Thank you. I have to say, I think I developed a respiratory illness when I got off the plane, and I have subsequently lost my voice, so I will try very hard to get through this talk. But, well, the title of this talk is Family Dysfunction Associated with a Child Encountering Sepsis Requiring Critical Care. My presentation is based on findings from the LAPS study, and again, as the others. And these findings that I'm going to show have been published by two psychologists, Dr. Lexa Murphy and Dr. Tanya Palermo, myself, and other LAPS investigators in the Journal of Pediatric Critical Care Medicine. I think I'm going the wrong way. Okay, that seemed to work. Okay, good. So my only disclosure is that I am a principal investigator for the Collaborative Pediatric Critical Care Research Network, and the Collaborative Network participated in the LAPS trial. A pediatric septic shock is associated with a range of emotional, cognitive, and physical health changes that follow hospitalization and often require intensive medical follow-up. This can pose a significant burden on parents and families. And when I use the word burden, I'm not suggesting that parents would consider that their child is a burden, but rather that parents of children that are recovering from sepsis, like parents of children with other critical illnesses, they face various challenges, stressors, and have needs that are associated with their child's illness and recovery. A parent and family dysfunction may exist prior to the child's admission for sepsis. It may be brought on during the hospitalization or occur afterwards because of the stress associated with the child's illness. Parent and family dysfunction may persist long after hospitalization for some families. Understanding the trajectories and the risk factors for parent and family dysfunction may help clinicians direct resources for family psychosocial care. So the objective of this secondary analysis of the LAPS study that I'm presenting today is to identify trajectories or the time course of parents and family outcomes after a child's PICU admission for community-acquired septic shock and to try to identify factors associated with these trajectories. Our hypotheses are that there's a subset of families that will demonstrate a persistent elevated parent distress and impaired family functioning 12 months after hospitalization and that there are sociodemographic and clinical factors that will be associated with persistent parent distress and family dysfunction. As mentioned, this study is a secondary analysis of the LAPS cohort. Participants included in this study were families of 12-month survivors of pediatric septic shock that completed the baseline survey and at least one of the follow-up surveys. So of the 392 families that were included in LAPS, there were 260 that were included in this secondary analysis of the parent and family outcomes. Outcome measures included the level of parent psychological distress as evaluated by the brief symptom inventory or BSI and the level of family dysfunction as evaluated by the general functioning scale of the family assessment device. Now the BSI and the FAD were assessed on study enrollment to obtain a retrospective baseline assessment of the parent and family and then at 1, 3, 6, and 12 months following the child's admission. Sociodemographic variables were collected at study enrollment and clinical variables were collected at study enrollment and during the PICU course to evaluate factors that may be associated with parent and family dysfunction. Sociodemographic data included the child's sex, age, race, ethnicity, the parent's sex, education level, income range, insurance status, and whether the child resided in a single-parent household. Clinical variables included the pediatric risk of mortality or PRISM score at admission, composite organ dysfunction was assessed on admission and daily using the pediatric logistic organ dysfunction 2 or PILOD scale, and a cumulative PILOD score was calculated by summing the daily PILOD scores for the entire PISU stay. Other clinical variables included the maximum vasoactive inotrope score, the duration of the PICU stay, the use of invasive or noninvasive mechanical ventilation, and the occurrence of specific pathologic neurologic signs or events during the PICU stay. Chronic comorbid conditions were categorized using the pediatric medical complexity algorithm for a three-year period prior to the child's admission and categorized as no chronic comorbid condition, noncomplex comorbid condition, or a complex comorbid condition. Now, the brief symptom inventory 18-item version was used, and it's a measure of psychological distress. It assesses somatization, depression, anxiety, and panic symptoms. So parents rated how distressed they were by each item in the last seven days from the time they were completing the survey. Each item is rated on a five-point scale from zero to four, where zero they don't feel that way at all, to four extremely. Now, one of the 18 items in the BSI assesses suicidality, but because we could not monitor the survey responses or intervene in real time, we had to remove that item. So the BSI clinical cutoffs are 10 for men and 13 for women, but because the clinical cutoffs vary by sex and because we had to remove an item, I'm going to present BSI as mean scores rather than as the percent of parents above a certain