Traumatic Symptoms on Child Symptom Development

WISE, ANNA E., Ph.D., August 2020 PSYCHOLOGICAL SCIENCES

THE DIFFERENTIAL IMPACT OF MATERNAL VERSUS PATERNAL POST-

TRAUMATIC SYMPTOMS ON CHILD SYMPTOM DEVELOPMENT

Dissertation Advisor: Douglas Delahanty

Higher parental post-traumatic stress symptoms (PTS) following a child’s traumatic event are consistently associated with higher child PTS in a variety of trauma samples. However, research examining the extent to which parent reactions impact the child have focused almost entirely on mother-child relationships. The present study investigated the individual and combined impact of maternal and paternal symptoms on child PTS development following hospital care for an acute injury. We recruited 137 mother-child dyads and 105 father-child dyads (including 94 mother-father-child triads) from the emergency room of a midwestern

Children’s Hospital following emergency medical services (EMS) transport for the child’s acute injury. Parents and children completed self-report measures of posttraumatic stress disorder

(PTSD) and depression symptoms in-hospital. At two-weeks post-injury we assessed parent and child acute stress symptoms, and at 3-months post-injury we again measured child and parent self-reported PTSD symptoms (PTSS) and depression symptoms. Results revealed that, after controlling for child’s concurrent symptoms, mother’s baseline and 2-week acute stress symptoms were associated with child 3-month PTS (ß = 0.32, p = 0.00; ß = 0.36, p = 0.00, respectively). However, in similar analyses, neither father’s baseline nor 2-week acute stress symptoms were associated with child 2-week acute stress or 3-month PTS. Both mother’s and

father’s baseline depression symptoms were associated with child 2-week (ß = 0.18, p = 0.02; ß

= 0.28, p = 0.00, respectively), but not 3-month PTS. Examining families with moms, dads, and children, the interaction of parent’s PTS was not associated with child PTS outcomes. Results indicate that parents’ PTS following child acute injury differentially impact child PTS up to 3- months post-injury. Specifically, mother’s and father’s depression symptoms are associated with child short-term acute stress symptoms. However, with respect to longer-term child PTS outcomes, only mother’s initial PTSS were a significant predictor. Results suggest that assessment of parental symptoms may improve identification of children at-risk of developing psychopathology and in need of early intervention following a severe injury. Furthermore, identification of parental, specifically maternal, early elevated PTS may present an opportunity for early intervention in order to bolster child and familial resilience following child injury.

THE DIFFERENTIAL IMPACT OF MATERNAL VERSUS PATERNAL POSTTRUMATIC

STRESS ON CHILD SYMPTOM DEVELOPMENT

A dissertation submitted

to Kent State University in partial

fulfillment of the requirements for the

Degree of Doctor of Philosophy

Anna E. Wise

August 2020

Dissertation written by

Anna E. Wise

B.S., The Pennsylvania State University, 2012

M.A., Kent State University, 2017

Ph.D., Kent State University, 2020

Approved by

, Chair, Doctoral Dissertation Committee Douglas L. Delahanty, Ph.D.

, Members, Doctoral Dissertation Committee Karin G. Coifman, Ph.D.

Jeffery A. Ciesla, Ph.D.

Andrea Warner Stidham, Ph.D., RN

Peña L. Bedesem, Ph.D.

Accepted by

, Chair, Department of Psychological Sciences Maria Zaragoza, Ph.D.

, Interim Dean, College of Arts and Sciences Mandy Munro-Stasiuk, Ph.D.

TABLE OF CONTENTS…………………………………………………………………… v

LIST OF FIGURES…………………………………………………………………………. vii

LIST OF TABLES………………………………………………………………………….. viii

ACKNOWLEDGMENTS…………………………………………………………………… xi

CHAPTERS

I. Introduction………………………………………………………………………. 1

PTS and Childhood Injury……………………………………………………….. 1

Parent Psychopathology and Child PTS………………………………………… 4

Parent and Family Factors Associated with Parent and Child PTS…………….. 6

Prior Trauma Exposure and Overprotection…………………………….. 6

Family Functioning………………………………………………………. 7

Parental Gender Influences on Child Outcomes………………………… 8

Child Variables that Moderate the Relationship Between Parent and Child PTS.. 9

Child Gender and Age………………………………………………….. 9

Child Pubertal Status……………………………………………………. 10

Child Trauma History…………………………………………………… 11

Child Pre-Trauma Functioning………………………………………….. 12

Present Study……………………………………………………………………. 13

II. Methods…………………………………………………………………………. 15

Parent Study…………………………………………………………………….. 15

Participants……………………………………………………………………….. 15

Procedure……………………………………………………………………….. 16

Measures……………………………………………………………………… 17

Statistical Power Analysis………………………………………………………. 23

Data Analytic Plan………………………………………………………………. 24

Preliminary Statistical Analyses………………………………………………… 24

Primary Statistical Analyses…………………………………………………….. 24

III. Results……………………………………………………………………………. 26

Preliminary Statistical Analyses…………………………………………………. 26

Primary Statistical Analyses……………………………………………..……… 27

Exploratory Statistical Analyses…………………………………………………. 28

IV. Discussion……………………………………………………………….………. 34

Primary Aims and Hypotheses…………………………………………………… 34

Exploratory Aims and Hypotheses………………………………………………. 35

Limitations………………………………………………………………………... 36

Research and Clinical Implications of Findings…………………………………. 37

REFERENCES……………………………………………………………………………….. 39

LIST OF FIGURES

Figure 1. Statistical Models for Hypothesis 1……………………………………………… 65

Figure 2. Statistical Model for Hypothesis 2……………………………………………….. 65

Figure 3. Statistical Model for Hypothesis 3………………………………………………. 66

Figure 4. Statistical Model for Hypothesis 4……………………………………………….. 66

Figure 5. Statistical Model for Hypothesis 5……………………………………………….. 67

Figure 6. Figure 1. Moderation Effects of Child Gender by Mother’s Baseline PTSS on

Child 3-month PTSS (N = 103)…………………………………………………………….. 67

Figure 7. Moderation Effects of Child Gender by Mother’s Acute Stress Symptoms on

Child 3-month PTSS (N = 92)……………………………………………………………… 68

Figure 8. Moderation Effects of Child Gender by Mother’s Baseline Depression on Child

2-week Acute Stress Symptoms (N = 133)………………………………………………… 68

Figure 9. Moderation Effects of Child Gender by Mother’s Baseline Depression on Child

2-week Acute Stress Symptoms (N = 104).……………………………………………….. 69

Figure 10. Moderation Effects of Child Pubertal Status by Mother’s Baseline PTSS on

Child 3-month PTSS (N = 100)……………………………….………………………… 69

Figure 11. Moderation Effects of Child Pubertal Status by Mother’s Acute Stress

Symptoms on Child 3-month PTSS (N = 89)…………………………………………… 70

Figure 12. Moderation Effects of Child Pubertal Status by Mother’s Depression

Symptoms on Child 2-week Acute Stress Symptoms (N = 88)…………………………… 70

Figure 13. Moderation Effects of Child Pubertal Status by Father’s Depression Symptoms on Child 2-week Acute Stress Symptoms (N = 72)………………………………………… 71

vii

LIST OF TABLES

Table 1. Summary of Measures………………..…………………………………………… 52

Table 2. Pearson’s correlation (r) matrix for child symptom variables...………………… 53

Table 3. Pearson’s correlation (r) matrix for parent symptom variables.………………… 53

Table 4. Pearson’s correlation (r) matrix for dependent variables and possible covariates... 54

Table 5. Linear Regression Analyses predicting Child 2-week Acute Stress Symptoms from Mother’s Baseline PTSS (Model 1; N = 139) and Mother’s Baseline Depression

Symptoms (Model 2; N= 137) controlling for Child’s Baseline Trauma-Related Distress and Depression Symptoms.……………………………………………………………… 55

Table 6. Linear Regression Analyses predicting Child 3-month PTS from Mother’s

Baseline PTSS (Model 1; N = 105), Mother’s 2-week Acute Stress Symptoms (Model 2;

N= 93), and Mother’s Baseline Depression Symptoms (Model 3; N= 105) controlling for

Child’s Baseline Trauma-Related Distress, Acute Stress Symptoms, and Depression

Symptoms………………………………………………………………………………….. 56

Table 7. Linear Regression Analyses predicting Child 2-week Acute Stress Symptoms from Father’s Baseline PTSS (Model 1; N = 109) and Father’s Baseline Depression

Symptoms (Model 2; N= 105) controlling for Child’s Baseline Trauma-Related Distress and Depression Symptoms………………………………………………………………… 57

Table 8. Linear Regression Analyses predicting Child 3-month PTS from Father’s

Baseline PTSS (Model 1; N = 85), Father’s 2-week Acute Stress Symptoms (Model 2;

N= 62), and Father’s Baseline Depression Symptoms (Model 3; N= 81) controlling for

Child’s Baseline Trauma-Related Distress, Acute Stress Symptoms, and Depression

Symptoms………………………………………………………………………………….. 58

viii

Table 9. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from the Interaction Term between Maternal and Paternal Baseline PTSS (N= 73)…………….. 59

Table 10. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from the Interaction Term between Maternal and Paternal 2-week Acute Stress Symptoms (N=

55)…………………………………………………………………………………………... 59

Table 11. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from the Interaction Term between Maternal and Paternal Baseline Depression Symptoms (N=

70)…………………………………………………………………………………………... 60

Table 12. Hierarchical Multiple Regression Analyses predicting Child 2-week Acute

Stress Symptoms from the Interaction Term between Maternal and Paternal Baseline

Depression Symptoms (N= 88)…………………………………………………………….. 61

Table 13. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from

Mother’s Baseline PTSS, Child Baseline Trauma-Related Distress, and Child Trauma

History (N= 99)…………………………………………………………………………….. 61

Table 14. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from

Mother’s Baseline PTSS, Child Baseline Trauma-Related Distress, and Family

Functioning (N= 96)………………………………………………………………………... 62

Table 15. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from

Mother’s 2-week Acute Stress Symptoms, Child 2-week Acute Stress Symptoms, and

Family Functioning (N= 85)………………………………………………………………... 62

Table 16. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from

Mother’s Baseline PTSS, Child Baseline Trauma-Related Distress, and Mother’s Report of Child Pre-Trauma Functioning (N= 99)…………………………………………………. 63

Table 17. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from

Mother’s 2-week Acute Stress Symptoms, Child 2-week Acute Stress Symptoms, and

Mother’s Report of Child Pre-Trauma Functioning (N= 88)………………………………. 63

Table 18. Hierarchical Multiple Regression Analyses predicting Child 2-week Acute

Stress Symptoms from Mother’s Baseline Depression Symptoms, Child Baseline

Depression Symptoms, and Mother’s Report of Child Pre-Trauma Functioning (N= 137).. 64

Table 19. Hierarchical Multiple Regression Analyses predicting Child 2-week Acute

Stress Symptoms from Father’s Baseline Depression Symptoms, Child Baseline

Depression Symptoms, and Father’s Report of Child Pre-Trauma Functioning (N= 105)… 64

ACKNOWLEDGEMENTS

I would like to express sincere gratitude for those who have provided both functional and emotional support throughout the preparation and completion of this project. Firstly, I thank my advisor, Douglas Delahanty, Ph.D., for his contributions through each stage of this process. His guidance has been instrumental in my development as a researcher. I would also like to express appreciation to my dissertation committee for offering their time and expertise to this research project. Thank you to the funding agency, The Ohio Department of Public Safety-Emergency

Medical Services, as well as our colleagues and medical staff at Akron Children’s Hospital for their support in the implementation of this project. Lastly, I would like to thank my colleagues and research assistants from the Stress and Health Laboratory at Kent State University for their contributions to data collection. The culmination of support, guidance, and mentorship from these individuals has helped to make this project possible.

