DEPRESSION AND ANXIETY 00:1–7 (2014)
Research Article LONG-TERM OUTCOMES AMONG CHILD AND ADOLESCENT SURVIVORS OF THE 2010 HAITIAN EARTHQUAKE Jude Mary C´enat, Ph.D.∗ and Daniel Derivois, Ph.D.
Background: We examined the prevalence and predictive factors of PTSD and depression in relation with peritraumatic distress, trauma exposure, and sociodemographic characteristics among children and adolescent who survived the 2010 Haiti’s earthquake. Methods: We analyzed data collected between June and July 2012 from a sample of 872 participants aged 7 to 17 in 12 schools, door-to-door canvassing and two centers for street children at Port-au-Prince. Participants completed the Impact of Event Scale Revised (IES-R), Peritraumatic Distress Inventory, Child Depression Inventory 2 (CDI), and sociodemographic and traumatic exposure questionnaires. Results: Of 872 participants, respectively 322 (36.93%); and 403 (46.21%) reported a clinically significant symptoms of PTSD and depression, which were significantly higher among girls. The best predictive variables are peritraumatic distress for PTSD (β = 0.53, P < .0001) a traumatic exposure for depression (β = 0.23, P < .0001). The comorbidity between PTSD and depression symptoms is 22.25%. Conclusions: This first study in children on the prevalence of PTSD and depression resulting from the 2010 Haiti earthquake demonstrates a need for improvement in treatment aimed at reducing PTSD and depression. Such treatment should be geared primarily toward girls, adolescents between the ages of 14 and 17 and those children and adolescents who have lost a family member in the earthquake. Depression and Anxiety 00:1–7, C 2014 Wiley Periodicals, Inc. 2014. Key words: children and adolescents; peritraumatic distress; depression; Haitian earthquake; PTSD
A
Center of Research in Psychopathology and Clinical Psychology (CRPPC), Psychology Institute, University of Lyon 2, France Contract grant sponsor: National Research Agency (ANR); contract grant number: ANR-10-HAIT-002 RECREAHVI. ∗ Correspondence
to: Jude Mary Cenat, Center of Research in Psy´ chopathology and Clinical Psychology (CRPPC), Universite´ Lyon 2, 5, avenue Pierre Mendes-France – 69676 Bron Cedex. E-mail: ` [email protected] Received for publication 28 January 2014; Revised 8 April 2014; Accepted 8 April 2014 DOI 10.1002/da.22275 Published online in Wiley Online Library (wileyonlinelibrary.com).
C 2014 Wiley Periodicals, Inc.
INTRODUCTION
t 4:52 pm on January 12, 2010, the Haitian Republic was struck by one of the biggest natural disasters in its history, surpassed only by the quakes of 1770 and 1842. The violent earthquake measured 7.0 on the Richter scale. In just 35 s the towns of Port-au-Prince, Jacmel, and L´eogˆane suffered damage on a massive scale and some parts were reduced to rubble. For 12 days following the earthquake, the American Geological Institute recorded 52 aftershocks of a magnitude equal to or greater than 4.5. It has affected around half of the total Haitian population (5 million) and left over 300,000 people injured; with 4,000 to 7,000 amputees and over 222,000 fatalities.[1] The 2010 International Organization for Migration report notes that the quake left over 600,000 people homeless and that, in March 2010, around 1.3 million people were living in refugee camps scattered around the capital and other towns.
2
C´enat and Derivois
Researchers stress that exposure to natural disasters of this type usually generate high levels of psychological distress in survivors;[2] who have often lost loved ones or who are depressed by the loss of their physical and social environment. Studies show that the prevalence of the symptoms of Post-Traumatic Stress Disorder (PTSD) varies from 6.8 to 9.2% within the various sections of the general population. On the other hand, in studies carried out on populations which have suffered high magnitude earthquakes, the prevalence rate of PTSD symptoms varies between 10.34 and 74%.[3–6] . The variation depends on the populations’ level of exposure, the loss of family and friends during the disaster, the delay between the event and the evaluation, the standards of living and social assistance.[2, 7–15] Being female and young are often cited as two potential risk factors with regard to the development of PTSD. Although many studies have shown that gender is a proven risk factor,[4, 5] very few studies have been carried out specifically on age as a risk factor. Furthermore, fewer studies have been carried out on children and adolescents than on adult populations. A recent study[16] present low social support, peritraumatic fear, perceived life threat, social withdrawal, comorbid psychological problem, and poor family functioning as the greatest potential risk factors for development of PTSD. The recent works following the Wenchuan earthquake in China,[17] following the Aquila quake in Italy,[18, 19] and following the Spitak earthquake in Armenia,[2, 7, 8] show a prevalence rate of between 15.8 and 37.5% among child and adolescent earthquake survivors. Numerous studies have also shown that there is a high comorbidity–sometimes in excess of 15%–between PTSD and depression.[8, 20–23] Recent studies show that exposure to a traumatic event can cause symptoms of depression.