Psychological distress among parents of children with obstetric brachial plexus injury visiting pediatric departments

Volume 1
|
Pages 37-43
|
2022
423 Views
|
44 Downloads
|
0 Crossref Citations
PDF

Abstract

Obstetrical brachial plexus injury (OBPI) is a severe nerve injury that is destructive with expected lifelong repercussions among affected children. A child with morbidity can affect a family in several ways, encompassing social, relational, financial, and emotional states. However, such effects on households remain mostly unrecognized, where the focus remains solely on the child’s health or his/her treatment endeavors, with little attention given to the parent's emotional state. Therefore, this study aimed to measure psychological distress among parents of children with OBPI. This descriptive cross-sectional study recruited 100 parents with children aged between 18 months and 16 years under treatment for OBPI who visited different healthcare facilities using a purposive sampling technique. Data were collected by conducting face-to-face interviews. The study used the General Health Questionnaire-12 (GHQ-12) to assess parents’ psychological distress. The positive items were assigned scores from 0 to 3 (i.e., always to never), and the negative items were assigned scores from 3 to 0 (i.e., always to never). The outcome score ranged between 0 and 36, with higher scores indicating a greater likelihood of general psychological distress. Descriptive statistics were calculated to achieve the study objectives. Most children suffering from OBPI were male (64%) rather than female (36%). All positive items of the GHQ-12 questionnaire had an average low score, indicating parents were not feeling reasonably happy, less able to concentrate on their routine work, somewhat incapable of making decisions, and unable to enjoy day-to-day activities. In contrast, negative items had an average high score, indicating that parents constantly felt under strain, could not overcome difficulties, felt unhappy and depressed, and lost confidence. The average GHQ-12 score was 23.47 ± 2.54, depicting a high level of psychological distress among parents of children with OBPI. Our study concluded that parents of children with OBPI are at potential risk of various psychological problems. Therefore, health personnel should be aware of these parents’ psychological adjustment and refer them for psychological support when necessary.

Keywords

Psychological distress; Obstetric brachial plexus neuropathies; Pediatrics; Public hospitals; Private hospitals

1. Introduction

Nerve injuries can affect the patient’s mobility, which may cause paralysis of the affected limb and difficulty performing daily activities [1]. Obstetrical brachial plexus injury (OBPI) is a nerve injury that is destructive with expected lifelong repercussions among affected children [2]. Children with OBPI are likely to develop complications such as spindly arms, shoulder injuries, or dislocation of shoulder joints [3]. The risk factors for OBPI include shoulder dystocia, spontaneous vaginal delivery, breech delivery, cesarean delivery, instrumental delivery, macrosomia, maternal diabetes, and complex or prolonged labor for any reason [4,5,6]. The incidence rate of OBPI varies with the type of previously conducted studies; globally, it ranges between 0.1 and 6.1 per 1000 live newborn infants [7].

OBPI is a rare disorder that generally involves an injury in the shoulder and axillary regions of the child [8]. Children with OBPI often cannot perform their tasks independently, rely on their parents or attendants to perform their daily activities and are referred to specialized healthcare professionals for treatment [9]. It helps preserve muscle mass and regain lost muscular strength, preventing muscle shortening and deformities in affected limb joints. Children with OBPI need regular follow-up, which takes considerable time and may continue for an unprecedented period depending upon several factors, including the severity of the injury, parental beliefs, knowledge, and attitudes toward the disease [10,11].

Children with OBPI require early diagnosis and treatment, whether conservative or operative, depending on the degree of nerve damage [12]. Conservative management is preferred in cases of minimal neuronal damage or nondegenerative nerve injuries [13]. The treatment of OBPI focuses on the prevention of muscular atrophy, prevention of secondary deformities, suppression of pain, recovery of somatosensory deficits, and postoperative care [14]. Treatment protocols are developed with modalities and exercises based on a detailed history and thorough physical examination [4]. These modalities include therapeutic ultrasound for muscle relaxation and electrical nerve stimulators for simulating compressed nerves due to underlying pathology [8]. Initially, passive exercises are performed, followed by an active exercise plan with assistance. The child learns the movement pattern with time, and a home plan is devised for the child [15]. The treatment and recovery of nerve injuries can be challenging due to the slowest rate of neuronal regeneration.

A child with morbidity can affect a family in several ways, encompassing social, relational, financial, and emotional states [16,17]. Such effects on households remain mostly unrecognized, especially in developing countries such as Pakistan, where the focus remains solely on the child’s health or his/her treatment endeavors, with little attention given to the parent's emotional state. It is also evident from the literature that mothers and fathers are exposed to increased stress levels and are at risk of psychological distress [18].

