Trajectories of maternal symptoms of posttraumatic stress disorder predict long-term mental health of children following the Wenchuan earthquake in China: A 10-year follow-up study

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Trajectories of maternal symptoms of posttraumatic stress disorder predict long-term mental health of children following the Wenchuan earthquake in China: a 10-year follow-up study Xiaoyan Chen , Jieling Chen , Xuliang Shi , Min Jiang , Yuanyuan Li , Ya Zhou , Maosheng Ran , Yuan Lai , Tong Wang , Fang Fan , Xianchen Liu , Cecilia.L. W. Chan PII: DOI: Reference:

S0165-0327(19)33283-5 https://doi.org/10.1016/j.jad.2020.01.084 JAD 11533

To appear in:

Journal of Affective Disorders

Received date: Revised date: Accepted date:

5 December 2019 16 January 2020 20 January 2020

Please cite this article as: Xiaoyan Chen , Jieling Chen , Xuliang Shi , Min Jiang , Yuanyuan Li , Ya Zhou , Maosheng Ran , Yuan Lai , Tong Wang , Fang Fan , Xianchen Liu , Cecilia.L. W. Chan , Trajectories of maternal symptoms of posttraumatic stress disorder predict long-term mental health of children following the Wenchuan earthquake in China: a 10-year follow-up study, Journal of Affective Disorders (2020), doi: https://doi.org/10.1016/j.jad.2020.01.084

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Highlights 

Chronic posttraumatic stress disorder in mothers was longitudinally associated with children poorer mental health (in particularly, PTSD and anxiety symptoms).



A family systems approach is recommended to help mothers with chronic PTSD and their children to recover from the earthquake.

Trajectories of maternal symptoms of posttraumatic stress disorder predict long-term mental health of children following the Wenchuan earthquake in China: a 10-year follow-up study

Authors: Xiaoyan Chen1, Jieling Chen2, Xuliang Shi3, Min Jiang1, Yuanyuan Li1, Ya Zhou5, Maosheng Ran4, Yuan Lai1, Tong Wang1, Fang Fan1*, Xianchen Liu1, Cecilia. L. W. Chan4 1

School of Psychology, South China Normal University, Guangzhou, Guangdong,

China 2

The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong

Kong, China 3

College of Education, Hebei University, Hebei, China

4

Department of Social Work and Social Administration, The University of Hong

Kong, Hong Kong, China 5

Department of Psychology, Lund University, 221 00 Lund, Sweden

*

Corresponding author: Center for Studies of Psychological Application, South China

Normal University, Shipai Road, Guangzhou, 510631, China. E-mail address: [email protected]

Abstract Background: Maternal psychopathology can be an important factor associated with psychological adjustment of children. However, there is limited research on long-term impacts of maternal posttraumatic stress disorder (PTSD) on children’s mental health. This study examined how PTSD trajectories of women exposed to the 2008 Wenchuan earthquake in China predicted their children’s mental health symptoms 10 years after the earthquake. Methods: 410 dyads of mothers and their adolescent children who exposed to the Wenchuan earthquake were investigated at 12 and 18 months post-earthquake. While the mothers completed measures of earthquake exposure and PTSD symptoms, the

children completed measures of earthquake exposure, PTSD, depression and anxiety symptoms. In the 10-year follow up, 257 out of the 410 children completed measures of PTSD, depression and anxiety symptoms. Data were analyzed using linear regression. Results: Four trajectories of maternal PTSD symptoms were identified: (a) chronic (9.5%); (b) resilient (66.3%); (c) delayed (7.6%); and (d) recovery (16.6%); More importantly, the findings demonstrated that children whose mothers experienced chronic PTSD reported higher level of PTSD and anxiety symptoms 10 years after the earthquake. Limitations: Only two waves of maternal PTSD were collected, self-reported tools other than clinical reviews were used to collect data, and a significant proportion of participants did not respond at the 10-year follow-up. Conclusions: This study identified maternal PTSD trajectories following the Wenchuan earthquake. Chronic PTSD symptoms in mothers were associated with increased risk of children’s PTSD and anxiety 10 years after the earthquake. Keywords: maternal PTSD trajectories, children mental health, mother-child dyad, earthquake, longitudinal cohort