[17] These same studies show prevalence rates of between 14.04 and 59.2% following earthquakes, based on gender, age, and other sociodemographic characteristics.[24] Studies carried out following the Wenchuan quake in China[17] show a comorbidity rate of 8.6% between the symptoms of PTSD and those of depression. To what extent does this apply to the January 2010 quake in Haiti? At this point, some studies have been conducted among adults since the earthquake,[25] while others studies have been restricted to certain areas—not all in Portau-Prince,[26, 27] or to evaluate care programs or other initiatives among people indirectly exposed to the earthquake, even though they, too, had been shown, in other studies carried out in similar contexts, to be prone to developing symptoms of PTSD, depression and various other disorders. In spite of the extensive damage caused by the quake of January 12, 2010 in Haiti, no study has hitherto been conducted to evaluate the prevalence of the symptoms of PTSD and depression among children and adolescents among a large population across all the municipalities of Port-au-Prince. This study is part of the ANR-10-HAIT-002 RECREAHVI research Depression and Anxiety
project; the main objective of which is to evaluate, over a period of 4 years (2010–2014), the mechanisms adopted by children and adolescents to overcome the trauma inflicted by this earthquake. The aim of this article is to evaluate the prevalence of symptoms of PTSD and depression in relation to peritraumatic distress, gender, age, and other sociodemographic characteristics, among a population of children and adolescents who survived the 2010 earthquake in Haiti, two and a half years later. It also examines the link between these variables, their predictive factors, and the comorbidity among all three. We examine the independent and combined effects of a number of variables on PTSD and depression.
METHOD PARTICIPANTS The sample of this study recruited 30 months after the earthquake of 2010 includes 872 children and adolescents; of whom 491 are girls (56.30%) with an average age of 14.91 (SD = 1.94). Most participants were school pupils (recruited from 12 schools scattered around Portau-Prince and door-to-door canvassing), although 56 (6.42%) were street children who did not attend school (selected from two centers caring for street children). Conditions for inclusion in the group were as follows: (1) they were aged between 7 and 17; (2) they were present in one of the most seriously affected zones of Port-au-Prince during the quake, (3) they had not received any psychological treatment. Children who received psychological treatment were excluded because they are not many and in the majority cases they were supported by unqualified students engaged by Non-governmental Organization (NGO) following the earthquake. We have estimated that these children must be the subject of a separate study. Informed consent for participation was provided by a parent or tutor for the school children and by the Ministry of Social Affairs across IBERS (Social Wellbeing Institute) for street children (the centre where they are received gave its approval and it was also made signed the children. The majority of these children do not want to have contact with their parents or their parents died). The study was conducted in accordance with a protocol approved by the Institutional Review Boards of Ministry of Public Health and Population, Ministry of National Education and Professional Formation, Ministry of Social Affairs and State University of Haiti.
PROCEDURES Data for this study were collected between June and July 2012 from 12 schools, two homeless children’s centres, and through door-todoor canvassing in Port-au-Prince and its suburbs. The schools were scattered throughout several municipalities in the capital seriously affected by the quake (Port-au-Prince, Carrefour, Delmas, P´etion Ville, Tabarre and Cit´e Soleil). Following an initial count, door-to-door canvassing was carried out in the neighborhoods and among the categories least represented in the study. With parental permission, (via a signature on the informed consent form), the children and adolescents were helped to fill out questionnaires by 12 senior psychology students from the Human Sciences faculty at the Haiti State University (one of the project partners). These students were all experienced in the administration of questionnaires and had been given a day’s training on study procedures. They read and filled out questionnaires for children to facilitate their understanding. Of 872 participants, 202 (23.16%) lived in Port-au-Prince downtown municipality, 173 (19.84%) in Carrefour, 151 (17.32%) in Delmas, 106 (12.15) in Petion-Ville, 105 (12.04%) in Tabarre, 79 (9.06%) in Cit´e Soleil, and 56 (6.42%) street children who
Research Article: PTSD and Depression Following the 2010 Haiti Earthquake
often walk through several municipalities. The questionnaires focused on sociodemographic data, traumatic experience, level of traumatic exposure, peritraumatic distress, PTSD, depression, social support, and resilience. The children were informed that they could withdraw from the study at any time, without having to give their reasons—as stipulated in the informed consent form.
