International Journal of Psychiatry in Clinical Practice, 2007; 11(3): 190 199
ORIGINAL ARTICLE
Risk factors for the development of PTSD and depression among child and adolescent victims following a 7.4 magnitude earthquake
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
AYSEL EKS¸I1, KATHRYN L. BRAUN2, HAYRIYE ERTEM-VEHID3, GULCAN PEYKERLI3, REYHAN SAYDAM3, DERYA TOPARLAK4 & BEHIYE ALYANAK5 1
Institute of Child and Adolescent Health, Istanbul University, Istanbul, Turkey, 2University of Hawaii, Honolulu, HI, USA, Child Health Center, The Medical School, Istanbul University, Istanbul, Turkey, 4Pediatric Unit, The Medical School, Istanbul University, Istanbul, Turkey, and 5Child Psychiatry Department, The Medical School, Istanbul University, Istanbul, Turkey 3
Abstract Objective. PTSD and major depression occur frequently following traumatic exposure, both as separate disorders and concurrently. Although much of Turkey is under threat of severe earthquakes, risk factors for developing psychiatric disorders among Turkish children have not yet been studied. The aim of the study was to examine risk factors for PTSD and depression develpoment in children. Method. A total of 160 survivors (102 girls and 58 boys) severely impacted by Turkey’s 7.4-magnitude quake participated in a psychiatric interview 6 20 weeks after the disaster. The mean age was 14.43. Logistic regression was used to test effects of pre-disaster, disaster-related and post-disaster factors on diagnoses, yielding odds ratios (OR). Results. CAPS indicated that 96 (60%) had PTSD, and psychiatric interview found 49 (31%) with depression. Children diagnosed with PTSD were more likely to have witnessed death (OR /2.47) and experienced an extreme parental reaction (OR /3.45). Children with depression were more likely to be male (OR /4.48), have a higher trait anxiety score (OR /1.12 for every additional point), sustain injury (OR /4.29), and have lost a family member in the quake (OR /10.96). Focusing on the 96 children with PTSD, those with comorbid depression were more likely male, have a higher trait anxiety score, and have lost of family member. Conclusions. Mental health professionals should offer support to children witnessing death or losing a family member in a disaster. The ability of the family to remain calm and reassuring also may be a key factor in preventing PTSD.
Key Words: PTSD, depression, child, risk-factors, earthquake
Introduction Millions of people all over the world have been affected by man-made disasters such as terrorist attacks, or natural disasters, such as earthquakes, floods, hurricanes, tornados, and tsunamis during the last decade. Studies reveal that like adults, children can also experience stress reactions, which may lead to lasting Posttraumatic Stress Disorder (PTSD) [1 3]. PTSD is a prolonged, pathological anxiety that may occur subsequent to a severe trauma that constitutes a threat to life or physical integrity, elicits intense fear, horror, or helplessness. To meet criteria for PTSD, the child’s response must include a specific number of symptoms from each of the three broad categories: the feeling of reexperiencing the trauma, symptoms of avoidance, and hyperarousal; and the symptom clusters must be present for at least a month following the
traumatic event (Diagnostic & Statistical Manual DSM-IV) [4]. While not all people who have suffered a qualifying trauma go on to develop a disorder, investigators have documented pre-trauma, post-trauma, and trauma-related risk factors that may increase vulnerability to a PTSD. Pre-trauma factors include pre-existing anxiety, gender, age, personality traits, familial factors, parental PTSD, violence within the family, and experiencing abuse/maltreatment [5 8]. Trauma-related risk factors are events related directly to the trauma, which include severity of the event in terms of life-threat, one’s proximity to the threat, duration of experience, witnessing of mutilating injury or grotesque death, personal injury, and loss of significant family members [7 9,11]. Post-trauma variables and later adversities that may increase psychiatric morbidity include separation
Correspondence: Prof. Dr. Aysel Eks¸i, Ozgurluk Sokak, Kooperatif Evleri No. 1, Yenikoy, Istanbul, Turkey. Tel: /90 212 262 4873. Fax: /90 2212 262 1351. E-mail: [email protected]
(Received 30 January 2006; accepted 23 August 2006) ISSN 1365-1501 print/ISSN 1471-1788 online # 2007 Taylor & Francis DOI: 10.1080/13651500601017548
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Risk for PSD in child quake survivors 191 from families, displacement of families, unfavourable conditions, and lack of psychological services [57,10 12]. It is documented that depression is also a common sequel to disasters [7,13 16], and a substantial number of symptoms overlap among PTSD and other psychiatric diagnoses, such as panic disorder, social phobia, substance use disorders, and other anxiety disorders [1 3]. DSM-IV defines a Major Depressive episode or syndrome as one in which at least five of the following symptoms have been present during the same 2-week period: Persistent sad or irritable mood, significant change in appetite or body weight, diminished interest, loss of pleasure in almost all activities, sleep disturbances, psychomotor agitation or retardation, feelings of worthlessness or inappropriate guilt, difficulty concentrating, suicidal ideation, and recurrent thoughts of death or suicide [4]. Our interest in this subject began on 17 August 1999, when a 7.4-magnitude earthquake occurred in the Marmara region of Turkey at 03:00 h, followed by significant aftershocks. According to official estimates, the death toll was more than 20,000, and 30,000 people were injured and left homeless. Many children were trapped, injured, witnessed death and suffering, or had family members die. This unexpected, large-scale disaster and the aftershocks produced fear, helplessness and utmost horror in children as well as in adults. Considering the magnitude and damage of the earthquake, we anticipated that the severity of PTSD and depression would be much higher than reported in many studies. However, although the whole region is still under the threat of severe earthquakes, risk factors for development of psychiatric disorders among Turkish children have not yet been studied. This is the first study specific to Turkish children and adolescents in Turkish culture, exploring risk factors for the development of PTSD and depression following a devastating earthquake.