On a personal note, the unwavering support and encouragement offered by family and friends has kept my spirit fueled and allowed me to persevere through the trials and tribulations of completing both my dissertation and graduate school. I would like to thank my close friends and fellow graduate students at Kent State University for sharing their friendship, perspective, and knowledge. I offer my sincerest gratitude to my parents and my siblings. I am forever indebted to them for their steadfast encouragement and reassurance even when it meant moving a few states away which resulted in missing out on holidays and important milestones. Finally, I would like to thank my husband, Dylan, who has been put to the ultimate test in flexibility. His encouragement and unconditional support in my professional pursuits has meant everything to me.

I. INTRODUCTION Exposure to severe injury places children at an increased risk of developing psychopathology such as posttraumatic stress disorder (PTSD), depression, and anxiety (Cox, Kenardy, &

Hendrikz, 2008). Many pre-, peri-, and post-trauma factors have been shown to increase risk of developing these disorders (Trickey, Siddaway, Meiser-Stedman, Serpell, & Field, 2012). Post- trauma familial psychological factors, specifically parental (primarily maternal) psychopathology symptoms, are consistently related to child outcomes (see Morris, Gabert-Quillen, & Delahanty,

2012 for a meta-analysis). Much less research has focused on the impact of paternal psychopathology symptoms on child outcomes or combined parental influences on child symptom development following child acute injury. Further understanding of the association between parental psychopathology and child outcomes can help with identifying at-risk children and families in need of early intervention. The present study was designed to prospectively investigate the development of child post-traumatic stress pathology following an acute injury and the implications that parental post-traumatic stress symptoms (PTS) may have on child PTS development. Although prior literature has considered maternal-child dyads almost exclusively, the present study considers both the individual and combined impact of maternal and paternal symptoms on child PTS.

PTS and Childhood Injury

PTSD is a psychological disorder that may develop following exposure to a traumatic event that threatens death, serious injury, or sexual violence to oneself or a close friend or relative

(American Psychiatric Association, 2013). PTSD symptoms include persistently re-experiencing

the event in a distressing manner, avoidance of trauma-related stimuli, negative thoughts and cognitions, and trauma-related arousal and reactivity (American Psychiatric Association, 2013).

Symptoms must be present for at least one month following trauma exposure to meet criteria for

PTSD. Acute Stress Disorder (ASD) is a disorder closely related to PTSD that also develops following traumatic event exposure. An ASD diagnosis includes symptoms from five symptom categories (intrusions, negative mood, dissociation, avoidance, and arousal), and nine symptoms

(irrespective of category) must be present to meet diagnostic criteria. Symptoms must be present at least 3 days but no more than 1 month following a traumatic event to meet criteria for this disorder (American Psychiatric Association, 2013).

The vast majority (approximately 90%) of adults will experience at least one traumatic event that meets ASD or PTSD DSM-5 criteria (American Psychiatric Association, 2013) for traumatic event exposure at some point in their lives, and many will experience two or more types of events (Kilpatrick, Resnick, Milanak, Miller, Keyes, & Friedman, 2013). Even though traumatic events are common, the likelihood of developing PTSD is relatively low; 8-10% of adults and

11-25% of children exposed to a traumatic event develop PTSD (Kilpatrick et al., 2013; Alisic,

Zalta, Van Wesel, Larsen, Hafstad, Hassanpour, & Smid, 2014). Rates of poor mental health outcomes differ following trauma, and the nature of the trauma tends to significantly influence prevalence rates. For example, less than 20% of individuals exposed to non-interpersonal traumas develop ASD, while 20-50% develop ASD following exposure to interpersonal trauma

(American Psychiatric Association, 2013). According to a meta-analysis, rates of PTSD are much higher for children exposed to interpersonal (25.2%) compared to non-interpersonal

(9.7%) traumas (Alisic et al., 2014). ASD and PTSD commonly present with comorbid psychological disorders such as depression and alcohol or substance abuse in adults (Campbell,

Felker, Liu, Yano, Kirchner, Chan, ... & Chaney, 2007) and anxiety disorders, mood disorders, obsessive-compulsive disorder, and suicidal ideation in children (Ford, 2015; Panagioti,

Gooding, Triantafyllou, & Tarrier, 2015). Therefore, it is important to consider post-traumatic health outcomes broadly, rather than assessing a single diagnostic outcome in order to understand wide-ranging post-trauma functioning.

Rates of depression are also consistently elevated following child trauma exposure

(Campbell et al., 2007; Cénat, & Derivois, 2015). A recent meta-analysis found that 24% of children exposed to a traumatic event meet criteria for a depressive disorder (Vibhakar, Allen,

Gee, & Meiser-Stedman, 2019) which is significantly higher compared to child and adolescent depression prevalence estimates in the general public (2-11%: Polanczyk, Salum, Sugaya, Caye,

& Rohde, 2015; Mojtabai, Olfson, & Han, 2016). Given these high prevalence rates, in addition to measuring ASD and PTSD, we also measured child depression rates in our sample.

Globally, unintentional child injuries are the leading cause of death for children aged 10-

19 years old (WHO, 2008). In addition, over 30 million children in the United States require hospital care for non-fatal injuries annually (CDC, 2020). Approximately 14% of children develop ASD after receiving care in an emergency department following an acute injury while approximately 9% develop PTSD (Meiser-Stedman, McKinnon, Dixon, Boyle, Smith, &

Dalgleish, 2017), and 6% develop clinically significant depression symptoms (Nixon, Nehmy,

Ellis, Ball, Menne, & McKinnon, 2010). Even though rates of diagnostic levels of ASD, PTSD, and depression are low, a large minority of parents and children will experience distress (23-

28%), and a majority will experience at least one clinically significant PTSD symptom (83-88%) following a child’s traumatic injury (Winston, Kassam-Adams, Vivarelli-O’Neill, Ford,

Newman, Baxt,… & Cnaan, 2002). Subsyndromal PTSD is associated with the same comorbid

disorders and suicidal behaviors as diagnostic PTSD, underscoring the importance of identifying predictors of child PTS even in populations with subsyndromal PTSD and depression (Müller,

Vandeleur, Rodgers, Rössler, Castelao, Preisig, Ajdacic-Gross, 2014; Fink, Gradus, Keyes,

Calabrese, Liberzon, Tamburrino, ... & Galea, 2018). Given the comorbidity between ASD/PTSS and depression symptoms in child trauma samples, we will examine the correlation between child depression symptoms and PTSS to determine if these symptoms should be examined separately or combined as a latent construct of child PTS.

Parental Psychopathology and Child PTS

Parental posttraumatic stress disorder symptoms (PTSS) and depression symptoms stemming from a child’s trauma have shown a strong concordance with child PTS development and are an important consideration in the study of predictors of child outcomes following child trauma exposure (de Vries, Kassam-Adams, Cnaan, Sherman-Slate, Gallagher, & Winston, 1999;

Daviss, Mooney, Racusin, Ford, Fleischer, & McHugo, 2000; Keppel-Benson, Ollendick, &

Benson, 2002; Landolt, Ystrom, Sennhauser, Gnehm, & Vollrath, 2012; Schreier, Ladakakos,

Morabito, Chapman, & Knudson, 2005; Nugent, Christopher, & Delahanty, 2006; Ostrowski,

Christopher, van Dulmen, & Delahanty, 2007; De Young, Hendrikz, Kenardy, Cobham, &

Kimble, 2014; Halevi, Djalovski, Vengrober, & Feldman, 2016; Koenen, Moffitt, Poulton,

Martin, & Caspi, 2007). A meta-analysis of 35 studies found a significant association between child and parental PTSS (weighted r=.31) and child PTSS and parent depression (weighted r=.32) following child exposure to a traumatic event (Morris, Gabert-Quillen, & Delahanty,

2012).

Maternal rates of PTSS are often higher than rates of PTSS in a child following the child’s exposure to a traumatic event (Landolt, Vollrath, Ribi, Gnehm, & Sennhauser 2003; Nelson &

Gold, 2012), and mothers are more likely to develop PTSS following a child’s trauma compared to fathers (Landolt et al., 2012). Parental PTSS related to the child’s trauma are also more strongly related to child PTSS than general parental distress (Nugent et al., 2006), suggesting that parental PTSS contributes specific risk to child PTSS development. One potential explanation for the high concordance between parent and child PTSS is that the parent’s symptoms may interfere with parental availability to the child during the early post-traumatic period (Schwartz, Dohrenwend, & Levav, 1994). Furthermore, parent and child symptom concordance tends to increase over time (Koplewicz, Vogel, Solanto, Morrissey, Alonso,

Abikoff, ... & Novick, 2002). Although parent and child PTSS are often unrelated in the acute phase following a trauma (Winston et al., 2002; Bryant, Marosszeky, Crooks, & Gurka 2004), studies looking at more chronic symptoms tend to find significant associations (Koplewicz et al.,

2002; Schreier et al., 2005), underscoring the necessity of longitudinal investigations to fully understand the relationship between parent and child PTSS.

The impact of parental depression on child psychopathology following child traumatic event exposure is also well-established (see Morris, Gabert-Quillen, & Delahanty, 2012 for a meta- analysis). Children with depressed mothers respond to stressful events with more depression symptoms than children with non-symptomatic mothers (Hammen, Burge, & Adrian, 1991).

More recently, research from a child Cognitive Behavioral Therapy (CBT) intervention study suggested a bidirectional, indirect association between maternal depression and child PTSS following child trauma exposure, such that lower maternal depression scores partially mediated child PTSD symptom improvement from pre- to post-treatment, and conversely, fewer child

PTSS partially mediated maternal depression symptom improvement from pre- to post-treatment

(Neill, Weems, & Scheeringa, 2018).

Although the literature reviewed above has largely investigated depression and PTSS as separate psychological predictors and outcomes, there is significant momentum to understand human dysfunction and psychological constructs more broadly (Insel, Cuthbert, Garvey,

Heinssen, Pine, Quinn, Sanislow, & Wang, 2010). Additionally, there is a large amount of symptom overlap between the diagnostic criteria for depression and PTSD (American

Psychiatric Association, 2013), and high symptom overlap often contributes to high correlations between depression and PTSS measures (Gros, Price, Magruder, & Frueh, 2012). High symptom overlap along with new approaches to investigating mental disorders indicate that there is support for investigating the impact of parental PTS more broadly. Therefore, similar to our analyses with child symptoms, we will investigate the correlation between parental depression symptoms and PTSS to determine if these symptoms should be examined separately or combined as a latent construct of parental PTS.

