ORIGINAL RESEARCH
published: 04 October 2017
doi: 10.3389/fpsyg.2017.01655
Posttraumatic Stress Disorder,
Parenting, and Marital Adjustment
among a Civilian Population
Michal Hershkowitz, Rachel Dekel, Shimon Fridkin and Sara Freedman*
School of Social Work, Bar Ilan University, Ramat Gan, Israel
Edited by:
Xavier Noel,
Free University of Brussels, Belgium
Reviewed by:
Serge Brand,
University of Basel, Switzerland
Leila Heckel,
Deakin University, Australia
*Correspondence:
Sara Freedman
sara.freedman@biu.ac.il
While psychopathology in general is linked to poorer marital and parental satisfaction,
there is a paucity of data regarding these interactions in parents with Posttraumatic stress
disorder (PTSD). The current study addresses this issue among a civilian population.
Two hundred trauma-exposed parents, mean age of 37.2, 62% mothers, were
assessed using self-report questionnaires, for background variables, PTSD symptoms
using the Posttraumatic Stress Diagnostic Scale (PDS), depression symptoms (Beck
Depression Inventory, BDI), marital satisfaction (Dyadic Adjustment Scale, DAS-7),
parenting behavior (Alabama Parenting Questionnaire, APQ-9), and parenting satisfaction
(Parenting Satisfaction Questionnaire). We hypothesized that positive parenting behavior
and parenting satisfaction would be negatively correlated with PTSD symptom levels, and
that this relationship would be mediated by marital satisfaction; the independent effects of
depression on marital and parenting functioning were also examined. Data was analyzed
using structural equation modeling (SEM). Results indicated that PTSD was related to
poorer parenting behavior (B = 0.089, p = 0.033), depression had a negative impact
on parenting satisfaction (B = 0.983, p = 0.003), and marital satisfaction (B = −0.672,
p = 0.004), and marital satisfaction fully mediated the relationship between depression
and parenting. The findings demonstrated that the effects of PTSD can cast a pall not
only over the individual but over the entire family. Interventions are needed to address
these issues.
Keywords: PTSD, marital satisfaction, parenting, civilian trauma
Specialty section:
This article was submitted to
Psychopathology,
a section of the journal
Frontiers in Psychology
Received: 01 February 2017
Accepted: 08 September 2017
Published: 04 October 2017
Citation:
Hershkowitz M, Dekel R, Fridkin S and
Freedman S (2017) Posttraumatic
Stress Disorder, Parenting, and Marital
Adjustment among a Civilian
Population. Front. Psychol. 8:1655.
doi: 10.3389/fpsyg.2017.01655
Frontiers in Psychology | www.frontiersin.org
INTRODUCTION
Posttraumatic stress disorder (PTSD) is broadly associated with difficulties in family functioning.
Studies have specifically examined the effects on significant others, showing that spouses of veterans
with PTSD also report elevated levels of PTSD, as well as emotional stress and caregiver burden
(Ben Arzi et al., 2000; Campbell and Renshaw, 2013). Vietnam veterans with severe PTSD have
reported reduced marital and sexual satisfaction (Koenen et al., 2003). Numbing symptoms in
particular appear to impact interpersonal relationships, with studies showing that a reduction in
numbing symptoms, as a result of therapy, was related to an increase in relationship satisfaction in
Vietnam veterans (Lunney and Schnurr, 2007), and that increased numbing symptoms predicted
poorer relationship satisfaction in a cohort of National Guard service members and their partners
(Campbell and Renshaw, 2013).
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PTSD, Parenting and Marital Adjustment
examined the impact of depression as well as PTSD on family
functioning.
In this study, we attempted to address these gaps, by
examining the relationship between parenting and PTSD among
a civilian population. We hypothesized that positive parenting
behavior and parenting satisfaction would be related to each
other, and both would be negatively correlated with PTSD
symptom levels. We further hypothesized, that this relationship
would be mediated by marital satisfaction. Since depression
is both comorbid with PTSD and negatively impacts family
functioning, the independent effects of depression on marital and
parenting functioning were also examined.
