1. University of Pennsylvania School of Medicine The Children’s Hospital of Philadelphia Effect of Parental Depression on School Attendance and Emergency Room Use James Guevara, MD, MPH David Mandell, ScD Thomas Crowder Shooshan Danagoulian, MA, MSc Jacqueline Reyner, BA Susmita Pati, MD, MPH The Children’s Hospital of Philadelphia University of Pennsylvania School of Medicine University of California, Berkeley

2. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Background Asthma and ADHD are each associated with increases in emergency department (ED) visits and school absences Parental depression results in parenting behaviors that have been associated with increases in ED visits and may increase school absences Not clear whether effects of parental depression are independent of child chronic health conditions

3. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Study Aims 1.To estimate the prevalence of parental depression in a nationally representative population of children 2.To determine the independent association of parental depression and school attendance/ED use among children with and without chronic health conditions

4. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Study Design Secondary analysis of 1997-2004 National Health Interview Survey (NHIS) NHIS employs multistage probability sampling scheme to provide nationally representative data on civilian non-institutionalized population in U.S. NHIS comprised of 4 core components: Household, Family, Sample Adult, and Sample Child Household, Sample Adult, and Sample Child components were merged for each year using unique family reference and child identifiers

5. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Main Independent Variables ADHD and asthma were identified by parent report of health conditions - “Have you ever been told your child has…” Parental depression was measured by 3 questions assessing sadness, hopelessness, or worthlessness among adult household members over past 30 days - Responses of “All” or “Most of the time” to any of 3 questions were categorized as depression

6. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Main Outcomes School absences and ED visits reported by adult respondents School absences: days of school missed due to illness or injury in past 12 months ED visits: number of visits to a hospital ER for child’s health in past 12 months

7. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Potential Confounding Variables Child: age, sex, race, insurance status Family: maternal education status, parents present in household, family income category Survey: survey year

8. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Analysis Data were weighted to reflect complex sampling design Bivariate analyses of outcomes with independent main and potential confounding variables Multivariate weighted regression models were estimated for each outcome controlling for independent and confounding variables

9. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Results 220,141 children <18 years old in survey over all 8 years Of these, 104,930 children had data available on all child and family variables This sample weighted to represent 58,000,000 children in U.S.

10. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine

11. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Demographic Characteristics of Sample

12. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine

13. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Adjusted increase in ED visits and School Absences

14. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Conclusions Parental depression was low in this sample using available measures Depression was more common among parents of children with chronic health conditions than those of children without Depression was more common among single, poor, and minority parents Children of depressed parents have similar increases in school absences and ED use as children with common chronic health conditions

15. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Limitations Adult respondent report of school absences and ED visits may reflect recall bias Lack of validated depression measure in survey may underestimate parental depression

16. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Implications Strategies to improve recognition and treatment of parental depression in pediatric health settings should be disseminated Strategies should target those at greatest risk: minorities, single parents, impoverished, or have children with chronic health conditions Future research using nationally representative surveys may benefit from inclusion of validated measures of depression

17. The Children's Hospital of Philadelphia University of Pennsylvania School of Medicine Acknowledgments This study was funded by NIH grants MH065696 and HD047655 The authors have no conflicts of interest to declare