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Acute Stress Disorder Among Parents of Infants in the Neonatal Intensive Care Nursery

Received, accepted January 26, 2005. From the Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, Stanford University School of Medicine, and Lucile Packard Children's Hospital, Palo Alto, CA. Address correspondence and reprint requests to Dr. Richard Shaw, Dept. of Psychiatry and Behavioral Sciences, Stanford Univ. School of Medicine, 401 Quarry Rd., Palo Alto, CA 94305-5719. e-mail: rjshaw{at}Stanford.edu

ABSTRACT

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The authors examined the prevalence of acute stress disorder (ASD) in parents of infants hospitalized in the neonatal intensive care unit (NICU). Forty parents were assessed after the birth of their infants. Parents completed self-report measures of ASD, parental stress, family environment, and coping style: 28% of parents developed symptoms of ASD. ASD was associated with female gender, alteration in parental role, family cohesiveness, and emotional restraint. Family environment and parental coping style are significantly associated with the development of trauma symptoms. Results from this study suggest potential interventions to help minimize psychological distress in parents.

INTRODUCTION

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Having a newborn infant hospitalized in the neonatal intensive care unit (NICU) is an unexpected and traumatic event.¹ Considerable research has examined sources of parental stress in the NICU. Miles et al.² have developed a framework for identifying specific domains of stress that occur in the neonatal ICU, and they emphasize the importance of the alteration in the expected parental role. Previous studies suggest a relationship between parental stress and symptoms of anxiety and depression.^3–6

Recently, researchers have identified posttraumatic stress disorder (PTSD) as a model to describe and explain the psychological reaction of parents to their NICU experience.^7–10 The model of a NICU hospitalization as a traumatic event has many parallels with the literature describing PTSD in parents of children with cancer and other pediatric medical conditions.^11,12 Acute stress disorder (ASD), the form of traumatic stress that is experienced in the first weeks after a traumatic event, is considered to be a precursor to PTSD. However, although ASD seems particularly relevant as a specific model for consideration in the context of traumatic stress in parents of NICU infants, there have been no previous studies that have examined this phenomenon among parents of NICU infants.

In this study, we examined ASD among parents of NICU infants and explored its relationship with ratings of parental stress as well as sociodemographic and medical variables. We also examined the relationship of two variables that have been shown in previous studies to influence the development of trauma symptoms, specifically, quality of family environment and parental coping style.¹³ In research relating distress among cancer survivors to their coping style, the use of suppression has been associated with greater development of PTSD, whereas repression appears to be related to less risk of psychological distress.¹⁴

On the basis of these previous studies, we developed the following specific hypotheses: 1) Parents of NICU infants will be at risk for developing symptoms of ASD; 2) Symptoms of ASD will be positively related to ratings of severity of parental stress; 3) Symptoms of ASD are likely to be greater in parents who report less family cohesiveness and greater levels of conflict; and 4) Parents with high levels of emotional restraint and those classified as Suppressors will be more likely to develop symptoms of ASD.

METHOD

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Research Participants
This study was approved by the appropriate institutional review board. Parents were asked to participate in a study on their reactions to having an infant in the NICU. Only English-speaking parents who had an infant in the NICU were included. Written informed consent was obtained from each parent after the procedures had been fully explained. Approximately one-third of those parents who were approached to invite them into the study agreed to participate. The sample included 40 parents who participated: 24 parents from couples in which both fathers and mothers participated, 13 mothers, and 3 fathers. All parents completed self-report questionnaires 2 to 4 weeks after the NICU hospitalization of their infants.

Table 1 presents the descriptive statistics summarizing the sociodemographic characteristics by the parents' gender, and Table 2 presents the neonates' medical information. Mothers and the fathers did not differ significantly in their background, apart from their employment status. Parents were generally well-educated and of relatively high socioeconomic status.

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TABLE 1. Sociodemographic Variables

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TABLE 2. Infant Medical Variables

Measures
The Stanford Acute Stress Reaction Questionnaire (SASRQ),^15,16 a 30-item self-report questionnaire, assessed ASD symptoms. Respondents used a scale of 1 to 5 to indicate the frequency with which each ASD symptom was experienced during or after having an infant in the NICU. The measure has been shown to have excellent reliability and convergent validity with measures of adult PTSD.^6,15 The Cronbach alpha for this sample on this measure (0.90) indicated good internal consistency.

Participants completed a brief demographic questionnaire that assessed age, ethnicity, education, employment status, income, religious affiliation, and religious practice.

Participants completed a brief questionnaire regarding their neonate's condition, including gestational age and birth weight. Data regarding Apgar scores and length of stay in the NICU were collected by chart review.

The Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU² assessed parental perceptions of stressors arising from the physical and psychosocial environment of the NICU. This 46-item instrument included three subscales assessing specific sources of stress: Sights and Sounds of the NICU (5 items), Infant Behavior and Appearance (19 items), and Parental Role Alteration (11 items). An additional subscale assessed Staff Behaviors and Communication (11 items). Cronbach alpha coefficients suggested satisfactory internal consistency both for the overall measure (0.89) and for each subscale (0.73, 0.83, and 0.83, respectively). Also, the PSS: NICU has been shown to have good construct validity.²

The Neonatal Index of Parental Satisfaction (NIPS),¹⁶ a 27-item self-report questionnaire, assessed parents' satisfaction with the medical care of their infants in the NICU. This measure has shown satisfactory reliability and validity in discriminating between parents who differ in their satisfaction with their infant's care.¹⁷

The Family Environment Scale (FES),¹⁸ a 90-item True/False self-report questionnaire, assessed parents' perceptions of their current family environment. It assessed several domains of family functioning, including Cohesion, Expressiveness, and Conflict and Control. This instrument has been evaluated as having good psychometric properties, including validity.¹⁸

The Weinberger Adjustment Inventory (WAI),¹⁹ an 84-item questionnaire, assessed the dimensions of distress, restraint, denial of distress, and repressive defensiveness. High levels of distress are associated with anxiety, depression, low self-esteem, and low well-being. High levels of restraint are associated with impulse-control, suppression of aggression, responsibility, and consideration of others. The WAI has been shown to have favorable psychometric properties, with internal consistencies ranging from 0.85 to 0.91. In this study, parental personality profiles were determined by categorizing groups bifurcated at the median scores of the two scales (Distress: 2.89; Restraint: 2.68). Parents whose Distress score was lower than the median and Restraint score was higher than the median were classified as Repressors (N=8). Parents whose Distress and Restraint scores were both lower than the median were categorized as Nonreactive (N=10). Parents whose Distress score was higher than the median and Restraint score lower than the median were classified as Reactive (N=10). Parents whose Distress and Restraint scores were both higher than the median were classified as Suppressors (N=12).

Data Analysis
Statistical analysis was conducted with SPSS for Windows, version 12.0. The Mann-Whitney U test was computed to examine the significance of differences in ASD symptoms between mothers and fathers. We examined the associations between severity of ASD and parental stress and quality of family environment by use of Spearman rank-order correlations (all tests were two-tailed). We used Kruskal-Wallis one-way analysis of variance to test the significance of the differences in severity of ASD symptoms across coping styles.

RESULTS

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Acute Stress Disorder
Eleven respondents (28%) met all symptom criteria used to diagnosis ASD for the stress of having an infant hospitalized in the NICU; 44% of mothers (N=11) were classified as meeting the symptom criteria for ASD, although none of the fathers did. Severity of ASD symptoms, as measured by number of ASD symptoms, was greater among mothers than fathers (p<0.01; Mann-Whitney U test). Figure 1 presents the ASD symptom profile by parents' gender. There is a similar pattern among mothers and fathers, with more hyperarousal and dissociation symptoms than intrusion and avoidance symptoms. Among the 12 couples, the husbands' severity of ASD was not significantly correlated with that of the wife (r_s=0.21; NS). Finally, severity of ASD was not associated with the respondents' sociodemographic characteristics or with the assessments of the neonates' medical condition.

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FIGURE 1.  Number of ASD Symptoms by Gender

Parental Stress in the NICU and ASD
Greater ASD symptom severity was strongly related to concerns regarding Parental Role Alteration (r_s=0.53; p<0.001) and was moderately related to stress pertaining to Infant Behavior and Appearance (r_s=0.32; p<0.05) and to the Sights and Sounds of the NICU (r_s=0.32; p=0.05). Ratings of Staff Behavior and Communication and ratings of parental satisfaction with medical care were not significantly related to the severity of ASD symptoms. To control for the gender differences in severity of ASD, we examined gender differences in perceived stress. We found mothers to have significantly greater concerns than fathers regarding Parental Role Alteration (t[38]=2.56; p<0.01). Partial correlations, controlling for gender, indicated that the association between ASD and concerns regarding Parental Role Alteration remained significant (r=0.44; p<0.01). Other parental concerns were not related to gender.

Family Environment and ASD
Severity of ASD symptoms was significantly and negatively associated with FES ratings of Cohesion (r_s = –0.32; p<0.05) and with the system-maintenance dimension of Control (r_s=0.36; p<0.05). Severity of ASD was not significantly associated with the other FES indices. There were no significant gender differences on these subscales.

Coping Style and ASD
Mothers and fathers did not significantly differ in their coping style. Parents' ASD symptom severity was significantly related to their coping style (t[39]=3.85; p<0.05). Scheffé post-hoc contrasts indicated that parents' ASD symptoms were greater among those high in use of restraint (r_s=0.38; p<0.05). The WAI Distress score, by itself, was not significantly associated with ASD. However, the combination of Distress and Restraint was related to ASD (²[3]=9.88; p<0.05; Kruskal-Wallis test). As shown in Figure 2, parents classified as Suppressors endorsed the most ASD symptoms, and Reactive individuals reported the fewest ASD symptoms.