Parent and Family Factors Associated with Parent and Child PTS

Given the consistently demonstrated relationship between parent and child PTS, research has attempted to identify parent and familial factors (such as prior parent trauma exposure, parental overprotection, family functioning, and parent gender) that may explain some of the variance in this relationship (see Wise & Delahanty, 2017 for a review specific to child injury samples).

Prior Trauma Exposure and Overprotection

There is some evidence, though limited, that parental prior trauma exposure is independently associated with higher PTSS in adolescents following accidental injury, and the association between parental and child PTSS was no longer significant after controlling for parental prior trauma exposure (Zatzick, Grossman, Russo, Pynoos, Berliner, Jurkovich, ... & Rivara, 2006).

Conversely, Yehuda and colleagues (2001) investigated the impact of parent Holocaust exposure

on PTSS development in adult offspring and found that parental PTSD was a more significant predictor of offspring PTSD than was parental Holocaust exposure. However, parental Holocaust exposure was a more significant predictor of offspring depressive disorders compared to parental

PTSD. These results suggest that parental trauma exposure may be more strongly associated with child depression symptoms, and parental PTSS stemming from prior trauma exposure may be more predictive of child PTSD.

Family Functioning

The construct of family functioning is broad, and it has been operationalized in a multitude of ways within the child trauma literature. In one study it was defined as an unstable living environment (i.e., operationalized as changing residences three or more times before age 11) or experiencing changes in parent figure, and these factors were found to be associated with a higher risk for PTSD following trauma exposure in a large birth cohort study (Koenen et al.,

2007). Family conflict is another aspect of family functioning that has been associated with poorer child psychological outcomes following trauma (Bokszczanin, 2008). For instance, lower parental support and higher levels of family conflict predicted more PTSS in a sample of adolescent flood survivors (Bokszczanin, 2008). One study of Latinx adolescents found that gender and family functioning interacted to predict PTSS such that poor family cohesion was more predictive of PTSS in girls compared to boys, and family conflict was more predictive of

PTSS in boys compared to girls (Suarez-Morales, Mena, Schlaudt, & Santisteban, 2017).

However, a study conducted in a sample of families exposed to a natural disaster found that family functioning was not directly associated with higher levels of PTSD in children, though it was associated with higher parent reports of past child emotional difficulties (McDermott &

Cobham, 2012).

While there is mixed evidence regarding the relationship between family functioning and child PTS, two studies have found that family dysfunction moderated the positive relationship between trauma exposure and psychopathology (Dorrington, Zavos, Ball, McGuffin,

Sumathipala, Siribaddana, ... & Hotopf, 2019; Romano, Babchishin, & Wong, 2016). In both studies, poorer family functioning was associated with a stronger relationship between trauma exposure and psychological outcome measures. Further, family functioning was broadly defined in different ways for the two studies (as affective involvement, affective responsiveness, behavioral control, communication, problem solving, and roles in Romano, Babchishin, &

Wong, 2016, and reverse coded as parental neglect, parental antipathy, punishment, and separation from family in Dorrington et al., 2019). Additionally, when compared to a non-trauma exposed community-based sample, there is some evidence that exposure to a natural disaster can increase family dysfunction (McDermott, & Cobham, 2012), indicating that family dysfunction may be higher in the months following certain types of traumas versus others. Given that there is evidence for a direct relationship between family functioning and child psychological outcomes following trauma, the present study will account for family functioning as a covariate in the association between parent and child PTS.

Parental Gender Influences on Child Outcomes

Most studies examining parental influences on child outcomes following trauma exposure have included only mother/child dyads or have investigated parental influence broadly, without consideration of parent gender (see Morris et al., 2012 and Trickey et al., 2012 for meta- analyses). Much less research has focused on the impact of paternal psychopathology on child outcomes or investigated the impact of parent gender on the relationship between parental psychopathology and child outcomes. Further, results from the limited studies that have

investigated maternal versus paternal effects on child outcomes have been mixed. Some research suggests that maternal, but not paternal PTSS are related to child PTS (Haag & Landolt, 2017;

Yehuda, Bell, Bierer, & Schmeidler, 2008; Stuber, Christakis, Houskamp, & Kazak, 1996), while other research has found that paternal, but not maternal PTSS, are associated with child

PTS (Schick, Morina, Klaghofer, Schnyder, & Müller, 2013; Kazak, Alderfer, Rourke, Simms,

Streisand, & Grossman, 2004; Magal-Vardi, Laor, Toren, Strauss, Wolmer, Bielorai, Rechavi, &

Toren, 2004; Kiliç, Özgüven, & Sayil, 2003). Longitudinal investigations by Bronner and colleagues (2008) found that the impact of parental symptoms may differ over time, such that maternal PTSS have an acute impact on child PTS while paternal PTSS have a more lasting effect. Thus, findings may differ depending upon the timing of assessments. Furthermore, differences in the relationship between maternal versus paternal psychopathology and child PTS may differ based on the parental psychopathology that is being assessed. For instance, a meta- analysis of 35 studies concluded that maternal PTSS had a significantly stronger association with child PTS compared to paternal PTSS, but maternal and paternal depression symptoms equally predicted child PTS (Morris et al., 2012). Existent literature has not examined the interactive effect of maternal and paternal symptomology in two-parent households on child symptom development. The present study examined both the individual and interactive effect of parental

PTS on child PTS outcomes.

Child Variables that Moderate the Relationship Between Parent and Child PTS

Child Gender and Age

In addition to parent factors, child demographic variables have been consistently found to impact the relationship between parental and child PTS. Child gender may be a particularly important factor to consider when investigating the impact of parental symptoms on child

outcomes. Research has found differential effects of parental symptoms on male versus female children. For instance, maternal PTSS are more acutely associated with PTSS in male children, while female children tend to be more negatively impacted by maternal PTSS over time

(Ostrowski, Christopher, & Delahanty, 2006). However, others have found no differential effect of parental PTSS on male versus female children (Landolt et al., 2003; Juth, Silver, Seyle,

Widyatmoko, & Tan, 2015).

Differential findings may be due to failure to consider the likely interaction between child age and gender. Older females are at a higher risk of developing PTSS than are younger females; however, in males, age is negatively associated with PTSS (Bokszczanin, 2008; Korol, Green, &

Gleser, 1999). Green and colleagues (1991) found that age was positively associated with child

PTSS, especially in females, again indicating specific risk in older females. Despite older female children developing PTSS at higher rates than younger females, the impact of parent symptoms on the child are higher for younger children (Laor, Wolmer, & Cohen, 2001). This is likely due to the influence of developmental stage; around approximately age 8, children begin to develop and use their own coping and cognitive strategies and no longer rely as much on external sources, such as parents, for emotion and behavior regulation (Salmon, & Bryant, 2002; Cole,

Michel, & Teti, 1994; Eisenberg, 1998). Given these findings, child age and gender will be examined as moderators of the association between parent and child PTS in the present study.

Child Pubertal Status

Child recovery post-trauma may also differ depending on the child’s pubertal status at the time of trauma exposure. For instance, trauma exposure during puberty is associated with an increased risk for anxiety disorders compared to trauma exposure during other developmental periods, and trauma exposure during grade school (i.e. 2-6 years before puberty) is associated

with an increased risk for developing a depressive disorder (Marshall, 2016). In contrast, recency of trauma exposure was the best predictor of PTSD diagnosis regardless of developmental stage among adolescent girls (Marshall, 2016). Within an adult sample, Weber and colleagues found that compared to healthy adults, adults with a psychiatric diagnosis were more likely to report a higher number of stressful events before puberty, but not during adulthood (Weber, Rockstroh,

Borgelt, Awiszus, Popov, Hoffmann, ... & Pröpster, 2008). There is some evidence for a complex and reciprocal relationship between trauma exposure and pubertal status. For instance, childhood exposure to abuse is associated with early (age 11 or younger) menarche (Boynton-

Jarrett, Wright, Putnam, Hibert., Michels, Forman, & Rich-Edwards, 2013) and younger age at menarche is associated with a higher rate of mental disorders (Toffol, Koponen, Luoto, &

Partonen, 2014). Given the demonstrated relationship between child pubertal status and psychological outcomes following trauma exposure, we conducted exploratory analyses investigating child pubertal status as a moderator of the relationship between parent and child

PTS.

Child Trauma History

As mentioned, prior trauma history consistently predicts PTSS in adults (see Ozer, Best,

Lipsey, & Weiss, 2003 for a meta-analysis), with trauma type being an important consideration.

That is, having a trauma history was a stronger predictor of PTSS when the current traumatic experience was interpersonal (i.e., abuse) compared to non-interpersonal (i.e., combat, accident;

Ozer, Best, Lipsey, & Weiss, 2003). The predictive utility of prior traumatization on PTSS in children is less clear, and the results have been mixed (see Cox, Kenardy, & Hendrikz, 2008 and

Trickey, Siddaway, Meiser-Stedman, Serpell, & Field, 2012 for meta-analyses). There is some evidence that type of prior trauma exposure may be a better predictor of PTSS compared to the

presence or absence of trauma history in children (Daviss, Mooney, Racusin, Ford, Fleischer, and McHugo, 2000). For instance, childhood sexual assault was found to be the only type of trauma that was associated with PTSS following hospitalization for a pediatric accidental injury, suggesting that a history of sexual abuse may be a particularly important predictor of psychopathology (Daviss, Mooney, Racusin, Ford, Fleischer, and McHugo, 2000). Given these findings, child trauma history was explored as a covariate in our models examining the relationship between parent and child PTS.

Child Pre-Trauma Functioning

Factors related to a child’s functioning prior to trauma exposure are consistently related to child symptom outcomes. For instance, children with difficult temperament, antisocial behavior, and/or who were unpopular among peers prior to trauma exposure were at higher risk of developing PTSD following trauma exposure compared to children who did not have these pre- trauma dispositions (Koenen et al., 2007). Further, a meta-analysis found a small, yet significant, effect size for the association between child pre-trauma psychological problems and PTSS following exposure to a traumatic event (Trickey et al., 2012). Another large-scale epidemiological study found that children with more pre-existing internalizing or psychotic symptoms had a greater risk of developing PTSD following trauma exposure (Lewis, Arseneault,

Caspi, Fisher, Matthews, Moffitt, ... & Danese, 2019). Other research has found that the type of pre-existing symptoms is an important consideration. Pre-existing anxiety, but not depressive, symptoms were associated with a higher risk of developing PTSS following trauma exposure even though affective disorders were most likely to co-occur with PTSS (Copeland, Keeler,

Angold, & Costello, 2007). Given the established relationship between child pre-trauma

functioning and PTS, child pre-trauma functioning was explored as a covariate in our investigation of the relationship between parent and child PTS.