1. Introduction Long-term mental health sequela of children’s exposure to a natural disaster is a major public health concern. Some studies have sought to identify risk and protective factors for children’s mental health following the traumatic exposure (Ma et al., 2011; Fan et al., 2015). Parental mental health, especially maternal posttraumatic stress disorder (PTSD), can be an important factor associated with psychological adjustment of children. (Morris et al., 2012). However, research on long-term impacts of maternal PTSD post disaster on children’s mental health is limited. Previous studies that investigated the relationships between maternal PTSD or distress and their children’s mental health after disaster exposure were mostly cross-sectional (Chemtob et al., 2010; Alisic et al., 2011; Sangalang et al., 2017; Leen-Feldner et al., 2013). For instance, Kerns et al. (2014) studied 460 families during the 6 months following the Boston Marathon bombing, and found caregivers’ distress was positively associated with children’s posttraumatic stress symptoms after controlling for caregivers’ traumatic exposure. Only a few of longitudinal studies examined the relationships between maternal PTSD and children’s mental health and the findings were mixed. One study conducted with 489 offspring of 166 father-mother pairs showed that maternal PTSD longitudinally predicted children’s depression and anxiety with effect sizes of 0.26 and 0.57, respectively (Al-Turkait and Ohaeri, 2008). Similar longitudinal associations were also established in some other studies (Ostrowski et al., 2007; Shi et al., 2018). On the contrary, Self-Brown et al. (2006) found that parental PTSD (121 dyads) could not moderate between children’s community violence exposure and their depressive symptoms. Kolaitis et al. (2011) found that maternal PTSD could not predict children’s (n= 57; aged 7-18 years) PTSD 6 months later after a road traffic accident. Although these studies provided some initial evidence for the effects of maternal PTSD on children’s mental health, they are subject to a common limitation of not examining the interindividual variability in maternal PTSD after a disaster. The existence of heterogeneity of maternal PTSD trajectories might partly account for the inconsistent findings on the longitudinal relationships between maternal PTSD and children’s mental health. Studies on adult PTSD trajectories after disasters indicate that there are typically four patterns: 1) resilient: low or minimal symptoms over time; 2) chronic: consistently high level of symptoms; 3) recovery: elevations in symptoms at onset but decreases as the term progresses; 4) delayed: no or low symptoms but increases over

time (Boscarino and Adams, 2009; Norris et al., 2009). To date, very a few studies have investigated how different patterns of maternal PTSD are associated with mental health of their children (Graham-Bermann et al., 2011). For example, a 4-wave study of 360 mother-child dyads who became displaced after the Hurricane Katrina observed high levels of posttraumatic stress symptoms for children whose parents were in a chronic trajectory of posttraumatic stress symptoms (Self-Brown et al., 2014). However, these studies did not control the severity of the dyads’ traumatic exposure, and thus difficult to disentangle the effects of maternal posttraumatic symptoms from those of traumatic exposure on children’s adjustment (Kerns et al., 2014). Moreover, these studies did not examine the whether there were differential associations of maternal PTSD trajectories with children’s multiple mental health indicators including PTSD, anxiety, and depression. In view of previous research limitations, the current study conducted a 10-year follow-up of children exposed to the 2008 Wenchuan earthquake in China. Our prior study longitudinally examined these children’s mental health symptoms (including PTSD, depression, and anxiety symptoms) at 6, 12, 18, 24 and 30 months after the earthquake, as well as their mothers’ PTSD symptoms at 12 and 18 months after the earthquake [for a detailed description of the Wenchuan Earthquake Adolescent Health Cohort (WEAHC) Study (see Fan et al., 2017)]. This current study aimed to investigate the impacts of maternal PTSD trajectories on children’s mental health 10 years after the earthquake, which could provide insights for developing tailored intervention to population groups with different needs and characteristics. Specific objectives of this study were to: (1) identify the distribution of different maternal PTSD trajectory groups across two time points (12 and 18 months) after the earthquake; and (2) examine the relationship between maternal PTSD trajectories and children’s multiple mental health indicators (including PTSD, depression, and anxiety symptoms)10 years after the earthquake.

