In our cohort of SDPs, the morbidity of PTSD reached 30.9% according to the clinical cut-off of 50 in PCL-C scale, while in the group of age over 60 the morbidity reached 31.6% (the average score of PCL-C was 42.65) and 28.6% in the group aged below 60. There was no significant difference between the two group as SDPs all aged over 49 close to the acknowledged average age for the old people in China. In fact, Chinese women usually retire at 50 and men at 55, therefore, the group aged from 49 to 59 are deemed as the subgroup of old people who are facing the challenge of aging or undergoing aging. As the result showed, the morbidity of PTSD was about twice higher in Shidu older adults compared to that reported in the bereaved old people who lost the spouse in an old age . It emphasizes that loss of the only child is the bitterest distress to old people within the realm of bereavement . Especially, in China, familism culture is a collectivist culture and has a profound effect on Chinese society, where the parent-child bonds are much strained . A Chinese saying states that ‘losing one’s parent(s) in one’s youth, losing one’s spouse in middle-age, and losing one’s child in old age’ are the three greatest tragedies in life. Therefore, combined with the statistics, Shidu older adults might experience more unforgettable grieving process and higher vulnerability to PTSD, and, undoubtedly, deserve more assistance and help from the psychologists and social workers.
To explore the potential risk factors of PTSD in SDPs, two main influential factors were analyzed: the different characteristics of the parents and the deceased child based on the previous similar research of PTSD related to bereavement of child. The results showed the gender of SDPs was a stronger predictor of PTSD, indicating females had larger possibility of PTSD after the loss of their only child, which was consistent with the previous findings of parents’ bereavement [28, 29]. In a traditional Chinese family, mothers are expected to feed and take good care of their only child, and spend more time and love in the child than fathers, so mothers form a closer bond with their child, reflected in another Chinese proverb- “A begging mother is better than an official father”. Therefore, losing the only child produced more burden and stress for mothers than for fathers . The other stronger predictor was the annual hospital visits which was significant in the two-step regression model. However, the medical conditions which were represented by the total number of the physical diseases were not significant in the regression. It could be explained by that a mental health state might be greatly related to the Shidu older adults’ vulnerability to PTSD since a lot of previous studies reported other mental disorders like depression , anxiety and insomnia usually coexisted in the bereaved people with PTSD [30, 31], which were significantly associated with the hospital visit time. However, in our study, the risk factors regarding PTSD in Shidu older adults by differentiating the symptoms were our focuses, instead of emerging the symptoms profiles from PTSD, prolonged grief disorder or depression, with the aim at yielding important information about PTSD profiles of distress following loss. Different from the other studies, the associations with PTSD among SDPs’ characteristics of education, marriage, and religion were not significant, which might partly owe to the local sampling. Although the income level was negatively related to PCL-C scores, it had tiny contribution to the possibility of having PTSD. As for the characteristics of the dead child, only the cause of death turned to be significantly contributed to the prevalence of PTSD. Notably, SDPs of child died from accidents have more possibility of PTSD than those of child died from diseases. It was documented a sudden and violent loss of a loved one can adversely affect mental health and grief in a substantial number of the bereaved . PTSD were more severe after sudden and violent losses than losses following natural deaths, and the trajectory of recovery seemed to be slower . A large national study showed the mothers whose children died from unnatural causes had an overall hazard ratio of 1.72, whereas the corresponding figure for those whose children died from natural causes was 1.33, reporting a higher hazard ratio in mothers whose children died unexpectedly . Murphy et al. studied 175 bereaved parents for 5 years following three types of violent deaths: accidents, homicides, and suicides . The report supported that the sudden, violent deaths of children produce particularly negative outcomes for the parents. As presumed by Floyd et al., the deaths that are violent or unexpected (e.g., accidents, homicide) could cause severe turmoil and emotional distress that overtax coping resources and produce more negative bereavement outcomes than deaths from non-violent, expected circumstances (e.g., long-term illness) . However, a lot of studies of children died from cancer showed the possibility of having PTSD in bereaved parents are inconclusive, as the follow-up results diverse, but few of the studies are reported the elder SDPs’ chronic PTSD prevalence. Considering this, we investigated the years of being Shidu as a potential related factor of PTSD. and attained negative association between the time and PTSD in first-step regression. However, after the characteristics of the dead children entered, the contribution of years of being Shidu was not significant. Referred to the previous studies , the insignificant result might be due to the unknown relationship between the age and the cause of the child death, since the children with fatal diseases usually died at a young age and the parents have a long time to suffer from the distress, gradually developing into chronic PTSD, while a child died suddenly or unexpectedly usually in a older age resulting in the early PTSD. Further studies and expanded samples should be helpful to test the role in terms of the years of being Shidu. Besides, in line with other studies , there was no proof for significant effect of sex of the dead child on morbidity in these Shidu older adults, however, the results might be different if this study is replicated in a population with a different grief culture and, more importantly, different gender schemas.
