Paternal PTSD or depression, adolescent mental health, and family functioning: A study of UK military families
Publication: Journal of Military, Veteran and Family Health
Volume 10, Number 2
LAY SUMMARY
LAY SUMMARY
Limited research has explored the relationships between paternal mental health, adolescent offspring mental health, and family functioning in United Kingdom military populations. The authors investigated this in a study of 105 serving and ex-serving members of the United Kingdom Armed Forces, with adolescent offspring ages 11 to 17 years. It was found military fathers with symptoms of PTSD or depression had more family difficulties, particularly around communication. Their adolescent offspring were also more likely to meet criteria for mental health disorders. These findings demonstrate the importance of supporting military fathers and their families with mental health and well-being.
Abstract
Introduction: Adolescent mental health and family functioning have received limited attention in UK military families. This study investigated their association with posttraumatic stress disorder (PTSD) and depression in military fathers. Methods: In total, 105 serving and ex-serving members of the UK Armed Forces, and 137 of their adolescent offspring (ages 11 to 17 years), were included in this cross-sectional secondary data analysis. Data were collected online and at home using validated questionnaires. Results: Probable PTSD or depression was associated with more impaired general family functioning (unadjusted b = 0.21; 95% CI, 0.07–0.35; p = 0.003) and increased likelihood of adolescent mental health disorders (unadjusted OR = 2.30; 95% CI, 1.10–4.81; p = 0.027). The direction and strength of these associations did not substantially change after adjusting for covariates. Discussion: This highlights the importance of supporting the well-being of military families, especially when parents have mental health problems.
Résumé
Introduction : La santé mentale des adolescents et le fonctionnement familial ont reçu peu d’attention dans les familles de Forces armées du Royaume-Uni. Cette étude a examiné leur association avec le trouble de stress post-traumatique (TSPT) et la dépression chez les pères militaires. Méthodologie : Au total, 105 membres en service ou libérés des Forces armées du Royaume-Uni et 137 de leurs enfants adolescent(e)s (de 11 à 17 ans) ont été inclus(e) dans cette analyse de données secondaires transversales. Les données ont été recueillies en ligne et à la maison à l’aide de questionnaires validés. Résultats : Un TSPT ou une dépression probable était associé à une plus grande perturbation du fonctionnement familial général (b non corrigé = 0,21; IC à 95 %, 0,07 à 0,35; p = 0,003) et à une probabilité accrue de troubles de santé mentale chez les adolescent(e)s (RC non corrigé = 2,30; IC à 95 %, 1,10 à 4,81; p = 0,027). L’orientation et la force de ces associations n’ont pas tellement changé après correction pour tenir compte des covariables. Discussion : Ces constats font ressortir l’importance de soutenir le bien-être des familles de militaires, particulièrement lorsque les parents éprouvent des problèmes de santé mentale.
INTRODUCTION
Among United Kingdom service personnel, an estimated 21.9% meet criteria for a common mental disorder, and 6.2% for posttraumatic stress disorder (PTSD).1 Mental health problems in military parents could pose challenges to their families and offspring, who already experience a range of stressors as a result of military service, such as regular relocation and separation from parents.2 In particular, mental health problems in service personnel have been associated with impaired structural, organizational, and transactional dynamics of family life (termed family functioning),3–6 problems readjusting to family life after returning from deployment,7 and marital or relationship problems.3,6,8 As well as impacting family life in general, mental health problems in service personnel were shown to impact interactions with their offspring, specifically problems with parenting,3,6,8 parent-child bonding,4 and perceived relationship quality with offspring.9
Mental health difficulties in parents are also thought to be associated with mental health difficulties in offspring. Research in this area has often focused on maternal mental health, but one review found paternal mental health can also play an important role.10 It particularly highlighted an association between paternal depression and adolescent anxiety, depression, and internalizing problems, while evidence for other paternal mental health disorders such as PTSD was less conclusive.10 Investigations in U.S., Australian, and Kuwaiti military populations showed a relationship between paternal and offspring mental health.11–13 To date, this relationship has received less attention in UK military families. One study conducted in UK military families found paternal PTSD was associated with hyperactivity among offspring, but not with other social and emotional problems.14 Further understanding these relationships is important, since mental health problems during adolescence can, in turn, have a marked impact on outcomes such as lower educational attainment15 and unemployment.16
To improve understanding of these associations in UK military families, the authors aimed to investigate whether families whose military fathers met criteria for probable PTSD or depression were at increased risk of 1) impaired family functioning and 2) adolescent mental health disorders.
METHODS
Design, setting, and procedures
Reporting follows STROBE guidelines for cross-sectional studies (Appendix Table A1).17 This was a secondary, exploratory analysis of the Service Parents’ & Adolescents’ Challenges & Experiences study (SPACE study), a study designed to explore the effects of paternal PTSD on adolescent offspring. Participants for this cross-sectional study were drawn from the King’s Centre for Military Health Research (KCMHR) Health and Wellbeing cohort of UK Armed Forces service personnel and the Children and Military Fathers with PTSD study (KIDS study).14,18,19 Fathers were invited to participate in the SPACE study if they had at least one child ages 11 to 17 years. Data collection ran from January 2016 to January 2017. Fathers were initially invited, followed by mothers, long-term partners, and adolescent offspring (where consent was given by the father to contact them). Adolescents either provided consent or assent depending on age and geographical location, and, where possible, consent was sought from both biological parents. Where this was not possible, consent was sought from the parent with parental responsibility for the participating adolescent.
