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International Journal of Nursing Practice 2014; ••: ••–••
RESEARCH PAPER
Posttraumatic stress symptoms seen in children within the 3-month period after the Van earthquake in Turkey Sibel Küçükog˘lu PhD Assistant Professor, Faculty of Health Science, Atatürk University, Erzurum, Turkey
Naci Yıldırım RN Nurse and Master of Science Student, Psychiatric Department, Van Research and Education Hospital, Van, Turkey
Onur Burak Dursun PhD Assistant Professor, Department of Child Psychology, Faculty of Medicine, Erzurum, Turkey
Accepted for publication August 2013 Küçükog˘lu S, Yıldırım N, Dursun OB. International Journal of Nursing Practice 2014; ••: ••–•• Posttraumatic stress symptoms seen in children within the 3-month period after the Van earthquake in Turkey The research was conducted to determine the posttraumatic stress symptoms seen in children within the 3 month period after the Van earthquake in Turkey. The research was conducted between December 2011 and January 2012 with the earthquake survivor children in the 7–12 age group living in the tent city built in the central area of Van. The research data were collected by the researcher using the Childhood Post-Traumatic Stress Reaction Index (CPTS-RI) and a questionnaire prepared by the researchers that contained questions on some information about the earthquake and on sociodemographic characteristics.It was found out that 8.6% (26) of the children had mild symptoms of posttraumatic stress disorder (PTSD), 19.7% (60) of the children had moderate symptoms of PTSD, 47.7% (145) of the children had severe symptoms of PTSD and 24.0% (73) of the children had very severe symptoms of PTSD. Furthermore, a significant difference (P < 0.001) was found between mean CPTS-RI scores and the economic losses experienced in the families of the children. In the study, PTSD was identified in the majority of children in the 7–12 age group who experienced the Van earthquake. Key words: child, earthquake, posttraumatic stress disorder.
INTRODUCTION Earthquakes are different from other natural disasters in the sense that they occur suddenly, they cause huge destruction and immense loss of life and property, and the
Correspondence: Sibel Küçükog˘lu, Faculty of Health Science, Atatürk University, Erzurum 25240, Turkey. Email: s_nadaroglu@ hotmail.com doi:10.1111/ijn.12305
aftershocks caused by the earthquakes continue to traumatize people.1 Besides, earthquakes bring about massive damages in the lives of people by causing injuries and by leading to a sudden loss of a significant other (family member, relative or friend) and their properties, and making people lose their homes.2 Once more, a massive and devastating earthquake occurred on 23 October 2011 in our country, which is popular for devastating earthquakes. According to the data of the Bog˘aziçi University © 2014 Wiley Publishing Asia Pty Ltd
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Kandilli Observatory and Earthquake Research Institute National Earthquake Monitoring Center, an earthquake of 7.2 magnitude struck mainly Ercis¸ County and the nearby locations such as Van Province and the surrounding cities at 13:41. A second earthquake of 5.6 magnitude struck Edremit County of Van Province at 21:23 on 9 November 2011, when economical, physical and psychological damages and losses to Van earthquake had not been compensated yet. Six hundred forty-four people were killed in both earthquakes.3 (The Van earthquake took place east of Turkey, with an average height 1725 m. For this reason, the region has severe continental climate. This climate is very cold and especially manifests itself with long winters. When the Van earthquake happened, the weather was very cold, and many people had been forced to live in tent cities established by the state for months.) Such factors as the severity of the earthquakes, larger size of the region struck by the earthquakes, the damages and losses caused, long-term aftershocks, housing problems, heavy climate conditions, multiplied the outcomes of these disasters as compared with outcomes of similar disasters. Traumatic events like traffic accidents, plane accidents, earthquakes or floods leave short-term or long-term psychological impacts among individuals or communities that are exposed to them. It is not true that everybody exposed to traumas will have disorders and not everybody is affected equally by traumas. Children, the elderly people, people with physical disabilities, those with poor economical status and those with a previous psychiatric disorder are affected by traumas more.4 Posttraumatic stress disorder (PTSD) includes psychiatric symptoms related to cognitive, emotional, behavioural and social disorders that develop after one undergoes or witnesses a trauma that threatens his/her life or his/her physical integrity.5 PTSD might occur in 3% of those who are exposed to natural disasters.6 According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), lifelong prevalence of PTSD—defined as an anxiety disorder that develops after a serious trauma or event—is around 8–9% in the American society. The studies conducted indicate that PTSD is the fourth most common psychiatric disorder.7 PTSD often occurs after a few hours or a few months following traumatic events. PTSD is considered if the symptoms last more than the normal period and it should be treated. If not treated, one’s occupational and private life is negatively affected. Early diagnosis and social support increase the likelihood of the success of the treatment.4 © 2014 Wiley Publishing Asia Pty Ltd
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Studies show that those who suffer seriously from natural disasters are children, young people and the elderly. Like adults, children are afraid of earthquake disaster, too. However, unlike adults, they have difficulty understanding that it is an uncontrollable natural event. The degree to which children are affected by earthquakes is determined by such factors as reaction of the family, degree of relationship of those killed in the earthquake, age/gender, past experiences, indirect effects of the earthquake, daily life, separation, domestic relations, economical conditions and social support.8–10 Catastrophes like earthquakes, floods and fires cause the children and the adolescents to experience emotional changes, and to undergo heavy and intensified anxiety that they themselves, their families and their friends will suffer a lot, and with the thought that the established order and balance will be ruined. Adults as well as children might be re-exposed to many traumatic event(s) during catastrophes. Children could witness heavy destructions, like seeing their houses or villages destroyed. They might also see many injured people and witness the death of their parents, sisters and brothers, and their relatives, and observe how numerous people are suddenly killed at the same time. Anybody who is exposed to these catastrophes might involuntarily recollect these event(s) over and over, cannot help but think about these traumatic event(s) and avoid talking about them and thus might be overstimulated, is likely to experience the disorder called PTSD.11 In the study of Sabuncuog˘lu et al., it was found that the prevalence of PTSD was 42% in the hospital admissions of the people suffering from the Marmara earthquake 6 months after the Marmara earthquake occurred.1 Another study on children was conducted 1 month after the Marmara earthquake, and of 1118 children subjects, 84 children were diagnosed with PTSD.12 Although earthquakes are the most common and the most devastating one among the natural catastrophes, psychological problems caused by earthquakes and their risk factors are dealt with less both in Turkey and in the world.13,14 Most of the studies related to the relevant topic were conducted after the 1999 Marmara earthquake in Turkey.14 Creating an awareness about the effects of the catastrophes is highly important to prevent and to solve the psychological problems caused by earthquakes.15,16 If posttraumatic disorders are not diagnosed and intervened on early, they might become a chronic and serious health problem. Traumatized people cannot benefit from joy of life, and pain directs their activities.17
Posttraumatic stress symptoms seen in children
Although there are many studies in the literature related with the psychiatric problems that developed after an earthquake, these studies were mostly on the adult age group and the number of studies on children is limited. In the studies performed with both adults and children, it is seen that most of the studies have only been conducted in sub-acute or chronic phase after the disaster, and the studies conducted in the acute phase are extremely limited. This study is aimed at determining the PTSD symptoms seen in school children in the acute phase, after a natural disaster that happened in Van Province.