2. Methods 2.1 Wenchuan Earthquake Adolescent Health Cohort Study An 8.0-magnitude earthquake hit Wenchuan Country in the Sichuan Province of China on May 12, 2008. This disaster resulted in 69,227 deaths, 374,176 injured and 18,222 missing. Six months after the huge earthquake, a WEACH study was set up in Dujiangyan city (one of the worst-hit areas in the earthquake), to investigate mental health outcomes of Chinese adolescents exposed to this disaster (Fan et al., 2017). Five-wave data collection was conducted in adolescents at 6, 12, 18, 24 and 30 months after the earthquake, and two-wave data collection was conducted in their mothers at 12 and 18 months after the earthquake. To understand the long-term impacts of the earthquake on children’s development, our team followed up those children again 10 years after the earthquake. 2.2 Participants and Procedure In the WEAHC study, there were 589 mother-child dyads who completed the questionnaires at 12 months (T12m) after the earthquake. While 410 (69.6%) mother-child dyads completed questionnaires at 18 months (T18m) after the earthquake. Others did not respond or returned invalid questionnaires at T18m. Among 410 dyads, 257 (62.7%) children were followed again at 10 years (T10y) after the earthquake (Sampling procedure see Figure 1). Data collection procedures of the WEAHC Study were detailed in our prior publications (e.g., Fan et al., 2017). Before collecting data, written informed consent was obtained from adolescent children and their mothers. Children participants were recruited from a high school in Dujiangyan and they completed a number of questionnaires in a classroom setting under the supervision of local teachers and supervision of psychological professionals from South China Normal University. Self-report questionnaires for the mothers were taken home and brought back to researchers by the children upon their mothers’ completion. Children’s data at 10 years (T10y) after the earthquake were collected through an online survey. All procedures were approved by the Human Research Ethics Committee of South China Normal University. Permission was also obtained from the participating school boards.

2.3 Measures 2.3.1 Posttraumatic Stress Disorder Symptoms The Posttraumatic Stress Disorder Self-Rating Scale (PTSD-SS) was used to evaluate maternal and children’s PTSD at T12m and T18m (Liu et al., 1998). It includes 24 items, rating on 5-point Likert scale from 1 (not at all) to 5 (extremely severe). A higher score indicates more severe PTSD symptoms. A cut-off score of 50 on PTSD-SS was indicative of “probable PTSD” (Liu et al., 1998). In the current study, the Cronbach’s α was 0.95 for children and 0.94 for mothers, respectively. In the 10-year follow-up study, the Posttraumatic Stress Disorder Checklist (PCL-5) was used to assess children’s PTSD symptoms. A primary reason for using a different measure of PTSD (the same case for measures of depression and anxiety) at T10y was that the children participants experienced a transition from adolescence to adulthood and the measure used at T12m was not suitable for use with adults. The scale has demonstrated good psychometric properties in Chinese children (Wang et al., 2018). It consists of 20 items, which is rated on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). In the current study, the Cronbach’s α for the PCL-5 was 0.91. 2.3.2 Depressive Symptoms The Depression Self-Rating Scale for Children (DSRSC) was used to measure children’s depressive symptoms at T12m. The scale consists of 18 items. Participants reported the frequency of symptoms on a 3-point Likert scale ranging from 0 (never) to 2 (most of the time). DSRSC was an acceptable tool to evaluate depressive symptoms in Chinese samples (Su et al., 2003). Probable depression was indicated by a cut-off score of 15. In this study, the Cronbach’s α for the DSRSC was 0.81. The Patient Health Questionnaire 9-item depression scale (PHQ-9) (Kroenke et al., 2001) was used to measure the severity of depressive symptoms at T10y. The scale showed excellent psychometric properties in Chinese sample (Wang et al., 2014). Each item is rated on a 4-point scale ranging from 1 (not at all) to 4 (nearly all days). In this study, the Cronbach’s α for PHQ-9 was 0.90. 2.3.3 Anxiety Symptoms