MEASURES Our objective in this article is to evaluate the symptoms of peritraumatic distress, PTSD and depression. These symptoms are studied in terms of their relationship to the level of traumatic exposure, gender, age and other sociodemographic characteristics. The traumatic exposure is evaluated using a dichotomous scale (yes/no) of 18 items. Subjects are asked to specify their experience of the quake, its impact on the people in their lives, the death of parents, friends, and other acquaintances. Life events (traumatic experience) were evaluated using the sub-scale designed for this purpose in the Clinician Administered PTSD Scale (CAPS).[28] According to various considerations, the research team chose to use the French version for all questionnaires and have recourse to investigators to fill themselves the questionnaires for the participants. Because contrary to what one might think, it was found in our previous studies that reading Creole is more difficult for Haitian children to read French. In addition, these questionnaires have been used in Haiti and showed very good reliability coefficients.[29] Impact of Event Scale—Revised (IES-R). We had initially considered using the IES-R version adapted for children and adolescents (Children’s revised impact of event scale—CRIES-13). However, following discussions with the research group involved in the project, and considering that two unpublished studies have tried to use it in Haiti and have not had satisfactory reliability coefficients and the factors of cultural adaptation, we decided to use the adult version with the Haitian children and adolescents, considering that it seemed more culturally appropriate. The IES-R contains three subscales and 22 items[30] : avoidance (eight items), intrusion (eight items), and hyperarousal (six items), and has been used with adults but also children and adolescents.[31–33] Each item presents a 5-point Likert scale (not at all, a little, moderately, a lot, enormously) which are scored from 0 to 4. The seriousness of PTSD symptoms is evaluated by a global score which varies from 0 to 88. This questionnaire is widely used and has demonstrated sound reliability and internal consistency with alpha coefficients going from 0.78 to 0.89.[30, 34–36] The French language version that we used for this research presents alpha coefficients from .81 to .93.[32] Cronbach’s αof .88 in our sample. We considered the cut-off point presented in the French and English language versions (33 for severe symptoms and 12 for moderate symptoms). Peritraumatic Distress Inventory (PDI). The Peritraumatic Distress Inventory (PDI) is a self-assessment questionnaire developed and validated by Brunet.[37] It evaluates the A2 criterion of the DSM IV[38] PTSD diagnosis, i.e. the emotional distress of an individual during the moments immediately following a traumatic event experience. It postulates a positive correlation between peritraumatic distress and the development of PTSD. The scale demonstrates sound internal consistency and alpha coefficients vary between .75 and .82. Cronbach’s α of .78 in our sample. It comprises 13 items on a 5-point Likert scale ranging from 0 to 4 (not at all true, partly true, mostly true, very true, and extremely true). For this study, we used the French language version validated by Jehel.[39] A score above 15 is indicative of significant distress. This cut-off is used in this research. Child Depression Inventory. Inspired by the Beck Depression Inventory,[40] the Child Depression Inventory[41, 42] scale contains 27 items which evaluate several factors of depression (such as negativity, relationship problems, ineffectiveness, anhedonia, low self-esteem), it is used with children and adolescents aged between 7 and 17.[43] For our research, we used the French version.[44] A score at or above 16 is
3
indicative of significant distress. This cut-off is used in this research. Cronbach’s α of .77 in our sample.
DATA ANALYSIS All statistical analysis was carried out using the Statistical Package for Social Science (SPSS) – version 19, for Windows. We carried out t-tests in order to examine the difference between age and gender for PTSD, depression, and peritraumatic distress evaluation scores. We also carried out chi-square tests in order to analyze the univariate links between PTSD, depression, and peritraumatic distress and certain sociodemographic characteristics. A bivariate correlation analysis was carried out in order to identify the links between the various variables (traumatic experience, traumatic exposure, peritraumatic distress, PTSD, and depression). Multivariate regression analysis was carried out in order to study the weight of different variables on PTSD and depression. Finally, we carried out a chi-square analysis in order to ascertain the significance of the comorbidity between peritraumatic distress, PTSD, and depression. These analyses enable us to meet the objectives outlined in the introduction to this article.