Methods Subjects This is a school-based study of 160 students which began 4 weeks after the quake in September 1999. Our research area, Adapazari, was suggested by the Dean of the Istanbul Medical School because of widespread destruction in this area. The local director of the Ministry of Education indicated the schools where the students were badly affected. The sample was drawn from schools in two townships of Adapazari, namely Hendek and Arifiye, both located in the epicentre of the earthquake. Officials estimated that about 1,100 students in the study age groups (9 18) had been expected to
enroll in schools in Hendek and Arifiye. There were considerably fewer students when we began our study. This is because most of them were living in tent camps and were not attending school regularly, or in the quake some students had died or many others had been sent to live with relatives in safer parts of the country. Others had been hospitalized. Thus, the subjects were not representative of the total student population. However, 659 students in our target age groups were attending schools in Hendek and Arifiye when we administered our questionnaire about the quake (described below) at our initial visit in September 1999. Responses showed that 153 students (mostly boys) had not been at the site when the quake occurred due to summer holiday. Another 77 students indicated that they and their families and homes had been relatively unaffected by the quake, although they were very much frightened like millions of other people in the Marmara region. Because we wanted to study children who were affected by the quake, these two groups were excluded from further analysis. The remaining 429 students all reported three or more negative quakerelated experiences (e.g., house collapsed, injured, family member injured, family member died, relocation) and were asked if they wished to participate in the study. They understood this to involve a one-onone interview with the psychiatrist, and 301 (70%) agreed. Written parental permission was received for 160 of these students. Thirty of these children were subsequently relocated to boarding schools in Istanbul *Camlica and Darussafaka *by families and school officials, and these children were interviewed in their respective boarding schools. (Note that study psychiatrists were not involved in relocation decisions.) Subjects included 102 girls (64%) and 58 boys (36%). The mean age was 14.43 years (range 9 18). All participants were Turkish Muslims, from schools in economically deprived regions. The study sample had a greater proportion of girls. This has been due to a greater willingness of girls to participate in the study (as found by Pynoos et al.) and the fact that many boys have been in summer camps during the quake [11]. The research team consisted of a psychiatrist and three psychologists, all native speakers of Turkish. They travelled from Istanbul to Adapazari, and frequently slept overnight in the Guest House of the Istanbul University in Sapanca. The University provided the transportation. Measures Self-report questionnaire. The research team constructed a 20-item questionnaire including demographic characteristics and a list of earthquake-related events. Data on age, gender, ethnic and religious background, occupation of parents,
192
A. Eks¸i et al.
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
and whereabouts during the quake were collected. Students were asked to review a list of nine events (identified in research studies with child survivors of earthquakes in Turkey, Armenia, Greece, Taiwan, and Japan). These yesno questions asked if the subject: (1) experienced any kind of serious danger (e.g., being trapped in rubble); (2) witnessed death and extreme suffering; (3) was injured; (4) had a family member injured; (5) had a family member die; (6) had another significant person die; (7) had their house destroyed; (8) moved to a tent camp or relative’s home; or (9) was placed in a boarding school.
Anxiety tests. The State-Trait Anxiety Inventory (STAI) (17) was administered in the classrooms. The STAI consists of 20 items to assess state anxiety (unpleasant emotional arousal in face of threatening demands or dangers) and 20 items to assess trait anxiety (which reflects the existence of stable individual differences in the tendency to respond with state anxiety in the anticipation of threatening situations). All tests were standardised [18] and have been widely used on Turkish subjects. Validity and reliability studies relating to the Turkish language and culture suggest their validity in Turkish populations [19]. The findings are briefly presented in Table I.
Individual interview. Psychiatric interview of each study participant was conducted by a trained psychiatrist in a 1-hour interview, held in a private room. These were scheduled to accommodate student and researcher availability and were conducted between 6 and 20 weeks post-quake. The interviews focused on recent quake experiences, pre-quake and post-quake circumstances, psychological state of students, complaints, and psychiatric symptomatology. The psychiatrist questioned each student in relation to previous life and pre-existing family problems, such as if anyone was physically or psychologically ill or recently died or if subject had previously experienced maltreatment or abuse or any kind of serious problem prior to the quake. When the subject answered ‘‘yes’’ to any of these questions, he/she was reported as having a pre-quake problem. Students were encouraged to talk freely about whatever had happened during and after the quake, concerning themselves, families, other significant people, homes, and attitudes and behaviour of parents/other adults. Their initial responses reported on the questionnaire were helpful in indicating which events had to be discussed in more detail. Depending on how the interview progressed, the clinician moved on to direct questions, taking care not to lead the discussion to specific answers.
Students also were questioned in relation to postdisaster circumstances (such as family reaction to the quake and boarding school placement), their recent stressful experiences, and complaints and psychiatric symptomatology. The goal of the assessment was to determine how children had coped with their experiences, what they had thought about what had happened to them, and how they viewed their current experiences. When talking about parents’ response to the quake, if students described symptoms of panic, wailing, praying, fainting, and other behaviour, the clinician interpreted this as an extreme parental reaction. Past research indicates that survivors may review and judge their own conduct, thus feelings of guilt and inferiority are practically universal. In this study, some students described strong feeling that the quake was punishment for some kind of sin, such as not practising religious orders, masturbating, or not being able to save loved ones. These were interpreted as quake-related feelings of guilt or blame. As Rutter [20] remarked, free descriptions in answer to open-ended questions provide accounts of behaviour that are most accurate and least prone to distortion; but these tend to be very lacking in detail, so it was necessary to follow with more specific questions. Considering that children are open to influence of suggestion, tend to overestimate or deny symptoms, or may become disturbed when speaking about the traumatic experience, it was important for the clinician to be sensitive to the cues provided by subjects. Assessing children who were bereaved by the traumatic disaster needed very careful handling, and every step was taken to gather accurate data in a professional manner.
The Clinician-Administered Post-Traumatic Stress Disorder Scale (CAPS). The psychiatrist administered the adult version of CAPS [21] during or at the end of the interview. (The Child CAPS was not standardised at the time.) CAPS is one of the most frequently used measures of PTSD, and it has been translated into Turkish and standardized. Validity and reliability studies in relation to the Turkish language and culture have been performed [22]. CAPS consists of 17 items in three clusters: ‘‘B’’ measures the extent to which the traumatic event is re-experienced; ‘‘C’’ measures the extent to which the subject avoids stimuli associated with the trauma; and ‘‘D’’ measures the extent of hyperarousal. The severity and frequency of each symptom are recorded separately. Severity is rated from 0 / asymptomatic to 4 /extreme, and frequency is rated from 0/never to 4 /every day. A symptom is considered present if its severity is at least 1 and its frequency is at least 2. For a diagnosis of PTSD, an
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Risk for PSD in child quake survivors 193 individual must have at least one symptom in cluster B (re-experiencing), three from cluster C (avoidance), and two from cluster D (hyper-arousal). To meet DSM-IV criteria for PTSD, symptoms in each of the three domains must not only be present but must also be severe enough to cause substantial impairment in social, academic, or interpersonal domains.
females served as the reference category for gender, and ‘‘absence of condition’’ served as the reference category for the other dichotomous variables. In the subset of 96 children with PTSD, 45 (47%) also had depression. For this reduced sample, we used correlation to identify significant correlates of concurrent depression and entered those into a onestage binary logistic regression model.