In terms of effects on children, studies have shown that
children of male veterans suffering from PTSD are more likely to
show behavior problems (Davidson and Mellor, 2001; Lambert
et al., 2014), higher anxiety (Ahmadzadeh and Malekian, 2004;
Lambert et al., 2014), and greater aggression (Beckham et al.,
1997; Ahmadzadeh and Malekian, 2004) than children whose
male veteran fathers do not suffer from PTSD.
In the few studies examining parenting in individuals with
PTSD, two have found that numbing symptoms were related to
poorer reported relationship quality and parenting satisfaction
in male veterans (Samper et al., 2004; Taft et al., 2008). Other
studies of parenting in veterans have shown that lower parental
satisfaction was related to hyperarousal symptoms in female
veterans (Berz et al., 2008). In a prospective study of Army
National Guard fathers, increases in PTSD symptoms were
associated with poorer couple adjustment and greater perceived
parenting challenges over time (Gewirtz et al., 2010).
Only two studies, to our knowledge, have examined parenting
and PTSD among civilian populations. In a study of a large
civilian population exposed to trauma, numbing was not found to
be predictive of relationship quality or parent–child conflict, after
controlling for work-related stress and finances (Lauterbach et al.,
2007). In a study of abused women, their exposure to violence
during childhood was related to reduced parental satisfaction
(Waldman-Levi et al., 2013).
Although studies have shown that in the general population
marital satisfaction and parenting are closely related (Coln et al.,
2013), these relationships have not been examined in PTSD
populations, with the exception of one study (Gewirtz et al.,
2010), which found that among a military population, increases
in PTSD over time were related to poorer couple adjustment
and poorer effective parenting. Although couple adjustment and
parenting were correlated, couple adjustment did not mediate the
relationship between PTSD and parenting. In addition, no study
to our knowledge has investigated marital satisfaction, parenting
and PTSD among a civilian population. The majority of studies
have included veterans, most of whom are men, and therefore
the impact of PTSD on civilian women’s marital satisfaction and
parenting is less well understood.
Viewing these studies collectively, it seems likely that PTSD
is directly related to poorer marital and parental satisfaction, as
well as to poorer parenting behavior. Although the relationship
between marital satisfaction and parenting may be bidirectional,
most previous studies of family functioning have examined the
effects of marital adjustment on parenting, thus there is an
assumption that a poorer relationship between spouses mediates
the relationship between psychopathology and parenting (Kwok
et al., 2015). However, this finding did not emerge in the only
study that has examined this with people suffering from PTSD
(Gewirtz et al., 2010). Since psychopathology in general (as
opposed to PTSD in particular) is related to poorer marital and
parenting adjustment (Papp et al., 2004), it is also important
to assess the role of depression. Approximately 50% of people
who suffer from PTSD also suffer from a concurrent major
depressive disorder, and depression in particular is likely to
impact perceived satisfaction from interpersonal relationships
(Kessler et al., 2005). No study as far as we are aware has
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METHODS
Participants
Trauma-exposed parents were recruited from mental health
clinics throughout Israel or via online trauma or parenting
forums; they were then asked to either fill out questionnaires
or respond to questions via a secure internet site. The study
was carried out in accordance with the recommendations of
the Declaration of Helsinki with written informed consent from
all subjects; ethical approval was obtained from the IRBs in
three institutions that housed the mental health clinics: Hadassah
Medical Organization, Jerusalem, Hillel Yafe Hospital, Hadera,
and Ichilov Hospital, Tel Aviv, as well as from the Ethics
Committee, the School of Social Work, Bar Ilan University for
subjects recruited online.
Sample
Questionnaires were distributed to 330 individuals, of whom 200
responded (60.6%); the sample size was therefore n = 200. Out of
200 respondents, 31 (15%) did not provide their gender data. Of
those who did, 45 (23%) were men and 124 (62%) were women
2 = 51.5, p < 0.001]. Eight participants (4%) did not report
[χ(1)
their age; the age of the remaining participants ranged from 23 to
59, with a mean of 37.20 (SD = 7.32). The number of children in
each family ranged between one and nine, with an average of 3.33.