RESULTS In total, 31.7% of children and adolescents stated that at least one of their family members had been lost or killed during the quake; 57.3% said that friends had been lost or killed; 11.6% stated that they were themselves injured (56.44% of them are above the PTSD threshold score); 16.3% said that they had witnessed the death of at least one family member; 63.1% saw dead bodies lying in the streets following the quake; 3.6% are disabled as a result of the quake (72.22% of them are above the PTSD threshold score) and 18.8% told us that their homes have become completely uninhabitable. About the multiple traumatic exposures, of the 872 participants, 76.83% (80.45% of girls and 72.18% of boys) obtain a score at or above of three. Of the 872 participants, 841 of them, or 96.45% said they have witnessed or experienced at least one traumatic event before the earthquake, they experienced mostly natural disasters (such as floods and hurricanes), 85.55%, physical assaults (23.97%). After the earthquake, 87.04% of them experienced a traumatic experience: 68.23 of them experienced natural disasters and 17.20%, physical assaults. Before the earthquake, 66.98% experienced between one and five traumatic events, 25.11% between 6 and 10 events, and 4.36% experienced more than 10 events. After the earthquake, 66.06% experienced between one and five traumatic events, 18.23% between six and 10 events, and 2.75% experienced more than 10 events. All this in a space of 29–30 months. Other events very present include kidnappings, sexual assaults and accidents. The average score on the peritraumatic distress index (PDI) is 18.85 (SD = 9.94) and varies from 0 to 48. The average score for girls is 21.17 (SD = 9.51), whereas this figure is 15.85 (SD = 9.68) for boys, t (870) = 8.12, P < .0001.Scores varied from 0 to 79 in the IES-R PTSD evaluation and the average score for both sexes combined is 28.72 (SD = 16.35). For boys, the average score is 26 (SD = 17.10) whereas for girls it is 30.83 (SD = 15.43), Depression and Anxiety
C´enat and Derivois
4
TABLE 1. Peritraumatic distress, PTSD, and depression symptoms among child, adolescent over the clinical cut-off levels and sociodemographical characteristics (N = 872) Peritraumatic distress Inventory (PDI)
Total Girls Boys Age 7–13 years 14–17 years Family death Yes No Living With parents Without parents Religion Catholic Voodoo Adventist Baptist Pentecostal Other Protestant Non-religious Parent Work Unemployed ∗P
PTSD presence (IES-R)
Depression (CDI)
n (%)
X2
n (%)
X2
n (%)
X2
555 (63.65) 356 (72.51) 199 (52.23)
132.79***
322 (36.93) 204 (41.58) 118 (30.18)
165.17***
403 (46.21) 256 (52.14) 147 (38.58)
74.95***
761.80*** 99 (49.75) 454 (67.46) 4.71* 190 (68.84) 365 (61.24)
77 (38.69) 326 (48.44) 20.60***
132 (47.83) 190 (31.88) 495.23***
439 (56.94) 116 (72.05)
18.12**
597.72***
309 (43.46) 94 (58.38) 973.03***
72 (45.86) 46 (32.39) 78 (35.13) 20 (23.81) 52 (42.62) 41 (35.04) 13 (46.43) 189.18**
483 (64.92) 77 (60.16)
7.74*** 150 (54.35) 253 (42.45)
245 (34.46) 68 (42.24)
105 (66.88) 97 (68.30) 138 (62.16) 49 (58.33) 80 (65.57) 70 (59.83) 14 (50)
80.45***
0.34 70 (35.17) 252 (37.44)
275.15** 596.86***
83 (52.87) 58 (40.84) 102 (45.94) 45 (53.57) 42 (34.42) 57 (48.72) 16 (57.14) 452.64***
283 (38.04) 39 (30.47)
199.61*** 347 (46.64) 56 (43.75)
< .05; ∗∗ P < .01; ∗∗∗ P < .001.
t (870) = 4.38, P < .0001. The average CDI score is 15 and varies from 0 to 34. The average score for girls is 15.98 (SD = 6.28), for boys it is 13.72 (SD = 6.72), t (870) = 5.11, P < .0001 Table 1 shows significant differences according to age for peritraumatic distress and depression. For the whole of our sample, Table 1 shows the rate of prevalence of peritraumatic distress symptoms is 63.65% (girls: 72.51%; boys: 52.23%, X 2 = 132.79, P < .001 this is 36.93% for PTSD (girls: 41.58%; boys: 30.18%, X 2 = 165.17, P < .001, and 46.21% for depression (girls: 52.14%; boys: 38.58%, X 2 = 74.95, P < .001 The rate of prevalence of moderate PTSD symptoms, that is to say the percentage of children and adolescents who scored
between 12 and 32 points, is 48.74%, or, 49.90% for girls and 47.24% for boys. The prevalence of severe and moderate PTSD symptoms together is therefore 85.66% in our sample. There are no significant differences between the various municipalities about PTSD and depression. The results also reveal that orphans, children not living with their parents and children whose parents are not working present a significantly greater prevalence for peritraumatic distress, depression and PTSD symptoms (Table 1). Table 1 shows also that children with no religion have higher symptoms of PTSD and depression prevalence. Table 2 presents the high and moderate correlation coefficients between PTSD, peritraumatic distress,
TABLE 2. Association among the variables (N = 872)
TE2 TET TE PDI IES-R CDI
TE1
TE2
TET
TE
PDI
IES-R
0.57** 0.89** 0.18** 0.13** 0.15** 0.03
— 0.89** 0.19** 0.18** 0.17** 0.1**
— 0.21** 0.18** 0.18** 0.72
— 0.26** 0.27** 0.29**
— 0.57** 0.23**
— 0.34**
∗ P < .05; ∗∗ P < .01. TE1 , Traumatic Experience befor earthquake; TE2 , Traumatic Experience after earthquake; TET , Traumatic Experience Total; TE, Traumatic Exposure.
Depression and Anxiety
Research Article: PTSD and Depression Following the 2010 Haiti Earthquake
5
TABLE 3. Results of multivariate regression analyses predicting PTSD and depressive symptoms (N = 872)
PTSD symptoms Age Sex Traumatic experience before earthquake Traumatic experience after earthquake Traumatic Exposure to the earthquake Peritraumatic distress Depressive symptoms Age Sex Traumatic experience before earthquake Traumatic experience after earthquake Traumatic exposure Peritraumatic distress
F
P
R2
77.03
Research Article LONG-TERM OUTCOMES AMONG CHILD AND ADOLESCENT SURVIVORS OF THE 2010 HAITIAN EARTHQUAKE Jude Mary C´enat, Ph.D.∗ and Daniel Derivois, Ph.D.