Analysis
Results
SPSS (Statistical Package for Social Sciences) software was used to manage and analyze data. Twosided, independent-sample t -tests and chi-square tests were used to compare differences in continuous and categorical variables, respectively. Correlation was used to test age differences in characteristics of the sample, as well as to identify variables within categories that were highly inter-correlated. Binary logistic regression was used to examine independent predictors of PTSD and depression in the full sample. In accordance with our conceptual framework, variables that may predict the development of PTSD and depression were organized into three categories: (1) pre-quake factors; (2) event factors; and (3) postquake response factors. Within each category, we checked for inter-correlation of variables, which guided the dropping of some variables from subsequent multivariate analyses. We found that two variables ‘‘child in serious danger’’ and ‘‘lived in tent camp’’ inter-correlated with many of the other variables (r /0.30), and they were omitted from further analysis. Because diagnosis could be related to timing of the psychiatric interview (conducted between 1 and 5 months post-quake), we also included a variable termed ‘‘weeks post quake’’ as a predictor. We used logistic regression to test 14 variables as predictors of PTSD and depression. Variables were entered in four blocks: (1) pre-quake factors, including four variables gender, age, trait anxiety score, and pre-existing family problems (1 /yes, 0/no); (2) event factors (including six dichotomous variables) witnessed death, personally injured, family member injured, lost family member, lost other significant person, and house destroyed; (3) response (post-quake) factors (including three dichotomous variables) an extreme reaction of the adult family members (including wailing, praying, fainting, or panic), quake-related feelings of guilt or blame, and relocation of child to a boarding school; and (4) weeks since quake . This procedure yields odd ratios with 95% confidence intervals for each variable. Factor blocks were entered sequentially, and at each step differences in the 2 log likelihood values were checked against chi-square tables to see if the addition of the new block of variables improved model fit. When used as categorical predictors,
As shown in Table I, the children were severely affected by the earthquake. Specifically, 78% of children reported being in serious danger during the quake, 50% witnessed death and extreme suffering of other human beings, 14% reported personal injury, 35% reported injury of a family member, 24% experienced death of a family member, 43% experienced the death of a significant other, and 84% had their house destroyed. As a result, 63% of families lived in a tent camp, and 18% of children were sent to a boarding school. Clinical diagnosis showed that 96 students (60%) met the full criteria of PTSD on DSM-IV, and 49 students (31%) had major depression. The mean total CAPS score was 42.13 for the sample. A few differences were seen by gender or age (Table I). For example, a significantly larger proportion of boys was injured than girls, and girls were more likely to have lived with the family in a tent camp. A larger proportion of girls reported preexisting family problems. Younger children were more likely than older children to have been injured, have a family member die, or be placed in boarding school. Mean weeks between the quake and the psychiatric interview was significantly greater for girls and older children. Boys had higher mean CAP total scores, and greater proportions of boys had PTSD and depression diagnoses compared to girls. A depression diagnosis was negatively correlated with age. Table II displays comparisons between children with and without PTSD and with and without depression. Variables associated with PTSD included male gender, the witnessing of death and suffering, losing a family member, moving to a tent camp, having a parent with an extreme reaction to the quake, feeling quake-related blame or guilt, and fewer weeks from the quake. Variables associated with depression include male gender, younger age, higher Trait and State anxiety scores, being injured in the quake, losing a family member, being relocated to tent camp or boarding school, and feeling quake-related blame or quilt. Findings from the binary logistic regression modelling for PTSD are shown in Table III. Considering just the pre-quake factors (Model 1), the findings suggest that boys were more likely than girls to develop PTSD. When event factors were considered
194
A. Eks¸i et al.
Table I. Characteristics of the total sample and by gender. Gender differences
Variable
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Pre-quake factors Mean age Male gender Trait anxiety score State anxiety score Preexisting family problemsa
Total sample (n/160)
Boys (n /58)
Girls (n/102)
14.43 (SD/2.12) 58 (36.3) 46.44 (SD/8.72) 45.91 (SD/9.46) 31 (19.4)
14.19 46.23 46.04 4 (6.9)
14.57 46.56 45.83 27 (26.5)
Age differences Significance probabilityb
1.09, 158, 0.23, 158, 0.14, 158, 9.07, 158,
0.28 0.82 0.89 0.003
Significance probabilityc
0.42, 0.11, 0.08, 0.12,
0.55 0.15 0.34 0.14
Event factors Child in serious dangera Child witnessed deatha Child injureda Family member injureda Family member dieda Other significant person dieda House destroyeda
125 80 23 36 39 68 134
(78.1) (50.0) (14.4) (35.0) (24.4) (42.5) (83.8)
2 34 13 22 16 27 47
(72.4) (58.6) (22.4) (37.9) (27.6) (46.6) (81.0)
83 46 10 34 23 41 87
(81.4) (45.1) (9.8) (33.3) (22.5) (40.2) (85.3)
1.73, 1, 0.19 2.71, 1, 0.10 4.78, 1, 0.03 0.34, 1, 0.56 0.51, 1, 0.48 0.61, 1, 0.43 0.49, 1, 0.48
0.01, 0.85 0.01, 0.99 0.14, 0.05 0.11, 0.10 0.31, 0.0001 0.07, 0.30 0.12, 0.08
Response factors Family lived in tent campa Placed in boarding schoola Family had extreme reactiona Child felt blame/guilta
101 30 50 21
(63.1) (18.8) (31.3) (13.1)
31 15 17 9
(53.4) (25.9) (29.3) (15.5)
70 15 33 12
(68.6) (14.7) (32.4) (11.8)
3.66, 1, 0.06 3.02, 1, 0.08 1.59, 1, 0.69 0.46, 1, 0.50
0.13, 0.29, 0.02, 0.01,
Weeks since quake
16.31 (SD/5.52)
14.41
17.39
CAPS B-cluster (range 2 37) C-cluster (range 0 48) D-cluster (range 0 32) Total score (range 2 111) PTSD Depressiona
15.86 (SD/8.11) 13.70 (SD/10.24) 12.31 (SD/8.84) 42.13 (SD/23.60) 96 (60.0) 49 (30.6)
17.96 15.60 12.73 46.99 41 (70.1) 25 (43.1)
14.67 12.62 12.07 39.35 55 (53.9) 24 (23.5)