Understanding the psychological distress experienced by families, especially parents of children with OBPI, is crucial so that interventions can be suggested following the parents’ needs. In addition, a dearth of local literature is available highlighting the impact of OBPI on parents. Therefore, this study was conducted with the objective of measuring psychological distress among parents of children with OBPI visiting public and private healthcare facilities using the General Health Questionnaire-12 (GHQ-12).

2. Material and methods

2.1. Study design and ethics approval

This descriptive cross-sectional study obtained ethical clearance from the Central College of Family Physicians (No. CCFP-ERC-22003) and sought administrative approval from the targeted healthcare facilities. The data were collected for nine months, between February and October 2022.

2.2. Study setting

We conducted the study at five public and private healthcare facilities, including Jinnah Hospital, Children Hospital, Meer Children & Family Clinic, Mayo Hospital, and Physio Rehab & CP Clinic, Lahore.

2.3. Participants' recruitment

The study recruited parents of children between 18 months and 16 years under treatment for OBPI and parents willing to become part of the study [18]. However, children under treatment for less than six months and parents having any other child with a disability and already on antidepressants were excluded from the study.

2.4. Sampling technique and sample size

This sample size of 45 was calculated using the Raosoft calculator by keeping a 5% margin of error, a 95% confidence interval, and a 3% response distribution [19]. However, the study recruited 100 parents using a nonpurposive sampling technique.

2.5. Study instrument

A few close- and open-ended questions were used to calculate children's and their parent's demographic information. Additionally, we used a reliable and validated GHQ-12 scale to assess parents’ psychological distress [20].

2.6. Data collection

The researcher conducted face-to-face interviews with the parents at the targeted healthcare facilities for an average duration of 10 minutes.

2.7. Study measures

The demographic section of the questionnaire comprised a set of questions, including the child's age, gender, attendant relation with the child, parent's age, locality of the family, parent’s occupation, and parents’ monthly household income. In addition, the GHQ-12 consisted of 12 items, each assessing the severity of psychological distress over the past few weeks using a 4-point Likert-type scale (from 0 to 3). The positive items were corrected from 0 (always) to 3 (never), and the negative items were corrected from 3 (always) to 0 (never). The overall outcome score ranged between 0 and 36, with higher scores indicating a greater likelihood of general psychological distress [20].

2.8. Statistical analysis

The descriptive statistics were calculated using frequencies, percentages, mean, standard deviation, median, interquartile, minimum, and maximum. The data were analyzed using Statistical Package for Social Sciences (SPSS) (version 25.00).

3. Results

Table 1 depicts children suffering from obstetric brachial plexus injuries had an average age of 3.59 ± 2.36 years. The average monthly parent’s income was Pakistani rupees (PKR) 47,860.00 ± 15,238.19. 

Table 1. Sociodemographics of children's families (n = 100).
Variables Mean ± SD Range
Min. Max.
Child's age (in years) 3.59 ± 2.36 1.50 11.00
Mother's age (in years) 32.69 ± 4.05 22.00 44.00
Father's age (in years) 37.03 ± 5.61 27.00 51.00
Parent's monthly income (in PKR) 47,860.00 ± 15,238.19 25,000.00 90,000.00

Most children suffering from OBPI were male (64%) rather than female (36%). A meager number of children’s mothers were employed (21%), and the majority were housewives (79%). Moreover, 44% of parents realized the injury of their children a few days after birth, followed by 30% of parents who realized it after examination by medical personnel, 17% a few weeks after birth, and 9% a month after birth. Table 2 further delineates that mothers accompanied 86% of children suffering from OBPI as attendants.

Table 2. Sociodemographics and medical characteristics of children's families (n = 100).
Sociodemographic Characteristics N %
Gender of the child Male 64 64.00
Female 36 36.00
The locality of the family Rural 26 26.00
Urban 74 74.00
Mother's occupation Employed 21 21.00
Housewife 79 79.00
Father's occupation Self-employed 12 12.00
Employed 82 82.00
Unemployed 6 6.00
Attendant's relationship with the child Mother 86 86.00
Father 14 14.00
Hospital visited Public hospital 65 65.00
Private hospital 35 35.00
Knowledge of injury A few days later, after birth 44 44.00
A few weeks later, after birth 17 17.00
A month later after birth 9 9.00
During examination by medical personnel 30 30.00

Table 3 shows that all positive items of the GHQ-12 questionnaire had an average low score, indicating parents were not feeling reasonably happy, less able to concentrate on their routine work, somewhat incapable of making decisions, and unable to enjoy day-to-day activities. In contrast, negative items had an average high score, indicating that parents constantly felt under strain, could not overcome difficulties, felt unhappy and depressed, and lost confidence. The average GHQ-12 score was 23.47 ± 2.54, depicting a high level of psychological distress among parents of children with OBPI.