2 = 472.85, p <
One hundred eighty-one (91%) were married [χ(3)
2 =
0.001], and 156 (78%) had a post-high-school education [χ(5)
422.58, p < 0.001]. One hundred and thirty-three (62%) reported
2 = 125.54, p <
at least an average socioeconomic status [χ(3)
0.001].
Measures
Demographic questionnaire: A questionnaire constructed for the
purposes of this study assessed demographic information such as
gender, age, education, marital status, economic status, number,
and age of children. Traumatic events were assessed using the
Posttraumatic Stress Diagnostic Scale (PDS), which gives a list of
potential traumatic events, and includes a category of “other” for
events not included in the list. Events reported included illness
(N = 35, 17.5%), terror attack (N = 32, 16%), accidents (N =
14, 7%), murder or suicide of close person (N = 30, 15%), sexual
abuse (N = 37, 18.5%), physical abuse (N = 12, 6%), and other
(N = 36, 18%).
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PTSD, Parenting and Marital Adjustment
exogenous and the endogenous variables in the structural model.
Gender was not included since the small number of men did not
allow statistical analyses.
Bootstrapping procedures have been advocated as an
approach that is well suited for testing hypothesized mediating
effects (Shrout and Bolger, 2002; Mackinnon et al., 2004;
Preacher and Hayes, 2008). Therefore, bootstrapping procedures
were employed to test this hypothesis.
The Posttraumatic Stress Diagnostic Scale, PDS (Foa et al.,
1993). This scale assesses all 17 symptoms of PTSD (DSM IV),
which are rated on a 4-point scale, ranging from 0 (not at all) to
3 (almost always). Cronbach’s alpha for this study was 0.96.
The Beck Depression Inventory—II (BDI, Beck et al., 1993).
This 21-item questionnaire assesses symptoms of depression.
Cronbach’s alpha for this study was 0.94.
The Dyadic Adjustment Scale—Short Form (DAS-7, Hunsley
et al., 1995). This abbreviated version of the full questionnaire
that measures marital satisfaction. Its seven items assess marital
agreement (three items), joint activities (three items), and general
happiness with the relationship (one item); all items are scored on
a six-point scale. The final score is the average of all seven items.
Cronbach’s alpha in this study was 0.86.
The Parenting Satisfaction Questionnaire (Kurdek and Fine,
1991). This questionnaire consists of three questions regarding
satisfaction derived from fulfilling one’s role as a parent. Answers
are given on a seven-point scale; Cronbach’s alpha for this study
was 0.86.
The Alabama Parenting Questionnaire—Short Form
Questionnaire (APQ-9, Elgar et al., 2006). This abbreviated
version of the full version APQ (Shelton et al., 1996) assesses
parenting behavior The questionnaire has nine items, examining
three aspects of parenting: positive parenting, lack of consistency
in discipline, and lack of supervision. For the purpose of this
study, the questionnaire was translated into Hebrew and checked
with back translation and two independent, bilingual judges.
The questionnaire items were answered on a five-point scale.
Cronbach’s alpha in this study was 0.69 (positive parenting), 0.60
(inconsistent discipline), and 0.65 (lack of supervision).
RESULTS
Table 1 presents the correlations between study variables.
In light of these correlations, a maximum likelihood
estimation was employed to estimate the hypothesized research
model. The structural model demonstrated a close model fit, c2 =
3.61 (df = 4, N = 200, p = 0.46), CFI = 0.99, NFI = 0.99, RMSEA
= 0.00. The final structural model illustrated in Figure 1.
The measures of the final structural equation model fit and the
estimated model parameters, including direct and indirect effects,
are presented in Table 2.