3.38, 158, 0.001 2.51, 158, 0.01 1.78, 158, 0.08 0.45, 158, 0.65 1.99, 158, 0.05 4.33, 1, 0.04 6.67, 1, 0.01
0.07 0.0001 0.77 0.99
0.28, 0.001 0.09, 0.07, 0.12, 0.12, 0.09, 0.17,
0.28 0.37 0.15 0.13 0.21 0.02
a
Dichotomous variables were coded 1/condition present and 0/condition absent. Significance tests included unpaired t -tests for continuous variables and chi-squared tests for dichotomous variables; Reported are T-score or chi-square statistic, degrees of freedom, and p value. c Significance was tested using Pearson’s r between two continuous variables and Kendal’s tb between interval and dichotomous variables. These are reported, followed by the p values. b
(Model 2), the model fit improved; the witnessing of death was the only significant variable. Adding response factors (Model 3) again improved the fit, and extreme parental reaction was significant. The variable ‘‘time since quake’’ was not significant, nor did adding it improve the model. Thus, Model 3 provided the best fit, suggesting that children who developed PTSD were more likely to have witnessed death (OR /2.47) and have a parent display an extreme reaction (such as wailing, fainting, or panicking) to the quake (OR /3.45). Examining predictors of depression (Table IV), among pre-quake factors (Model 1), male gender, younger age, and higher Trait anxiety were significant. Entering the event factors (Model 2) improved model fit. Age was no longer a significant predictor, but male gender, higher trait anxiety score, being injured, and losing a family member all were significant. Adding the response factors (Model 3) and ‘‘weeks post quake’’ (Model 4) did not improve the model fit. Thus, Model 2’s fit was best, suggesting that children developing depression were more likely to be boys than girls (OR /4.48), to have a higher trait anxiety score (OR /1.12 for each
additional point), to have been injured (OR / 4.29), and to have lost a family member in the quake (OR /10.96). Within the subset of 96 children with PTSD (not shown in table), correlation analysis suggested that the 45 with concurrent depression were more likely to be male, have a high trait anxiety score, to have lost a family member, and to have been sent to boarding school. In one-model binary regression, three variables retained significance, including male gender (OR /2.88), to have a higher trait anxiety score (OR /1.08 for each additional point), and to have lost a family member in the quake (OR /6.85). Discussion Certainly the child’s subjective understanding of the traumatic event can be more important than the event itself. However, since Turkey is continuously under the threat of severe earthquakes, and risk factors for development of psychiatric disorders among Turkish children have not yet been studied, the aim of this study was to obtain information on
Risk for PSD in child quake survivors 195 Table II. Characteristics of the sample by PTSD and depression status. PTSDa
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Variable Pre-quake factors Male gender Mean age Trait anxiety score State anxiety score Preexisting problemsa Event factors Child in serious dangera Child witnessed death/sufferinga Child injureda Family member injureda Family member dieda Other significant person dieda House destroyeda Response factors Moved to tent or relative’s homea Placed in boarding schoola Extreme parental reactiona Child felt blame/guilta Weeks post-quake
Depression (n /49)
No depress. (n/111)
Significance Probability b
4.33, 1, 0.04 1.49, 158, 0.14 1.70, 158, 0.09 1.72, 158, 0.09 0.33, 1, 0.57
25 (51.0) 13.57 49.41 49.57 12 (24.5)
33 (29.7) 14.81 45.13 44.29 19 (17.1)
6.67, 1, 0.01 3.54, 158, 0.001 2.92, 158, 0.04 3.36, 158, 0.001 1.18, 1, 0.28
(79.7) (34.4) (10.9) (31.3) (15.6) (35.9) (85.9)
0.15, 1, 0.70 10.42, 1, 0.001 1.02, 1, 0.31 0.66, 1, 0.42 4.43, 1, 0.04 1.88, 1, 0.17 0.38, 1, 0.54
34 30 13 19 26 23 40
(69.4) (61.2) (26.5) (38.8) (53.1) (46.9) (81.6)
91 50 10 37 13 45 94
(82.0) (45.0) ( 9.0) (33.3) (11.7) (40.5) (84.7)
3.16, 1, 0.08 3.56, 1, 0.06 8.48, 1, 0.004 0.44, 1, 0.51 31.54, 1, 0.0001 0.57, 1, 0.45 0.23, 1, 0.63
(75.0) (15.6) (20.3) (20.3)
6.46, 1, 0.01 0.68, 1, 0.41 5.94, 1, 0.02 6.66, 1, 0.01
20 18 14 11
(40.8) (36.7) (28.6) (22.4)
81 12 36 10
(73.0) (10.8) (32.4) (9.0)
15.10, 1, 0.0001 14.99, 1, 0.0001 0.24, 1, 0.63 5.39, 1, 0.02
2.99, 158, 0.003
15.43
PTSD (n /96)
No PTSD (n /64)
41 (42.7) 14.31 47.39 46.95 20 (20.8)
17 (26.6) 14.73 45.02 44.35 11 (17.2)
74 58 16 36 29 45 79
(77.1) (60.4) (16.7) (37.5) (30.2) (46.9) (82.3)
51 22 7 20 10 23 55
53 20 37 18
(55.2) (20.8) (38.5) (21.7)
48 10 13 3
15.27
Depressiona
17.88
Significance Probability b
16.70
1.35, 158, 0.18
a
Dichotomous variables were coded 1 /condition present and 0/condition absent. Significance tests included unpaired t -tests for continuous variables and chi-squared tests for dichotomous variables; reported are T score or chi-square statistic, degrees of freedom, and p value. b
the occurrence of particular events and to examine risk factors for developing PTSD and depression. In the child psychiatric literature, rates of PTSD following natural disasters seem to be between 28 and 95%. Our finding of PTSD in 60% of children significantly affected by Turkey’s 7.4-magnitude earthquake in 1999 was lower than that found in several other studies of earthquakes of similar magnitude [5,9 12]. For example, after a quake in Armenia, when Grigorian assessed 179 subjects, 72% received a diagnosis of PTSD [9]. Goenjian evaluated 65 Armenian children and found that 85% met criteria for PTSD [10]. One and a half years after the Armenian disaster, 111 children were assessed by DSM-III-R criteria for PTSD, and 70.3% were given this diagnosis [11]. In Athens, a month after Greece’s quake, 115 children and their parents were investigated by several questionnaires, and it was found that 78% of the subjects had mild to severe PTSD symptoms [23]. Only a few studies found lower rate of PTSD than ours. For example, another severe quake occurred, just a month after Turkey’s quake, in Taiwan. Hsu et al. [7] investigated 323 students 6 weeks postquake and found only 21.7% with PTSD. Roussos et al. [14] studied 1,937 Greek students residing 10 km from the epicentre of the Athens quake and found a PTSD rate of 4.5%. Two studies among the Turkish adult survivors estimated PTSD rates of 42% within a month of the quake, 23% at 13 months, and 39% at 20 months post-quake [24,25].