Present Study

The present study investigated the impact of maternal and paternal PTS in response to a child’s injury on child PTS development up to 3 months post-injury. The longitudinal design allowed for the investigation of possible differential impacts of maternal and paternal responses to a child’s acute injury over time. Furthermore, we also investigated the impact of combined parental PTS on child PTS development. Child and parent trauma history, child pre-trauma functioning, and family functioning were explored as potential covariates. Child gender and child pubertal status were explored as moderators.

Specific aims and hypotheses:

Aim 1: Determine the extent to which maternal self-reported PTS at each time point predicted child self-reported PTS at the subsequent time point.

Hypothesis 1: Higher maternal PTS will be positively associated with subsequent child

PTS.

Aim 2: Determine the extent to which paternal self-reported PTS at each time point predict child self-reported PTS at the subsequent time point.

Hypothesis 2: Higher paternal PTS will be positively associated with subsequent child

PTS.

Aim 3: Determine the extent to which collective parental PTS impacts subsequent child

PTS in two-parent households.

Hypothesis 3: The interaction of maternal and paternal baseline PTS will be positively and more strongly associated with child 3-month PTS compared to paternal and maternal individual baseline PTS, controlling for child baseline PTS.

Aim 4 (exploratory): Determine the extent to which the above models (aims 1-3) change with the inclusion of child trauma history, parent trauma history, child pre-trauma functioning, and family functioning.

Hypothesis 4: Inclusion of the control variables will not change the significance of the three models.

Aim 5: (exploratory): Determine if the relationships tested in aims 1-3 above are moderated by child gender and child pubertal status.

Hypothesis 5: Child gender will moderate the relationship between parent and child PTS

(direction not hypothesized given the exploratory nature of this aim).

Hypothesis 6: Child pubertal status will moderate the relationship between parent and child PTS (direction not hypothesized given the exploratory nature of this aim).

II. METHODS

Parent study

The present data were collected as part of a larger study examining early predictors of post-traumatic distress in child injury victims and their families. The parent study also sought to establish incidence rates of Acute Stress Disorder and PTSD in child traumatic injury victims and their parents. Given that fathers are an underexamined group in the trauma literature, the parent study made a concerted effort to study paternal impacts on child outcomes.

Participants

Eligible participants were children aged 8-18 years old who were transported by

Emergency Medical Services (ambulance or helicopter) to the Emergency Department of a Level

2 trauma center in a mid-western city after an acute, non-burn, non-abuse related injury, and the child’s parent(s) or guardian(s). Parent/guardian was defined as any individual who 1. was a custodial parent, 2. lived with the child, and 3. had or shared primary responsibility for the child.

Parents in our sample included the following: biological parents, adopted parents, stepparents, biological aunt/uncle, and biological grandparent. For ease of reading, we will refer to all types of caregivers as “parent(s)/mother/father” throughout the document. When more than one parent was involved in caregiving responsibilities, researchers made a concerted effort to recruit both parents. Our participants experienced a broad range of injuries including sports injuries, injuries while engaged in recreational activities (i.e. horse riding, snow sports, etc.), motor vehicle accidents, ATV accidents, dog bite, falls, pedestrian or cyclists struck by car, and physical altercations between peers. We initially recruited 230 children, 224 mothers, and 167 fathers.

After participant attrition and data missing at random the following data were available for analyses and are listed by time point. Data regarding child variables assessed at time of injury included depression symptoms (N=154) and immediate event appraisals (N= 158). At two- weeks post-injury acute stress symptoms (N=113) were assessed, and at 3-months post-injury data on PTSS (N= 80), depression symptoms (N=77), trauma history (N=80), family functioning

(N=77), and child pubertal development (N= 75) were assessed. Maternal variables that were assessed at time of time of injury included depression symptoms (N= 219) and immediate trauma responses (N=222). At two-weeks post-injury acute stress symptoms (N=149) were assessed, and at 3-months post-injury trauma history (N=73) was assessed. Finally, paternal variables that were assessed at time of injury include depression symptoms (N=157) and immediate trauma responses (N= 164). At two-weeks post-injury acute stress symptoms (N=61) were assessed, and at 3-months post-injury trauma history (N= 47) was assessed.

After accounting for attrition and missing data, our samples for the regression analyses in aims 1 and 2 included 137 mother-child dyads and 105 father-child dyads. Our sample for aim 3 included 94 mother-father-child triads.

Child participants averaged 13 years old (SD = 2.92); most were male (67%) and

Caucasian (74%). Mothers averaged 41 years old (SD = 6.6); most were Caucasian (78%), married (59%), and had some education beyond high school (i.e., trade school, associate’s or bachelor’s degree, advanced college degree; 71%). Fathers averaged 43 years old (SD = 8.3); most were Caucasian (80%), married (67%) and had some education beyond high school (trade school, associate’s or bachelor’s degree, advanced college degree; 52%).

Procedure

Institutional review board approval was obtained following a review of the study procedures by Akron Children’s Hospital. Children and at least one parent were identified as meeting inclusion criteria by medical chart review. Once they were triaged to a hospital room, research staff approached medical personnel to ensure inclusion criteria were met. Eligible participants included youths who were transported by Emergency Medical Services from the scene of the accident or from another medical facility to the Emergency Department following a non-burn, acute injury. Exclusion criteria included a score of 13 or less on the Glasgow Coma

Scale (Teasdale & Jennett, 1974), suspected abuse-related injury, suspected self-inflicted injury, and severe intellectual disability. Also, participants were excluded if they were in a coma or were unconscious for more than one hour before or during emergency room admission or if the parent or child was not fluent in English. Upon receiving approval from patients’ doctors, researchers approached the families, described the study procedures, further determined eligibility, and obtained written informed consent from parents and children aged 11-18 and verbal assent from children aged 8-10. Once consent/assent was obtained all participating family members completed an initial self-report assessment in the hospital. At two-weeks post-injury, youth and parents/guardians individually completed clinical interviews via telephone with a trained researcher. At three-months post-injury, youth and parents/guardians were mailed self-report assessments that were completed privately and independently at their home and then mailed back to our lab. The assessments at each time point took approximately 10-20 minutes for each family member to complete. Each family was reimbursed with a $20 gift card upon completion of each time point.

Measures

Child immediate subjective distress related to the injury was assessed with a measure adapted from Stallard and Smith (2007). This measure assessed child appraisals of stressor severity with 6 items (i.e., “How serious was your accident?”; rated on a 5-point scale), alienation from other people (i.e., Do you feel that people don’t really understand what you’ve been through?”; rated on a 4-point scale), negative interpretation of symptoms (i.e., “Something must be wrong with me.”; rated on a 6-point scale), injustice (i.e., “This isn’t fair.”; rated on a 6- point scale), permanent change (i.e., “I will never get over this.”; rated on a 6-point scale), and heightened future danger (i.e., Bad things always happen to me.”; rated on a 6-point scale). A total sum score was used to estimate overall child immediate subjective distress. The scale demonstrated good internal consistency (α= .88) in the current sample.

The Impact of Event Scale-Revised (IES-R; Weiss, 2007) was used to assess initial parent PTSS in response to their child’s injury. The IES-R is a 22-item self-report measure with items rated on a 5-point Likert scale ranging from 0 (never) to 5 (extremely). The scale assesses subjective distress caused by a specified traumatic event, and the items correspond to DSM-IV

PTSD symptoms (American Psychiatric Association, 1994). Sample items include, “I felt as if it didn’t happen or wasn’t real”, “Pictures about it popped into my mind”, and “Reminders of it caused me to have physical reactions, such as sweating, trouble breathing, nausea, or a pounding heart”. The total measure score is a sum of all items. Parents were prompted to think of the child’s injury while filling out the questionnaire. This measure demonstrated excellent internal consistency in female and male parents (α = .98, .97, respectively) in the current sample.

Child and parent two-week acute stress disorder (ASD) symptoms (ASDS) were assessed using the Acute Stress Disorder Interview (ASDI; Bryant, Harvey, Dang, & Sackville, 1998).

The 19 dichotomously scored items are based on DSM-IV-TR Acute Stress Disorder symptoms,

and the interview takes about 5-10 minutes to complete. The first item asked participants to provide a brief description of the trauma. This description was followed by the symptom items.

Sample items include “When your injury happened did you think that you or someone else was going to be injured or die?”, “During or since your injury, have you felt numb or distant from your own emotions?”, “Have you kept remembering your injury even when you have not wanted to?”. This measure demonstrated good internal consistency for children, female parents, and male parents (α = .83, .87, .88, respectively) in the current sample.

The Child PTSD Symptom Scale (CPSS; Foa, Johnson, Feeny, & Treadwell, 2001) was used to assess child PTSS at three-months post-injury. A 27-item self-report version of the CPSS was used to assess PTSD symptoms in children. Twenty items assessed PTSD symptoms, and seven items assessed functional impairment related to symptoms. At the time that the study was proposed, the DSM-IV-TR was transitioning to DSM-5, therefore there were no validated measures assessing PTSS with DSM-5 criteria. We added 4 additional items to the original measure to assess negative alterations in mood/cognitions and omitted one symptom item (i.e. foreshortened future) in order to conform to the proposed symptom structure of PTSD. The 20 symptom items are rated on a 4-point frequency scale from 0 = “not at all” to 3 = “5 or more times a week” and the functional impairment items are rated on a dichotomous scale where 0 =

“absent” and 1 = “present”. This measure yields two sum scores for total symptom severity and total severity-of-impairment score. Sample items include ‘Having upsetting thoughts or images about the event that came into your head when you didn’t want them too”, “Acting or feeling as if the event was happening again (hearing something or seeing a picture about it and feeling as if

I am there again)”, “Trying not to think about, talk about, or have feelings about the event”. The

CPSS has excellent test-retest reliability (r = .86) and good convergent validity with other child

PTSD symptom measures (74.5-76.5% agreement; Foa, Johnson, Feeny, & Treadwell, 2001).

This measure demonstrated excellent internal consistency (α= .94) in the current sample.

The PTSD Symptom Scale (PSS; Foa, Riggs, Dancu, Rothbaum 1993) was used to assess parent three-month PTSS. Respondents were instructed to complete the measure regarding their symptoms stemming from their child’s injury as the anchoring event. A 27-item self-report version of the PSS was administered with 20 items that assessed DSM-5 PTSD symptoms, and 7 items assessed functional impairment related to symptoms. Again, we added 4 additional items to the original measure to assess negative alterations in mood/cognitions and omitted one symptom item (i.e. foreshortened future) in order to adapt to the proposed DSM-5 PTSD symptom structure. The 20 symptom items are rated on a 4-point frequency scale from 0 = “not at all” to 3 = “5 or more times per week/ very much/ almost always” and the functional impairment items are rated on a dichotomous scale where 0 = “absent” and 1 = “present”. This measure yields two sum scores for total symptom severity and total severity-of-impairment score. Sample items include, “Having bad dreams or nightmares about the traumatic event”,

“Experiencing physical reactions when reminded of the traumatic event (sweating, increased heart rate)”, “Feeling distant or cut off from the people around you”, and “Having trouble concentrating”. The PSS has excellent internal consistency (α = .91), adequate test-retest reliability (r = .74), and good convergent validity with other PTSD symptom measures

(sensitivity = 62%; specificity = 100%; positive predictive power = 100%, negative predictive power = 82%; Foa, Riggs, Dancu, Rothbaum 1993). This measure demonstrated excellent internal consistency for female and male parents (α = .94, .89, respectively) in the current sample.