Background: We examined the prevalence and predictive factors of PTSD and depression in relation with peritraumatic distress, trauma exposure, and sociodemographic characteristics among children and adolescent who survived the 2010 Haiti’s earthquake. Methods: We analyzed data collected between June and July 2012 from a sample of 872 participants aged 7 to 17 in 12 schools, door-to-door canvassing and two centers for street children at Port-au-Prince. Participants completed the Impact of Event Scale Revised (IES-R), Peritraumatic Distress Inventory, Child Depression Inventory 2 (CDI), and sociodemographic and traumatic exposure questionnaires. Results: Of 872 participants, respectively 322 (36.93%); and 403 (46.21%) reported a clinically significant symptoms of PTSD and depression, which were significantly higher among girls. The best predictive variables are peritraumatic distress for PTSD (β = 0.53, P < .0001) a traumatic exposure for depression (β = 0.23, P < .0001). The comorbidity between PTSD and depression symptoms is 22.25%. Conclusions: This first study in children on the prevalence of PTSD and depression resulting from the 2010 Haiti earthquake demonstrates a need for improvement in treatment aimed at reducing PTSD and depression. Such treatment should be geared primarily toward girls, adolescents between the ages of 14 and 17 and those children and adolescents who have lost a family member in the earthquake. Depression and Anxiety 00:1–7, C 2014 Wiley Periodicals, Inc. 2014. Key words: children and adolescents; peritraumatic distress; depression; Haitian earthquake; PTSD
A
Center of Research in Psychopathology and Clinical Psychology (CRPPC), Psychology Institute, University of Lyon 2, France Contract grant sponsor: National Research Agency (ANR); contract grant number: ANR-10-HAIT-002 RECREAHVI. ∗ Correspondence
to: Jude Mary Cenat, Center of Research in Psy´ chopathology and Clinical Psychology (CRPPC), Universite´ Lyon 2, 5, avenue Pierre Mendes-France – 69676 Bron Cedex. E-mail: ` [email protected] Received for publication 28 January 2014; Revised 8 April 2014; Accepted 8 April 2014 DOI 10.1002/da.22275 Published online in Wiley Online Library (wileyonlinelibrary.com).
C 2014 Wiley Periodicals, Inc.
INTRODUCTION
t 4:52 pm on January 12, 2010, the Haitian Republic was struck by one of the biggest natural disasters in its history, surpassed only by the quakes of 1770 and 1842. The violent earthquake measured 7.0 on the Richter scale. In just 35 s the towns of Port-au-Prince, Jacmel, and L´eogˆane suffered damage on a massive scale and some parts were reduced to rubble. For 12 days following the earthquake, the American Geological Institute recorded 52 aftershocks of a magnitude equal to or greater than 4.5. It has affected around half of the total Haitian population (5 million) and left over 300,000 people injured; with 4,000 to 7,000 amputees and over 222,000 fatalities.[1] The 2010 International Organization for Migration report notes that the quake left over 600,000 people homeless and that, in March 2010, around 1.3 million people were living in refugee camps scattered around the capital and other towns.
2
C´enat and Derivois
Researchers stress that exposure to natural disasters of this type usually generate high levels of psychological distress in survivors;[2] who have often lost loved ones or who are depressed by the loss of their physical and social environment. Studies show that the prevalence of the symptoms of Post-Traumatic Stress Disorder (PTSD) varies from 6.8 to 9.2% within the various sections of the general population. On the other hand, in studies carried out on populations which have suffered high magnitude earthquakes, the prevalence rate of PTSD symptoms varies between 10.34 and 74%.[3–6] . The variation depends on the populations’ level of exposure, the loss of family and friends during the disaster, the delay between the event and the evaluation, the standards of living and social assistance.[2, 7–15] Being female and young are often cited as two potential risk factors with regard to the development of PTSD. Although many studies have shown that gender is a proven risk factor,[4, 5] very few studies have been carried out specifically on age as a risk factor. Furthermore, fewer studies have been carried out on children and adolescents than on adult populations. A recent study[16] present low social support, peritraumatic fear, perceived life threat, social withdrawal, comorbid psychological problem, and poor family functioning as the greatest potential risk factors for development of PTSD. The recent works following the Wenchuan earthquake in China,[17] following the Aquila quake in Italy,[18, 19] and following the Spitak earthquake in Armenia,[2, 7, 8] show a prevalence rate of between 15.8 and 37.5% among child and adolescent earthquake survivors. Numerous studies have also shown that there is a high comorbidity–sometimes in excess of 15%–between PTSD and depression.[8, 20–23] Recent studies show that exposure to a traumatic event can cause symptoms of depression.[17] These same studies show prevalence rates of between 14.04 and 59.2% following earthquakes, based on gender, age, and other sociodemographic characteristics.