

3 (9.7)

n/a

Horsch et al. (2007), Horsch et al. (2012)

Anxiety and depression

Anxiety: 43.3% reported clinically significant

symptoms
Depression: 16.7% reported clinically significant
symptoms
Comorbidity: Mothers with PTSD had
significantly higher levels of anxiety and depression
than mothers without PTSD.
Binary logistic regression: PDS explained more
variance in PTSD symptoms over and above that
contributed by HADS

(3) What are the predictors of

mothers PTSD symptoms?

Cognitive Model of PTSD (Ehlers & Clark, 2000)

Nature of trauma
memory

Negative appraisals of trauma and/or sequelae

Matching triggers

Current threat
Intrusions
Arousal symptoms
Strong emotions

Strategies intended to control

threat/symptoms

Predictors of maternal PTSD

Non-cognitive predictors
Trauma severity
Psychiatric history
Social support
Cognitive predictors
Negative cognitive appraisals
Dysfunctional strategies

Trauma severity
80% of children hospitalised at time of
traumatic stressor for an average of 3.05
(2.7) days
HbA1C at time of traumatic stressor: 9.36
(1.7)

Measure

Mean score (SD)

SPS (Social Provisions Scale) total

Subscales
Guidance
Reassurance of worth
Social integration
Attachment
Nurturance
Reliable alliance

80.55 (10.1)

Correlation
with PDS
(Pearsons r)
-.40***

13.55 (2.5)
12.77 (2.3)
12.57 (2.2)
13.32 (2.5)
13.98 (1.9)
14.34 (2.0)

-.23*
-.39***
-.29*
-.38**
-.24*
-.27*

PTCI (Posttraumatic Cognitions Inventory) total

Subscales
Negative cognitions about self
Negative cognitions about world
Self-blame

75.01 (45.4)

.61***

2.01 (1.2)
2.49 (1.5)
2.02 (1.4)

.58***
.58***
.64***

12.22 (8.4)

.68***

5.76 (4.5)
4.88 (4.0)
1.59 (1.6)

.49***
.71***
.53***

RIQ (Response to Intrusions) total

Subscales
Thought suppression
Rumination
Numbing

*p<.05, **p<.01, ***p<.001

Independent
variable
Model 1 (Enter)
HbA1c
Days in hospital
Psychiatric history
SPS total score
Model 2
(Stepwise)
HbA1c
Days in hospital
Psychiatric history
SPS total score
RIQ total score
Model 3
(Stepwise)
HbA1c
Days in hospital
Psychiatric history
SPS total score
RIQ total score
PTCI total score

SE B

Beta

R2
.175

-.31
.16
-1.96
-.32

.70
.50
2.50
.12

-.06
.04
-.10
-.36

-.44
.31
-.79
-2.64

.662
.755
.435
.011
.493

-.36
-.27
2.36
-.09
.751

.55
.40
2.12
.10
.132

-.07
-.07
.12
-.10
.70

-.66
-.67
1.12
-.87
5.72

.513
.505
.269
.387
.000
.534

-.53
-.121
1.93
-.04
.56
.060

.54
.39
2.06
.10
.16
.03

-1.00
-.03
1.00
-.05
.52
.27

-.97
-.31
.94
-.42
3.62
2.11

.336
.760
.354
.68
.001
.040

Risk factors : significant positive relationship between PTSD and

- low social support (p < .05)
Cognitive predictors: significant positive relationships between PTSD
and
- negative cognitive appraisals (about the self, the world and
others)
(p < .05)
- dysfunctional cognitive strategies (p < .001)
Cognitive predictors (negative cognitive appraisals and dysfunctional
cognitive strategies) predicted unique variance over and above risk
factors (trauma severity, history of trauma, psychiatric history, social
support): adjusted R = 0.53; p < .05
Horsch et al. (2012)

(4) Do mothers who experience PTSD

symptoms struggle to adhere to their
childs treatment regimen?

PTSD and treatment adherence

With increasing age, children assume more
responsibility for their diabetes management
Split sample into younger (0-8 years) and older
(9-16 years) children
For mothers of younger but not older children,
PTSD significantly correlated with measure of
adherence and childs HbA1C (both p < .05)
Same results when comparing group of mothers
with or without PTSD (both p < .05)
Horsch et al. (2014)

Discussion (1)
An unmet need of psychological support for mothers

Aspects of the diagnostic and treatment process in relation to their

childs diabetes can have a significant emotional impact on mothers.

Mothers could be routinely asked when their child is first discharged

from hospital after diagnosis whether they require psychological
support.

Mothers who struggle to manage their childs illness effectively could

be assessed with regards to emotional difficulties and offered
psychological support.
Early detection

The findings of the study stress the importance of cognitive factors in

the prediction of chronic PTSD, which could inform a possible
screening tool to detect those at risk.

The screening tool could be routinely administered to mothers of

children who were recently diagnosed with type I diabetes and could
be evaluated for its effectiveness.

Discussion (2)
Psychological interventions

Provide written information to educate about and normalise symptoms

CBT to modify their negative cognitive appraisals and dysfunctional
strategies
Increase social support (informal and formal support systems)

Study limitations

Response rate (42.4 %) was relatively (but not unusually) low

Examination of causality in any of the observed relationships is not
possible (cross-sectional study)
Psychometric properties of questionnaire measuring dysfunctional
strategies unknown
Retrospective reporting of symptoms

Role of diabetes nurses

help parents by reframing intense psychological distress
as a possible reaction to perceiving certain aspects of
their childs diabetes diagnosis and treatment as
traumatic
provide emotional support
implement appropriate interventions, such as teaching
coping strategies
advocate further assessment (referral to clinical
psychologist)
provide appropriate referrals to mental health services

Suggestions from parents

Counselling/ professional psychological support

Parent support group/ buddy system
Improve hospital routine
More frequent and regular home visits by nurse and dietician
Written information for parents
More information from staff
Better collaboration between staff and parents
Information pack for schools or school visit by nurse
Increase staffing levels, particularly nurses
Telephone helpline for parents
More up-to-date information on diabetes research
Opportunity for parents to meet older children with diabetes
Buddy system for children
Support group for teenagers
Diabetes newsletter for children

Thank you for your attention!

antje.horsch@chuv.ch