Naturally differences in rates of PTSD depend on various factors, such as when the study is performed and which criteria of DSM (III, III-R or IV) and assessment methods are used. For example, Wang et al. examined the effects of diagnostic criteria on the frequency in two groups after an earthquake in North China [26]. The rate of PTSD was 24.2% by using DSM-IV criteria and 41.4% by using DSM-III-R criteria. The authors concluded that introduction in DSM-IV of a criterion requiring clinically significant distress or impairment in functioning for a diagnosis of PTSD was a major contributor to the lower rate of DSM-IV PTSD. In our study, we rigorously followed the requirements for a diagnosis of PTSD that symptoms must be severe enough to cause substantial distress-impairment. Thus, caution should be used in comparing rates of post-disaster PTSD, taking care to note which criteria were used. Discrepancies are also attributable to magnitude and place of disaster and number of casualties. Looking at risk factors for developing PTSD, age and gender have been considered in many studies. Much of the psychiatric literature suggests that being female is a risk factor for developing PTSD, although a few investigators have found no significant association between gender and PTSD reactions [7,8,11]. In our study, gender was not a predictor of PTSD when other variables were controlled for. Some studies have found that age of a child significantly affects development of PTSD
196
A. Eks¸i et al.
Table III. Predictors of PTSD (n/160). Model 1 Pre-quake factors OR (95% CI)
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Pre-quake factors Male gendera Age Trait anxiety score Preexisting family problemsa
2.21 0.87 1.03 1.50
Model 2 Pre-quake/event factors OR (95% CI)
(1.07 4.50)b (0.74 1.03) (0.99 1.08) (0.63 3.58)
Event factors Child witnessed death/sufferinga Child injureda Family member injureda Family member dieda Other significant person dieda House destroyeda
1.95 0.90 1.03 1.60
(0.92 4.15) ( 0.74 1.09) (0.99 1.08) (0.64 4.00)
2.80 1.28 1.12 1.47 1.36 1.34
(1.34 5.84)c (0.44 3.73) (0.50 2.50) (0.56 3.87) (0.67 2.77) (0.45 3.95)
Response factors Extreme parental reactiona Child felt blame or guilta Child relocated to boarding schoola
Model 3 Pre-quake/event/ response factors OR (95% CI)
1.95 0.88 1.04 1.38
(0.89 4.27) (0.71 1.08) (0.99 1.08) (0.53 3.59)
2.53 1.60 1.01 1.38 1.51 1.47
(1.17 5.48)c (0.52 4.92) (0.43 2.39) (0.47 4.05) (0.72 3.19) (0.46 4.77)
3.36 (1.45 7.76)c 3.53 (0.93 13.45) 0.90 (0.30 2.69)
a
1.66 0.90 1.04 1.45
(0.74 3.76) (0.73 1.11) (0.99 1.09) (0.56 3.80)
2.47 1.57 1.04 1.21 1.55 1.22
(1.14 5.37)b (0.50 4.89) (0.44 2.45) (0.40 3.67) (0.73 3.30) (0.36 4.07)
3.45 (1.48 8.06)c 2.83 (0.72 11.12) 0.99 (0.33 3.05) 0.94 (0.87 1.02)
Weeks post-quake 2 log likelihood Difference between successive models Degrees of freedom
Model 4 All factors/weeks post quake OR (95% CI)
204.55
192.73 11.82b 6
180.26 12.47c 3
177.95 2.31 1
Dichotomous variables with 0 (condition absent) as reference group. p B/0.05; cp B/0.01.
b
symptoms; however, these findings have not always been consistent [6]. Instead, the witnessing of death and suffering was found to be a significant risk factor for the development of PTSD. Indeed, when the quake suddenly occurred at 03:00 h, adolescents (mostly boys) participated in rescue efforts; thus they witnessed death and suffering at home or next-door. Many other subjects were exposed to very dramatic scenes in the streets. Exposure to traumatic images was also regarded as a risk by some other investigators [1,2,6 8,12,15,16,27]. About a third of the children reported that parents and other adult figures exhibited extreme reactions during and following the quake, and this was found to be a significant risk factors for the development of PTSD. This included parents who became selfabsorbed with crying, wailing, or praying loudly, and these reactions likely increased children’s feelings of insecurity, fright, helplessness, and anxiety. Certainly children and their parents respond to each other’s stress, and parents serve as role models for coping [1 3,5,7]. Events that initially are not perceived as threatening and/or frightening may become so after observing the panic reactions of parents or teachers. This was seen in another study with Turkish earthquake child survivors, which found that negative effects on children were more pronounced when their fathers became irritable and detached [28]. Thus, the ability of the family to remain calm and reassuring may be a key factor in preventing PTSD.
It is of interest that in this study group that included all subjects with adverse experiences, not all developed PTSD. It is likely that there were several protective factors that reduced risk for PTSD. One of them might have been the presence of supportive, protective parents/parent substitutes as, in the psychiatric interview, many children stated that they received psychological support, warmth, and encouragement from families or family-substitute relatives afterwards. In this study, depression was found in 31% of the subjects. Given the cross-sectional design of the study, we were unable to discern whether major depression predisposed children to developing PTSD or whether PTSD lowered resistance to depressive illness. However, the development of major depression was found among survivors of other earthquakes [1,9,12,13,15,16,24,25,29]. For example, in a study of the Armenia quake, it was found that 22% of victims had a major depressive disorder 3 6 months after the quake [17]. In Greece, one study estimated rates of clinical depression at 14% [14] and another study estimated rates of 32% [23]. Among adult survivors of Turkey’s 1999 earthquake, 18% were found to have major depression [25]. Krug et al indicated that after severe earthquakes, floods, and hurricanes, suicide rates increase [29]. In our study, risk factors of depression included male gender, higher trait anxiety score, death of a family member, and personal injury. Of these four variables, the first three also were predictors of
Risk for PSD in child quake survivors 197 Table IV. Predictors of depression (n/160). Model 1 Pre-quake Factors OR (95% CI)
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Pre-quake factors Male gendera Age Trait anxiety Preexisting family problemsa
3.16 0.71 1.08 2.37
(1.40 7.13)c (0.59 0.86)c (1.03 1.13)c (0.91 6.21
Event factors Child witnessed death/sufferinga Child injureda Family member injureda Family member killeda Other significant person killeda House destroyeda
Model 2 Pre-quake/event factors OR (95% CI)
3.62 (1.40 9.37)c 0.86 (0.68 1.09) 1.11(1.05 1.18)c 2.35 (0.81 6.82) 1.58 3.80 1.11 9.87 0.78 1.36
(0.63 4.00) (1.16 12.89)b (0.43 2.88) (3.24 30.01)c (0.32 1.90) (0.42 4.41)
Response factors Extreme parental reactiona Child felt blame or guilta Child relocated to boarding schoola
Model 3 Pre-quake/event/ response factors OR (95% CI)
3.41 0.87 1.11 2.19
(1.31 8.86)b (0.68 1.12) (1.05 1.18)c (0.74 6.48)
4.48 0.82 1.12 2.27
(1.61 12.51)c (0.64 1.06) (1.05 1.18)c (0.75 6.84)
1.53 3.73 1.01 8.58 0.75 1.48
(0.60 3.91) (1.08 12.89)b (0.42 2.86) (2.69 27.39)b (0.30 1.86) (0.45 4.87)
1.67 4.29 1.14 10.96 0.70 1.93
(0.65 4.32) (1.19 14.87)b (0.43 3.02) (3.27 36.74)b (0.28 1.78) (0.56 6.67)
1.00 (0.38 2.62) 1.98 (0.61 6.47) 1.40 (0.40 4.85)
1.01 (0.39 2.64) 2.87 (0.79 10.43) 1.19 (0.34 4.18) 1.10 (0.99 1.21)
Weeks post-quake 2 log likelihood 164.79 Difference between successive models: Degrees of Freedom
Model 4 All factors/weeks post quake OR (95% CI)
136.59 28.20c 6
135.05 1.54 3
131.46 3.59 1
a
Dichotomous variables with 0 (condition absent) as reference group.