Table 3. Psychological distress among parents of children with OBPI (n = 100).
Description Mean Score (Mean ± SD)
Able to concentrate 1.18 ± 0.69
Playing a useful part 1.39 ± 0.78
Capable of making decisions 1.12 ± 0.78
Able to enjoy day-to-day activities 1.22 ± 0.84
Able to face problems 1.31 ± 0.86
Feeling reasonably happy 0.91 ± 0.59
Loss of sleep over worry 1.99 ± 0.70
Felt constantly under strain 2.33 ± 0.60
Could not overcome difficulties 2.15 ± 0.63
Feeling unhappy and depressed 2.25 ± 0.61
Losing confidence 2.03 ± 0.72
Thinking of self as worthless 1.85 ± 0.83
Overall score 23.47 ± 2.54

4. Discussion

Our study showed that more children suffering from OBPI were male than female. A meager number of children’s mothers were employed, and the majority were homemakers. Moreover, half of the parents realized the injury of their children a few days after birth, followed by parents who realized it after examination by medical personnel, a few weeks after birth, and a month after birth. All positive items of the GHQ-12 questionnaire had an average low score, indicating parents were not feeling reasonably happy, less able to concentrate on their routine work, somewhat incapable of making decisions, and unable to enjoy day-to-day activities. In contrast, negative items had an average high score, indicating that parents constantly felt under strain, could not overcome difficulties, felt unhappy and depressed, and lost confidence. The average GHQ-12 score was significant, showing a high level of psychological distress among parents of children suffering from OBPI.

The results of our study are consistent with an Australian study that assessed stress levels in fathers and mothers of children with OBPI and recruited 26 pairs of parents who completed self-reports of global stress, psychological distress, and condition-related stress [18]. The study revealed that both parents of children with OBPI experienced psychological distress; no difference was observed between fathers' and mothers' mean scores. Furthermore, all stress variables were strongly correlated for the mothers [18].

Our study's results are also consistent with another study carried out in Turkey that assessed the level of anxiety and depression burnout among mothers of children with OBPI and the effects of their recovery on the mothers’ mental health [21]. The study incorporated 18 mothers, and the Narakas classification system was used to assess the severity of OBPI; the Beck Anxiety Inventory, Beck Depression Inventory, and Maslach Burnout Inventory were used to assess mothers' mental health. The results highlighted that mothers of infants in Narakas group III had mild depression, and their depression score constantly increased along with mothers with infants in Narakas group II. In contrast, mothers with infants in Narakas groups I and II showed a minimal anxiety score. Furthermore, there was no statistically significant difference between anxiety, depression, emotional exhaustion, depersonalization, and personal accomplishment scores of the mothers concerning the severity of the OBPI [21].

Another study conducted in the United Kingdom (UK) using EQ-5D-5 L and characteristic questionnaires aligns with our results that revealed poorer mean utility scores of the OBPI patients (0.80 ± 0.19) and parents (0.56 ± 0.28) than the standard scores of the English population [22]. In addition, the parents and patients reported poor quality of life with mental health issues. Additionally, a survey that included 51 parents using Patient Health Questionnaire-9 (PHQ-9) and PCL-S screening tools reported that 46% of the responding mothers and two out of ten fathers having newborns with OBPI had depression [23]. OBPI is a cause of psychological distress among sufferer families, which may be due to the illness's longevity and fear of possible surgery for the OBPI child, which is evident from the previously conducted mixed method study that showed that surgery of the OBPI child was a significant predictor of a higher Impact On Family Scale (IOFS) total impact score (p = 0.02) [24].

Contrary to our results, a study highlighted that parents with children with OBPI were moderately affected by their child's disorder [25]. Similarly, another study assessed the quality of life of parents of children with neonatal brachial plexus palsy and identified different system- and patient-related factors that contribute to the quality of life, specifically emotional adjustment, and revealed that the parents’ reported quality of life was overall good [26]. Nevertheless, such disorders among children can cause trauma for parents and caregivers who directly or indirectly look after their children, with increasing responsibilities affecting their daily life activities, social life, and mental health [27,28].

This study contributes to the scientific literature focusing on the Pakistani perspective, which marks the potential strength of the study. On the other hand, the study was performed for a limited time and counted on one tool for assessing psychological distress, which marks a study's weakness.