The Center for Epidemiological Studies Depression Rating Scale (CES-D; Radloff, 1977) was used to assess parental baseline and 3-month depression symptoms. The CES-D is a 20-item self-report measure of depression that assesses depressed mood, feelings of worthlessness and guilt, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disturbances. Sample items include, “I was bothered by things that usually don’t bother me.”, “I had trouble keeping my mind on what I was doing.”, “I felt that I could not shake off the blues even with help from my family and friends.”. The measure has demonstrated high internal consistency (α ranging from .85-.90) and good construct validity (Radloff, 1977). This measure demonstrated good internal consistency for female parents at baseline and 3-months post-injury

(α = .86, .82, respectively) and questionable to good internal consistency for male parents at baseline and 3-months post-injury (α = .82, .68, respectively).

The Center for Epidemiological Studies Depression Rating Scale for Children (CES-DC;

Roberts, Andrews, Lewinsohn, & Hops, 1990) was used to assess child baseline and 3-month depression symptoms. The CES-DC is a 20-item self-report measure of depression rated on a 4- point Likert scale. This measure assesses symptoms over the past week, and a higher score indicates a higher level of depression symptoms. Sample items include, “I was bothered by things that usually don’t bother me.”, “I felt like I was just as good as other kids.”, and “I was more quiet than usual.” This measure has demonstrated high internal consistency (α ranging from .87 to .92) and fair test-retest reliability (r > .50; Roberts, et al., 1990) and demonstrated good internal consistency at both baseline and 3-months post-injury (α = .88, .83, respectively) in the current sample.

The Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) was used at baseline to measure child pre-trauma functioning. This 25-item, self-report measure is designed

to assess parent reports of five aspects of child temperament. Subscales measure emotional symptoms, conduct problems, hyperactivity/inattention, peer problems, and prosocial behaviors.

Each item is rated on a 3-point Likert scale from “Not true” to “Very true/often true” and each subscale is comprised of 5 items. Subscales are scored by calculating a sum score. The subscales demonstrated acceptable internal consistency in this sample (αs ranging from .60- .78). Since we were using this measure to represent a construct of overall child negative pre-trauma functioning, we summed items from all subscales except the prosocial behaviors subscale for the current study (possible score range= 0-40).

Child pubertal status was measured using the Pubertal Development Scale (PDS;

Petersen, Crockett, Richards, & Boxer, 1988). This 8-item self-report measure assesses different aspects of pubertal development (i.e., growth spurts, body hair growth) on a 4-point Likert scale

(i.e., “not yet begun”, “has barely started”, “is definitely underway”, “growth seems complete”), and gender-specific aspects of pubertal development (i.e., menstruation, breast development, facial hair, and voice changes) are rated on a 3-point scale (i.e., “No”, “Yes, barely”, and “Yes, definitely”). This measure also assesses height, weight, and stage of development compared to peers. The response options for the “development in comparison to peers” question are “Much earlier”, “Somewhat earlier”, “About the same”, “Somewhat later”, and “Much later”. A higher score on the measure indicates later stage of pubertal development. Internal consistency for this measure is questionable to good (αs ranging from .68 to .83; Petersen, Crockett, Richards, &

Boxer, 1988). This measure demonstrated good internal consistency for female and male children (αs= .82; .86, respectively) in this sample.

Parent and child trauma history was measured with the Traumatic Stress Schedule (TSS;

Norris, 1990). This measure assesses exposure to 10 potentially traumatic events, including

robbery, physical and sexual assault, sudden death (i.e., accident, suicide, or homicide) or serious injury of a loved one, fire, motor vehicle accident, and other serious accident. In addition to asking about exposure to these events, if a person indicates exposure to an event they are asked 5 follow-up questions (i.e., how many times has this happened to you?, how old were you the first time it happened?, On a scale of 1-7 how much did you fear for your life during this event?, To what extent were you physically injured during the event?, To what extent were you distressed by the event?). A sum of the 10 exposure items was used for the current study.

Family functioning was measured using the Issues Checklist Abridged (ICA; Robin &

Foster, 1989). This is a 44-item, self-report measure that assesses whether various topics have been discussed within the last month. Respondents select Yes or No for whether they discussed the topic and, if the topic was discussed, they provide a rating on a 5-point Likert scale with regard to how calm or angry (1= calm, 5 = angry) they felt during the discussion. This rating scale provides two summary scores: a Quantity of Issues Discussed score and an Intensity of

Issues Discussed score. The intensity score is the average of the intensity ratings for each discussion topic marked “Yes”.

Statistical Power Analysis

Because data collection for this study was concluded, there were pre-determined sample sizes: N’s= 137 (aim 1), 105 (aim 2), and 94 (aim 3). A priori statistical power analyses were performed to determine if an effect size could be detected with the current sample sizes. Two power analyses were conducted for the 2 proposed models (i.e. cross-lagged and regression).

Two predictors were identified in the cross-lagged models for each path and four predictors were identified in the regression models. With an alpha of p=.05 and power = .80, sample sizes of 43,

43 and 85 for aims 1, 2, and 3 respectively, are needed in order to have power to detect medium-

sized effects. This suggests that the current sample size is sufficient to test our hypotheses

(GPower 3.1; Faul, Erdfelder, Lang, & Buchner, 2007).

Data Analytic Plan

Preliminary Statistical Analyses

IBM SPSS 23 (Version 23.0; Arbuckle, J. L.) was used for the following analyses.

Preliminary bivariate correlations were calculated to examine the relationships among continuous variables of interest (i.e., child immediate trauma-related distress, two-week acute stress symptoms, and three-month PTSS; child immediate and three-month depression; parent

(male and female) immediate, two-week, and three-month PTSS; parent (male and female) immediate and three-month depression), and to determine possible covariates (i.e., child and parent trauma history, child pre-trauma functioning, and family functioning). Variables that were significantly correlated with the dependent variables were retained as covariates in the subsequent analyses. Bivariate correlations for each family member (i.e., child, mother, and father) were conducted to examine the relationship between PTSD and depression symptom measures within each time point. If symptom measures were correlated at greater than r=.50 then continuous symptom sum scores from PTSD and depression measures were used in the following analyses. If symptom measures were correlated at less than r=.50 then PTSD and depression symptoms were examined separately. Based on prior research, we anticipated that

PTSD and depression symptoms for all participants would be highly correlated.

Primary Statistical Analyses

Multiple regression analyses were used with data from N = 137 mother-child dyads to test hypothesis 1. Each model controlled for prior child symptoms. Multiple regression analyses were used with data from N = 105 father-child dyads to test hypothesis 2. Each model controlled

for child prior symptoms. Since we investigated the collective parental effect on children, data from a subsample of participants in which both parents participated and provided data (N= 94 triads) were used in the analyses testing aim three. Multiple regression models were conducted to investigate hypothesis 3. Baseline parent PTS sum scores were grand mean centered for the calculation of the interaction term.

A Bonferroni multiple comparisons correction of the alpha level was used to adjust for

Type 1 error that may result from conducting multiple analyses on the dependent variables. Six tests were conducted on child 2-week acute stress and therefore a p-value of .008 was used to indicate statistical significance for analyses of this dependent variable. Eight tests were conducted on child 3-month PTS and therefore a p-value of .006 was used to indicate statistical significance for analyses of this dependent variable.

For aim 4, child and parent trauma history, child pre-trauma functioning, and family functioning were explored as covariates of the relationships described in Aims 1-3 above. These variables were individually added to any models that were significant to determine if the models remained significant after adding each covariate.

In aim 5, child gender and child pubertal status were explored as potential moderators of the relationship between parent PTS and child PTS. Again, these moderator variables were investigated in the significant statistical models in Aims 1-3 above.

III. RESULTS

Preliminary Statistical Analyses

Examination of bivariate correlations between child depression (CES-DC) and child immediate trauma-related distress (Stallard and Smith injury-related appraisals) at baseline indicated that scores were not correlated above .50 (r = .45); therefore, child baseline depression and trauma reaction scores were examined as separate covariates in the regression models.

Examination of bivariate correlations between child depression (CES-DC) and PTSS (CPSS) measures at 3-months post-injury indicated that scores were correlated above .50 (r= .69). As such, depression and PTSS symptom scores were summed across measures to create a posttraumatic symptoms (PTS) dependent variable for child 3-month post-injury symptoms.

Overlapping symptoms (i.e., irritability, concentration concerns, anhedonia, persistent negative affect, sleep concerns, social detachment) on these measures were only included once in the sum score. Only Acute Stress Disorder symptoms were assessed at the 2-week post-injury assessment; therefore, the 2-week outcomes do not include a measure of depression symptoms.

Parent baseline symptom measure scores on the IES-R and CES-D were correlated below .50

(for mothers, r = .24 and for fathers, r = .49); therefore, parent’s baseline PTSS and depression symptoms were examined separately as predictors of child PTS.

Examination of bivariate correlations indicated that child trauma history was correlated with child 3-month PTS outcomes, but not child 2-week acute stress symptoms. Parent trauma history was not correlated with any child outcomes. Family functioning was correlated with child

3-month PTS, but not child 2-week acute stress symptoms. Female parent’s reports of child pre-

trauma functioning were correlated with both 3-month and 2-week child outcomes. Male parent’s reports of child pre-trauma functioning were correlated with child 2-week, but not 3- month, outcomes. Only covariates that were significantly correlated with outcome variables were retained in the analyses.

Primary Statistical Analyses

Hypothesis 1: Higher maternal PTS will be positively associated with subsequent child PTS.

Linear regression analyses indicated that our hypotheses regarding mother’s PTSS predicting subsequent child symptomology were partially supported. Mother’s baseline PTSS were not significantly associated with child 2-week acute stress symptoms (ß = 0.04, p = 0.67).

However, mother’s baseline PTSS and 2-week acute stress symptoms were significantly associated with child 3-month PTS (ß = 0.32, p = 0.00; ß = 0.36, p = 0.00, respectively) after controlling for child acute stress symptoms. The overall models accounted for 14% and 16% of the variance in child 3-month PTS (ps = 0.00).

Regarding the predictive utility of mother’s depression symptoms on child PTS, results from our linear regression analyses indicated that mother’s baseline depression symptoms trended towards a significant association with child 2-week acute stress symptoms (ß = 0.18, p =

0.02) after controlling for child baseline depression symptoms. However, mother’s baseline depression symptoms were not associated with child 3-month PTS when controlling for child baseline depression symptoms (ß = 0.05, p = 0.56).

Hypothesis 2: Higher paternal PTS will be positively associated with subsequent child PTS.