The Chinese version of the Screen for Child Anxiety Related Emotional Disorders (SCARED) was used to evaluate children’s anxiety symptoms (Su et al., 2008) at T12m. It consists of 41 items, and each item is rated on a scale ranging from 0 (almost never) to 2 (often). A higher score indicates more severe anxiety symptoms. Probable clinical anxiety was indicated by a cutoff score of 25. In this study, the Cronbach’s α for the SCARED was 0.93. The Screen for Adult Anxiety Related Disorders (SCAARED; Angulo et al., 2017) was used to assess the anxiety of children at T10y. The scale includes 44 items and each item is rated on a scale ranging from 0 (not true of hardly ever true) to 2 (very true or often true). A higher score indicates more severe anxiety symptoms. In this study, the Cronbach’s α for SCAARED was 0.97. 2.3.4 Severity of Exposure to Earthquake Four self-rated items were selected to assess the severity of exposure to the earthquake in adolescents, including: 1= family members’ death, missing, and/or injury; 2= house damage; 3= property loss; and 4= direct witness of tragic scenes. The responses were rated on a 5-point scale, with 1 representing the highest level of exposure and 5 representing the lowest (Fan et al., 2015). In this study, the total score was inversely recoded (ranging from 4 to 20), therefore, a higher total score indicates higher earthquake exposure. The sum of these four items: (1) family members’ death, missing, and/or injury (1= injured/killed/missing, 2= no); (2) house damage (1=severe, 2= no/slight); (3) property loss (1=severe, 2= no/slight); (4) direct witness of tragic scenes (1=lots of witness, 2= not/few witness); were used to evaluate maternal earthquake exposure. A higher total score indicates a greater degree of exposure to the earthquake. 2.3.5 Demographics Demographic information of mothers were collected at T12m, including age, education level, income, number of children. Demographic information of children were collected at T6m (6 months after the earthquake), including age and gender. 2.4 Statistical Analyses Of 589 mother-child dyads who completed the questionnaires at T12m, 410 (69.6%) completed questionnaires at T18m. Chi-square test was used to compare those

mothers who did and did not participate at T 18m. The results showed that there were no significant differences except that mothers who participated were more likely to report that their child had a sibling (see Table S1). Chi-square analyses tested for any differences between children’s characteristics after 10 years’ follow up, the results presented no significant differences among main variables (see Table S2). There were missing data on mothers’ age (1.2%) and earthquake exposure (1.6%) as well as on children’s PTSD at T12m (3.1%), depression at T12m (0.4%), anxiety at T12m (0.4%), earthquake exposure (7.8%), and PTSD at T10y (0.4%). Little’s Missing Completely at Random (MCAR) test was used to analyze the missing values in all variables, and it showed that the missings were at random, χ2 (41) = 27.085, p = 0.95. Expectation-maximization (EM) algorithm was employed to impute missing data for those variables. To depict the changes of maternal PTSD from T12m to T18m, the subjects were classified into the probable PTSD and no PTSD according to the cutoff score of 50 for PTSD-SS. Thereafter, according to previous studies (e.g., Boscarino and Adams, 2009), four patterns of trajectories were formed: those without probable PTSD at either T 12m or T18m (Resilience); those maintained probable PTSD at both T12m and T18m (Chronic); those with PTSD at T12m but no probable PTSD at T18m (Recovery); and those with no PTSD at T12m followed by probable PTSD at T18m (Delayed PTSD). Pearson correlations were used to describe the relationships between mothers’ PTSD symptoms, children’s mental health, and earthquake exposure. Finally, according to previous studies (e.g., Van Der Waerden et al., 2015), linear regression was used to analyze if maternal PTSD trajectory membership could predict children’s mental health (PTSD symptoms, depression and anxiety). We tested crude models and adjusted model. The crude models only involved trajectory memberships as independent variables, and the adjusted models included trajectory memberships as well as maternal covariates (i.e., age, income, educational level, earthquake exposure) and children’s covariates (i.e., gender, age, earthquake exposure, mental health at T12m). PTSD symptoms, depression and anxiety were transformed into Z score before entering the regression model, because of the different selection of questionnaires. 3. Results