Questionnaire data were collected online and by two research assistants during a home visit with the father, his adolescent offspring, and their biological mother or stepmother if she resided with the father. As a thank you for their time, adolescents were offered shopping vouchers worth £20. Parents were offered shopping vouchers worth £30, reflecting the greater time commitment.
This study received ethical approval from the United Kingdom Ministry of Defence Research Ethics Committee (654/MODREC/15), the King’s College Hospital local Research Ethics Committee, and the United States of America Human Protection Research Office (A-17980).
Paternal depression and PTSD
Paternal depression was measured using the 9-item Patient Health Questionnaire depression scale (PHQ-9).20,21 The PHQ-9 was completed during the home visit. This self-report questionnaire contains nine items and asks participants about their experience of mental health symptoms over the previous two weeks using a Likert scale of 0 (not at all) to 3 (nearly every day). Responses are then summed to provide a total score (possible range 0 to 27). Cut-off scores of 5, 10, 15, and 20 have been proposed as indicators of mild, moderate, moderately severe, and severe depression, respectively.20 Therefore, in this study, a score of 5 or higher was used to indicate any level of paternal depression. The PHQ-9 has been shown to have good psychometric properties and was previously used in military populations.22,23 In this sample, there were no missing data items on the PHQ-9, and internal consistency was excellent, Cronbach’s α = 0.90.
Paternal PTSD was assessed using the self-report National Center for PTSD Checklist (PCL-5).24 The PCL-5 was completed during the home visit. It comprises 20 items asking respondents to rate how much they were bothered by a series of problems over the previous month on a scale of 0 (not at all) to 4 (extremely). Responses are then summed to provide a total score (possible range 0 to 80). A total score of 33 or higher was taken to indicate probable PTSD, based on previous evaluations of the PCL-5 in military populations.25 The PCL-5 was used in preference to the PCL-M (military version), as the questions are not restricted to military-related trauma. The PCL-5 was validated for use in military populations.25 In this sample, one father was missing a single data item on the PCL-5, which was imputed with a 0. Following this, internal consistency was excellent on the PCL-5, Cronbach’s α = 0.95. For statistical analyses, a composite variable of depression and PTSD was generated. This binary variable indicated the presence of probable depression or PTSD versus no depression or PTSD.
Family functioning
Family functioning was assessed using the self-report McMaster Family Assessment Device (FAD).26 The FAD was completed during the home visit, but non-resident mothers who were not present during the home visit could complete the FAD online. Each family member rated how well 60 items (some of which were reverse scored) described their family on a Likert scale (strongly agree, agree, disagree, strongly disagree). After reverse scoring, missing items were imputed with a score of 1 if three or fewer items were missing (if more items were missing, imputation was not carried out). Across all 314 FAD questionnaires completed by fathers, mothers, and adolescents as part of this study, 11 (3.5%) were missing a single FAD item, and 8 (2.6%) were missing 2 FAD items; these items were therefore imputed with a 1. A further 3 (1.0%) had 11 or more missing FAD items, which were therefore left as missing.
FAD sub-scales were then scored for everyone by taking the mean average across items capturing general family functioning (12 items), problem solving (6 items), communication (9 items), roles (11 items), affective responsiveness (6 items), affective involvement (7 items), and behaviour control (9 items). Finally, mean average scores were taken on the resulting sub-scales across all available informants for each family. Higher scores indicated more problematic family functioning and could be further interpreted using cut-off scores recommended by Miller et al.,27 where sub-scale scores meeting or exceeding the sub-scale cut-off value can be considered indicative of unhealthy functioning in that area. Among the families included in this analysis, the number of family members who completed the FAD ranged between 2 and 5 (median = 3, interquartile range = 2 to 3). The FAD was shown to have good psychometric properties, and the general family functioning scale was previously used in military populations.27,28 Following imputation of missing items, and across all family members, internal consistency was modest to excellent for each sub-scale, ranging from Cronbach’s α = 0.67 (behaviour control) to Cronbach’s α = 0.88 (general family functioning).
Adolescent mental health disorders
Adolescents’ emotional and behavioural well-being was assessed using the Development & Well-Being Assessment (DAWBA), a structured diagnostic assessment covering all major mental health diagnoses in the 2010 edition of the International Classification of Diseases, 10th Edition (ICD-10).29,30 The DAWBA was completed online by participating fathers, mothers, stepmothers, and adolescents. A clinician then reviewed responses in combination with computer-generated probability scores to decide likely diagnoses for each adolescent (part of the clinician’s role in this process was deciding how to balance information from multiple sources that might sometimes conflict). The DAWBA has been shown to have good validity and inter-rater reliability.30,31 Three binary variables were generated, one indicating whether adolescents met criteria for any ICD-10 mental health disorder and two composite variables indicating whether adolescents met criteria for an internalizing disorder and for a neurodevelopmental, externalizing, or other mental health disorder (see Appendix Table A2 for groupings).