Linear regression analyses indicated that our hypotheses regarding paternal PTSS were not supported. Father’s baseline PTSS were not significantly associated with child 2-week acute stress symptoms (ß = 0.15, p = 0.10), and father’s baseline PTSS and 2-week acute stress

symptoms were not associated with child 3-month PTS (ß = 0.07, p = 0.55; ß = 0.04, p = 0.76, respectively). With regard to paternal depression symptoms, father’s baseline depression symptoms were associated with child 2-week acute stress symptoms (ß = 0.28, p = 0.00) after controlling for child depression symptoms. However, similar to our finding in mothers, father’s baseline depression symptoms were not associated with child 3-month PTS after controlling for child baseline depression symptoms (ß = 0.12, p = 0.21).

Hypothesis 3: The interaction between maternal and paternal baseline PTS will be positively and more strongly associated with child 3-month PTS compared to paternal and maternal individual baseline PTS, controlling for child baseline PTS.

Hierarchical multiple linear regression results indicated that this hypothesis was not supported. The interaction term between maternal and paternal baseline PTSS was not associated with child 3-month PTS (ß = -0.15, p = 0.24). Given that maternal 2-week acute stress symptoms were significantly associated with child 3-month PTS, we investigated the association between parental 2-week acute stress symptoms and child 3-month PTS. Again, the interaction term for parental 2-week acute stress symptoms was not associated with child 3-month PTS (ß = -0.19, p

= 0.17).

Hierarchical multiple regression results indicated that our hypothesis regarding parental depression symptoms was also not supported. The interaction term between maternal and paternal baseline depression symptoms was not associated with child 3-month PTS (ß = -0.22, p

= 0.09). Further, the interaction term for parental baseline depression symptoms was not associated with child 2-week acute stress symptoms (ß = -0.10, p = 0.29).

Exploratory Statistical Analyses

Hypothesis 4: There is a positive relationship between parental PTS and subsequent child PTS, controlling for child trauma history, parent trauma history, family functioning, and child pre- trauma functioning.

Covariates that were significantly correlated with outcome variables were entered into significant regression models. Collinearity was examined in all models using variance inflation factor (VIF) and tolerance statistics.

Child trauma history. Given that child trauma history was significantly associated with child 3-month PTS, we examined this variable as a covariate in two models that were previously found to significantly predict 3-month child PTS. In the first model, baseline mother’s PTSS was found to be significantly associated with child 3-month PTS after controlling for child baseline trauma-related distress and child trauma history. The regression results indicated that being exposed to more prior traumas (ß = 0.30, p = 0.00) and higher maternal baseline PTSS (ß = 0.31, p = 0.00) were associated with higher child PTS at 3-months post-injury. Child baseline trauma- related distress (ß = 0.18, p = 0.06) was no longer significantly associated with child 3-month

PTS when mother’s baseline PTSS was added to the model. The overall model accounted for

26% of the variance in child 3-month PTS, and adding the predictor variable, mother’s baseline

PTSS, to the model significantly improved the model fit, F (1, 96) = 12.42, p = .00. Mother’s baseline PTSS remained as a significant predictor of child 3-month PTS with child trauma history included in the model as a covariate.

The second model examining child trauma history as a covariate indicated that mother’s

2-week acute stress symptoms were significantly associated with child 3-month PTS after controlling for child trauma history and child 2-week acute stress symptoms. There was a trending positive association between child trauma history (ß = 0.23, p = 0.02) and child 3-month

PTS. There was a significant positive association between mother’s 2-week acute stress symptoms (ß = 0.35, p = 0.00) and child 3-month PTS. The overall model accounted for 23% of the variance in child 3-month PTS, and adding mother’s 2-week acute stress symptoms to the model significantly improved the model fit, F (1, 85) = 12.44, p = .00. Child 2-week acute stress symptoms (ß = 0.14, p = 0.16) were no longer significantly associated with child 3-month PTS after mother’s 2-week acute stress symptoms were added to the model. Mother’s 2-week acute stress symptoms remained as a significant predictor of child 3-month PTS with child trauma history included in the model as a covariate.

Family functioning. Given that family functioning was significantly correlated with child

3-month PTS, we examined this variable as a covariate in the models that significantly predicted child 3-month PTS. Results from the hierarchical linear regression analysis indicated that mother’s baseline PTSS (ß = 0.32, p = 0.00) were significantly associated with child 3-month

PTS after controlling for child baseline trauma-related distress (ß = 0.20, p = 0.04) and family functioning (ß = 0.07, p = 0.46). The overall model accounted for 18% of the variance in child 3- month PTS, and adding mother’s baseline PTSS significantly improved the model fit, F (1, 93) =

10.21, p = .00. Mother’s baseline PTSS contributed 8.7% unique variance to child 3-month PTS and remained a significant predictor after covariates were added to the model. Family functioning was no longer significantly associated with child 3-month PTS after other covariates and predictors were added to the model.

Family functioning was also investigated as a covariate in the relationship between mother’s 2-week acute stress symptoms and child 3-month PTS. Results indicated that mother’s

2-week acute stress symptoms (ß = 0.35, p = 0.00) were significantly associated with child 3- month PTS after controlling for child 2-week acute stress symptoms (ß = 0.14, p = 0.19) and

family functioning (ß = 0.12, p = 0.27). The overall model accounted for 18% of the variance in child 3-month PTS with mother’s 2-week acute stress symptoms contributing 10% unique variance. Adding mother’s 2-week acute stress symptoms to the model significantly improved the model fit, F (1, 82) = 10.21, p = .00. Mother’s 2-week acute stress symptoms remained as a significant predictor of child 3-month PTS when covariates were added to the mode. Again, family functioning was no longer significantly associated with child 3-month PTS when other covariates and predictors were added to the model.

Mother’s report of child pre-trauma functioning. Mother’s reports of child pre-trauma functioning were significantly correlated with child 3-month PTS and were examined as a covariate in three models. The results from the first hierarchical linear regression model found that mother’s baseline PTSS (ß = 0.30, p = 0.00) were significantly associated with child 3- month PTS after controlling for child pre-trauma functioning (ß = 0.31, p = 0.00) and child baseline trauma-related distress (ß = 0.13, p = 0.16). The overall model accounted for 25% of the variance in child 3-month PTS with mother’s baseline PTSS contributing 8% unique variance.

Adding mother’s baseline PTSS to the model significantly improved the model fit, F (1, 96) =

10.37, p = .00.

Mother’s 2-week acute stress symptoms were significantly associated with child 3-month

PTS (ß = 0.33, p = 0.00) after controlling for mother’s reports of child pre-trauma functioning (ß

= 0.46, p = 0.00) and child 2-week acute stress symptoms (ß = 0.16, p = 0.07). The overall model accounted for 39% of the variance in child 3-month PTS with mother’s 2-week acute stress symptoms contributing 9% unique variance. Adding mother’s 2-week acute stress symptoms to the model significantly improved the model fit, F (1, 85) = 13.41, p = .00.

Mother’s baseline depression symptoms were no longer significantly associated with child 2-week acute stress symptoms (ß = 0.15, p = 0.05) after controlling for child baseline depression symptoms (ß = 0.44, p = 0.00) and mother’s report of child pre-trauma functioning (ß

= 0.10, p = 0.20). Mother’s report of child pre-trauma functioning was also no longer significantly associated with child 2-week acute stress symptoms in this model.

Father’s report of child pre-trauma functioning. Father’s report of child pre-trauma functioning was significantly correlated with child 2-week acute stress symptoms and was included in relevant analyses. Results indicated that father’s baseline depression symptoms were significantly associated with child 2-week acute stress symptoms (ß = 0.28, p = 0.00) after controlling for child baseline depression symptoms (ß = 0.50, p = 0.00) and father’s report of child pre-trauma functioning (ß = -0.02, p = 0.87). The overall model accounted for 33% of the variance in child 2-week acute stress symptoms with father’s baseline depression symptoms contributing 9% unique variance. Adding father’s baseline depression symptoms to the model significantly improved the model fit, F (1, 102) = 10.09, p = .00, and father’s baseline depression remained a significant predictor of child 2-week acute stress with child pre-trauma functioning included in the model.

Hypothesis 5: Child gender moderates the relationship between parent and child PTS (direction not hypothesized given the exploratory nature of this aim).

Child gender. Child gender did not moderate the relationship between mother’s baseline

PTSS and child 3-month PTS or mother’s 2-week acute stress symptoms and child 3-month PTS.

Child gender also did not moderate the relationship between mother’s or father’s baseline depression symptoms and child 2-week acute stress symptoms.

Hypothesis 6: Child pubertal status moderates the relationship between parent and child PTS

(direction not hypothesized given the exploratory nature of this aim).

Child pubertal status. Child pubertal status did not moderate the relationship between mother’s baseline PTSS and child 3-month PTS or mother’s 2-week acute stress symptoms and child 3-month PTS. Child pubertal status also did not moderate the relationship between mother’s or father’s baseline depression symptoms and child 2-week acute stress symptoms.

Child pubertal status x child gender. Given results from Bokszczanin (2008) and Korol and colleagues (1999) that the interaction between child developmental stage and child gender may impact the relationship between parent and child PTS, we examined this in our sample. The interaction between child pubertal status and child gender did not moderate any of the relationships between parental and child PTS following child trauma.

IV. DISCUSSION

Primary Aims and Hypotheses

We investigated the predictive utility of parental PTS on child PTS two-weeks and three- months following a child’s injury. We found a dissimilar association between mother’s and father’s PTSS and child symptoms while there was a comparable association between mother’s and father’s depression symptoms and child symptoms. Specifically, mother’s baseline and 2- week PTSS were significantly associated with child’s 3-month symptoms; however, father’s

PTSS were not associated with child PTS. On the other hand, both mother’s and father’s baseline depression symptoms were associated with child 2-week acute stress symptoms. Additionally, maternal PTSS and depression symptoms had a differential impact on child symptom development. Mother’s initial depression symptoms following child injury were associated with earlier (2-week) child symptoms while mother’s initial PTSS were associated with later (3- month) symptom development.

Overall, our results are consistent with findings from a recent meta-analysis that shows high correspondence between child PTS and parental depression and PTSS (Morris, Gabert-

Quillen, & Delahanty, 2012). To the author’s knowledge, this is the first investigation that has found a differential timing effect of mother’s and father’s depression versus PTSS symptoms on child PTS. Our findings suggest that initial parental depression symptoms were associated with child acute (2-week) outcomes, while initial maternal PTSS symptoms were associated with longer-term (3-month) child PTS.

Correlational analyses indicated that while child baseline trauma-related distress and depression were not significantly correlated, child PTSS and depression symptoms 3-months following trauma exposure were highly correlated. Given their high correlation, child 3-month post-injury PTSS and depression symptoms were combined into a continuous symptom sum score. Our results suggest that the relationship between child trauma-related distress and PTSS become more strongly related to child depression symptoms over time following child trauma exposure.

Parental baseline PTSS and depression symptoms were not highly correlated. Although this is consistent with the baseline association between child trauma-related symptoms and depression symptoms, the low correlation between parental baseline symptoms was unexpected.