comorbid depression in the subsample of 96 children with PTSD. Because our study sample had a greater proportion of girls, we are cautious about pointing to gender as a factor in depression development. New findings from a study of National Institutes of Health showed that girls and boys have similar chances of developing symptoms of depression [30]. It is not surprising that higher trait anxiety score was a risk factor for depression, as many other studies have found that PTSD, anxiety and depressive reactions were highly inter-correlated [1,2,8,10,15,16]. For example, it was suggested that children with generalized anxiety disorder appear to be at significant risk for comorbid major depression [10]. Unlike Asarnow [5], who stated that level of trait anxiety appeared to be the single strongest risk for the development of severe PTSD, we did not find a significant association between PTSD and trait anxiety. Nor was trait anxiety score the most powerful predictor of depression. Rather, we found the major risk factor for depression to be death of a family member. In fact, a considerable number of research studies have found clinical symptoms of a major depressive episode in children after the death of a parent, and bereavement in childhood has been considered a potential risk factor for subsequent psychopathology [15,31 35]. For example, Weller et al. [31] found that 37% of bereaved children met criteria for depression 1 month after parental death. In another study it was indicated that severity of posttraumatic stress and depressive reactions were highly correlated, and
that extent of loss of family members was independently correlated with PTSD and depression [15]. Although only 14% of children in our study sustained significant injury, this appeared to be a predictor of depression. These injuries included fractured and crushed limbs, some of which became gangrenous and required amputation. A few students had Crush Syndrome and needed dialysis. Other investigators also have found that being physically injured was a major risk factor for PTSD and depression [7,24,35,36]. Stoddard reviewed 10 years of research on physical injuries and concluded that despite the high priority that injuries receive in paediatric research, psychiatric aspects are neglected; and there is a need for assessment and for planning of treatment based on severity of injury, comorbid psychopathology, bodily location and prognosis [36]. To control for timing of the psychiatric interview (conducted between 1 and 5 months post-quake), we tested the variable ‘‘weeks post-quake’’ as a predictor of diagnosis. Although, on average, children diagnosed with PTSD were interviewed closer in time to the quake than children without PTSD, this variable was not significant when entered into the logistic regression models. However, it is important to note that children diagnosed with PTSD and/or depression in this study were offered treatment through the Child Health Institude in Istanbul. Follow-up assessment 18 months later showed that 25 children who obtained treatment differed significantly from those who did not receive treatment on several variables: they had experienced more
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
198
A. Eks¸i et al.
traumatic quake-related events (4.9 vs. 3.9), were more likely to have been injured themselves, were more likely to have lost a family member, and were more likely to have a concurrent diagnosis of depression (80.0 vs. 28.6%). Follow-up assessment indicated that therapy helped children to overcome depression to some extent. Still, experience of trauma was associated with poor response in cases who lost parents and family integrity, who had somatic injury and boarding schooling. Follow-up findings, subject of another manuscript, suggested that symptoms of PTSD and depression were much reduced at 18 months, suggesting that for some, PTSD symptoms resolve with time.
Statement of interest
Clinical implications
References
(1) This study suggests the need for disaster-related treatment interventions for children. Our study revealed that risk for developing PTSD and depression was increased for children who were injured, witnessed death, lost a family member, and had a parent with an extreme reaction.
[1] The Practice Parameters for the Assessment and Treatment of Children and Adolescents with PTSD. J Am Acad Child Adolesc Psychiatry 1998;37(suppl):10. [2] Pfefferbaum B. PTSD in children: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1997;36: 1503 11. [3] Yule W. Post-traumatic stress disorder. In: Rutter M, Taylor E, editors. Child and adolescent psychiatry, 4th ed. London: Blackwell Science; 2003. p 520 8. [4] American Psychiatric Association (APA) diagnostic and statistical manual of mental disorders. 4th ed (DSM- IV). Washington, DC: American Psychiatric Association; 1994. [5] Asarnow J, Glynn S, Pynoos R, Nahum J, Gutherie D, Cantwell DP, et al. When the earth stops shaking. J Am Acad Child Adolesc Psychiatry 1999;38:1016 23. [6] Green BI, Korol M, Grace MC, Vary MG, Leonard AC, Gleser GC, et al. Children and disaster: Age, gender and parental effects on PTSD symptoms. J Am Acad Child Adolesc Psychiatry 1991;30:945 51. [7] Hsu C, Chong M, Yang P, Yen C. PTSD among adolescent earthquake victims in Taiwan. J Am Acad Child Adolesc Psychiatry 2002;41:875 81. [8] Lonigan CJ, Shannon MP, Taylor CM, Finch AJ, Sallee FR. Children exposed to disaster: II. Risk factors for the development of post traumatic stress disorder symptomatology. J Am Acad Child Adolesc Psychiatry 1994;33: 94 105. [9] Grigorian HM. The Armenian earthquake. In: Austin LS, editor. Responding to disaster. Washington, DC: American Psychiatric Press; 1992. p 157 67. [10] Goenjian AK, Steinberg AM, Najarian LM, Fairbanks LA, Tadhjian M. Prospective study of PTSD, anxiety and depressive reactions after earthquake and political violence. Am J Psychiatry 2000;157:895 911. [11] Pynoos RS, Goenjian A, Tashian M, Karakashian M, Manjikian R. PTS reaction in children after the 1998 Armenian earthquake. Br J Psychiatry 1993;163:239 47. [12] Najarian LM, Goenjian AK, Pelcovitz D, Mandel F, Najarian B. Relocation after a disaster: Post traumatic stress disorder in Armenia after the earthquake. J Am Acad Child Adolesc Psychiatry 1996;35:374 83. [13] Armenian HK, Morikawa M, Melkonian AK, Hovanesian A, Akiskal K. Risk factors for depression in the survivors of the 1988 earthquake in Armenia. J Urban Health 2002;79(3): 373 82. [14] Roussos A, Goenjian AK, Steinberg AM, et al. Posttraumatic stress and depressive reactions among children and adolescents after the 1999 earthquake in Greece. Am J Psychiatry 2005;162:530 7. [15] Goenjian AK, Pynoos RS, Steinberg AM, Najarian LM, Asarnow JR, Karayan I, et al. Psychiatric comorbidity in
(2) The ability of the family to remain calm and reassuring is a key factor in preventing stress reactions in children following disasters. All parents and teachers should be educated to keep their reactions under control, as their fear responses will augment children’s fear responses and contribute in turn to the development of PTSD and depression. (3) Interventions for children and even for adolescents may be of limited effectiveness if the family is not considered as a whole. In fact, providing care and support to their overly stressed parents might be among the most effective ways to provide care and support for the children affected by disaster. Also critical are care and support for families who have members die in the disaster, including extended families that may have to step in to care for children who lose parents and guardians. Key Points
death of a family member, suggesting that these children should receive attention from mental health professionals. Other at-risk groups were males, children with high trait anxiety scores, and children injured in the quake
We thank to the Istanbul University Research Fund for financially sponsoring the technical analysis, Number 1398-05 052 000. We also thank the students who so generously gave up their time to participate in the study.