Covariates
Socio-demographic and military factors were also considered. Adolescent age and gender were collected as part of this current study. Paternal engagement type (Regular/reserve) and service (army/Royal Air Force/naval services) were collected from Phase 1 of the KCMHR Health and Wellbeing cohort.19 Paternal age, relationship status (in a relationship/single), serving status (serving/ex-serving), rank (commissioned officer/other), and deployment status (Iraq or Afghanistan/neither) were collected from Phase 3 of the KCMHR Health and Wellbeing cohort,1 and supplemented from the KIDS study if missing from Phase 3.
Statistical analyses
Linear regression analyses were conducted to examine the associations between probable paternal PTSD or depression and each family functioning sub-scale. Logistic regression analyses were conducted to examine the association between probable paternal PTSD or depression and adolescent mental health disorders, accounting for clustering within families using cluster-robust standard errors (this was unnecessary for analyses of family functioning, as only one FAD score per family was used).32 Models were adjusted for socio-demographic covariates, then additionally for military covariates. In a set of sensitivity analyses, the authors repeated these analyses twice with PTSD and depression considered separately and as continuous total scores in separate regressions. PTSD scores were scaled so the resulting regression coefficients represented a 15-point difference on the PCL-5, and depression scores were scaled so the resulting regression coefficients represented a 5-point difference on the PHQ-9, these having been proposed as clinically meaningful differences in previous literature.33,34 The authors also stratified the main analysis of adolescent mental health disorders by adolescent gender, although it should be noted the cell sizes for stratified analyses were small. Complete case analyses were conducted. Statistical significance was defined as p < 0.05. Analyses were conducted using Stata, version 18.0 (StataCorp, College Station, TX).
RESULTS
Descriptive statistics
In total, n = 105 fathers, and their n = 137 adolescent children had complete data available for analysis (Appendix Figure A1, Appendix Table A3). The characteristics of included fathers are summarized in Table 1. Of the 105 included fathers, the majority served as Regular personnel (n = 88, 83.8%), in ranks other than commissioned officers (n = 71, 67.6%), and in the army (n = 67, 63.8%). Most were in a relationship (n = 96, 91.4%). Over one-third of fathers met criteria for either probable PTSD or depression (n = 41, 39.1%). All fathers who met criteria for probable PTSD also met criteria for any depression.
| Characteristic | Frequency | % |
|---|---|---|
| Age (years), mean and 95% confidence interval | 44.5 (43.3–45.6) | |
| Relationship status | ||
| Single | 9 | 8.6% |
| In a relationship | 96 | 91.4% |
| Serving status | ||
| Serving | 55 | 52.4% |
| Ex-service | 50 | 47.6% |
| Engagement type | ||
| Regular | 88 | 83.8% |
| Reserve | 17 | 16.2% |
| Service | ||
| Army | 67 | 63.8% |
| Royal Air Force | 23 | 21.9% |
| Naval services | 15 | 14.3% |
| Rank | ||
| Commissioned officer | 34 | 32.4% |
| Other ranks | 71 | 67.6% |
| Deployment status | ||
| Iraq or Afghanistan | 77 | 73.3% |
| Neither | 28 | 26.7% |
| Mental health — categorical variables | ||
| Probable PTSD | 11 | 10.5% |
| Any depression | 41 | 39.1% |
| Probable PTSD or depression | 41 | 39.1% |
| Mental health — continuous variables | ||
| PTSD score, median and interquartile range | 12 (5–21) | |
| Depression score, median and interquartile range | 3 (1–7) |
On average, the included families scored in the healthy range for all family functioning sub-scales (Table 2), and scores on the sub-scales were very highly correlated (Appendix Table A4). Characteristics of the n = 137 included adolescents are summarized in Table 3. Over one-third of included adolescents met criteria for a mental health disorder (n = 51, 37.3%).
| Family functioning (FAD) (cut-off scores for unhealthy functioning in parentheses) | Mean | 95% CI |
|---|---|---|
| General family functioning (2.0) | 1.84 | 1.77–1.91 |
| Communication (2.2) | 2.13 | 2.07–2.18 |
| Roles (2.3) | 2.14 | 2.09–2.19 |
| Affective responsiveness (2.2) | 2.06 | 1.98–2.13 |
| Affective involvement (2.1) | 2.04 | 1.97–2.11 |
| Behaviour control (1.9) | 1.74 | 1.69–1.79 |
| FAD = Family Assessment Device. | ||
| Characteristic | Frequency | % |
|---|---|---|
| Age (years), mean and 95% confidence interval | 13.9 (13.6–14.2) | |
| Gender | ||
| Male | 75 | 54.7% |
| Female | 62 | 45.3% |
| Mental health | ||
| Any mental health disorder | 51 | 37.2% |
| Internalizing disorder | 37 | 27.0% |
| Neurodevelopmental, externalizing, or other mental health disorder | 23 | 16.8% |
Associations between probable paternal PTSD or depression and family functioning
There was evidence probable paternal PTSD or depression was associated with worse general family functioning (b = 0.21; 95% CI, 0.07–0.35; p = 0.003). This association remained after adjusting for socio-demographic characteristics and military factors (Table 4). However, the average general family functioning score in families where the father met criteria for probable PTSD or depression still did not meet the cut-off for unhealthy functioning.