3.1 Sample characteristics A total 589 mother-child dyads completed the baseline survey, and 410 mothers and their children completed the 18-month follow-up survey. 257 children’s data were collected after 10 years’ earthquake. Sample characteristics of the mother-child dyads are showed in Tables 1 and 2. The average age of mothers and children during the earthquake was 40.29 ± 4.22 and 15.36 ± 0.65, respectively. 3.2 Correlations between main variables As shown in Table 3, mothers’ PTSD symptoms and children’s mental health were positively correlated with each other. Mothers’ earthquake exposure was positively related to their own PTSD symptoms at T12m. Similarly, children’s earthquake exposure was positively associated with their own mental health. 3.3 Trajectories of maternal symptoms of PTSD Figure 2 presents the trajectory patterns of maternal PTSD after 12 months and 18 months’ earthquake. Among the 410 mothers, 39 (9.5%) had consistently high PTSD (chronic PTSD group), 272 (66.3%) maintained consistently low level of PTSD (resilient PTSD group), 68 (16.6%) showed a decreasing pattern from PTSD to no PTSD (recovery group); and 31 (7.6%) showed an increasing pattern from no PTSD to PTSD (delayed PTSD group). 3.4 Maternal PTSD trajectories and children mental health Table 4 presents the results of the predictive effects of maternal PTSD trajectories on children’s mental health 10 years after the earthquake. In fully adjusted regression models, compared with the “resilient PTSD” group, children whose mothers were in the “chronic PTSD” group had higher levels of PTSD and anxiety symptoms. 4. Discussion Our longitudinal study had two major findings. First, the study reported four different types of the maternal PTSD trajectories, namely, chronicity, delayed-onset, recovery, and resilience. Second, compared to the resilience group, children whose mothers with chronic PTSD showed more severe PTSD and anxiety symptoms. The findings advanced our understanding of the impacts of a natural disaster on the psychological reactions of mothers and their children, providing implication for

implementing and evaluating interventions. Four groups of maternal PTSD trajectories were classified according to previous studies (Boscarino and Adams, 2009; Norris et al., 2009). At both times of measurements, mothers who without PTSD represented the largest proportion of the sample (66.3%), indicating that most mothers refrained from clinical PTSD after the earthquake, which aligns with previous findings (Bonanno, 2004; Bonanno et al., 2015). However, mothers with chronic PTSD still accounted for approximately 10% of the study population, suggesting the importance of providing mental health care and services to the earthquake-affected adult population. In 410 earthquake-exposed Chinese mother-child dyads, this study examined maternal PTSD in the early phase post-earthquake as a risk factor for children’s mental health 10 years after the earthquake. Of the particular importance is that we examined the interindividual heterogeneity in temporal changes of maternal PTSD and followed-up the children from adolescence to young adulthood. Interestingly, our findings showed that chronic maternal PTSD significantly predicted children’s PTSD symptoms and anxiety symptoms 10 years after the earthquake, even after adjusted for the dyads’ earthquake exposure, demographic factors, and children’s mental health at baseline. Yet, our study did not find significant predictive effects of maternal PTSD trajectories on children’s depression. As stated earlier, there is very limited research regarding the associations between maternal PTSD change patterns and children’s mental health. For example, in a study of 360 mother-child dyads, Self-Brown et al. (2014) found that maternal chronic PTSD pattern across four time points after being displaced by the Hurricane Katrina predicted children’s higher levels of PTSD at the fourth time point. These studies were limited by examining mother-child dyads’ posttraumatic symptoms within a same follow-up period. Our findings provided the initial evidence for the longitudinal associations between maternal PTSD change patterns in the early phase post-disaster and children’s mental health in later life. There are several possible explanations for the longitudinal associations between chronic maternal PTSD and children’s mental health problems. First, mothers with chronic mental diseases tend to have dysfunctional parenting behaviors (see review, Cobham et al., 2016) such as hostile parenting (Kelley et al., 2010) or “anxious” parenting (Chemtob et al., 2010), which might confer risk for mental ill-health in children. Second, PTSD is highly comorbid with other psychiatric conditions such as depression or substance dependence and cause an overall functional impairment

(Cabizuca et al., 2009). Parents who indulged in coping with their own PTSD following a disaster might have no energy or time to provide their children with sufficient and effective advice or support to cope with the disaster (Scheeringa and Zeanah, 2001). Some studies also found that parents with PTSD symptoms seemed more likely to deliver disaster-related negative information to their children by mothers with chronic PTSD, which might also heighted their risk for mental ill-health (Cohen and Eid, 2007). Moreover, the cross-generational transmission of mental problems in trauma-exposed mother-child dyads might also be due to their shared genetic or biological vulnerabilities (see review, Yehuda and Bierer, 2009; Langeland and Olff, 2008). This study did not investigate these mechanisms. Much remains unclear to date how these mechanisms independently and interactively influence the associations between maternal PTSD and children’ mental ill-health. Future research is needed to address such issues. Research regarding characteristics of different PTSD change patterns indicates that trauma survivors with a chronicity or delayed-onset pattern should both be considered as the high-risk population and paid more clinical attention compared with those showing a resilience or recovery pattern (e.g., Fan et al., 2015). In this study, however, we did not find significant longitudinal associations between maternal delayed PTSD and children’s mental health problems. One possible explanation is that mothers in the delayed group did not suffer from PTSD symptoms in the early phase post-earthquake and they might have more energy to take care of and provide necessary supports to their children. These might facilitate children’s successful psychological adaptation to the disaster and in turn reduce the risk for latter mental health problems. 5. Limitations Despite the strengths of a long-term longitudinal design, this study had some limitations. First, all measures relied on self-report questionnaires, which may cause reporting bias. Second, maternal PTSD symptoms were only measured in two waves because of difficulties in collecting data following the huge earthquake. Despite some previous studies also collected two waves (Berninger et al., 2010; Boscarino and Adams, 2009; Koenen et al., 2003), future study should extend the follow-up term if possible. Third, a significant proportion of participants did not respond at 10-year follow-up. Finally, we did not collect accurate data related the information that if the