PTSD was found to have a negative direct effect on parenting
behavior [B = −0.089, SEB = 0.036, bias-corrected bootstrap
95% confidence intervalB = (−0.146; −0.004); β = −0.165, SEβ
= 0.067, bias-corrected bootstrap 95% confidence intervalβ =
(−0.288; −0.009); p = 0.033]. Depression was found to have
a negative direct effect on marital satisfaction [B = −0.672,
SEB = 0.151, bias-corrected bootstrap 95% confidence intervalB
= (−1.055; −0.420); β = −0.409, SEβ = 0.092, bias-corrected
bootstrap 95% confidence intervalβ = (−0.600; −0.253); p =
0.004] and parenting satisfaction [B = −0.983, SEB = 0.138,
bias-corrected bootstrap 95% confidence intervalB = (−1.311;
−0.749); β = −0.433, SEβ = 0.058, bias-corrected bootstrap
95% confidence intervalβ = (−0.553; −0.312); p = 0.003]. Age
was found a positive direct effect on parenting satisfaction [B =
−0.028, SEB = 0.009, bias-corrected bootstrap 95% confidence
intervalB = (0.007; 0.043); β = 0.167, SEβ = 0.053, biascorrected bootstrap 95% confidence intervalβ = (0.025; 0.250);
p = 0.029]. Number of children was found a negative direct
effect on parenting satisfaction [B = −0.117, SEB = 0.040,
bias-corrected bootstrap 95% confidence intervalB = (−0.208;
−0.047); β = −0.171, SEβ = 0.059, bias-corrected bootstrap
Data Analysis
All hypotheses and research questions were treated via structural
equation modeling (SEM) using the IBM SPSS Amos 23 for
Windows software package. Two main advantages of SEM are
extensive assessment of an a priori specified model, which
is clearly advantageous for the model specified in this study;
likewise, SEM corrects for error variance, and thus more
accurately identifies parameters of interest.
We used five fit indices: model chi-square, the root mean
square error of approximation (RMSEA; Cudeck and Browne,
1992), the normed fit index [NFI, the non-normed fit index (NFI,
Bentler and Bonett, 1980; Bollen, 1990) and the comparative
fit index (CFI; Bentler, 1990)]. For the RMSEA statistic, lower
values indicate a better model fit, when the value 0.08 is the
traditional threshold for an acceptable fit (and 0.05 for a close
fit). For the NFI and CFI statistics, better-fitting models achieve
higher values, with 0.90 and 0.95 as traditional thresholds for an
acceptable and a close model fit, respectively (Kline, 2011). Also
for NFI statistics, better-fitting models achieve higher values, with
0.90 and 0.95 as traditional thresholds for an acceptable and a
close model fit, respectively (Bentler and Bonett, 1980).
In the hypothesized model, PTSD, depression, parenting
behavior and satisfaction, and marital satisfaction, were specified
as observed variables with multiple indicators.
To control for demographics, we included age and number of
children in the analysis, allowing these variables to link both the
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TABLE 1 | Correlations among study variables (N = 200).
Variable
1. Age
1
2
3
4
5
6
–
2. Number of children
0.35**
3. Depression
0.14*
−0.09
–
–
4. PTSD
0.16*
−0.15*
0.85**
–
5. Marital satisfaction
−0.14*
0.08 −0.45** −0.37**
6. Parenting behavior
−0.18*
−0.17* −0.28** −0.24**
0.31**
–
0.00 −0.54** −0.46**
0.54**
0.35**
7. Parenting
satisfaction
0.01
–
*p < 0.05; **p < 0.01.
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PTSD, Parenting and Marital Adjustment
FIGURE 1 | Final structural equation model predicting parenting behavior, parenting satisfaction, and marital satisfaction. N = 200, *p < 0.05; **p < 0.01;
***p < 0.001.
bootstrap 95% confidence intervalB = (−0.171; −0.035); β =
−0.105, SEβ = 0.038, bias-corrected bootstrap 95% confidence
intervalβ = (−0.197; −0.046); p = 0.005] was fully mediated by
marital satisfaction.
TABLE 2 | Standardized path coefficients for final structural equation model.
Dependent
constructs
Independent constructs
PTSD Depression
Age
Number of
children
Marital
satisfaction
–
–
DISCUSSION
DIRECT EFFECTS
Marital satisfaction
0.006
−0.409**
–
–
−0.433**
0.167*
Parenting
satisfaction
Parenting behavior −0.165*
–
−0.040
−0.171**
0.373**
−0.208*
0.257**
To our knowledge, these results are the first to examine parenting,
marital satisfaction and PTSD among a civilian population. The
results indicate that, as hypothesized, PTSD is negatively related
to parenting behavior, and this finding corroborates previous
research conducted among a military population (Gewirtz et al.,
2010). It was also hypothesized that PTSD would be related to
parenting satisfaction, but this hypothesis was not borne out. In
addition, the effect of PTSD on parenting behaviors was direct
and not mediated via marital satisfaction. Again, this finding
replicates findings from previous research (Gewirtz et al., 2010).