| Family functioning outcome (cut-off scores for unhealthy functioning in parentheses) (n = 105) | No paternal PTSD or depression, mean (95% CI) | Probable paternal PTSD or depression, mean (95% CI) | Unadjusted b (95% CI) | p | Adjusted b*(95% CI) | p | Adjusted b†(95% CI) | p |
|---|---|---|---|---|---|---|---|---|
| General family functioning (2.0) | 1.75 (1.67–1.84) | 1.96 (1.85–2.08) | 0.21 (0.07–0.35) | 0.003 | 0.24 (0.11–0.37) | <0.001 | 0.22 (0.09–0.35) | 0.002 |
| Problem solving (2.2) | 1.92 (1.85–2.00) | 2.07 (1.97–2.16) | 0.15 (0.03–0.26) | 0.017 | 0.15 (0.04–0.27) | 0.011 | 0.14 (0.02–0.27) | 0.023 |
| Communication (2.2) | 2.06 (1.99–2.14) | 2.22 (2.13–2.31) | 0.16 (0.05–0.28) | 0.007 | 0.17 (0.06–0.28) | 0.003 | 0.16 (0.04–0.28) | 0.008 |
| Roles (2.3) | 2.09 (2.03–2.14) | 2.22 (2.13–2.31) | 0.13 (0.03–0.24) | 0.012 | 0.14 (0.04–0.25) | 0.006 | 0.13 (0.02–0.24) | 0.017 |
| Affective responsiveness (2.2) | 2.00 (1.91–2.09) | 2.15 (2.02–2.28) | 0.15 (0.00–0.31) | 0.048 | 0.18 (0.04–0.32) | 0.012 | 0.15 (0.00–0.29) | 0.047 |
| Affective involvement (2.1) | 2.00 (1.91–2.09) | 2.10 (1.99–2.21) | 0.10 (−0.04–0.24) | 0.153 | 0.14 (0.01–0.27) | 0.035 | 0.13 (−0.01–0.27) | 0.065 |
| Behaviour control (1.9) | 1.70 (1.65–1.76) | 1.80 (1.70–1.90) | 0.09 (−0.01–0.20) | 0.074 | 0.11 (0.00–0.21) | 0.042 | 0.08 (−0.02–0.18) | 0.136 |
| Adolescent mental health outcome (n = 137) | No paternal PTSD or depression, n (%) | Probable paternal PTSD or depression, n (%) | Unadjusted OR (95% CI) | p | Adjusted OR* (95% CI) | p | Adjusted OR† (95% CI) | p |
| Any mental health disorder | ||||||||
| No | 62 (69.7%) | 24 (50.0%) | Reference | — | Reference | — | Reference | — |
| Yes | 27 (30.3%) | 24 (50.0%) | 2.30 (1.10–4.81) | 0.027 | 2.13 (0.97–4.67) | 0.059 | 1.81 (0.79–4.14) | 0.157 |
| Internalizing disorder | ||||||||
| No | 70 (78.7%) | 30 (62.5%) | Reference | — | Reference | — | Reference | — |
| Yes | 19 (21.4%) | 18 (37.5%) | 2.21 (1.04–4.71) | 0.040 | 2.24 (0.96–5.24) | 0.063 | 1.98 (0.81–4.84) | 0.135 |
| Neurodevelopmental, externalizing, or other mental health disorder | ||||||||
| No | 77 (86.5%) | 37 (77.1%) | Reference | — | Reference | — | Reference | — |
| Yes | 12 (13.5%) | 11 (22.9%) | 1.91 (0.75–4.85) | 0.175 | 1.65 (0.62–4.42) | 0.315 | 1.47 (0.51–4.24) | 0.472 |
b = unstandardized regression coefficient; OR = odds ratio; CI = confidence interval.
*
Adjusted for socio-demographic characteristics (paternal age, paternal relationship status, adolescent age, adolescent gender).
†
Adjusted for socio-demographic characteristics (paternal age, paternal relationship status, adolescent age, adolescent gender) and for military factors (serving status, engagement type, service, rank, deployment status).
Analyses of the remaining family functioning sub-scales indicated probable paternal PTSD or depression was associated with worse scores on problem-solving (b = 0.15; 95% CI, 0.03–0.26; p = 0.017), communication (b = 0.16; 95% CI, 0.05–0.28; p = 0.007), roles (b = 0.13; 95% CI, 0.03–0.24, p = 0.012), and affective responsiveness (b = 0.15; 95% CI, 0.00– 0.31, p = 0.048) sub-scales. These associations remained after adjusting for socio-demographic characteristics and military factors. However, of these, the average score among families in which the father met criteria for probable PTSD or depression only met or exceeded the cut-off for unhealthy functioning on the communication sub-scale. Using this cut-off, 58.5% of families in which the father met criteria for probable PTSD or depression had unhealthy communication (compared to 32.8% in the comparison group).