[24] Studies carried out following the Wenchuan quake in China[17] show a comorbidity rate of 8.6% between the symptoms of PTSD and those of depression. To what extent does this apply to the January 2010 quake in Haiti? At this point, some studies have been conducted among adults since the earthquake,[25] while others studies have been restricted to certain areas—not all in Portau-Prince,[26, 27] or to evaluate care programs or other initiatives among people indirectly exposed to the earthquake, even though they, too, had been shown, in other studies carried out in similar contexts, to be prone to developing symptoms of PTSD, depression and various other disorders. In spite of the extensive damage caused by the quake of January 12, 2010 in Haiti, no study has hitherto been conducted to evaluate the prevalence of the symptoms of PTSD and depression among children and adolescents among a large population across all the municipalities of Port-au-Prince. This study is part of the ANR-10-HAIT-002 RECREAHVI research Depression and Anxiety
project; the main objective of which is to evaluate, over a period of 4 years (2010–2014), the mechanisms adopted by children and adolescents to overcome the trauma inflicted by this earthquake. The aim of this article is to evaluate the prevalence of symptoms of PTSD and depression in relation to peritraumatic distress, gender, age, and other sociodemographic characteristics, among a population of children and adolescents who survived the 2010 earthquake in Haiti, two and a half years later. It also examines the link between these variables, their predictive factors, and the comorbidity among all three. We examine the independent and combined effects of a number of variables on PTSD and depression.
METHOD PARTICIPANTS The sample of this study recruited 30 months after the earthquake of 2010 includes 872 children and adolescents; of whom 491 are girls (56.30%) with an average age of 14.91 (SD = 1.94). Most participants were school pupils (recruited from 12 schools scattered around Portau-Prince and door-to-door canvassing), although 56 (6.42%) were street children who did not attend school (selected from two centers caring for street children). Conditions for inclusion in the group were as follows: (1) they were aged between 7 and 17; (2) they were present in one of the most seriously affected zones of Port-au-Prince during the quake, (3) they had not received any psychological treatment. Children who received psychological treatment were excluded because they are not many and in the majority cases they were supported by unqualified students engaged by Non-governmental Organization (NGO) following the earthquake. We have estimated that these children must be the subject of a separate study. Informed consent for participation was provided by a parent or tutor for the school children and by the Ministry of Social Affairs across IBERS (Social Wellbeing Institute) for street children (the centre where they are received gave its approval and it was also made signed the children. The majority of these children do not want to have contact with their parents or their parents died). The study was conducted in accordance with a protocol approved by the Institutional Review Boards of Ministry of Public Health and Population, Ministry of National Education and Professional Formation, Ministry of Social Affairs and State University of Haiti.
PROCEDURES Data for this study were collected between June and July 2012 from 12 schools, two homeless children’s centres, and through door-todoor canvassing in Port-au-Prince and its suburbs. The schools were scattered throughout several municipalities in the capital seriously affected by the quake (Port-au-Prince, Carrefour, Delmas, P´etion Ville, Tabarre and Cit´e Soleil). Following an initial count, door-to-door canvassing was carried out in the neighborhoods and among the categories least represented in the study. With parental permission, (via a signature on the informed consent form), the children and adolescents were helped to fill out questionnaires by 12 senior psychology students from the Human Sciences faculty at the Haiti State University (one of the project partners). These students were all experienced in the administration of questionnaires and had been given a day’s training on study procedures. They read and filled out questionnaires for children to facilitate their understanding. Of 872 participants, 202 (23.16%) lived in Port-au-Prince downtown municipality, 173 (19.84%) in Carrefour, 151 (17.32%) in Delmas, 106 (12.15) in Petion-Ville, 105 (12.04%) in Tabarre, 79 (9.06%) in Cit´e Soleil, and 56 (6.42%) street children who
Research Article: PTSD and Depression Following the 2010 Haiti Earthquake
often walk through several municipalities. The questionnaires focused on sociodemographic data, traumatic experience, level of traumatic exposure, peritraumatic distress, PTSD, depression, social support, and resilience. The children were informed that they could withdraw from the study at any time, without having to give their reasons—as stipulated in the informed consent form.