/
/
/
/
/
/
/
/
/
/
. Of the 160 students, 60% met the diagnostic criteria for PTSD on CAPS. Considering the magnitude and damage by the earthquake, it does not seem to be as high as that reported in some other studies. According to the logistic regression analysis, significant risk factors for PTSD development were witnessing death and having parents exhibit extreme reactions. The ability of the family to remain calm and reassuring may be a key factor in preventing PTSD . Our study revealed that 31% had Major Depression on DSM IV. This rate was higher than other studies. The most powerful predictor was
/
/
/
/
/
/
/
/
/
/
Risk for PSD in child quake survivors 199 children after the 1988 earthquake in Armenia. J Am Acad Child Adolesc Psychiatry 1995;34(9):1174 84. Kilpatrick DG, Ruggiero KJ, Acierno R. Witnessing violence and risk of PTSD, major depression, substance abuse/ dependence, and comorbidity: Results from the National Survey of Adolescents. J Consult Clin Psychol 2003;71: 692 700. Spielberger C. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Presss; 1983. Oy B. Children’s Depression Inventory: Validity and reliability study (In Turkish). Turk J Psychiatry 1991;2:132 6. Ozusta, S. Cocuklar icin durumluk-surekli kaygi envanterini uyarlamasi. Gecerlik-guvenirlik calismasi. 1993. Basilmamis yu¨ksek lisans tezi (In Turkish). Rutter M, Yule W. Applied scientific thinking in clinical assessment. In: Rutter M, Taylor E, editors. Child and adolescent psychiatry, 4th ed. London: Blackwell Science; 2003. p 103 16. Blake DD, Weathers FW, Nagy LM. A clinician administered rating scale for assessing current and lifetime PTSD (The CAPS-I). Behav Ther 1990;13:187 8. Aker T, Ozeren M, Basoglu M. Klinisyen Tarafindan Uygulanan TSSB Olc¸eg˘i. TSSB-O. Gecerlik-Guvenirlik C ¸ alismasi. Turk Psikiyatri Derg 1999;10:286 93 (in Turkish). Kolaitis G, Kotsopoulos J, Tsiantis J, Haritaki S, Rigizou F, Zacharaki L, et al. Post traumatic stress reactions among children following the Athens earthquake of September 1999. Eur Child Adolesc Psychiatry 2003;12(6):273 80. Altindag A, Ozen S, Sir A. One-year follow-up study of post traumatic stress disorder among earthquake survivors in Turkey. Compr Psychiatry 2005;46:328 33. Salcioglu E, Basoglu M, Livanou M. Long-term psychological outcome for non-treatment seeking earthquake survivors in Turkey. J Nerv Ment Dis 2003;191(3):154 60. Wang X, Gao L, Shinfuku N, Zhang H, Zhao C, Shen Y. Longitudinal study of earthquake related PTSD in a /
[16]
/
/
[17] [18]
/
[19]
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
[20]
[21]
/
[22]
[23]
/
/
[24]
/
[25]
/
[26]
/
[27]
/
/
/
/
/
[28]
/
/
[29]
/
/
[30]
[31]
/
/
/
[32]
/
[33]
/
[34]
/
/
randomly selected community sample in North China. Am J Psychiatry 2000;157:1260 6. Jaycox LH, Stein BD, Kataoka SH, Wong M, Fink A, Escudero P, et al. Violence exposure, post traumatic stress disorder and depressive symptoms among recent immigrant school children. J Am Acad Child Adolesc Psychiatry 2002; 41:1104 10. Kilic EZ, Ozquven H, Sayil I. The psychological effects of parental mental health on children experiencing disaster: The experience of Bolu earthquake in Turkey. Fam Process 2003;42:485 95. Krug EG, Kresnow M, Peddicord JP, Dahlberg LL, Powell KE, Crosby AE, et al. Suicide after natural disasters. New Engl J Med 1998;338(6):373 8. National Institute of Mental Health. Evidence based mental health. Vol. 9. London: BMJ Publishing Group; 2006. p 30 1. Weller RA, Weller EB, Fristad MA, Bowes JM. Depression in recently bereaved children. Am J Psychiatry 1991; 148(11):536 40. Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J. Childhood and adolescent depression: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1996;35: 1575 83. Dowdney L, Wilson R, Maughan B, Allerton M, Schofield P, Skuse D. Psychological disturbance and service provision in parentally bereaved children. Br Med J 1999;319:354 7. Cerel J, Fristad M, Verducci J, Weller R, Weller E. Childhood bereavement: Psychopathology in the 2 years postparental death. J Am Acad Child Adolesc Psychiatry 2006; 45(6):681 90. Vehid H, Alyanak B, Eksi A. Suicide ideation after the 1999 earthquake in Marmara, Turkey. Tohoku J Exp Med 2006; 208:19 24. Stoddard F, Saxe G. Ten-year research review of physical injuries. Research update reviews. J Am Acad Child Adolesc Psychiatry 2001;40(10):1128 45. /
/
/
/
[35]
/
/
[36]
/
/
ORIGINAL ARTICLE
Risk factors for the development of PTSD and depression among child and adolescent victims following a 7.4 magnitude earthquake
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
AYSEL EKS¸I1, KATHRYN L. BRAUN2, HAYRIYE ERTEM-VEHID3, GULCAN PEYKERLI3, REYHAN SAYDAM3, DERYA TOPARLAK4 & BEHIYE ALYANAK5 1
Institute of Child and Adolescent Health, Istanbul University, Istanbul, Turkey, 2University of Hawaii, Honolulu, HI, USA, Child Health Center, The Medical School, Istanbul University, Istanbul, Turkey, 4Pediatric Unit, The Medical School, Istanbul University, Istanbul, Turkey, and 5Child Psychiatry Department, The Medical School, Istanbul University, Istanbul, Turkey 3
Abstract Objective. PTSD and major depression occur frequently following traumatic exposure, both as separate disorders and concurrently. Although much of Turkey is under threat of severe earthquakes, risk factors for developing psychiatric disorders among Turkish children have not yet been studied. The aim of the study was to examine risk factors for PTSD and depression develpoment in children. Method. A total of 160 survivors (102 girls and 58 boys) severely impacted by Turkey’s 7.4-magnitude quake participated in a psychiatric interview 6 20 weeks after the disaster. The mean age was 14.43. Logistic regression was used to test effects of pre-disaster, disaster-related and post-disaster factors on diagnoses, yielding odds ratios (OR). Results. CAPS indicated that 96 (60%) had PTSD, and psychiatric interview found 49 (31%) with depression. Children diagnosed with PTSD were more likely to have witnessed death (OR /2.47) and experienced an extreme parental reaction (OR /3.45). Children with depression were more likely to be male (OR /4.48), have a higher trait anxiety score (OR /1.12 for every additional point), sustain injury (OR /4.29), and have lost a family member in the quake (OR /10.96). Focusing on the 96 children with PTSD, those with comorbid depression were more likely male, have a higher trait anxiety score, and have lost of family member. Conclusions. Mental health professionals should offer support to children witnessing death or losing a family member in a disaster. The ability of the family to remain calm and reassuring also may be a key factor in preventing PTSD.