Sensitivity analyses considering paternal PTSD and depression separately as continuous total scores showed further evidence for both PTSD and depression symptoms being significantly associated with worse general family functioning, including after adjustment for socio-demographic and military covariates (Table 5). Depression scores were likewise significantly associated with worse family functioning on all remaining sub-scales, whereas following adjustment for socio-demographic and military covariates, PTSD scores were only significantly associated with worse scores on communication, roles, and affective responsiveness sub-scales.
| Exposure: paternal PTSD score | Unadjusted b (95% CI) | p | Adjusted b* (95% CI) | p | Adjusted b† (95% CI) | p |
|---|---|---|---|---|---|---|
| General family functioning | 0.12 (0.05 to 0.19) | 0.001 | 0.12 (0.06–0.19) | <0.001 | 0.13 (0.05–0.21) | 0.002 |
| Problem solving | 0.07 (0.00–0.13) | 0.037 | 0.07 (0.01–0.13) | 0.024 | 0.07 (−0.00 to 0.14) | 0.056 |
| Communication | 0.07 (0.01–0.13) | 0.027 | 0.07 (0.01–0.13) | 0.016 | 0.07 (0.00–0.14) | 0.048 |
| Roles | 0.06 (0.01–0.12) | 0.018 | 0.07 (0.02–0.12) | 0.011 | 0.07 (0.00–0.13) | 0.040 |
| Affective responsiveness | 0.10 (0.02–0.17) | 0.013 | 0.10 (0.03–0.17) | 0.004 | 0.09 (0.01–0.17) | 0.038 |
| Affective involvement | 0.06 (−0.01 to 0.13) | 0.092 | 0.07 (0.00–0.13) | 0.047 | 0.07 (−0.01 to 0.15) | 0.090 |
| Behaviour control | 0.06 (0.01–0.12) | 0.016 | 0.07 (0.02–0.12) | 0.010 | 0.05 (−0.01 to 0.11) | 0.083 |
| Exposure: paternal depression score | Unadjusted b (95% CI) | p | Adjusted b* (95% CI) | p | Adjusted b† (95% CI) | p |
| General family functioning | 0.13 (0.07–0.19) | <0.001 | 0.14 (0.08–0.20) | <0.001 | 0.14 (0.08–0.21) | <0.001 |
| Problem solving | 0.08 (0.02–0.13) | 0.005 | 0.08 (0.03–0.14) | 0.003 | 0.08 (0.02–0.14) | 0.007 |
| Communication | 0.09 (0.03–0.14) | 0.002 | 0.09 (0.04–0.14) | 0.001 | 0.09 (0.04–0.15) | 0.002 |
| Roles | 0.08 (0.03–0.12) | 0.002 | 0.08 (0.03–0.13) | 0.001 | 0.08 (0.03–0.13) | 0.002 |
| Affective responsiveness | 0.09 (0.02–0.16) | 0.010 | 0.10 (0.04–0.17) | 0.001 | 0.09 (0.02–0.16) | 0.016 |
| Affective involvement | 0.07 (0.00–0.13) | 0.038 | 0.08 (0.02–0.14) | 0.007 | 0.08 (0.02–0.15) | 0.015 |
| Behaviour control | 0.07 (0.03–0.12) | 0.003 | 0.08 (0.03–0.12) | 0.001 | 0.07 (0.02–0.12) | 0.008 |
PTSD = posttraumatic stress disorder; b = unstandardized regression coefficient; CI = confidence interval.
Note: PTSD score has been scaled to represent a 15-point change on the PCL-5, and depression score has been scaled to represent a 5-point change on the PHQ-9.
*
Adjusted for socio-demographic characteristics (paternal age, paternal relationship status, adolescent age, adolescent gender).
†
Adjusted for socio-demographic characteristics (paternal age, paternal relationship status, adolescent age, adolescent gender) and for military factors (serving status, engagement type, service, rank, deployment status).
Associations between probable paternal PTSD or depression and adolescent mental health disorders
Probable paternal PTSD or depression was associated with adolescents meeting criteria for any mental health disorder (OR = 2.30; 95% CI, 1.10–4.81; p = 0.027) (Table 4). Although this association was no longer statistically significant after adjusting for socio-demographic characteristics and military factors, the direction and strength of the association remained similar.
A similar pattern of results emerged when focusing analysis on adolescent internalizing disorders. Probable paternal PTSD or depression was associated with adolescent internalizing disorders (OR = 2.21; 95% CI, 1.04–4.71; p = 0.040), and while this association was no longer statistically significant after adjusting for socio-demographic characteristics and military factors, the strength and direction of the association remained similar. However, evidence for an association between probable paternal PTSD or depression and adolescent neurodevelopmental, externalizing, or other mental health disorder was weaker.
Stratifying by adolescent gender suggested the association between probable paternal PTSD or depression and any adolescent mental health disorder was stronger among adolescent boys (OR = 3.23; 95% CI, 1.18–8.85; p = 0.023) than among adolescent girls (OR = 1.58; 95% CI, 0.52–4.82; p = 0.425). However, it should be noted sample sizes following stratification were small (Appendix Table A5).
Sensitivity analyses considering paternal PTSD and depression separately as continuous total scores suggested higher paternal depression scores were associated with increased odds for mental health disorders in adolescent offspring, particularly internalizing disorders. Odds ratios remained similar, but no longer statistically significant, after adjusting for socio-demographic and military covariates. Furthermore, neither the unadjusted nor adjusted associations between paternal PTSD scores and adolescent mental health were statistically significant (Table 6).