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FIGURE 2.  Mean Rank of ASD Symptoms by Coping Style

DISCUSSION

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This is the first study to document ASD symptoms in parents of NICU infants, although previous studies have identified parents of premature infants as being at higher risk of posttraumatic stress reactions;^7–9 28% of the parents in this study met full symptom criteria for a diagnosis of ASD, which is consistent with previous findings on the development of ASD after a traumatic event.¹⁶ The nature of the symptoms endorsed by the parents was consistent with many of the clinical observations of NICU parents; these included symptoms of hyperarousal, flashbacks related to the event of the birth and NICU hospitalization, and avoidance of contact with the NICU.

Notably, none of the fathers, but almost half of the mothers, met all symptom criteria for a diagnosis of ASD. Increased levels of maternal distress have been attributed to their greater psychological involvement with their infant.^20,21 Other attributions have referred to gender differences in parental coping. Fathers are more likely to discount the severity of the problem, minimize their own emotional response, and spend more energy supporting their spouses during the NICU hospitalization.^22,23 Also, fathers are more likely to take instrumental action to address specific aspects of the crisis, whereas mothers tend to use escapist coping methods that may make them more prone to psychological distress.²² These gender differences are consistent with previous research demonstrating gender differences in ASD and PTSD in response to a variety of traumatic life events.^15,24

ASD symptoms were not found to be related to any of the characteristics that directly pertained to the infant's medical status, including length of stay in the NICU, birth weight, gestational age, and Apgar scores. By contrast, severity of ASD symptoms was significantly related to the parent's stress assessed by the PSS: NICU. Analysis of specific sources of stress in the NICU showed that alteration in the parental role—including not being able to help, hold, or care for the infant, protect the infant from pain, or share the infant with other family members—was the factor most strongly associated with symptoms of ASD. This pattern of results is consistent with previous findings on PTSD in parents of cancer survivors: the subjective appraisal of the seriousness of the illness, rather than the objective disease characteristics, predicts psychological outcome.^12,25 Given that parents have little control over their infant's medical status, our study provides some reason for optimism in working with these parents, since it suggests that parental factors may be of greater relevance.

The findings of this study demonstrated that family cohesion and expressiveness are associated with less psychological distress in parents. These findings are consistent with studies of PTSD in trauma survivors,²⁶ as well as studies of the adjustment of families of medically ill children, including cancer survivors.^12,27 The protective role of family cohesion and expressiveness, along with the negative effect of the use of control to maintain the functioning of family systems, may reflect the salutogenic role of social support and the pathogenic role of the tendency of some parents to attempt to practice control in the uncontrollable environment of the NICU.

This study also extended previous research on parental coping as one factor that may help explain differences in psychological outcome in NICU parents. Previous studies have shown that adults classified as Repressors may be less prone to manifest PTSD symptoms, at least in the short term, whereas those classified as Suppressors may be more likely to report psychological distress.^13,28 Studies have also shown a relationship between PTSD symptoms and avoidant coping style in different groups, including women with cancer and patients with traumatic brain injury.^29,30 In our study, parents classified as Suppressors and those with the tendency to use Restraint were found to be more likely to manifest symptoms of ASD. This is consistent with studies showing that suppression of emotional responses, particularly negative emotions, is associated with poor psychosocial adjustment and with PTSD symptoms in patients with breast cancer.^14,31 Amir et al.³² have proposed that the use of suppression strengthens avoidance and does not allow the traumatic events to be adequately processed. Parents classified with a reactive coping style were least likely to develop symptoms of ASD, suggesting that the ability to both recognize and express emotional distress may promote adaptation.

The results and conclusions of this study should be seen as preliminary in nature, since the sample size is small, and the study is cross-sectional in nature. Our study also depended upon self-report measures to assess complex constructs such as coping style and PTSD. The findings of this study must be interpreted with the knowledge that, in all studies of PTSD, there is the possibility that the tendency to avoid triggers that may remind participants of the traumatic event may lead to their underreporting of symptoms or to the exclusion of extremely symptomatic subjects from the study.

The concept of trauma stress response is useful in explaining many of the clinical phenomena observed among parents of NICU infants. The traumatic stress model, for example, may be particularly helpful in explaining the "vulnerable child syndrome," a term describing the tendency, often seen in parents of premature infants, toward being overprotective and having difficulty with limit-setting.^33,34 Ironically, such parental responses—hypervigilance, withdrawal, or irritability—may lead to poor health-care behaviors in children with medical illness.³⁵

The finding that alteration in parental role is rated as a primary source of stress suggests that efforts to include parents in a parental role at the bedside may have potential benefits. In particular, interventions should focus on reducing the parental feelings of helplessness and inadequacy by establishing the parental role, even with severely ill infants. These findings suggest that it is also important to try to prepare parents, whenever possible, for the expected psychological reactions that may occur in the event of a NICU hospitalization and, also, to support parents during the transition to home care.³⁵ Potential interventions might include those that model adaptive coping strategies for NICU parents, those that utilize parent and peer support, and programs that allow parents the opportunity for debriefing after the hospitalization.^36–38

ACKNOWLEDGMENTS

 
This project was supported by funding from NIH M01 RR00070 for The General Clinical Research Center Program, Stanford University School of Medicine, Palo Alto, CA.

REFERENCES

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