5. Conclusions

Our study concluded that parents of children with OBPI are at potential risk of various psychological problems. Therefore, health personnel should be aware of these parents’ psychological adjustment and refer them for psychological support when necessary. We recommend further research to explore healthcare professionals’ perspectives regarding parental psychological distress and health systems’ strengths for minimization of parental psychological distress and early diagnosis and prompt management of OBPIs to improve the quality of life of parents as well as children.

Author contributions

Conceptualization, MA, ZH and NS; methodology, MA, ZH and NS; software, MA, ZH and NS; validation, MA, ZH and NS; formal analysis, MA, ZH and NS; investigation, MA; resources, ZH; data curation, MA, ZH and NS; writing—original draft preparation, MA; writing—review and editing, ZH and NS; visualization, MA, ZH and NS; supervision, ZH and NS; project administration, MA. All authors have read and agreed to the published version of the manuscript.

Publication history

Received Revised Accepted Published
17 November 2022 27 December 2022 28 December 2022 30 December 2022

Funding

This research received no specific grant from the public, commercial, or not-for-profit funding agencies.

Ethics statement

This study obtained ethical clearance from the Central College of Family Physicians (No. CCFP-ERC-22003) and sought administrative approval from the targeted healthcare facilities.

Consent to participate

Informed consent was obtained from all participants included in the study.

Data availability

All data are presented in this study.

Acknowledgments

We wish to thank all participating parents of children, staff, and administrators at Mayo Hospital, Jinnah Hospital, Children Hospital, Meer Children & Family Clinic, and Physio Rehab & CP Clinic, Lahore.

Conflicts of interest

The authors declare no conflicts of interest.

Copyright

© 2022 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) License. The use, distribution, or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Publisher's note

Logixs Journals remains neutral concerning jurisdictional claims in its published subject matter, including maps and institutional affiliations.

References

[1]

Webber CM, Shin AY, Kaufman KR. Kinematic profiles during activities of daily living in adults with traumatic brachial plexus injuries. Clin Biomech. 2019;70:209-16. https://doi.org/10.1016/j.clinbiomech.2019.10.010

[2]

Giddins G. Discussions about obstetric brachial plexus injuries. Hand Clin. 2022;38(3):329-35. https://doi.org/10.1016/j.hcl.2022.02.006

[3]

Van der Looven R, Le Roy L, Tanghe E, Samijn B, Roets E, Pauwels N, et al. Risk factors for neonatal brachial plexus palsy: A systematic review and meta‐analysis. Dev Med Child Neurol. 2020;62(6):673-83. https://doi.org/10.1111/dmcn.14381

[4]

DeFrancesco CJ, Shah DK, Rogers BH, Shah AS. The epidemiology of brachial plexus birth palsy in the United States: Declining incidence and evolving risk factors. J Pediatr Orthop. 2019;39(2):e134-40. https://doi.org/10.1097/BPO.0000000000001089

[5]

Vakhshori V, Bouz GJ, Alluri RK, Stevanovic M, Ghiassi A, Lightdale N. Risk factors associated with neonatal brachial plexus palsy in the United States. J Pediatr Orthop B. 2020;29(4):392-8. https://doi.org/10.1097/BPB.0000000000000706

[6]

Gandhi RA, DeFrancesco CJ, Shah AS. The association of clavicle fracture with brachial plexus birth palsy. J Hand Surg Am. 2019;44(6):467-72. https://doi.org/10.1016/j.jhsa.2018.11.006

[7]

Vaquero G, Ramos A, Martinez JC, Valero P, Nunez-Enamorado N, Simon-De las Heras R, et al. Obstetric brachial plexus palsy: Incidence, monitoring of progress and prognostic factors. Rev Neurol. 2017;65(1):19-25. https://doi.org/10.33588/rn.6501.2016504

[8]

O’Berry P, Brown M, Phillips L, Evans SH. Obstetrical brachial plexus palsy. Curr Probl Pediatr Adolesc Health Care. 2017;47(7):151-5. https://doi.org/10.1016/j.cppeds.2017.06.003

[9]

Annika J, Paul U, Anna-Lena L. Obstetric brachial plexus palsy–A prospective, population-based study of incidence, recovery and long-term residual impairment at 10 to 12 years of age. Eur J Paediatr Neurol. 2019;23(1):87-93. https://doi.org/10.1016/j.ejpn.2018.06.006

[10]

Pondaag W, Malessy MJA. Evidence that nerve surgery improves functional outcome for obstetric brachial plexus injury. J Hand Surg Eur. 2021;46(3):229-36. https://doi.org/10.1177/1753193420934676

[11]

Hems TEJ, Savaridas T, Sherlock DA. The natural history of recovery of elbow flexion after obstetric brachial plexus injury managed without nerve repair. J Hand Surg Eur. 2017;42(7):706-9. https://doi.org/10.1177/1753193417712924