One possible explanation for this could be the timing of assessment. Parent symptoms were assessed at the time of the child’s injury while child symptoms were assessed later at 3-months after the injury. Parental depression assessed at the time of injury is likely an estimate of the parent’s pre-existing depression while their PTSS symptoms are more likely to be associated with their response to their child’s injury. Although there is no evidence demonstrating this, we would predict that parent depression and PTSS symptom concordance would increase overtime following the trauma. Indeed, in our sample we found that while child baseline trauma-related distress and depression symptoms were also not significantly correlated, child PTSS and depression symptoms did become significantly correlated in the months following the trauma.

Given the addition of the interaction term to test Hypothesis 3, this research question was tested in a subsample of families where both parents participated in the research study.

Hypothesis 3 was not supported, and the interaction between parental PTSS and depression symptoms did not significantly predict any child outcomes. This finding was especially

surprising with regard to parental initial depression symptoms and child 2-week acute stress symptoms given that both maternal and paternal depression symptoms independently predicted child 2-week acute stress symptoms. Our subsample could be lacking power to detect an effect, or it is possible that families with both parents participating in the study were inherently different than families with one parent as a participant.

Exploratory Aims and Hypotheses

Four variables (child trauma history, family functioning, mother’s reports of child pre- trauma functioning, and father’s reports of child pre-trauma functioning) were examined as covariates in the significant models. We found that mother’s baseline depression symptoms were no longer significantly associated with child 2-week cute stress symptoms after controlling for child baseline depression symptoms and mother’s reports of child pre-trauma functioning. Child baseline depression symptoms was the only predictor that remained significant in this model, suggesting that child baseline depression symptoms may be more predictive of child 2-week acute stress symptoms than mother’s baseline depression or mother’s report of child pre-trauma functioning. Upon covarying for these variables, the independent variables were still significantly associated with the dependent variables. This suggests that the results were robust and that parental symptoms continued to predict child subsequent PTS after accounting for other variables that are known to be associated with child symptom development following an acute injury.

Moderator variables (e.g., child gender and pubertal status) were also investigated in the models that were previously found to significantly predict child PTS outcomes. In these exploratory models, we found that child gender and child pubertal status did not moderate these relationships. These results are contrary to findings by Ostrowski and colleagues (2006), but

consistent with prior work finding that parental PTSS were not differentially associated with child gender (Landolt et al., 2003; Juth, Silver, Seyle, Widyatmoko, & Tan, 2015). Our results regarding child pubertal status are consistent with work by Marshall (2016) which suggested that pubertal status at time of trauma exposure is not associated with outcomes. Our findings that child age did not moderate the relationship between parental PTS and child PTS may be due to the limited range of child age in our sample. Prior work has found that at approximately age 8 children begin to develop their own coping and cognitive strategies and no longer rely on external sources, such as parents, for coping (Salmon, & Bryant, 2002; Cole, Michel, & Teti,

1994; Eisenberg, 1998). The mean child age in our sample was 13 (SD=2.92) which is a developmental stage where children are gaining more independence in their coping and cognitive strategies for emotion and behavioral regulation. Therefore, our findings may be limited due to the older age of our child sample.

Limitations

The present study is not without limitations. First, only child acute stress, not depression, symptoms were measured at 2-weeks post-injury. This limits some of the conclusions that can be made about the differential impact of parental depression versus PTSS symptoms on child 2- week and 3-month symptoms. If we had created a PTS variable combining child depression and acute stress symptoms at 2-weeks post-injury, similar to the variable created to represent child 3- month PTS, there may have been a greater range in child symptoms which may have produced different results. Also, the current findings are specific to children who experienced an acute injury and may not generalize to other trauma samples. Also, given the limited sample size, specifically the low participation rate of fathers, some effects may not have been detected due to limited power. Although the small number of father’s in our sample is a potentially limiting

factor with regard to detecting statistical power, it should be noted that our sample of fathers is considerable when compared to other research in the trauma literature.

Research and Clinical Implications of Findings

Future examinations of these relationships should continue to strive to recruit more fathers/paternal caregivers since mothers have historically been more represented within prospective child psychopathology research. Our results suggest that there may be differential effects of mothers’ versus fathers’ PTSS on child symptom development, and more studies with larger samples sizes are needed for further investigation and replication. Results from our correlational analyses suggest that child PTSS and depression symptoms are highly correlated following an acute injury; however, parental PTSS and depression symptoms following child injury were not significantly associated. More research is needed for replication of this finding.

Additionally, further research in trauma populations is needed using quality of life measures as outcomes rather than singular diagnostic outcome measures. Future research should also investigate potential moderators and mediators of the relationships between parent initial PTS and child subsequent PTS development. Prior research has suggested that marital or family discord (Burke, 2003; Bokszczanin, 2008), family dysfunction (Dorrington, Zavos, Ball,

McGuffin, Sumathipala, Siribaddana, ... & Hotopf, 2019; Romano, Babchishin, & Wong, 2016), trauma history (particularly the interpersonal versus non-interpersonal nature of the trauma:

Daviss, Mooney, Racusin, Ford, Fleischer, and McHugo, 2000), child pre-existing psychological symptoms (Lewis, Arseneault, Caspi, Fisher, Matthews, Moffitt, ... & Danese, 2019), and the interaction between child age and gender (Bokszczanin, 2008; Korol, Green, & Gleser, 1999) are important variables that should continue to be investigated as potential mediators or moderators of the relationship parental initial PTS and subsequent child PTS.

Despite limitations, the present study has contributed to the literature by further elucidating the impact of parental PTS on child PTS following child trauma exposure. Our results suggest that parent gender, symptom presentation (depression vs PTSS), and timing of assessment are all important factors in examining the predictive utility of parental PTS on child

PTS. Furthermore, early intervention (within 2-weeks post-trauma) on maternal depression and

PTSD symptoms and paternal depression symptoms may promote resilience in children following child injury.

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Tables Table 1. Summary of Measures.

Baseline Two-weeks 3-months

Parent Measures Impact of Event Scale- Acute Stress PTSD Symptom Scale Revised (IES-R) Disorder Interview (PSS) (ASDI) Center for Center for Epidemiological Studies Epidemiological Studies Depression Rating Scale Depression Rating Scale (CES-D) (CES-D) Strengths and Difficulties Questionnaire (SDQ)

Traumatic Stress Schedule (TSS)

Child Measures Stallard and Smith Acute Stress Child PTSD Symptom Appraisal Questions Disorder Interview Scale (CPSS) (ASDI) Center for Center for Epidemiological Studies Epidemiological Studies Depression Rating Scale Depression Rating Scale (CES-DC) (CES-DC) Pubertal Development Scale (PDS)

Traumatic Stress Schedule (TSS)

Issues Checklist Abridged (ICA)

Table 2. Pearson’s correlation (r) matrix for child symptom variables. 1. 2. 3. 4.

1. Child immediate trauma-related distress ------

2. Child baseline depression symptoms (CES-DC) 0.45** ------

3. Child 3-month PTSS (CPSS) 0.22* 0.38** -- --

4. Child 3-month depression symptoms (CES-DC) 0.28* 0.47** 0.69** --

*p < 0.05, ** p < 0.01

Table 3. Pearson’s correlation (r) matrix for parent symptom variables. 1. 2. 3. 4.

1. Mother’s baseline PTSS (IES-R) ------

2. Mother’s baseline depression (CES-D) 0.24** ------

3. Father’s baseline PTSS (IES-R) 0.34** 0.13 -- --

4. Father’s baseline depression (CES-D) 0.36** 0.24** 0.49** --

*p < 0.05, ** p < 0.01

Table 4. Pearson’s correlation (r) matrix for dependent variables and possible covariates. 1. 2. 3. 4. 5. 6. 7. 8.

1. Child 2-week acute ------stress symptoms 2. Child 3-month PTS 0.27* ------

3. Child trauma history 0.05 0.33** ------

4. Mother trauma 0.18 0.14 0.22* ------history 5. Father trauma history -0.20 -0.01 0.38** 0.15 ------

6. Family functioning 0.14 0.24* 0.22* 0.22* -0.28* ------

7. Mother’s report of 0.33** 0.40** 0.13 0.22* -0.10 0.22* -- -- child pre-trauma functioning 8. Father’s report of 0.27** 0.21 0.00 0.26* -0.06 0.16 0.67** -- child pre-trauma functioning

*p < 0.05, ** p < 0.01

Table 5. Linear Regression Analyses predicting Child 2-week Acute Stress Symptoms from Mother’s Baseline PTSS (Model 1; N = 139) and Mother’s Baseline Depression Symptoms (Model 2; N= 137) controlling for Child’s Baseline Trauma-Related Distress and Depression Symptoms. Model 1

B (SE B) β

Child baseline distress 0.11 (0.20) 0.44**

Mother’s baseline PTSS 0.01 (0.02) 0.04

R2 0.19

F 17.75**

Model 2

B (SE B) β

Child baseline depression 0.18 (0.03) 0.47**

Mother’s baseline depression 0.08 (0.03) 0.18*

R2 0.29

F 29.55**

*p < 0.01, ** p < 0.006

Table 6. Linear Regression Analyses predicting Child 3-month PTS from Mother’s Baseline PTSS (Model 1; N = 105), Mother’s 2-week Acute Stress Symptoms (Model 2; N= 93), and Mother’s Baseline Depression Symptoms (Model 3; N= 105) controlling for Child’s Baseline Trauma-Related Distress, Acute Stress Symptoms, and Depression Symptoms. Model 1 B (SE B) β

Child baseline distress 0.18 (0.08) 0.15

Mother’s baseline PTSS 0.27 (0.08) 0.32**

R2 0.14

F 9.77**

Model 2 B (SE B) β

Child 2-week acute stress symptoms 0.34 (0.34) 0.11

Mother’s 2-week acute stress symptoms 1.24 (0.37) 0.36**

R2 0.16

F 9.56**

Model 3 B (SE B) β

Child baseline depression symptoms 0.55 (0.12) 0.44**

Mother’s baseline depression symptoms 0.07 (0.13) 0.05

R2 0.20

F 13.95**

*p < 0.01, ** p < 0.006

Table 7. Linear Regression Analyses predicting Child 2-week Acute Stress Symptoms from Father’s Baseline PTSS (Model 1; N = 109) and Father’s Baseline Depression Symptoms (Model 2; N= 105) controlling for Child’s Baseline Trauma-Related Distress and Depression Symptoms. Model 1

B (SE B) β

Child baseline distress 0.10 (0.02) 0.40**

Father’s baseline PTSS 0.04 (0.02) 0.15

R2 0.21

F 15.52**

Model 2 B (SE B) β

Child baseline depression 0.20 (0.31) 0.50**

Father’s baseline depression 0.13 (0.37) 0.28**

R2 0.36

F 27.70**

*p < 0.01, ** p < 0.006

Table 8. Linear Regression Analyses predicting Child 3-month PTS from Father’s Baseline PTSS (Model 1; N = 85), Father’s 2-week Acute Stress Symptoms (Model 2; N= 62), and Father’s Baseline Depression Symptoms (Model 3; N= 81) controlling for Child’s Baseline Trauma-Related Distress, Acute Stress Symptoms, and Depression Symptoms. Model 1 B (SE B) β