MEASURES Our objective in this article is to evaluate the symptoms of peritraumatic distress, PTSD and depression. These symptoms are studied in terms of their relationship to the level of traumatic exposure, gender, age and other sociodemographic characteristics. The traumatic exposure is evaluated using a dichotomous scale (yes/no) of 18 items. Subjects are asked to specify their experience of the quake, its impact on the people in their lives, the death of parents, friends, and other acquaintances. Life events (traumatic experience) were evaluated using the sub-scale designed for this purpose in the Clinician Administered PTSD Scale (CAPS).[28] According to various considerations, the research team chose to use the French version for all questionnaires and have recourse to investigators to fill themselves the questionnaires for the participants. Because contrary to what one might think, it was found in our previous studies that reading Creole is more difficult for Haitian children to read French. In addition, these questionnaires have been used in Haiti and showed very good reliability coefficients.[29] Impact of Event Scale—Revised (IES-R). We had initially considered using the IES-R version adapted for children and adolescents (Children’s revised impact of event scale—CRIES-13). However, following discussions with the research group involved in the project, and considering that two unpublished studies have tried to use it in Haiti and have not had satisfactory reliability coefficients and the factors of cultural adaptation, we decided to use the adult version with the Haitian children and adolescents, considering that it seemed more culturally appropriate. The IES-R contains three subscales and 22 items[30] : avoidance (eight items), intrusion (eight items), and hyperarousal (six items), and has been used with adults but also children and adolescents.[31–33] Each item presents a 5-point Likert scale (not at all, a little, moderately, a lot, enormously) which are scored from 0 to 4. The seriousness of PTSD symptoms is evaluated by a global score which varies from 0 to 88. This questionnaire is widely used and has demonstrated sound reliability and internal consistency with alpha coefficients going from 0.78 to 0.89.[30, 34–36] The French language version that we used for this research presents alpha coefficients from .81 to .93.[32] Cronbach’s αof .88 in our sample. We considered the cut-off point presented in the French and English language versions (33 for severe symptoms and 12 for moderate symptoms). Peritraumatic Distress Inventory (PDI). The Peritraumatic Distress Inventory (PDI) is a self-assessment questionnaire developed and validated by Brunet.[37] It evaluates the A2 criterion of the DSM IV[38] PTSD diagnosis, i.e. the emotional distress of an individual during the moments immediately following a traumatic event experience. It postulates a positive correlation between peritraumatic distress and the development of PTSD. The scale demonstrates sound internal consistency and alpha coefficients vary between .75 and .82. Cronbach’s α of .78 in our sample. It comprises 13 items on a 5-point Likert scale ranging from 0 to 4 (not at all true, partly true, mostly true, very true, and extremely true). For this study, we used the French language version validated by Jehel.[39] A score above 15 is indicative of significant distress. This cut-off is used in this research. Child Depression Inventory. Inspired by the Beck Depression Inventory,[40] the Child Depression Inventory[41, 42] scale contains 27 items which evaluate several factors of depression (such as negativity, relationship problems, ineffectiveness, anhedonia, low self-esteem), it is used with children and adolescents aged between 7 and 17.[43] For our research, we used the French version.[44] A score at or above 16 is
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indicative of significant distress. This cut-off is used in this research. Cronbach’s α of .77 in our sample.
DATA ANALYSIS All statistical analysis was carried out using the Statistical Package for Social Science (SPSS) – version 19, for Windows. We carried out t-tests in order to examine the difference between age and gender for PTSD, depression, and peritraumatic distress evaluation scores. We also carried out chi-square tests in order to analyze the univariate links between PTSD, depression, and peritraumatic distress and certain sociodemographic characteristics. A bivariate correlation analysis was carried out in order to identify the links between the various variables (traumatic experience, traumatic exposure, peritraumatic distress, PTSD, and depression). Multivariate regression analysis was carried out in order to study the weight of different variables on PTSD and depression. Finally, we carried out a chi-square analysis in order to ascertain the significance of the comorbidity between peritraumatic distress, PTSD, and depression. These analyses enable us to meet the objectives outlined in the introduction to this article.