| Exposure: paternal PTSD score | Mean paternal PTSD score (SD) | Unadjusted OR (95% CI) | p | Adjusted OR* (95% CI) | p | Adjusted OR†(95% CI) | p |
|---|---|---|---|---|---|---|---|
| Any mental health disorder | |||||||
| No | 12.8 (12.5) | Reference | — | Reference | — | Reference | — |
| Yes | 16.8 (17.0) | 1.32 (0.92–1.91) | 0.136 | 1.29 (0.86–1.92) | 0.219 | 1.07 (0.70–1.65) | 0.755 |
| Internalizing disorder | |||||||
| No | 13.7 (14.0) | Reference | — | Reference | — | Reference | — |
| Yes | 15.9 (15.7) | 1.16 (0.86–1.58) | 0.337 | 1.15 (0.78–1.71) | 0.474 | 0.98 (0.65–1.48) | 0.922 |
| Neurodevelopmental, externalizing, or other mental health disorder | |||||||
| No | 13.3 (12.7) | Reference | — | Reference | — | Reference | — |
| Yes | 19.2 (20.8) | 1.43 (0.91–2.27) | 0.125 | 1.40 (0.89–2.21) | 0.149 | 1.36 (0.80–2.33) | 0.256 |
| Exposure: paternal depression score | Mean paternal depression score (SD) | Unadjusted OR (95% CI) | p | Adjusted OR* (95% CI) | p | Adjusted OR† (95% CI) | p |
| Any mental health disorder | |||||||
| No | 3.93 (4.43) | Reference | — | Reference | — | Reference | — |
| Yes | 5.82 (5.80) | 1.45 (1.01–2.08) | 0.046 | 1.41 (0.95–2.09) | 0.086 | 1.26 (0.84–1.90) | 0.264 |
| Internalizing disorder | |||||||
| No | 4.13 (4.75) | Reference | — | Reference | — | Reference | — |
| Yes | 6.00 (5.62) | 1.41 (1.03–1.91) | 0.031 | 1.43 (0.95–2.15) | 0.082 | 1.33 (0.87–2.04) | 0.191 |
| Neurodevelopmental, externalizing, or other mental health disorder | |||||||
| No | 4.32 (4.68) | Reference | — | Reference | — | Reference | — |
| Yes | 6.17 (6.47) | 1.37 (0.86–2.18) | 0.184 | 1.31 (0.83–2.08) | 0.240 | 1.24 (0.75–2.04) | 0.406 |
OR = odds ratio; CI = confidence interval; SD = standard deviation.
Note: PTSD score has been scaled to represent a 15-point change on the PCL-5, and depression score has been scaled to represent a 5-point change on the PHQ-9.
*
Adjusted for socio-demographic characteristics (paternal age, paternal relationship status, adolescent age, adolescent gender).
†
Adjusted for socio-demographic characteristics (paternal age, paternal relationship status, adolescent age, adolescent gender) and for military factors (serving status, engagement type, service, rank, deployment status).
DISCUSSION
The aims of this study were to investigate whether UK military families whose fathers met criteria for probable PTSD or depression were at increased risk of impaired family functioning and of adolescent mental health disorders. Strong evidence was found for an association between probable paternal PTSD or depression and impaired family functioning, particularly on the communication sub-scale of the FAD. There was also some evidence for an association between probable paternal PTSD or depression and adolescent mental health disorders, particularly internalizing disorders and particularly among adolescent boys.
Finding that probable paternal PTSD or depression was associated with family functioning is consistent with previous military studies that investigated similar associations.3–6 For the probable paternal PTSD or depression exposure, and for the continuous PTSD score exposure, negative and statistically significant associations were found with all family functioning sub-scales other than affective involvement or behavioural control. Two previous studies that used the FAD found paternal PTSD to be significantly associated with all sub-scales other than roles and behaviour control.4,5 The finding that paternal PTSD or depression was particularly associated with communication is of interest. During depressive episodes, individuals often experience reduced energy, activity, and capacity for interest and enjoyment.29 Taken together, these symptoms might reduce paternal engagement in family behaviours that are captured by the communication sub-scale. This possibility would benefit from further research.
These findings are somewhat consistent with previous studies that demonstrated associations between paternal mental health and offspring mental health in military families.11–13 Some evidence was found for associations between probable paternal PTSD or depression and adolescent mental health disorders, but these associations were no longer statistically significant after adjusting for socio-demographic and military covariates (although the magnitude of odds ratios remained similar). Sensitivity analyses suggested these associations were perhaps driven by paternal depression symptoms in the sample, rather than by PTSD symptoms, but larger studies would be needed to confirm this with improved statistical power. Findings stratifying by adolescent gender are especially likely to be underpowered, but tentatively suggest stronger associations for adolescent boys; this would also need to be investigated in further studies.
Possible mechanisms in the relationship between paternal and offspring mental well-being were explored, with reviews implicating genetic processes, parenting, and the home environment in the transmission of risk.35,36 Maternal mental health was also proposed as a factor on the pathway between paternal and adolescent mental health35 and could therefore be investigated in future studies. Military families may additionally experience a range of stressors that could increase risk for mental health disorders, like relocation and parental physical trauma, as well as protective factors, such as strong community connections, which could foster parental resiliency and positive family functioning in military families.37 With family functioning potentially playing a role in the relationship between paternal and adolescent mental health, these relationships warrant further study in a military population.