cutoff level. The general functioning scale of the family assessment device is a 12-item measure. Parents rate how much each item describes their own family, again, on a four-point scale. A mean score of two or more indicates poor family functioning. So using the BSI and FAD data at 1, 3, 6, and 12 months post-admission, group-based trajectory modeling was performed to identify trajectories of parent psychological distress and family dysfunction. And after weighing the clinical relevance and the penalized fit for each candidate trajectory plot, a three-group trajectory model was chosen for the BSI, and a four-group trajectory model was chosen for the family assessment device. And variables hypothesized to contribute to parent distress or family dysfunction were used to model the high-risk BSI group and the high-risk FAD group membership probability. So this table shows the BSI and the FAD scores over time. Overall, the mean brief symptom inventory or psychological distress scores went from a mean of 12.9 at baseline to 7 at 12 months. So these scores suggest a decrease in parent psychological distress over that time period. The FAD score was 1.6, the mean, at each time point. However, the percent of families that had an FAD score over two at each time point, which is defined as poor functioning, increased significantly from about 20% at baseline to 30.9% at 12 months. So interestingly, levels of parent distress decreased over the 12 months while measures of the percentage of families with significant family distress increased over 12 months. So it's possible that family issues emerge after discharge as families continue to try to cope with their child's illness and recovery. So this slide shows the three-group trajectory model for parent psychological distress based on the BSI scores. And I don't have a pointer, but I'll try to explain each one. The largest group is group one, and that's the one closest to the bottom. That's the stable low distress group, which included 66% of the sample. So this group is characterized by low subclinical levels of psychological distress that were there at baseline and remain low across 12 months. I just will make a note that the solid line shows the observed mean scores at each time point, and the dotted line shows the modeled estimates of the trajectory over time. The second largest group is the persistent moderate high distress group, which included 25% of the sample. Group two is characterized by moderate high distress levels at baseline that persist over 12 months. The third group is the high distress with recovery group, which includes about 7% of the sample. This group is characterized by high levels of psychological distress with recovery over 12 months to subclinical levels. This slide shows the four-group trajectory model for family dysfunction based on the FAD scores. So the largest group, group one, is the stable high functioning group, which includes 40% of the sample. The group is characterized by low levels of family dysfunction at baseline that remain low over 12 months. Group two is the improving functioning group. Remember, high scores are worse. So the improving functioning group included 12% of the sample. Group two is characterized by low to moderate levels of family dysfunction at baseline that decreased to low levels of dysfunction over time. And then group three is the deteriorating function group, which included about a third of the sample. Group three is characterized by low levels of family dysfunction at baseline that increase over 12 months, approaching the cutoff of greater than two, which is clinically important family dysfunction. And then group four, the persistent high dysfunction group, included 15% of the sample. This group is characterized by clinically significant family dysfunction at baseline that persists during the follow-up. Now, regarding the sociodemographic and clinical risk factors, we found that parents of children in middle childhood, being that 5- to 12-year age group, had increased probability of being in the high-risk group for parent psychological distress compared to parents of children of other ages. And parents of children who are non-white or Hispanic had a decrease in the probability of being in the high-risk BSI group compared to parents of children who were white or non-Hispanic. And then our final multivariable model, only race and ethnicity, continued to be a significant predictor of the psychological distress high-risk group, and that non-white and Hispanic parents had a decreased probability of being in the high-risk group. None of our sociodemographic or clinical variables were associated with membership in the FAD group, high-risk group. So we conclude from these findings that the majority of families of survivors of pediatric septic shock are characterized by resilience. There is a subset of families that had elevated parent distress and family dysfunction that persisted one year following the pediatric septic shock admission. Also, sociodemographic and clinical factors largely did not explain membership in the high-risk groups. And overall, these findings suggest a need for continued family psychosocial screening after discharge rather than directing resources based on sociodemographics or severity of the child's illness. Thank you. Applause.

family dysfunction

pediatric sepsis

long-term distress

resilience

psychosocial screening