mothers or children receive therapy for PTSD. 6. Clinical implications This study made an initial attempt to investigate in a sample of disaster-exposed Chinese mothers and their children the longitudinal associations between maternal PTSD change patterns in the early phase post-disaster and children’s mental health in later life. The findings highlight the need to pay attention to the children’s psychological status if their mothers have PTSD symptoms. Identifying timely and offering effective supports to those mothers at risk is greatly necessary to facilitate child’s adjustment to a traumatic event. Family interventions could be recommended to relieve the symptoms within the mother-child dyads.

Role of the founding source The present study was funded by National Natural Science Foundation of China (Grant No. 31271096); Research on the Processes and Repair of Psychological Trauma in Youth, Project of Key Institute of Humanities and Social Sciences, MOE (Grant No. 16JJD190001); Guangdong Province Universities and Colleges Pearl River Scholar Funded Scheme, GDUPS (2016); China Postdoctoral Science Foundation (Grant No.2016 M590793, 2017 T100638); National Natural Science Foundation of China (Grant No. 31900789, 31871129). Contributors: Each author contributed substantially to the paper. Xiaoyan Chen was involved in data analyses and preparation of the manuscript. Jieling Chen and Xuliang Shi have made contributions to the design and comments of this paper. Min Jiang, Yuanyuan Li, Ya Zhou, Maosheng Ran, Yuan Lai and Tong Wang polished it. Xianchen Liu and Cecilia. L. W. Chan commented on and revised the manuscript. Fang Fan supervised the writing of the manuscript. All authors read and approved the final manuscript. Acknowledgment The authors want to express their sincere gratitude to all participants and their mothers for participating in the study and Women’s Federation of Chengdu, Sichuan Province, for their support. We thank Susan Lin and Larkin Street, McReynolds who kindly provided informed advice and comments on this manuscript. Conflict of interest The authors declare that they have no competing interests.

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Figure 1. Sampling procedure for the current study. T12m= Data collected at 12 months after the earthquake. T18m= Data collected at 18 months after the earthquake. T10y= 10 years after the earthquake.

Figure 2. Examination of maternal PTSD development trajectories (n=410). Change in maternal PTSD scores from T12m to T18m. Black line indicates chronic PTSD group. Purple, recovery group. Blue, delayed PTSD group. Red, resilient PTSD group.

Table 1 Sample characteristics (n=410). Characteristics N(%) / Mean(SD) Mothers Age at T12m, y Education 9 years 9 years Income ＜3000 RMB 3000-6000 RMB ＞6000 RMB Missing data

40.29(4.22) 262(63.9) 148(36.1) 174(42.4) 116(28.3) 114(27.8) 6(1.5)

No. of children 1 ≥2

349(85.1) 61(14.9)

Family member injured/killed/missing No Injured /Killed/missing Missing data

320(78.0) 79(19.3) 11(2.7)

House damage No/ slight severe Missing data

238(58.0) 159(38.8) 13(3.2)

Property loss No/slight Complete/severe Missing data

311(75.9) 88(21.5) 11(2.7)

Witness of tragic scenes No / Few Many Missing data

204(49.8) 195(47.6) 11(2.7)

Children Age at T6m, y Gender, male

15.36(0.65) 130(31.7)

Note. T6m= Data collected at 6 months after the earthquake. T 12m= Data collected at 12 months after the earthquake. SD= Std. Deviation.