Strengths and limitations
To the authors’ knowledge, this is the first UK-based study to examine the association between paternal and adolescent mental health in military families using a robust clinical measure to gather diagnostic data from multiple informants on adolescent mental health. This ensured the adolescent mental health data used was both reliable and clinically relevant.30
The sample size had several implications for this study. First, to increase statistical power, the main analysis focused on a composite of “probable” PTSD and “any” depression, largely because cell sizes were not sufficient to examine probable PTSD separately. However, supplementary analyses using continuous measures of PTSD and depression added more detailed findings for each separate set of symptoms. Second, caution is warranted in adjusting for large numbers of covariates where sample sizes are small. However, the authors equally found it important to adjust for socio-demographic and military covariates that could play an important role in family functioning and adolescent mental health. Finally, small sample sizes can limit the external generalizability of findings. Nonetheless, the sample originated from a representative, random cohort of the UK military.18,19
The authors relied on fathers providing consent to contact and recruit mothers and adolescents. Therefore, recruitment may have selected for intact or well-functioning families. The extent of contact between participating fathers and adolescents was also unknown, so it is possible fathers and adolescents who lived separately with other spouses or children completed the FAD with different family units in mind. However, given the FAD was collected during home visits at which the father and adolescent were both present, it remains likely they took the shared family environment into consideration. Importantly, family functioning data from multiple informants was used to increase validity,38 and the authors took an average across these informants to ensure the perspective of each family member was given equal weight in analysis. Family functioning scores sometimes vary between family members,39 so future studies might further investigate whether paternal mental health is associated with family functioning as perceived by different family members.
Conclusion
Evidence was found to suggest probable paternal PTSD or depression is associated with adolescent mental health disorders in military families, particularly internalizing disorders and particularly among boys. Probable paternal PTSD or depression was also associated with worse family functioning, particularly on the communication sub-scale. The prevalence of mental health disorders in the UK military is generally low,1 but this study highlights the continued importance of supporting service personnel with mental health and of extending that support to families and adolescent offspring.
REGISTRY AND REGISTRATION NO. OF THE STUDY/TRIAL
N/A
ANIMAL STUDIES
N/A
PEER REVIEW
This manuscript has been peer reviewed.
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APPENDIX
| Item no | Recommendation | Page | |
|---|---|---|---|
| Title and abstract | 1 | (a) Indicate the study’s design with a commonly used term in the title or the abstract. | 1 |
| (b) Provide in the abstract an informative and balanced summary of what was done and what was found. | 1–2 | ||
| Introduction | |||
| Background/rationale | 2 | Explain the scientific background and rationale for the investigation being reported. | 3–4 |
| Objectives | 3 | State specific objectives, including any prespecified hypotheses. | 4 |
| Methods | |||
| Study design | 4 | Present key elements of study design early in the paper. | 4 |
| Setting | 5 | Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection. | 4–5 |
| Participants | 6 | (a) Give the eligibility criteria and the sources and methods of selection of participants. | 4–5 |
| Variables | 7 | Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable. | 5–8 |
| Data sources/measurement | 8* | For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group. | 5–8 |
| Bias | 9 | Describe any efforts to address potential sources of bias. | N/A |
| Study size | 10 | Explain how the study size was arrived at. | Supplementary Figure 1 |
| Quantitative variables | 11 | Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why. | 5–9 |
| Statistical methods | 12 | (a) Describe all statistical methods, including those used to control for confounding. | 8–9 |
| (b) Describe any methods used to examine sub-groups and interactions. | 8–9 | ||
| (c) Explain how missing data were addressed. | 8–9 | ||
| (d) If applicable, describe analytical methods taking account of sampling strategy. | N/A | ||
| (e) Describe any sensitivity analyses. | 8–9 | ||
| Results | |||
| Participants | 13* | (a) Report numbers of individuals at each stage of study—e.g., numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completed follow-up, and analyzed. | Supplementary Figure 1 |
| (b) Give reasons for non-participation at each stage. | Supplementary Figure 1 | ||
| (c) Consider use of a flow diagram. | Supplementary Figure 1 | ||
| Descriptive data | 14* | (a) Give characteristics of study participants (e.g., demographic, clinical, social) and information on exposures and potential confounders | 9–10 (Note: we have not stratified characteristics by exposure group due to potentially disclosive cell sizes.) |
| (b) Indicate number of participants with missing data for each variable of interest. | Supplementary Table 3 | ||
| Outcome data | 15* | Report numbers of outcome events or summary measures. | 10 |
| Main results | 16 | (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (e.g., 95% confidence interval). Make clear which confounders were adjusted for and why they were included. | 10–12 |
| (b) Report category boundaries when continuous variables were categorized. | 5–7 | ||
| (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period. | N/A | ||
| Other analyses | 17 | Report other analyses done—e.g., analyses of sub-groups and interactions, and sensitivity analyses. | 10–12 |
| Discussion | |||
| Key results | 18 | Summarize key results with reference to study objectives. | 12–14 |
| Limitations | 19 | Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias. | 14–15 |
| Interpretation | 20 | Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence. | 15–16 |
| Generalizability | 21 | Discuss the generalizability (external validity) of the study results. | 15 |
| Other information | |||
| Funding | 22 | Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based. | Title page |
Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at https://www.plosmedicine.org, Annals of Internal Medicine at https://www.annals.org, and Epidemiology at httpa://www.epidem.com). Information on the STROBE Initiative is available at https://www.strobe-statement.org.