The current study has some limitations. First, the sample size might not be enough, due to the difficult access to the group, to show some other factors’ significant relation to the prevalence of PTSD, and restricted the explanation. It should be aware that SDPs went through a lot of bitterness, for example, the broken marriage, low economical statue, discrimination from the society and so on. Interaction effect of these ordeals with the loss grief may be difficult to control. Considering this, we used a question in our demographic investigation asking-“Have you been through traumatic events in the last year”, to avoid the influence of the complicated grief. However, it may not be effective as the long-term grief could not be easily excluded. Second, the morbidity of PTSD in Shidu older adults in the present study might not exactly reflect the actual situation as some participant withdrew from the interview, who could have more severe PTSD. Third, the R square of the regression was small, which indicates more potential factors were undiscovered or the interactions of these factors were not significantly verified. Cooperated with result from a latent profiles of physical and psychological outcomes of bereaved parents in China who lost their only child , indicators could include subjective physical health, negative psychological outcomes and positive psychological outcomes. However, it should be highlighted that in our study the instrument of PTSD was PCL-C in Chines version which adopted a three-factor model of measuring the disorder, different from the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) formalized in 2013, which provided a four-factor model and high psychometric quality. Therefore, the contribution of the tested factors would be underestimated if more symptoms should be considered as indicating the probability of PTSD. Therefore, the future researches are still needed to study the PTSD of Shidu older adults with the new diagnostic instrument. Due to the limited effort, a more comprehensive assessment including the prolonged grief disorder and the potential additional losses has not been implemented in the study. However, a key distinctive feature of PGD is “yearning for the deceased”, whereas “fear” is the hallmark symptom of PTSD . Recent researches have indicated that PGD may strongly overlap with Persistent Complex Bereavement Disorder, which is included in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition as a condition requiring further research . PGD is proposed as a separate construct in the DSM-5, and PGD symptoms strongly affect PTSD symptoms at the first year of a loss of loved one . However, PGD has still not been studied in the context of SDPs and not an extrinsic factor in predicting PTSD in SDPs. Essentially, the comorbidity of depression and PGD could make the diagnosis of PTSD more intricate. Lastly, a longitudinal investigation of the sample may help to understand the high initial PTSD frequency, and help to identify who suffers from the long-term consequences of being old-age SDPs. Undoubtedly, this will be a hard work. In these elaborate works of our study, it has been found home visits to older participants is a more appropriate, although costly, way of obtaining responses of a satisfying data quality. Therefore, future study may benefit from paying for home visits to all participants both in the PTSD and the non-PTSD group,which is also advocated by O’Connor . Despite these limitations, the results are noteworthy because this is the first study to evaluate PTSD in the Shidu older adults and explored the risk factors. In the future, more works should be done for the Shidu older adults such as the comorbidity of PTSD in them, other intermediates and moderators.
Despite these limitations, the present study makes several significant contributions to the knowledge on the sequelae of losing the only child. First, no previous cross-section study has reported on the prevalence of PTSD in Shidu older adults, while this study has found it was significantly higher than the other bereavement-related PTSD. These findings emphasize that Shidu is a major public health issue as a large group of Shidu parents in the coming century and the number is still increasing and suggest that screening assessments of PTSD in older SDPs might be useful in the identification of high-risk individuals for early interventions. Second, the current study has found a number of significant predictors of PTSD in SDPs. The results are somewhat consistent with the evidence about the predictors of PTSD after other types of bereavement. Especially, our results has implied women with frequent hospital visits, no matter for physic or mental health checks, who lost her child in an unexpected accidence could be a suffer of PTSD and need timely and substantial psychological help. Importantly, the overlap of predictors of psychiatric problems, like complicated grief and depression founded in studies about bereavement, has indicated the imperative intervention on these factors should be implemented. In turn, it would also be beneficial to combine the therapies which are targeting for the complicated grief and depression, in the treatment of PTSD in SDPs. Finally, the causes of child’s death were found to have the significant association with PTSD in SDPs. The accidence resulting in the unexpected death of the only child was a strong traumatic exposure to parents. Therefore, after-accidence psychological first aid should be promptly demanded and important. Overall, the results provide strong suggestive evidence that useful interventions could be developed in future prospective studies to target the prevention and treatment of PTSD in SDPs.