METHOD Type of research This descriptive research was conducted between December 2011 and January 2012.
Population and sample The population of the research was consisted of children earthquake victims aged 7–12 who reside in Mimar Sinan Tent City located at the centre of Van region. It was known that Mimar Sinan Tent City was the most crowded tent city, built on the second day after the earthquake and held nearly 6000 earthquake victims. Children and adolescents who had both verbal/receptive language disorders at a level that prevents communication with interviewer, and previous mental retardation, autism, schizophrenia, physical disability or a chronic physical illness are not included the study, as posttraumatic stress symptoms might need to be questioned by a different approach in these cases. After the 60th day of the earthquake, at the time of the study, 140 of the 150 tents have been selected by random sampling method in the tent city, 310 children and their families who reside in these tents have been informed, and 304 of the children who have agreed to participate in the study and have their ratification signed by both the child and parents have been included in the study.
Data collection The data of the research were gathered by the researcher using a questionnaire designed by the researchers that contained questions on some information about the earthquake and on sociodemographic characteristics and the Childhood Post-Traumatic Stress Reaction Index (CPTS-RI). The questionnaire was administered using face-to-face interview technique during December and January when
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aftershocks continued. The questionnaire form included questions about age and gender of the children, period of residence in the region, whether or not they were trapped under the wreckage, whether or not they owned the house, degree of the damage to the house, whether or not they lost a significant other, and the degree of the economical losses. The CPTS-RI was designed by Pynoos et al. to measure the severity of the symptoms of PTSD. CPTS-RI is a semi-structured, 20-item Likert-type index to assess stress reactions of children and adolescents after different traumatic experiences.18 The following are comparisons of CPTS-RI scores with clinical diagnosis of PTSD: 0–11 = suspect, 12–24 = mild, 25–39 = moderate, 40–59 = severe, 60–80 = very severe. It was proved that scores ≥40 were clinically correlated with PTSD diagnosis. Turkish validity and reliability tests of the CPTS-RI were performed by Erden et al.19 Consistency test of the index was repeated using test–retest method, and reliability was found as 0.86 and Cronbach’s alpha was found as 0.75. Interrater reliability kappa coefficient was 0.87. Cronbach’s alpha of the CPTS-RI in the current study was found to be 0.89. The consistency between DSM-IV diagnosis criteria for PTSD and the CPTS-RI scores was found to be significant.
Statistical analysis For the statistical analysis of the research, Windows SPSS 20.0 package software (IBM SPSS AMOS; IBM Corporation, Armonk, NY, USA) was used. Statistical significance was defined by a probability level of P < 0.05. For the analysis of the data obtained from the research, numbers, percentages, means, Kruskal–Wallis test, and t-test and variance analysis for the independent groups were used.
RESULTS Table 1 included information about sociodemographic data and earthquake experience of the children participant. It was determined that 53.3% of the children were boys and mean age of the children was 10.55 ± 1.33. There were 3.3% of the children who were trapped under the wreckage, 67.4% of them resided in the region for more than 10 years, 80.9% had their own houses, houses of 39.8% of the children were severely damaged, 17.8% lost one significant other in the earthquake and only 33.6% did not have any economical losses in the family after the earthquake. © 2014 Wiley Publishing Asia Pty Ltd
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Table 1 Distributions of some sociodemographic and earthquakerelated characteristics of the children participants Descriptive characteristic
n
Gender Girl 142 Boy 162 Age (mean) 10.55 ± 1.33 Whether being trapped under wreckage I was trapped under wreckage 10 I was not trapped under wreckage 294 Period of residence in the region (years) Less than 1 9 1–5 17 ≥6 278 Whether owning the house Their own house 246 Rented 58 Degree of damage to the house No damage 28 Slight damage 75 Moderate damage 64 Severe damage 121 Colossal damage 16 Loss of a significant other Yes 54 No 250 Economical loss after earthquake No loss/mild loss 102 Moderate 115 Severe 87 Total 304
%
46.7 53.3
Moderate 19,7% Severe 47,7%
Figure 1. Status of posttraumatic stress disorder symptoms of the children earthquake victims.
3.3 96.7 3 5.6 91.4 80,9 19.1 9.2 24.7 21.1 39.8 5.3 17.8 82.2 33.6 37.8 28.6 100
When CPTS-RI scores were investigated, mean score of 304 children was found to be 48.47 ± 16.85. According to this index, 8.6% of the children (n = 26) had mild level of PTSD symptoms, 19.7% of the children (60) had moderate level of PTSD symptoms, 47.7% of the children (60) had severe level of PTSD symptoms and 24.0% of the children (72) had very severe level of PTSD symptoms (Fig. 1). Items of CPTS-RI were listed in Table 2, and it was found that the most reported symptom by the children was that earthquake was perceived as a psychological trauma (83%), 74.3% of the children reported that earthquake caused a fear and 79% told that earthquake caused social isolation emotions. © 2014 Wiley Publishing Asia Pty Ltd
Mild 8,6%
Very Severe 24%
Table 3 included distribution of the mean CPTS-RI scores according to some characteristics of the children participant. No statistically significant difference was found between mean CPTS-RI scores and gender of the children (P > 0.05). A weak but positive correlation existed between mean CPTS-RI scores of the children earthquake victim in terms of mean age (P < 0.05). Also, no statistically significant correlation was found between mean CPTS-RI scores of the children earthquake victim in terms of period of residence in the region, whether or not they were trapped under the wreckage, whether or not they owned the house, and the degree of damage to the house (P > 0.05). When the status whether or not the children lost a significant other and the degree of the economical losses was analysed, mean CPTS-RI score of the children who lost a significant other was higher than those who did not lose a significant other, but no statistically significant difference was found between (P = 0.09). Moreover, there was a significant difference between mean CPTS-RI scores of the children and their economical losses in the families (P < 0.001).