[12]

Oberlin C. Rethinking surgical strategy in the management of obstetrical palsy. J Hand Surg Eur. 2021;46(7):705-7. https://doi.org/10.1177/17531934211032032

[13]

Park HR, Lee GS, Kim IS, Chang JC. Brachial plexus injury in adults. Nerve. 2017;3(1):1-11. https://doi.org/10.21129/nerve.2017.3.1.1

[14]

Smania N, Berto G, La Marchina E, Melotti C, Midiri A, Roncari L, et al. Rehabilitation of brachial plexus injuries in adults and children. Eur J Phys Rehabil Med. 2012;48(3):483-506.

[15]

de Santana Chagas AC, Wanderley D, de Oliveira Ferro JK, Alves de Moraes A, Morais de Souza FH, da Silva Tenório A, et al. Physical therapeutic treatment for traumatic brachial plexus injury in adults: A scoping review. PM R. 2022;14(1):120-50. https://doi.org/10.1002/pmrj.12566

[16]

Estrella EP, Castillo-Carandang NT, Cordero CP, Juban NR. Quality of life of patients with traumatic brachial plexus injuries. Injury. 2021;52(4):855-61. https://doi.org/10.1016/j.injury.2020.11.074

[17]

Beck CT. Caring for a child with an obstetric brachial plexus injury: A metaphor analysis. J Pediatr Nurs. 2017;36:57-63. https://doi.org/10.1016/j.pedn.2017.04.005

[18]

McLean LA, Harvey D, Mutimer K. Stress in mothers and fathers of children with obstetrical brachial plexus injuries. Child Health Care. 2015;44(2):105-18. https://doi.org/10.1080/02739615.2014.880919

[19]

Nauman W, Saeed R, Razzaq A, Sheraz S. Frequency of Erb’s palsy in Islamabad Capital Territory and Punjab region, Pakistan. Pak J Rehabil. 2022;11(2):69-75. https://doi.org/10.36283/pjr.zu.11.2/011

[20]

Sánchez-López MP, Dresch V. The 12-Item General Health Questionnaire (GHQ-12): Reliability, external validity and factor structure in the Spanish population. Psicothema. 2008;20(4):839-43.

[21]

Karadavut KI, Uneri SO. Burnout, depression and anxiety levels in mothers of infants with brachial plexus injury and the effects of recovery on mothers’ mental health. Eur J Obstet Gynecol Reprod Biol. 2011;157(1):43-7. https://doi.org/10.1016/j.ejogrb.2011.03.001

[22]

Yau CWH, Pizzo E, Prajapati C, Draycott T, Lenguerrand E. Obstetric brachial plexus injuries (OBPIs): Health-related quality of life in affected adults and parents. Health Qual Life Outcomes. 2018;16:212. https://doi.org/10.1186/s12955-018-1039-z

[23]

Dua K, Miller C, O'Hara NN, Abzug JM. The mental health implications of obstetric brachial plexus injuries (OBPI) on parents. AAHS 2017 Annual Meeting; 2017 Jan 10-14; Waikoloa, Hawaii. Massachusetts: American Association for Hand Surgery; 2017.

[24]

DeMatteo C, Bain JR, Gjertsen D, Harper JA. ‘Wondering and waiting’ after obstetrical brachial plexus injury: Are we underestimating the effects of the traumatic experience on the families?. Plast Surg. 2014;22(3):183-7. https://doi.org/10.1177/229255031402200313

[25]

Batool H, Khan AM, Khanum S. Evaluation of quality of life of parents having children with sensory disabilities. Pak J Humanit Soc Sci Res. 2019;2(2):33-44.

PDF
[26]

Squitieri L, Larson BP, Chang KWC, Yang LJS, Chung KC. Understanding quality of life and patient expectations among adolescents with neonatal brachial plexus palsy: A qualitative and quantitative pilot study. J Hand Surg Am. 2013;38(12):2387-97. https://doi.org/10.1016/j.jhsa.2013.09.006

[27]

Frade F, Neves L, Florindo-Silva F, Gómez-Salgado J, Jacobsohn L, Frade J. Rehabilitation of a child with neonatal brachial plexus palsy: Case report described by parents. Children (Basel). 2022;9(9):1298. http://dx.doi.org/10.3390/children9091298

[28]

Louden E, Allgier A, Overton M, Welge J, Mehlman CT.The impact of pediatric brachial plexus injury on families. J Hand Surg Am. 2015;40(6):1190–1195. https://doi.org/10.1016/j.jhsa.2015.03.020