*
Give information separately for exposed and unexposed groups.
| Internalizing disorders | Neurodevelopmental, externalizing, or other mental health disorders |
|---|---|
| Depressive episode | Hyperactivity |
| Other depression | Hyperkinesis |
| Undifferentiated anxiety/depression | Other hyperactivity |
| Separation anxiety | Conduct/oppositional |
| Specific phobia | Oppositional defiant |
| Social phobia | Conduct disorder confined to family |
| Panic disorder | Unsocialized conduct disorder |
| Agoraphobia | Socialized conduct disorder |
| Obsessive compulsive disorder | Pervasive developmental disorder/autism |
| Generalized anxiety disorder | Tic disorder |
| Other anxiety | Eating disorder |
| Any other disorder |
Note: Only disorders that at least one adolescent met criteria for are listed. All “internalizing disorders” are categorized as mood disorders (F30-F39), neurotic, stress-related, and somatoform disorders (F40-F48), or emotional disorders with onset specific to childhood (F93) in ICD-10, while all “neurodevelopmental, externalizing, or other mental health disorders” are categorized elsewhere in ICD-10.
| Variable | n missing (%) |
|---|---|
| Family functioning | 18/124 fathers (14.5%) |
| Paternal depression or PTSD | 19/124 fathers (15.3%) |
| Adolescent mental health | 1/160 adolescents (0.6%) |
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | |
|---|---|---|---|---|---|---|---|
| General family functioning | 1.00 | - | - | - | - | - | - |
| Problem solving | 0.84 | 1.00 | - | - | - | - | - |
| Communication | 0.79 | 0.79 | 1.00 | - | - | - | - |
| Roles | 0.71 | 0.67 | 0.68 | 1.00 | - | - | - |
| Affective responsiveness | 0.83 | 0.80 | 0.73 | 0.55 | 1.00 | - | - |
| Affective involvement | 0.73 | 0.60 | 0.55 | 0.61 | 0.64 | 1.00 | - |
| Behaviour control | 0.62 | 0.64 | 0.57 | 0.66 | 0.55 | 0.49 | 1.00 |
Note: n = 105. All reported correlations were p < 0.001.
| Adolescent mental health outcome | No paternal PTSD or depression, n (%) | Probable paternal PTSD or depression, n (%) | Unadjusted OR (95% CI) | p | Adjusted OR* (95% CI) | p | Adjusted OR† (95% CI) | p |
|---|---|---|---|---|---|---|---|---|
| Adolescent females (n = 62) | ||||||||
| Any mental health disorder | ||||||||
| No | 26 (63.4%) | 11 (52.4%) | Reference | — | Reference | — | Reference | — |
| Yes | 15 (36.6%) | 10 (47.6%) | 1.58 (0.52–4.82) | 0.425 | 1.22 (0.35–4.24) | 0.753 | 1.12 (0.31–4.05) | 0.858 |
| Adolescent males (n = 75) | ||||||||
| Any mental health disorder | ||||||||
| No | 36 (75.0%) | 13 (48.2%) | Reference | — | Reference | — | Reference | — |
| Yes | 12 (25.0%) | 14 (51.9%) | 3.23 (1.18–8.85) | 0.023 | 3.68 (1.27–10.64) | 0.016 | 2.73 (0.81–9.27) | 0.106 |
PTSD = posttraumatic stress disorder; OR = odds ratio; CI = confidence interval.
*
Adjusted for socio-demographic characteristics (paternal age, adolescent age) (paternal relationship status was excluded from these stratifications because of empty cells).
†
Adjusted for socio-demographic characteristics (paternal age, adolescent age) and for military factors (serving status, engagement type, service, rank, deployment status).
Information & Authors
Information
Published In
Journal of Military, Veteran and Family Health
Volume 10 • Number 2 • April 2024
Pages: 63 - 78
Copyright
The publisher holds the copyright for the article.
History
Received: 3 July 2023
Revision received: 22 January 2024
Accepted: 22 January 2024
Published in print: April 2024
Published online: 29 April 2024
Key Words:
Mots clés :
Data Availability
The data cannot be made publicly available but can be accessed with permissions from King’s Centre for Military Health Research, King’s College London, United Kingdom, via Professor NT Fear.
Authors
Contributors
Conceptualization: NT Fear
Formal Analysis: A Wickersham
Investigation: D Leightley, B Baig, M Chesnokov, A Stein, P Ramchandani, J Downs, N Parnell, K Rye, and A Verey
Writing — Original Draft: A Wickersham
Writing — Review & Editing: D Leightley, B Baig, M Chesnokov, A Stein, P Ramchandani, J Downs, N Parnell, K Rye, A Verey, and NT Fear
Supervision: D Leightley and NT Fear
Funding Acquisition: NT Fear
Competing Interests
A Wickersham was in receipt of a PhD studentship funded by the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. The views expressed are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. A Wickersham was also supported by ADR UK (Administrative Data Research UK), an Economic and Social Research Council investment (part of UK Research and Innovation) (Grant number: ES/W002531/1). D Leightley is a reservist in the UK Armed Forces. This work has been undertaken as part of his civilian employment. J Downs received support from a NIHR Clinician Scientist Fellowship (CS-2018–18-ST2–014) and Psychiatry Research Trust Peggy Pollak Research Fellowship in Developmental Psychiatry. NT Fear is part-funded by a grant from the UK Ministry of Defence.
Funding
The U.S. Department of Defense funded this work. The U.S. Department of Defense had no influence over the work plan, data analysis or data interpretation.
Ethics Approval
The study protocol was approved by an ethics committee and the ethics certificate information is available from the authors upon request.
Informed Consent
N/A
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Journal of Military, Veteran and Family Health 2024 10:2, 63-78
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