DISCUSSION Although there are various methodological differences in the studies about earthquake psychology, it is seen that psychological problems that occur after earthquakes are very common and might last for years. PTSD is widely seen in the studies that are community based, as well as in those conducted with high-risk groups.17 This study explored a weak but positive correlation in mean CPTS-RI scores according to the mean age of the children earthquake victim aged 7–12. Mean CPTS-RI score was 48.47 ± 16.85. It was noted that 47.7% (145) of the children had severe symptoms of PTSD and 24.0% (72) of the children had very severe symptoms of PTSD. A study
Posttraumatic stress symptoms seen in children
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Table 2 Criteria of Childhood Post-traumatic Stress Reaction Index (CPTS-RI) CPTS-RI item Events perceived as a trauma Fears Recurrent images Recurrent thoughts Recurrent distressing dreams of the event Feeling as if the traumatic event was recurring Anhedonia Detachment or estrangement from others Emotional avoidance Restricted range of affect Hyper-vigilance Sleeping disorder Quilt Difficulty recalling Difficulty concentrating Social withdrawal Distressing recollections Sense of foreshortened future Physiological reactions Outburst of anger
(A1) (A2) (B1) (B1) (B2) (B3) (C4) (C5) (C1) (C6) (D4) (D1) (D3) (D3) (C2) (B4) (B5) (D2)
made by Kadak et al. on adolescents who suffered from Van earthquake 6 months later found that less than half (40.69%) of the participants reported severe levels of PTSD symptoms, 53.04% were at greater risk for developing an anxiety-related disorder, 37.70% met the criteria for clinical depression and 36.73% revealed pathological levels of dissociative symptomotology.20 Alparslan et al. reported that of 1118 children subjects 1 month after the Marmara earthquake, 84 children were diagnosed with PTSD.12 It was observed 1.5 years after the Armenian earthquake that among the children who resided in the location nearest the epicentre, 17% had very severe symptoms of PTSD, 74.5% had severe symptoms of PTSD and 8.5% had moderate symptoms of PTSD.18 In the study of La Greca et al. on school-age children who suffered from the Andrew Hurricane in Florida, it was found that those who were more anxious, had attention deficit disorder more and had lower academic success 15 months before the Hurricane had symptoms of PTSD 3 months after the Hurricane compared with other children.21 The study of Karakaya et al. demonstrated that 22.2% of the adults might show PTSD even 3.5 years after the earthquake.22
Never (n/%)
Rarely/seldom (n/%)
Often/always (n/%)
8/2.6 17/5.6 25/8.2 25/8.2 41/13.5 31/10.2 124/40.8 85/28.0 44/14.5 74/24.3 41/13.5 56/18.4 110/36.2 72/23.7 67/22.0 26/8.6 29/9.5 164/53.9 50/16.4 128/42.1
43/14.2 61/20.1 68/22.4 78/25.7 108/35.5 82/27.0 73/24.0 97/31.9 86/28.3 103/33.9 74/25.0 85/28.0 92/30.3 78/25.7 79/26 37/12.1 83/27.3 48/15.8 101/33.2 66/21.7
297/83.2 226/74.3 211/69.4 201/66.2 155/51.0 191/62.8 107/35.2 122/40.1 174/57.2 127/41.8 187/61.6 163/53.6 102/33.6 154/50.7 158/51.9 241/79.2 192/63.1 92/30.3 153/50.4 110/36.2
Such risk factors that happen after natural catastrophes as loss of jobs and properties, low socioeconomical status, loss of a significant other and others are very important and they constitute the PTSD risk factors.23 It is emphasized that these risk factors play a key role in the increased psychopathology rates in the countries where earthquakes strike.21–27 It was reported in a study that was conducted in Greece 4 years after Parnithia earthquake that age, gender, educational status, marital status, personal or family history of psychiatric disorders, economical loss, being struck in a building during the earthquake, degree of the damage to the houses, loss of a friend or a neighbour, and extent of the fear experienced during the earthquake had effects on PTSD.2 In the present study, similar to the literature, a correlation was found between PTSD symptoms and economical loss in the family of the children participant, whereas no correlation was seen between being trapped under the wreckage and PTSD symptoms, which might have resulted from the fact that the number of the children trapped under the wreckage was small. In the current study, it was found that the PTSD symptom-criteria most reported by the children was that ‘this event was perceived as a trauma and caused fears and © 2014 Wiley Publishing Asia Pty Ltd
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Table 3 Distributions of mean PTSD scores of the children participants in terms of some characteristics Descriptive characteristic
PTSD X ± SD
Gender Girl 49.34 ± 16.99 Boy 47.71 ± 16.75 Age (mean) r = 0.138 Whether being trapped under wreckage I was trapped under 49.80 ± 9.39 wreckage I was not trapped under 48.43 ± 17.06 wreckage Period of residence in the region (years) Less than 1 40.77 ± 13.97 1–5 45.82 ± 20.03 ≥6 48.88 ± 16.72 Whether owning the house Their own house 48.56 ± 16.69 Rented 48.10 ± 17.67 Degree of damage to the house No damage 16.74 ± 3.16 Slight damage 15.81 ± 1.82 Moderate damage 18.26 ± 2.28 Severe damage 16.77 ± 1.52 Colossal damage 15.59 ± 3.89 Loss of a significant other Yes 52.00 ± 16.81 No 47.71 ± 16.80 Economical loss after earthquake No loss/mild loss 14.91 ± 1.47 Moderate 17.76 ± 1.65 Severe 15.91 ± 1.70
Test and P
CONCLUSION t = 0.840 P = 0.402 0.016 KW = 1371.500 P = 0.719
KW = 2.177 P = 0.337
t = 0.187 P = 0.852
KW = 3.859 P = 0.425
t = 1.699 P = 0.090 F = 11.120 P = 0.000
KW, Kruskal–Wallis; PTSD, posttraumatic stress disorder.
social isolation emotions’. In the study of Alyanak et al. that examined symptoms and severity of PTSD among children and adolescents after Marmara earthquake, it was pointed out that ‘avoidant symptom’ was the most commonly encountered criterion of PTSD symptom criteria.28 The study of Karakaya et al. on PTSD symptoms, depression and anxiety among adolescents 3.5 years after Marmara earthquake emphasized that the most frequently reported PTSD symptom of the students was ‘intrusive recollections and hyper-arousal symptoms’.22 Although symptoms of the children are different in these studies, PTSD symptoms might become permanent and a serious © 2014 Wiley Publishing Asia Pty Ltd
health problem if not diagnosed and intervened at an early period. Therefore, symptoms to be seen among the children should be detected at an early period and should be cared for before it is too late.
The psychiatric effects of trauma seen in children shortly after the Van earthquake have been investigated in our study. Studies on this field are very important in terms of revealing the range of psychiatric problems developed after earthquakes, understanding the factors effective in the development of psychiatric problems, and thus identifying children likely to develop psychiatric problems and allowing early intervention for these children. The multifaceted and multidimensional individual and social impact created by these traumas should be addressed and examined as much as possible by the scientific studies conducted on all sections of the society. This way, the required organizations could gain experiences on facing such a situation, understanding the reasons, easing the effects and being prepared. Doctors and nurses have great responsibilities in determining the children at risk in an early period. Considering the fact that doctors and nurses are in the team that take the first emergency action after disasters, the health sector personnel can protect children mentally by being trained and sensitive on identifying and preventing the development of mental disorder that can be seen in postdisaster children.