We hypothesized that depression would have a significant
impact on family relationships; the results indicate that the
impact of depression symptoms is significant not only for couple
relationships but also for family relationships in general. Both
lowered parenting satisfaction and poorer parenting behavior
are related to higher levels of depression; marital satisfaction
mediated both of these interactions.
Overall, these results, supporting our hypothesis that traumarelated psychopathology is related to difficulties in family
functioning. Higher levels of PTSD are related to more
problematic parenting behavior. Poor parenting practices have
long-term effects on parent-child relationships and child
development (Kaczynski et al., 2006; Gryczkowski et al., 2010),
and it is possible that these negative effects in turn impact
negatively on PTSD levels.
The impact of depression on family functioning has not been
formerly studied among this population. This study showed that
satisfaction levels are lowered when depression is higher, a logical
finding given that depressed people tend to be less satisfied
in general. However, these results also showed that marital
INDIRECT EFFECTS
Marital satisfaction
–
–
–
Parenting
satisfaction
0.002
–
−0.153**
–
–
–
–
Parenting behavior
0.001
−0.105**
–
–
–
*p < 0.05; **p < 0.01.
95% confidence intervalβ = (−0.317; −0.076); p = 0.005] and
parenting behavior [B = −0.050, SEB = 0.015, bias-corrected
bootstrap 95% confidence intervalB = (−0.082; −0.021); β =
−0.208, SEβ = 0.061, bias-corrected bootstrap 95% confidence
intervalβ = (−0.312; −0.081); p = 0.009]. Marital satisfaction was
found to have a positive direct effect on parenting satisfaction [B
= 0.516, SEB = 0.080, bias-corrected bootstrap 95% confidence
intervalB = (0.438; 0.663); β = 0.373, SEβ = 0.053, biascorrected bootstrap 95% confidence intervalβ = (0.238; 0.465);
p = 0.007] and parenting behavior [B = 0.126, SEB = 0.036,
bias-corrected bootstrap 95% confidence intervalB = (0.058;
0.195); β = 0.257, SEβ = 0.070, bias-corrected bootstrap 95%
confidence intervalβ = (0.116; 0.403); p = 0.009]. The effect of
depression on parenting satisfaction [B = −0.347, SEB = 0.097,
bias-corrected bootstrap 95% confidence intervalB = (−0.612;
−0.213); β = −0.153, SEβ = 0.042, bias-corrected bootstrap
95% confidence intervalβ = (−0.273; −0.096); p = 0.002] and
parenting behavior [B = −0.085, SEB = 0.032, bias-corrected
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the timing of the participants’ marriage and becoming a
parent. Secondly, the study participants were not all exposed
to the same traumatic event. Thirdly, the participants were
recruited from a wide range of backgrounds, and lastly, they
were assessed solely via the use of self-report measures. One
of these measures, assessing parenting behavior, showed
low internal consistency, and this may indicate that the
full questionnaire should have been used. These limitations
notwithstanding, the novel results which emerged bear
replication.
satisfaction can buffer the effects of depression on parenting.
Depression and PTSD are found to be comorbid in about 50%
of PTSD cases, and there are conflicting explanations for this
relationship. It is possible that they reflect a common posttrauma psychopathology, or that the depression is secondary to
the PTSD. In the current study, depression and PTSD were highly
correlated, but appeared to impact family functioning in different
ways, thus suggesting two interactive but separate processes.
These results indicate that programs aimed to help marital
relationships may have wider implications for overall family
functioning as well, and that interventions aimed at reducing
PTSD and depression also have the potential to positively affect
the patient’s family functioning.
This study has several methodological limitations. First,
it is a cross-sectional study, and no information is available
regarding the timing of the traumatic events in relation to
AUTHOR CONTRIBUTIONS
SaF and MH: study design, implementation, preparation of data
file, and writing up of results. RD: study design, and writing up of
results. ShF: statistical analyses.
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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
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October 2017 | Volume 8 | Article 1655