RESULTS In total, 31.7% of children and adolescents stated that at least one of their family members had been lost or killed during the quake; 57.3% said that friends had been lost or killed; 11.6% stated that they were themselves injured (56.44% of them are above the PTSD threshold score); 16.3% said that they had witnessed the death of at least one family member; 63.1% saw dead bodies lying in the streets following the quake; 3.6% are disabled as a result of the quake (72.22% of them are above the PTSD threshold score) and 18.8% told us that their homes have become completely uninhabitable. About the multiple traumatic exposures, of the 872 participants, 76.83% (80.45% of girls and 72.18% of boys) obtain a score at or above of three. Of the 872 participants, 841 of them, or 96.45% said they have witnessed or experienced at least one traumatic event before the earthquake, they experienced mostly natural disasters (such as floods and hurricanes), 85.55%, physical assaults (23.97%). After the earthquake, 87.04% of them experienced a traumatic experience: 68.23 of them experienced natural disasters and 17.20%, physical assaults. Before the earthquake, 66.98% experienced between one and five traumatic events, 25.11% between 6 and 10 events, and 4.36% experienced more than 10 events. After the earthquake, 66.06% experienced between one and five traumatic events, 18.23% between six and 10 events, and 2.75% experienced more than 10 events. All this in a space of 29–30 months. Other events very present include kidnappings, sexual assaults and accidents. The average score on the peritraumatic distress index (PDI) is 18.85 (SD = 9.94) and varies from 0 to 48. The average score for girls is 21.17 (SD = 9.51), whereas this figure is 15.85 (SD = 9.68) for boys, t (870) = 8.12, P < .0001.Scores varied from 0 to 79 in the IES-R PTSD evaluation and the average score for both sexes combined is 28.72 (SD = 16.35). For boys, the average score is 26 (SD = 17.10) whereas for girls it is 30.83 (SD = 15.43), Depression and Anxiety
C´enat and Derivois
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TABLE 1. Peritraumatic distress, PTSD, and depression symptoms among child, adolescent over the clinical cut-off levels and sociodemographical characteristics (N = 872) Peritraumatic distress Inventory (PDI)
Total Girls Boys Age 7–13 years 14–17 years Family death Yes No Living With parents Without parents Religion Catholic Voodoo Adventist Baptist Pentecostal Other Protestant Non-religious Parent Work Unemployed ∗P
PTSD presence (IES-R)
Depression (CDI)
n (%)
X2
n (%)
X2
n (%)
X2
555 (63.65) 356 (72.51) 199 (52.23)
132.79***
322 (36.93) 204 (41.58) 118 (30.18)
165.17***
403 (46.21) 256 (52.14) 147 (38.58)
74.95***
761.80*** 99 (49.75) 454 (67.46) 4.71* 190 (68.84) 365 (61.24)
77 (38.69) 326 (48.44) 20.60***
132 (47.83) 190 (31.88) 495.23***
439 (56.94) 116 (72.05)
18.12**
597.72***
309 (43.46) 94 (58.38) 973.03***
72 (45.86) 46 (32.39) 78 (35.13) 20 (23.81) 52 (42.62) 41 (35.04) 13 (46.43) 189.18**
483 (64.92) 77 (60.16)
7.74*** 150 (54.35) 253 (42.45)
245 (34.46) 68 (42.24)
105 (66.88) 97 (68.30) 138 (62.16) 49 (58.33) 80 (65.57) 70 (59.83) 14 (50)
80.45***
0.34 70 (35.17) 252 (37.44)
275.15** 596.86***
83 (52.87) 58 (40.84) 102 (45.94) 45 (53.57) 42 (34.42) 57 (48.72) 16 (57.14) 452.64***
283 (38.04) 39 (30.47)
199.61*** 347 (46.64) 56 (43.75)
< .05; ∗∗ P < .01; ∗∗∗ P < .001.
t (870) = 4.38, P < .0001. The average CDI score is 15 and varies from 0 to 34. The average score for girls is 15.98 (SD = 6.28), for boys it is 13.72 (SD = 6.72), t (870) = 5.11, P < .0001 Table 1 shows significant differences according to age for peritraumatic distress and depression. For the whole of our sample, Table 1 shows the rate of prevalence of peritraumatic distress symptoms is 63.65% (girls: 72.51%; boys: 52.23%, X 2 = 132.79, P < .001 this is 36.93% for PTSD (girls: 41.58%; boys: 30.18%, X 2 = 165.17, P < .001, and 46.21% for depression (girls: 52.14%; boys: 38.58%, X 2 = 74.95, P < .001 The rate of prevalence of moderate PTSD symptoms, that is to say the percentage of children and adolescents who scored
between 12 and 32 points, is 48.74%, or, 49.90% for girls and 47.24% for boys. The prevalence of severe and moderate PTSD symptoms together is therefore 85.66% in our sample. There are no significant differences between the various municipalities about PTSD and depression. The results also reveal that orphans, children not living with their parents and children whose parents are not working present a significantly greater prevalence for peritraumatic distress, depression and PTSD symptoms (Table 1). Table 1 shows also that children with no religion have higher symptoms of PTSD and depression prevalence. Table 2 presents the high and moderate correlation coefficients between PTSD, peritraumatic distress,
TABLE 2. Association among the variables (N = 872)
TE2 TET TE PDI IES-R CDI
TE1
TE2
TET
TE
PDI
IES-R
0.57** 0.89** 0.18** 0.13** 0.15** 0.03
— 0.89** 0.19** 0.18** 0.17** 0.1**
— 0.21** 0.18** 0.18** 0.72
— 0.26** 0.27** 0.29**
— 0.57** 0.23**
— 0.34**
∗ P < .05; ∗∗ P < .01. TE1 , Traumatic Experience befor earthquake; TE2 , Traumatic Experience after earthquake; TET , Traumatic Experience Total; TE, Traumatic Exposure.
Depression and Anxiety
Research Article: PTSD and Depression Following the 2010 Haiti Earthquake
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TABLE 3. Results of multivariate regression analyses predicting PTSD and depressive symptoms (N = 872)
PTSD symptoms Age Sex Traumatic experience before earthquake Traumatic experience after earthquake Traumatic Exposure to the earthquake Peritraumatic distress Depressive symptoms Age Sex Traumatic experience before earthquake Traumatic experience after earthquake Traumatic exposure Peritraumatic distress
F
P
R2
77.03