FUTURE DIRECTIONS The findings obtained in our study in terms of the prevalence of PTSD after an earthquake have generally been consistent with the literature. In this study, PTSD has been identified in the majority of children in the 7–12 age group, who had experienced the Van earthquake. It has been found that PTSD in children is significantly higher in this age group, who had losses of loved ones and economic losses. The earthquake in Van was neither the first nor will be the last large-scale earthquake encountered in Turkey. One of the primary objectives of this study is to help identify the early indicators to find out which of the children are at greater risk, after an experienced earthquake trauma, and to help to correct this before it becomes a health issue in Turkey, where we have to learn to cope with earthquakes. Within the scope of the Van earthquake, our results reveal that an appropriate and comprehensive psychiatric support should be provided to the
Posttraumatic stress symptoms seen in children
children resident in the region, and these children should be followed up after the given treatments. Monitoring the mental symptoms that might occur after this type of disasters and starting the prevention and intervention efforts early are of great importance for the mental health of the community.
LIMITATIONS The small number of cases is an important limitation of our study. The large-scale destruction of the earthquake, aftershocks that have continued for a long time and the severe climatic conditions are among the adverse environmental impacts that limit us to increase the number of cases. Another limitation of our study is the use of only the scan scales as the data source. The reason for this can be explained as the difficulty in using structured or semistructured interview alternatives, which are long and hard to be filled up, as the study has been conducted in tent city conditions in an acute phase, where people have had focused on their basic needs to be met immediately after a large-scale earthquake with severe consequences.
CONFLICT OF INTEREST The authors declare that they have no conflict of interest.
REFERENCES 1 Sabuncuog˘lu O, Ebrinç S, Çetin M. Depression, anxiety and behavior among adolescents in two affected areas after the Marmara Earthquake. Clinic Psychiatry 2003; 6: 189–197. 2 Livanou M, Kasvikis Y, Bas¸og˘lu M et al. Earthquake-related psychological distress and associated factors 4 years after the Parnitha earthquake in Greece. European Psychiatry: The Journal of the Association of European Psychiatrists 2005; 20: 137–144. 3 Karancı N, Kalaycıog˘lu S, Erkan BB, Özden T, Çalıs¸kan ˙I , Özaks¸ehir G (2011) Middle East Technical University 23 October-9 November 2011 Van Earthquakes analysis report, Ankara, 1–74. 4 Turkish Ministry of National Education, Psychological support in disasters and traumatic events. (310TDB011) 1–52, Ankara, 2011. 5 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th edn. Washington DC, USA: American Psychiatric Association, 1994; 2. 6 Hammond KW, Scurfield RM, Risse SC. Post-traumatic stress disorder. In: Dunner DL (ed.). Current Psychiatric Therapy. Philadelphia, PA, USA: WB. Sounders Company, 1993; 288–295.
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7 Tagay S, Herpertz S, Langkafel M, Senf W. Posttraumatic stress disorder in a psychosomatic outpatient clinic. Gender effects, psychosocial functioning, sense of coherence, and service utilization. Journal of Psychosomatic Research 2005; 58: 439–446. 8 Berument SK, Sayıl M, Uçanok Z. How can you help earthquake victim children? Parental Manuel Book. Turkish Psychology Bulletin 1999; 5: 78–88. 9 Wang R, Wang L, Li Z, Cao C, Shi Z, Zhang J. Latent structure of posttraumatic stress disorder symptoms in an adolescent sample one month after an earthquake. Journal of Adolescence 2013; 36: 717–725. 10 Ying LH, Wu XC, Lin CD, Chen C. Prevalence and predictors of posttraumatic stress disorder and depressive symptoms among child survivors 1 year following the Wenchuan earthquake in China. European Child & Adolescence Psychiatry 2013; 22: 567–575. 11 Özcan S. Group Guidance Program about psychological treatment of the disaster victim adolescents (Master Degree Thesis). Istanbul, Turkey: Marmara University Educational Sciences Institute, 2000. 12 Alparslan S, Koçkar AD, S¸enol S, Maral I. Psychiatric symptoms and anxiety levels in children and adolescents surviving the Marmara earthquake. Journal of Child and Youth Health 1999; 6: 135–142. 13 Bas¸og˘lu M, Kiliç C, Falciog˘lu E, Livanou M. Prevalence of posttraumatic stress disorder and comorbid depression in earthquake survivors in Turkey: An epidemiological study. Journal of Traumatic Stress 2004; 17: 133–141. 14 Altindag A, Özen S, Sir A. One-year follow-up study of posttraumatic stress disorder among earthquake survivors in Turkey. Comprehensive Psychiatry 2005; 46: 328–333. 15 Komsuog˘lu B. Awakening a Nightmare-for Memory of the Victims of 17th August. Kocaeli: Kocaeli University Publishing, 2000; 15–16. 16 Arısoy ES. Awakening a Nightmare-for Memory of the Victims of 17th August. Kocaeli: Kocaeli University Publishing, 2000; 17–18. 17 Aker AT. Approaches for Psycho-Social Traumas in Basic Health Services. Istanbul, Turkey: Mutludog˘an Ofset, 2000. 18 Pynoos RS, Geojian A, Tashjian M et al. Posttraumatic stress reactions in children after the 1988 Armenian earthquake. The British Journal of Psychiatry: The Journal of Mental Science 1993; 163: 239–247. 19 Erden G, Kılıç EZ, Uslu RI˙, Kerimog˘lu E. The validity and reliability study of Turkish version of Child Posttraumatic Stress Reaction Index. Journal of Child and Youth Health 1999; 6: 143–149. 20 Kadak MT, Nasırog˘lu S, Boysan M, Aydın A. Risk factors predicting posttraumatic stress reactions in adolescents after 2011 Van earthquake. Comprehensive Psychiatry 2013; 54: 982–990. pii: S0010-440X(13)00095-3. doi: 10.1016/ j.comppsych.2013.04.003.
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21 La Greca AM, Silverman WK, Wasserstein SB. Children’s predisaster functioning as a predictor of posttraumatic stress following Hurricane Andrew. Journal of Consulting and Clinical Psychology 1998; 66: 883–892. 22 Karakaya I, Ag˘aog˘lu B, Cos¸kun A, S¸is¸manlar S¸G, Öc ÖY. The symptoms of PTSD, depression and anxiety in adolescent students three and a half years after the Marmara earthquake. Turkish Psychiatry Journal 2004; 15: 257–263. 23 Dizer D. Evaluation of trauma perception, social support systems and hopelessness symptoms among the high school adolescents in Sakarya Province after 1999 Marmara Earthquake (Master Degree Thesis). Istanbul, Turkey: Maltepe University Social Sciences Institute, 2008. 24 Armenian HK, Morikawa M, Melkonian AK, Hovanesian A, Akishal K, Akishal HS. Risk factors for depression in survivors of the 1988 Earthquake in Armenia. Journal of Urban Health: Bulletin of the New York Academy of Medicine 2002; 79: 373–382.