Table 2 Descriptive of mothers and children characteristics (n=257). Characteristics

Mean (SD)

Mothers PTSD at T12m

41.02(14.28)

PTSD at T18m

37.32(13.42)

Earthquake exposure

8.96(1.53)

Children PTSD at T12m

40.87(15.07)

Depression at T12m

13.64(5.44)

Anxiety at T12m

27.63(14.12)

PTSD at T10 y

25.12(6.44)

Depression at T10 y

13.98(4.19)

Anxiety at T10 y

61.45(15.66)

Earthquake exposure

11.02(2.50)

Note. T12m= Data collected at 12 months after the earthquake. T 18m= Data collected at 18 months after the earthquake. T10y= Data collected at 10 years after the earthquake. SD= Std. Deviation.

Table 3 Correlations between main variables (n=257). 1

2

3

4

5

6

7

8

9

10

Mothers 1. PTSD at T12m

-

2. PTSD at T18m

0.36**

3. Earthquake exposure

0.15

*

0.08

-

0.33**

0.26**

0.14*

-

0.19

**

0.20

**

0.12

0.55**

-

0.27

**

0.20

**

0.07

0.69**

0.65**

0.21

**

0.28

**

0.48

**

0.33

**

0.28**

0.13

*

0.15

*

0.31

**

0.34

**

0.31

**

0.59**

-

0.17

**

0.21

**

0.40

**

0.36

**

0.43

**

0.58**

0.77**

0.25

**

0.22

**

0.15

**

**

**

Children 4. PTSD at T12m 5. Depression at T12m 6. Anxiety at T12m 7. PTSD at T10 y 8. Depression at T10 y 9. Anxiety at T10 y 10. Earthquake exposure

0.06

0.06

0.15

*

0.08 0.08 0.58

**

-

0.26

0.21

0.15*

-

Note: all variables were transformed into Z scores except the earthquake exposure. T12m= Data collected at 12 months after the earthquake. T18m= Data collected at 18 months after the earthquake. T10y= Data collected 10 years after the earthquake. * p < 0.05; **p < 0.01.

rude model 1=257

djusted model 2=253

Table 4 Maternal PTSD trajectories predict children’s mental health 10 years after the earthquake using linear regression. PTSS at T10y a Depression at T10y b Anxiety at T10y c B



95% CI

p

B



95% CI

p

B



95% CI

p

Resilient group

0.00

0.00

(ref.)

-

0.00

0.00

(ref.)

-

0.00

0.00

(ref.)

-

Chronic group

1.07

0.32

(0.67,1.46)

0.000

0.56

0.17

(0.15,0.97)

0.008

0.74

0.22

(0.33,1.15)

0.000

Recovery group

0.03

0.01

(-0.29,0.35)

0.86

0.17

0.06

(-0.17,0.50)

0.33

0.23

0.09

(-0.10,0.56)

0.18

Delayed group

-0.06

-0.02

(-0.48,0.37)

0.79

0.04

0.01

(-0.40,0.48)

0.86

-0.003

-0.001

(-0.44,0.44)

0.99

Resilient group

0.00

0.00

(ref.)

-

0.00

0.00

(ref.)

-

0.00

0.00

(ref.)

-

Chronic group

0.62

0.19

(0.22,1.01)

0.002

0.36

0.11

(-0.05,0.77)

0.08

0.52

0.16

(0.13,0.92)

0.01

Recovery group

-0.19

-0.07

(-0.50,0.11)

0.21

0.09

0.03

(-0.24,0.41)

0.61

0.05

0.02

(-0.27,0.37)

0.77

Delayed group

-0.10

-0.03

(-0.50,0.29)

0.61

-0.02

-0.005

(-0.45,0.41)

0.94

-0.06

-0.02

(-0.47,0.35)

0.77

Trajectories

Note. PTSS, depression and anxiety have been transformed into Z score. T12m= Data collected at 12 months after the earthquake. T10 y= Data collected at 10 years after the earthquake. a included covariates : maternal factors (age, income, educational level, earthquake exposure ) and children (gender, age, earthquake exposure, PTSS at T12m). b included covariates: maternal factors (age, income, educational level, earthquake exposure ) and children (gender, age, earthquake exposure, depression at T12m). c included covariates: maternal factors (age, income, educational level, earthquake exposure ) and children (gender, age, earthquake exposure, anxiety at T12m). 24