Child baseline distress 0.19 (0.09) 0.24

Father’s baseline PTSS 0.06 (0.09) 0.07

R2 0.05

F 3.30

Model 2 B (SE B) β

Child 2-week acute stress symptoms 0.85 (0.40) 0.27

Father’s 2-week acute stress symptoms 0.16 (0.51) 0.04

R2 0.04

F 2.38

Model 3 B (SE B) β

Child baseline depression symptoms 0.56 (0.12) 0.45**

Father’s baseline depression symptoms 0.18 (.15) 0.12

R2 0.21

F 11.55**

*p < 0.01, ** p < 0.006

Table 9. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from the Interaction Term between Maternal and Paternal Baseline PTSS (N= 73). Model 1 Model 2

B (SE B) β B (SE B) β

Child baseline distress 0.00 (0.10) 0.00 0.02 (0.10) 0.03

Mother’s baseline PTSS 0.24 (0.10) 0.27 0.26 (0.11) 0.30

Father’s baseline PTSS 0.10 (0.10) 0.11 0.06 (0.12) 0.07

Mother’s * Father’s baseline -0.01 (0.01) -0.15 PTSS

R2 0.06 0.07

F 2.56 2.29

*p < 0.01, ** p < 0.006

Table 10. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from the Interaction Term between Maternal and Paternal 2-week Acute Stress Symptoms (N= 55). Model 1 Model 2

B (SE B) β B (SE B) β

Child acute stress symptoms 0.35 (0.35) 0.15 0.37 (0.35) 0.16

Mother’s acute stress symptoms 0.68 (0.56) 0.19 0.52 (0.56) 0.15

Father’s acute stress symptoms 0.05 (0.51) 0.02 0.06 (0.51) 0.02

Mother’s * Father’s acute stress -0.35 (0.26) -0.19 symptoms

R2 0.03 0.05

F 1.58 1.69

*p < 0.01, ** p < 0.006

Table 11. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from the Interaction Term between Maternal and Paternal Baseline Depression Symptoms (N= 70). Model 1 Model 2

B (SE B) β B (SE B) β

Child baseline depression 0.42 (0.16) 0.30* 0.55 (0.18) 0.40* symptoms

Mother’s baseline depression 0.11 (0.15) 0.83 0.05 (0.15) 0.04 symptoms

Father’s baseline depression 0.37 (0.16) 0.27 0.40 (0.16) 0.29* symptoms

Mother’s * Father’s baseline -0.06 (0.03) -0.22 depression symptoms

R2 0.10 0.13

F 3.32 2.89

*p < 0.01, ** p < 0.006

Table 12. Hierarchical Multiple Regression Analyses predicting Child 2-week Acute Stress Symptoms from the Interaction Term between Maternal and Paternal Baseline Depression Symptoms (N= 88). Model 1 Model 2

B (SE B) β B (SE B) β

Child baseline depression 0.20 (0.03) 0.54** 0.21 (0.03) 0.54** symptoms

Mother’s baseline depression 0.07 (0.05) 0.13 0.07 (0.05) 0.14 symptoms

Father’s baseline depression 0.10 (0.04) 0.25** 0.11 (0.04) 0.27** symptoms

Mother’s * Father’s baseline -0.00 (0.00) -0.10 depression symptoms

R2 0.43 0.44

F 7.85** 1.12

*p < 0.01, ** p < 0.006

Table 13. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from Mother’s Baseline PTSS, Child Baseline Trauma-Related Distress, and Child Trauma History (N= 99). Model 1 Model 2

B (SE B) β B (SE B) β

Child baseline trauma-related 0.24 (0.08) 0.27** 0.15 (0.08) 0.18 distress Child trauma history 3.82 (1.15) 0.31** 3.72 (1.09) 0.30**

Mother’s baseline PTSS 0.31 (0.09) 0.31**

R2 0.17 0.26

F for change in R2 8.63** 11.86**

*p < 0.01, ** p < 0.006

Table 14. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from Mother’s Baseline PTSS, Child Baseline Trauma-Related Distress, and Family Functioning (N= 96). Model 1 Model 2

B (SE B) β B (SE B) β

Child baseline trauma-related 0.24 (0.09) 0.27* 0.18 (0.09) 0.20 distress Family Functioning 2.98 (2.17) 0.14 1.58 (2.12) 0.07

Mother’s baseline PTSS 0.31 (0.10) 0.32**

R2 0.10 0.18

F for change in R2 7.22* 10.21**

*p < 0.01, ** p < 0.006

Table 15. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from Mother’s 2-week Acute Stress Symptoms, Child 2-week Acute Stress Symptoms, and Family Functioning (N= 85). Model 1 Model 2

B (SE B) β B (SE B) β

Child acute stress symptoms 0.94 (0.42) 0.23 0.54 (0.41) 0.14

Family Functioning 4.66 (2.22) 0.22 2.47 (2.21) 0.12

Mother’s acute stress symptoms 1.59 (0.50) 0.35**

R2 0.09 0.18

F for change in R2 4.95 10.21**

*p < 0.01, ** p < 0.006

Table 16. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from Mother’s Baseline PTSS, Child Baseline Trauma-Related Distress, and Mother’s Report of Child Pre-Trauma Functioning (N= 99). Model 1 Model 2

B (SE B) β B (SE B) β

Child baseline trauma-related 0.19 (0.08) 0.22 0.12 (0.08) 0.13 distress

Mother’s report of child pre- 0.84 (0.24) 0.33 0.77 (0.23) 0.31** trauma functioning

Mother’s baseline PTSS 0.29 (0.09) 0.30**

R2 0.18 5.26

F for change in R2 5.26 10.37**

*p < 0.01, ** p < 0.006

Table 17. Hierarchical Multiple Regression Analyses predicting Child 3-month PTS from Mother’s 2-week Acute Stress Symptoms, Child 2-week Acute Stress Symptoms, and Mother’s Report of Child Pre-Trauma Functioning (N= 88). Model 1 Model 2

B (SE B) β B (SE B) β

Child acute stress symptoms 1.07 (0.35) 0.27* 0.64 (0.35) 0.16

Mother’s report of child pre- 1.26 (0.23) 0.49** 1.17 (0.21) 0.46** trauma functioning

Mother’s acute stress symptoms 1.45 (0.40) 0.33**

R2 0.30 0.39

F for change in R2 9.27** 13.41**

*p < 0.01, ** p < 0.006

Table 18. Hierarchical Multiple Regression Analyses predicting Child 2-week Acute Stress Symptoms from Mother’s Baseline Depression Symptoms, Child Baseline Depression Symptoms, and Mother’s Report of Child Pre-Trauma Functioning (N= 137). Model 1 Model 2

B (SE B) β B (SE B) β

Child baseline depression 0.18 (0.03) 0.47** 0.17 (0.03) 0.44** symptoms

Mother’s report of child pre- 0.10 (0.05) 0.15 0.07 (0.05) 0.10 trauma functioning

Mother’s baseline depression 0.07 (0.04) 0.15 symptoms

R2 0.28 0.30

F for change in R2 3.72 3.83

*p < 0.01, ** p < 0.006

Table 19. Hierarchical Multiple Regression Analyses predicting Child 2-week Acute Stress Symptoms from Father’s Baseline Depression Symptoms, Child Baseline Depression Symptoms, and Father’s Report of Child Pre-Trauma Functioning (N= 105). Model 1 Model 2

B (SE B) β B (SE B) β

Child baseline depression 0.19 (0.04) 0.49** 0.20 (0.03) 0.50** symptoms

Father’s report of child pre- 0.08 (0.06) 0.11 -0.01 (0.07) -0.02 trauma functioning

Father’s baseline depression 0.13 (0.04) 0.28** symptoms

R2 0.27 0.33

F for change in R2 1.69 10.09**

*p < 0.01, ** p < 0.006

Figures

Figure 1. Statistical Model for Hypothesis 1.

Figure 2. Statistical Model for Hypothesis 2.

Figure 3. Statistical Model for Hypothesis 3.

Figure 4. Statistical Model for Hypothesis 4.

Figure 5. Statistical Model for Hypothesis 5 and 6.

Figure 6. Moderation Effects of Child Gender by Mother’s Baseline PTSS on Child 3-month PTSS (N = 103).

30 26.0151

25 21.8122

20 17.6092

15 13.7124 month PTS - Males 11.0864 Females 8.4604 Child3 10

0 Low Mod High Mother's Baseline PTSS

Figure 7. Moderation Effects of Child Gender by Mother’s Acute Stress Symptoms on Child 3- month PTSS (N = 92).

30 25.8514 25

20 18.2298

month PTS 12.4857 - Males 10.6082 11.0904 9.6952 Females

10 Child3

0 Low Mod High Mother's Acute Stress Symptoms

Figure 8. Moderation Effects of Child Gender by Mother’s Baseline Depression on Child 2-week Acute Stress Symptoms (N = 133).

8 7.5147

6.8063 7

5.76395.7792 6

4.7215 5 4.0437 4 Males 3 Females

2 ChildAcute Stress Symptoms

0 Low Mod High Mother's Baseline Depression Symptoms

Figure 9. Moderation Effects of Child Gender by Mother’s Baseline Depression on Child 2-week Acute Stress Symptoms (N = 104).

9 8.0552 8

6.6773 7 6.3878

6 5.4999

4.7204 5 4.3226

4 Males Females 3

ChildAcute Stress Symptoms 2

0 Low Mod High Father's Baseline Depression Symptoms

Figure 10. Moderation Effects of Child Pubertal Status by Mother’s Baseline PTSS on Child 3- month PTSS (N = 100).

23.941 25

20 18.5833 17.4845

14.2865

15 13.2256 Early

month PTS - 11.0279 11.0886 Mid 9.9897 8.9515

Child3 10 Late

0 Low Mod High Mother's Baseline PTSS

Figure 11. Moderation Effects of Child Pubertal Status by Mother’s Acute Stress Symptoms on Child 3-month PTSS (N = 89).

25 23.5156

20 18.3488

15.3659 15 13.5908 13.1819 11.8157 Early

month PTS 10.4495 - 10 8.8328 Mid 7.2161

Child3 Late

0 Low Mod High Mother's Acute Stress Symptoms

Figure 12. Moderation Effects of Child Pubertal Status by Mother’s Depression Symptoms on Child 2-week Acute Stress Symptoms (N = 88).

6 5.317

5 4.577 4.6259 4.5282 4.4043 4.1826 4.2316 3.837 3.9349 4

3 Early Mid

2 Late ChildAcute Stress Symptoms 1

0 Low Mod High Mother's Baseline Depression Symptoms

Figure 13. Moderation Effects of Child Pubertal Status by Father’s Depression Symptoms on Child 2-week Acute Stress Symptoms (N = 72).

7 6.2105 5.9822 5.754 6 5.4598 5.0605 5 4.7091 4.6612 4.1387 4 3.5683 Early 3 Mid Late

2 ChildAcute Stress Symptoms

0 Low Mod High Father's Baseline Depression Symptoms