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25 Sattler DN, Preston AJ, Kaiser CF, Olivera VE, Valdez J, Schlueter S. Hurricane Georges’, A cross-national study examining preparedness, resource loss and psychological distress in the U.S. Virgin Islands, Puerto Rico, Dominican Republic and United States. Trauma Stress 2002; 15: 339– 350. 26 Watanabe C, Okumura J, Chiu TY, Wakai S. Social support and depressive symptoms among displaced older adults following the 1999 Taiwan earthquake. Journal of Abnormal Psychology 2004; 17: 63–67. 27 Ergüney S, Polat S. 18 months after earthquake, contrast anxiety and situation of Tüpras¸ 50th year high school students who had experienced the 1999 Marmara earthquake. Health and Society 2004; 14: 48–52. 28 Alyanak B, Eks¸i A, Toparlak D, Peykerli G, Saydam R. Adolescent posttraumatic stress disorder 2–6 months after an earthquake. Journal of Child and Youth Health 2000; 7: 71–80.
International Journal of Nursing Practice 2014; ••: ••–••
RESEARCH PAPER
Posttraumatic stress symptoms seen in children within the 3-month period after the Van earthquake in Turkey Sibel Küçükog˘lu PhD Assistant Professor, Faculty of Health Science, Atatürk University, Erzurum, Turkey
Naci Yıldırım RN Nurse and Master of Science Student, Psychiatric Department, Van Research and Education Hospital, Van, Turkey
Onur Burak Dursun PhD Assistant Professor, Department of Child Psychology, Faculty of Medicine, Erzurum, Turkey
Accepted for publication August 2013 Küçükog˘lu S, Yıldırım N, Dursun OB. International Journal of Nursing Practice 2014; ••: ••–•• Posttraumatic stress symptoms seen in children within the 3-month period after the Van earthquake in Turkey The research was conducted to determine the posttraumatic stress symptoms seen in children within the 3 month period after the Van earthquake in Turkey. The research was conducted between December 2011 and January 2012 with the earthquake survivor children in the 7–12 age group living in the tent city built in the central area of Van. The research data were collected by the researcher using the Childhood Post-Traumatic Stress Reaction Index (CPTS-RI) and a questionnaire prepared by the researchers that contained questions on some information about the earthquake and on sociodemographic characteristics.It was found out that 8.6% (26) of the children had mild symptoms of posttraumatic stress disorder (PTSD), 19.7% (60) of the children had moderate symptoms of PTSD, 47.7% (145) of the children had severe symptoms of PTSD and 24.0% (73) of the children had very severe symptoms of PTSD. Furthermore, a significant difference (P < 0.001) was found between mean CPTS-RI scores and the economic losses experienced in the families of the children. In the study, PTSD was identified in the majority of children in the 7–12 age group who experienced the Van earthquake. Key words: child, earthquake, posttraumatic stress disorder.
INTRODUCTION Earthquakes are different from other natural disasters in the sense that they occur suddenly, they cause huge destruction and immense loss of life and property, and the
Correspondence: Sibel Küçükog˘lu, Faculty of Health Science, Atatürk University, Erzurum 25240, Turkey. Email: s_nadaroglu@ hotmail.com doi:10.1111/ijn.12305
aftershocks caused by the earthquakes continue to traumatize people.1 Besides, earthquakes bring about massive damages in the lives of people by causing injuries and by leading to a sudden loss of a significant other (family member, relative or friend) and their properties, and making people lose their homes.2 Once more, a massive and devastating earthquake occurred on 23 October 2011 in our country, which is popular for devastating earthquakes. According to the data of the Bog˘aziçi University © 2014 Wiley Publishing Asia Pty Ltd
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Kandilli Observatory and Earthquake Research Institute National Earthquake Monitoring Center, an earthquake of 7.2 magnitude struck mainly Ercis¸ County and the nearby locations such as Van Province and the surrounding cities at 13:41. A second earthquake of 5.6 magnitude struck Edremit County of Van Province at 21:23 on 9 November 2011, when economical, physical and psychological damages and losses to Van earthquake had not been compensated yet. Six hundred forty-four people were killed in both earthquakes.3 (The Van earthquake took place east of Turkey, with an average height 1725 m. For this reason, the region has severe continental climate. This climate is very cold and especially manifests itself with long winters. When the Van earthquake happened, the weather was very cold, and many people had been forced to live in tent cities established by the state for months.) Such factors as the severity of the earthquakes, larger size of the region struck by the earthquakes, the damages and losses caused, long-term aftershocks, housing problems, heavy climate conditions, multiplied the outcomes of these disasters as compared with outcomes of similar disasters. Traumatic events like traffic accidents, plane accidents, earthquakes or floods leave short-term or long-term psychological impacts among individuals or communities that are exposed to them. It is not true that everybody exposed to traumas will have disorders and not everybody is affected equally by traumas. Children, the elderly people, people with physical disabilities, those with poor economical status and those with a previous psychiatric disorder are affected by traumas more.4 Posttraumatic stress disorder (PTSD) includes psychiatric symptoms related to cognitive, emotional, behavioural and social disorders that develop after one undergoes or witnesses a trauma that threatens his/her life or his/her physical integrity.5 PTSD might occur in 3% of those who are exposed to natural disasters.6 According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), lifelong prevalence of PTSD—defined as an anxiety disorder that develops after a serious trauma or event—is around 8–9% in the American society. The studies conducted indicate that PTSD is the fourth most common psychiatric disorder.7 PTSD often occurs after a few hours or a few months following traumatic events. PTSD is considered if the symptoms last more than the normal period and it should be treated. If not treated, one’s occupational and private life is negatively affected. Early diagnosis and social support increase the likelihood of the success of the treatment.4 © 2014 Wiley Publishing Asia Pty Ltd
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Studies show that those who suffer seriously from natural disasters are children, young people and the elderly. Like adults, children are afraid of earthquake disaster, too. However, unlike adults, they have difficulty understanding that it is an uncontrollable natural event. The degree to which children are affected by earthquakes is determined by such factors as reaction of the family, degree of relationship of those killed in the earthquake, age/gender, past experiences, indirect effects of the earthquake, daily life, separation, domestic relations, economical conditions and social support.8–10 Catastrophes like earthquakes, floods and fires cause the children and the adolescents to experience emotional changes, and to undergo heavy and intensified anxiety that they themselves, their families and their friends will suffer a lot, and with the thought that the established order and balance will be ruined. Adults as well as children might be re-exposed to many traumatic event(s) during catastrophes. Children could witness heavy destructions, like seeing their houses or villages destroyed. They might also see many injured people and witness the death of their parents, sisters and brothers, and their relatives, and observe how numerous people are suddenly killed at the same time. Anybody who is exposed to these catastrophes might involuntarily recollect these event(s) over and over, cannot help but think about these traumatic event(s) and avoid talking about them and thus might be overstimulated, is likely to experience the disorder called PTSD.11 In the study of Sabuncuog˘lu et al., it was found that the prevalence of PTSD was 42% in the hospital admissions of the people suffering from the Marmara earthquake 6 months after the Marmara earthquake occurred.1 Another study on children was conducted 1 month after the Marmara earthquake, and of 1118 children subjects, 84 children were diagnosed with PTSD.12 Although earthquakes are the most common and the most devastating one among the natural catastrophes, psychological problems caused by earthquakes and their risk factors are dealt with less both in Turkey and in the world.13,14 Most of the studies related to the relevant topic were conducted after the 1999 Marmara earthquake in Turkey.14 Creating an awareness about the effects of the catastrophes is highly important to prevent and to solve the psychological problems caused by earthquakes.15,16 If posttraumatic disorders are not diagnosed and intervened on early, they might become a chronic and serious health problem. Traumatized people cannot benefit from joy of life, and pain directs their activities.17
Posttraumatic stress symptoms seen in children
Although there are many studies in the literature related with the psychiatric problems that developed after an earthquake, these studies were mostly on the adult age group and the number of studies on children is limited. In the studies performed with both adults and children, it is seen that most of the studies have only been conducted in sub-acute or chronic phase after the disaster, and the studies conducted in the acute phase are extremely limited. This study is aimed at determining the PTSD symptoms seen in school children in the acute phase, after a natural disaster that happened in Van Province.
