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Use of Generalized Estimating Equations to Integrate Multiple Informant Reports

Yoko Nomura, PhD, MPH; Claude M. Chemtob, PhD

Arch Pediatr Adolesc Med. 2009;163(6):531-539.

Objective  To examine whether the number of maternal psychopathologies is associated with increased clinically significant behavioral problems in preschool children exposed to disaster, using child behavior ratings from multiple informants.

Design  Cross-sectional study.

Setting  Lower Manhattan, New York, New York.

Participants  One hundred two preschool child-mother dyads directly exposed to the World Trade Center attacks.

Exposures  Maternal disorders: 2 (posttraumatic stress disorder [PTSD] and depression), 1 (depression or PTSD), or none.

Main Outcome Measures  Maternal depression and PTSD were self-reported. Child behavioral problems were rated by mothers and teachers using a standardized behavioral checklist. For each informant, we created separate dichotomous variables that indicated whether the child's behavioral problems were severe enough to be clinically significant. We then used an analytic technique (generalized estimating equations) that integrates the child behavioral problem ratings by the mother and teachers to derive a more reliable indicator of clinically significant child behavioral problems.

Results  The rate of clinically significant child behavioral problems increased linearly relative to the number of maternal psychopathologies. The number of maternal psychopathologies was associated with a linear increase in functional impairment. Compared with children of mothers without psychopathologies, children of mothers with depression and PTSD were at greater risk for several clinically significant problems, notably, aggressive behavior (relative risk, 13.0), emotionally reactive behavior (11.2), and somatic complaints (10.5). Boys were more likely to have clinically significant behavior problems than were girls.

Conclusion  Concurrent maternal depression and PTSD was associated with dramatic increases in the rate of clinically significant behavioral problems in preschool children, particularly boys, 3 years after the World Trade Center attacks.

Author Affiliations: Departments of Psychiatry and Pediatrics, Mount Sinai School of Medicine, New York, New York.

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