METHOD Type of research This descriptive research was conducted between December 2011 and January 2012.
Population and sample The population of the research was consisted of children earthquake victims aged 7–12 who reside in Mimar Sinan Tent City located at the centre of Van region. It was known that Mimar Sinan Tent City was the most crowded tent city, built on the second day after the earthquake and held nearly 6000 earthquake victims. Children and adolescents who had both verbal/receptive language disorders at a level that prevents communication with interviewer, and previous mental retardation, autism, schizophrenia, physical disability or a chronic physical illness are not included the study, as posttraumatic stress symptoms might need to be questioned by a different approach in these cases. After the 60th day of the earthquake, at the time of the study, 140 of the 150 tents have been selected by random sampling method in the tent city, 310 children and their families who reside in these tents have been informed, and 304 of the children who have agreed to participate in the study and have their ratification signed by both the child and parents have been included in the study.
Data collection The data of the research were gathered by the researcher using a questionnaire designed by the researchers that contained questions on some information about the earthquake and on sociodemographic characteristics and the Childhood Post-Traumatic Stress Reaction Index (CPTS-RI). The questionnaire was administered using face-to-face interview technique during December and January when
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aftershocks continued. The questionnaire form included questions about age and gender of the children, period of residence in the region, whether or not they were trapped under the wreckage, whether or not they owned the house, degree of the damage to the house, whether or not they lost a significant other, and the degree of the economical losses. The CPTS-RI was designed by Pynoos et al. to measure the severity of the symptoms of PTSD. CPTS-RI is a semi-structured, 20-item Likert-type index to assess stress reactions of children and adolescents after different traumatic experiences.18 The following are comparisons of CPTS-RI scores with clinical diagnosis of PTSD: 0–11 = suspect, 12–24 = mild, 25–39 = moderate, 40–59 = severe, 60–80 = very severe. It was proved that scores ≥40 were clinically correlated with PTSD diagnosis. Turkish validity and reliability tests of the CPTS-RI were performed by Erden et al.19 Consistency test of the index was repeated using test–retest method, and reliability was found as 0.86 and Cronbach’s alpha was found as 0.75. Interrater reliability kappa coefficient was 0.87. Cronbach’s alpha of the CPTS-RI in the current study was found to be 0.89. The consistency between DSM-IV diagnosis criteria for PTSD and the CPTS-RI scores was found to be significant.
Statistical analysis For the statistical analysis of the research, Windows SPSS 20.0 package software (IBM SPSS AMOS; IBM Corporation, Armonk, NY, USA) was used. Statistical significance was defined by a probability level of P < 0.05. For the analysis of the data obtained from the research, numbers, percentages, means, Kruskal–Wallis test, and t-test and variance analysis for the independent groups were used.
RESULTS Table 1 included information about sociodemographic data and earthquake experience of the children participant. It was determined that 53.3% of the children were boys and mean age of the children was 10.55 ± 1.33. There were 3.3% of the children who were trapped under the wreckage, 67.4% of them resided in the region for more than 10 years, 80.9% had their own houses, houses of 39.8% of the children were severely damaged, 17.8% lost one significant other in the earthquake and only 33.6% did not have any economical losses in the family after the earthquake. © 2014 Wiley Publishing Asia Pty Ltd
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Table 1 Distributions of some sociodemographic and earthquakerelated characteristics of the children participants Descriptive characteristic
n
Gender Girl 142 Boy 162 Age (mean) 10.55 ± 1.33 Whether being trapped under wreckage I was trapped under wreckage 10 I was not trapped under wreckage 294 Period of residence in the region (years) Less than 1 9 1–5 17 ≥6 278 Whether owning the house Their own house 246 Rented 58 Degree of damage to the house No damage 28 Slight damage 75 Moderate damage 64 Severe damage 121 Colossal damage 16 Loss of a significant other Yes 54 No 250 Economical loss after earthquake No loss/mild loss 102 Moderate 115 Severe 87 Total 304
%
46.7 53.3
Moderate 19,7% Severe 47,7%
Figure 1. Status of posttraumatic stress disorder symptoms of the children earthquake victims.
3.3 96.7 3 5.6 91.4 80,9 19.1 9.2 24.7 21.1 39.8 5.3 17.8 82.2 33.6 37.8 28.6 100
When CPTS-RI scores were investigated, mean score of 304 children was found to be 48.47 ± 16.85. According to this index, 8.6% of the children (n = 26) had mild level of PTSD symptoms, 19.7% of the children (60) had moderate level of PTSD symptoms, 47.7% of the children (60) had severe level of PTSD symptoms and 24.0% of the children (72) had very severe level of PTSD symptoms (Fig. 1). Items of CPTS-RI were listed in Table 2, and it was found that the most reported symptom by the children was that earthquake was perceived as a psychological trauma (83%), 74.3% of the children reported that earthquake caused a fear and 79% told that earthquake caused social isolation emotions. © 2014 Wiley Publishing Asia Pty Ltd
Mild 8,6%
Very Severe 24%
Table 3 included distribution of the mean CPTS-RI scores according to some characteristics of the children participant. No statistically significant difference was found between mean CPTS-RI scores and gender of the children (P > 0.05). A weak but positive correlation existed between mean CPTS-RI scores of the children earthquake victim in terms of mean age (P < 0.05). Also, no statistically significant correlation was found between mean CPTS-RI scores of the children earthquake victim in terms of period of residence in the region, whether or not they were trapped under the wreckage, whether or not they owned the house, and the degree of damage to the house (P > 0.05). When the status whether or not the children lost a significant other and the degree of the economical losses was analysed, mean CPTS-RI score of the children who lost a significant other was higher than those who did not lose a significant other, but no statistically significant difference was found between (P = 0.09). Moreover, there was a significant difference between mean CPTS-RI scores of the children and their economical losses in the families (P < 0.001).
DISCUSSION Although there are various methodological differences in the studies about earthquake psychology, it is seen that psychological problems that occur after earthquakes are very common and might last for years. PTSD is widely seen in the studies that are community based, as well as in those conducted with high-risk groups.17 This study explored a weak but positive correlation in mean CPTS-RI scores according to the mean age of the children earthquake victim aged 7–12. Mean CPTS-RI score was 48.47 ± 16.85. It was noted that 47.7% (145) of the children had severe symptoms of PTSD and 24.0% (72) of the children had very severe symptoms of PTSD. A study
Posttraumatic stress symptoms seen in children
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Table 2 Criteria of Childhood Post-traumatic Stress Reaction Index (CPTS-RI) CPTS-RI item Events perceived as a trauma Fears Recurrent images Recurrent thoughts Recurrent distressing dreams of the event Feeling as if the traumatic event was recurring Anhedonia Detachment or estrangement from others Emotional avoidance Restricted range of affect Hyper-vigilance Sleeping disorder Quilt Difficulty recalling Difficulty concentrating Social withdrawal Distressing recollections Sense of foreshortened future Physiological reactions Outburst of anger
(A1) (A2) (B1) (B1) (B2) (B3) (C4) (C5) (C1) (C6) (D4) (D1) (D3) (D3) (C2) (B4) (B5) (D2)
made by Kadak et al. on adolescents who suffered from Van earthquake 6 months later found that less than half (40.69%) of the participants reported severe levels of PTSD symptoms, 53.04% were at greater risk for developing an anxiety-related disorder, 37.70% met the criteria for clinical depression and 36.73% revealed pathological levels of dissociative symptomotology.20 Alparslan et al. reported that of 1118 children subjects 1 month after the Marmara earthquake, 84 children were diagnosed with PTSD.12 It was observed 1.5 years after the Armenian earthquake that among the children who resided in the location nearest the epicentre, 17% had very severe symptoms of PTSD, 74.5% had severe symptoms of PTSD and 8.5% had moderate symptoms of PTSD.18 In the study of La Greca et al. on school-age children who suffered from the Andrew Hurricane in Florida, it was found that those who were more anxious, had attention deficit disorder more and had lower academic success 15 months before the Hurricane had symptoms of PTSD 3 months after the Hurricane compared with other children.21 The study of Karakaya et al. demonstrated that 22.2% of the adults might show PTSD even 3.5 years after the earthquake.22
Never (n/%)
Rarely/seldom (n/%)
Often/always (n/%)
8/2.6 17/5.6 25/8.2 25/8.2 41/13.5 31/10.2 124/40.8 85/28.0 44/14.5 74/24.3 41/13.5 56/18.4 110/36.2 72/23.7 67/22.0 26/8.6 29/9.5 164/53.9 50/16.4 128/42.1
43/14.2 61/20.1 68/22.4 78/25.7 108/35.5 82/27.0 73/24.0 97/31.9 86/28.3 103/33.9 74/25.0 85/28.0 92/30.3 78/25.7 79/26 37/12.1 83/27.3 48/15.8 101/33.2 66/21.7
297/83.2 226/74.3 211/69.4 201/66.2 155/51.0 191/62.8 107/35.2 122/40.1 174/57.2 127/41.8 187/61.6 163/53.6 102/33.6 154/50.7 158/51.9 241/79.2 192/63.1 92/30.3 153/50.4 110/36.2
Such risk factors that happen after natural catastrophes as loss of jobs and properties, low socioeconomical status, loss of a significant other and others are very important and they constitute the PTSD risk factors.23 It is emphasized that these risk factors play a key role in the increased psychopathology rates in the countries where earthquakes strike.21–27 It was reported in a study that was conducted in Greece 4 years after Parnithia earthquake that age, gender, educational status, marital status, personal or family history of psychiatric disorders, economical loss, being struck in a building during the earthquake, degree of the damage to the houses, loss of a friend or a neighbour, and extent of the fear experienced during the earthquake had effects on PTSD.2 In the present study, similar to the literature, a correlation was found between PTSD symptoms and economical loss in the family of the children participant, whereas no correlation was seen between being trapped under the wreckage and PTSD symptoms, which might have resulted from the fact that the number of the children trapped under the wreckage was small. In the current study, it was found that the PTSD symptom-criteria most reported by the children was that ‘this event was perceived as a trauma and caused fears and © 2014 Wiley Publishing Asia Pty Ltd
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Table 3 Distributions of mean PTSD scores of the children participants in terms of some characteristics Descriptive characteristic
PTSD X ± SD
Gender Girl 49.34 ± 16.99 Boy 47.71 ± 16.75 Age (mean) r = 0.138 Whether being trapped under wreckage I was trapped under 49.80 ± 9.39 wreckage I was not trapped under 48.43 ± 17.06 wreckage Period of residence in the region (years) Less than 1 40.77 ± 13.97 1–5 45.82 ± 20.03 ≥6 48.88 ± 16.72 Whether owning the house Their own house 48.56 ± 16.69 Rented 48.10 ± 17.67 Degree of damage to the house No damage 16.74 ± 3.16 Slight damage 15.81 ± 1.82 Moderate damage 18.26 ± 2.28 Severe damage 16.77 ± 1.52 Colossal damage 15.59 ± 3.89 Loss of a significant other Yes 52.00 ± 16.81 No 47.71 ± 16.80 Economical loss after earthquake No loss/mild loss 14.91 ± 1.47 Moderate 17.76 ± 1.65 Severe 15.91 ± 1.70
Test and P
CONCLUSION t = 0.840 P = 0.402 0.016 KW = 1371.500 P = 0.719
KW = 2.177 P = 0.337
t = 0.187 P = 0.852
KW = 3.859 P = 0.425
t = 1.699 P = 0.090 F = 11.120 P = 0.000
KW, Kruskal–Wallis; PTSD, posttraumatic stress disorder.
social isolation emotions’. In the study of Alyanak et al. that examined symptoms and severity of PTSD among children and adolescents after Marmara earthquake, it was pointed out that ‘avoidant symptom’ was the most commonly encountered criterion of PTSD symptom criteria.28 The study of Karakaya et al. on PTSD symptoms, depression and anxiety among adolescents 3.5 years after Marmara earthquake emphasized that the most frequently reported PTSD symptom of the students was ‘intrusive recollections and hyper-arousal symptoms’.22 Although symptoms of the children are different in these studies, PTSD symptoms might become permanent and a serious © 2014 Wiley Publishing Asia Pty Ltd
health problem if not diagnosed and intervened at an early period. Therefore, symptoms to be seen among the children should be detected at an early period and should be cared for before it is too late.
The psychiatric effects of trauma seen in children shortly after the Van earthquake have been investigated in our study. Studies on this field are very important in terms of revealing the range of psychiatric problems developed after earthquakes, understanding the factors effective in the development of psychiatric problems, and thus identifying children likely to develop psychiatric problems and allowing early intervention for these children. The multifaceted and multidimensional individual and social impact created by these traumas should be addressed and examined as much as possible by the scientific studies conducted on all sections of the society. This way, the required organizations could gain experiences on facing such a situation, understanding the reasons, easing the effects and being prepared. Doctors and nurses have great responsibilities in determining the children at risk in an early period. Considering the fact that doctors and nurses are in the team that take the first emergency action after disasters, the health sector personnel can protect children mentally by being trained and sensitive on identifying and preventing the development of mental disorder that can be seen in postdisaster children.
FUTURE DIRECTIONS The findings obtained in our study in terms of the prevalence of PTSD after an earthquake have generally been consistent with the literature. In this study, PTSD has been identified in the majority of children in the 7–12 age group, who had experienced the Van earthquake. It has been found that PTSD in children is significantly higher in this age group, who had losses of loved ones and economic losses. The earthquake in Van was neither the first nor will be the last large-scale earthquake encountered in Turkey. One of the primary objectives of this study is to help identify the early indicators to find out which of the children are at greater risk, after an experienced earthquake trauma, and to help to correct this before it becomes a health issue in Turkey, where we have to learn to cope with earthquakes. Within the scope of the Van earthquake, our results reveal that an appropriate and comprehensive psychiatric support should be provided to the
Posttraumatic stress symptoms seen in children
children resident in the region, and these children should be followed up after the given treatments. Monitoring the mental symptoms that might occur after this type of disasters and starting the prevention and intervention efforts early are of great importance for the mental health of the community.
LIMITATIONS The small number of cases is an important limitation of our study. The large-scale destruction of the earthquake, aftershocks that have continued for a long time and the severe climatic conditions are among the adverse environmental impacts that limit us to increase the number of cases. Another limitation of our study is the use of only the scan scales as the data source. The reason for this can be explained as the difficulty in using structured or semistructured interview alternatives, which are long and hard to be filled up, as the study has been conducted in tent city conditions in an acute phase, where people have had focused on their basic needs to be met immediately after a large-scale earthquake with severe consequences.
CONFLICT OF INTEREST The authors declare that they have no conflict of interest.
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7 Tagay S, Herpertz S, Langkafel M, Senf W. Posttraumatic stress disorder in a psychosomatic outpatient clinic. Gender effects, psychosocial functioning, sense of coherence, and service utilization. Journal of Psychosomatic Research 2005; 58: 439–446. 8 Berument SK, Sayıl M, Uçanok Z. How can you help earthquake victim children? Parental Manuel Book. Turkish Psychology Bulletin 1999; 5: 78–88. 9 Wang R, Wang L, Li Z, Cao C, Shi Z, Zhang J. Latent structure of posttraumatic stress disorder symptoms in an adolescent sample one month after an earthquake. Journal of Adolescence 2013; 36: 717–725. 10 Ying LH, Wu XC, Lin CD, Chen C. Prevalence and predictors of posttraumatic stress disorder and depressive symptoms among child survivors 1 year following the Wenchuan earthquake in China. European Child & Adolescence Psychiatry 2013; 22: 567–575. 11 Özcan S. Group Guidance Program about psychological treatment of the disaster victim adolescents (Master Degree Thesis). Istanbul, Turkey: Marmara University Educational Sciences Institute, 2000. 12 Alparslan S, Koçkar AD, S¸enol S, Maral I. Psychiatric symptoms and anxiety levels in children and adolescents surviving the Marmara earthquake. Journal of Child and Youth Health 1999; 6: 135–142. 13 Bas¸og˘lu M, Kiliç C, Falciog˘lu E, Livanou M. Prevalence of posttraumatic stress disorder and comorbid depression in earthquake survivors in Turkey: An epidemiological study. Journal of Traumatic Stress 2004; 17: 133–141. 14 Altindag A, Özen S, Sir A. One-year follow-up study of posttraumatic stress disorder among earthquake survivors in Turkey. Comprehensive Psychiatry 2005; 46: 328–333. 15 Komsuog˘lu B. Awakening a Nightmare-for Memory of the Victims of 17th August. Kocaeli: Kocaeli University Publishing, 2000; 15–16. 16 Arısoy ES. Awakening a Nightmare-for Memory of the Victims of 17th August. Kocaeli: Kocaeli University Publishing, 2000; 17–18. 17 Aker AT. Approaches for Psycho-Social Traumas in Basic Health Services. Istanbul, Turkey: Mutludog˘an Ofset, 2000. 18 Pynoos RS, Geojian A, Tashjian M et al. Posttraumatic stress reactions in children after the 1988 Armenian earthquake. The British Journal of Psychiatry: The Journal of Mental Science 1993; 163: 239–247. 19 Erden G, Kılıç EZ, Uslu RI˙, Kerimog˘lu E. The validity and reliability study of Turkish version of Child Posttraumatic Stress Reaction Index. Journal of Child and Youth Health 1999; 6: 143–149. 20 Kadak MT, Nasırog˘lu S, Boysan M, Aydın A. Risk factors predicting posttraumatic stress reactions in adolescents after 2011 Van earthquake. Comprehensive Psychiatry 2013; 54: 982–990. pii: S0010-440X(13)00095-3. doi: 10.1016/ j.comppsych.2013.04.003.
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21 La Greca AM, Silverman WK, Wasserstein SB. Children’s predisaster functioning as a predictor of posttraumatic stress following Hurricane Andrew. Journal of Consulting and Clinical Psychology 1998; 66: 883–892. 22 Karakaya I, Ag˘aog˘lu B, Cos¸kun A, S¸is¸manlar S¸G, Öc ÖY. The symptoms of PTSD, depression and anxiety in adolescent students three and a half years after the Marmara earthquake. Turkish Psychiatry Journal 2004; 15: 257–263. 23 Dizer D. Evaluation of trauma perception, social support systems and hopelessness symptoms among the high school adolescents in Sakarya Province after 1999 Marmara Earthquake (Master Degree Thesis). Istanbul, Turkey: Maltepe University Social Sciences Institute, 2008. 24 Armenian HK, Morikawa M, Melkonian AK, Hovanesian A, Akishal K, Akishal HS. Risk factors for depression in survivors of the 1988 Earthquake in Armenia. Journal of Urban Health: Bulletin of the New York Academy of Medicine 2002; 79: 373–382.
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25 Sattler DN, Preston AJ, Kaiser CF, Olivera VE, Valdez J, Schlueter S. Hurricane Georges’, A cross-national study examining preparedness, resource loss and psychological distress in the U.S. Virgin Islands, Puerto Rico, Dominican Republic and United States. Trauma Stress 2002; 15: 339– 350. 26 Watanabe C, Okumura J, Chiu TY, Wakai S. Social support and depressive symptoms among displaced older adults following the 1999 Taiwan earthquake. Journal of Abnormal Psychology 2004; 17: 63–67. 27 Ergüney S, Polat S. 18 months after earthquake, contrast anxiety and situation of Tüpras¸ 50th year high school students who had experienced the 1999 Marmara earthquake. Health and Society 2004; 14: 48–52. 28 Alyanak B, Eks¸i A, Toparlak D, Peykerli G, Saydam R. Adolescent posttraumatic stress disorder 2–6 months after an earthquake. Journal of Child and Youth Health 2000; 7: 71–80.