Key Words: PTSD, depression, child, risk-factors, earthquake
Introduction Millions of people all over the world have been affected by man-made disasters such as terrorist attacks, or natural disasters, such as earthquakes, floods, hurricanes, tornados, and tsunamis during the last decade. Studies reveal that like adults, children can also experience stress reactions, which may lead to lasting Posttraumatic Stress Disorder (PTSD) [1 3]. PTSD is a prolonged, pathological anxiety that may occur subsequent to a severe trauma that constitutes a threat to life or physical integrity, elicits intense fear, horror, or helplessness. To meet criteria for PTSD, the child’s response must include a specific number of symptoms from each of the three broad categories: the feeling of reexperiencing the trauma, symptoms of avoidance, and hyperarousal; and the symptom clusters must be present for at least a month following the
traumatic event (Diagnostic & Statistical Manual DSM-IV) [4]. While not all people who have suffered a qualifying trauma go on to develop a disorder, investigators have documented pre-trauma, post-trauma, and trauma-related risk factors that may increase vulnerability to a PTSD. Pre-trauma factors include pre-existing anxiety, gender, age, personality traits, familial factors, parental PTSD, violence within the family, and experiencing abuse/maltreatment [5 8]. Trauma-related risk factors are events related directly to the trauma, which include severity of the event in terms of life-threat, one’s proximity to the threat, duration of experience, witnessing of mutilating injury or grotesque death, personal injury, and loss of significant family members [7 9,11]. Post-trauma variables and later adversities that may increase psychiatric morbidity include separation
Correspondence: Prof. Dr. Aysel Eks¸i, Ozgurluk Sokak, Kooperatif Evleri No. 1, Yenikoy, Istanbul, Turkey. Tel: /90 212 262 4873. Fax: /90 2212 262 1351. E-mail: [email protected]
(Received 30 January 2006; accepted 23 August 2006) ISSN 1365-1501 print/ISSN 1471-1788 online # 2007 Taylor & Francis DOI: 10.1080/13651500601017548
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Risk for PSD in child quake survivors 191 from families, displacement of families, unfavourable conditions, and lack of psychological services [57,10 12]. It is documented that depression is also a common sequel to disasters [7,13 16], and a substantial number of symptoms overlap among PTSD and other psychiatric diagnoses, such as panic disorder, social phobia, substance use disorders, and other anxiety disorders [1 3]. DSM-IV defines a Major Depressive episode or syndrome as one in which at least five of the following symptoms have been present during the same 2-week period: Persistent sad or irritable mood, significant change in appetite or body weight, diminished interest, loss of pleasure in almost all activities, sleep disturbances, psychomotor agitation or retardation, feelings of worthlessness or inappropriate guilt, difficulty concentrating, suicidal ideation, and recurrent thoughts of death or suicide [4]. Our interest in this subject began on 17 August 1999, when a 7.4-magnitude earthquake occurred in the Marmara region of Turkey at 03:00 h, followed by significant aftershocks. According to official estimates, the death toll was more than 20,000, and 30,000 people were injured and left homeless. Many children were trapped, injured, witnessed death and suffering, or had family members die. This unexpected, large-scale disaster and the aftershocks produced fear, helplessness and utmost horror in children as well as in adults. Considering the magnitude and damage of the earthquake, we anticipated that the severity of PTSD and depression would be much higher than reported in many studies. However, although the whole region is still under the threat of severe earthquakes, risk factors for development of psychiatric disorders among Turkish children have not yet been studied. This is the first study specific to Turkish children and adolescents in Turkish culture, exploring risk factors for the development of PTSD and depression following a devastating earthquake.
Methods Subjects This is a school-based study of 160 students which began 4 weeks after the quake in September 1999. Our research area, Adapazari, was suggested by the Dean of the Istanbul Medical School because of widespread destruction in this area. The local director of the Ministry of Education indicated the schools where the students were badly affected. The sample was drawn from schools in two townships of Adapazari, namely Hendek and Arifiye, both located in the epicentre of the earthquake. Officials estimated that about 1,100 students in the study age groups (9 18) had been expected to
enroll in schools in Hendek and Arifiye. There were considerably fewer students when we began our study. This is because most of them were living in tent camps and were not attending school regularly, or in the quake some students had died or many others had been sent to live with relatives in safer parts of the country. Others had been hospitalized. Thus, the subjects were not representative of the total student population. However, 659 students in our target age groups were attending schools in Hendek and Arifiye when we administered our questionnaire about the quake (described below) at our initial visit in September 1999. Responses showed that 153 students (mostly boys) had not been at the site when the quake occurred due to summer holiday. Another 77 students indicated that they and their families and homes had been relatively unaffected by the quake, although they were very much frightened like millions of other people in the Marmara region. Because we wanted to study children who were affected by the quake, these two groups were excluded from further analysis. The remaining 429 students all reported three or more negative quakerelated experiences (e.g., house collapsed, injured, family member injured, family member died, relocation) and were asked if they wished to participate in the study. They understood this to involve a one-onone interview with the psychiatrist, and 301 (70%) agreed. Written parental permission was received for 160 of these students. Thirty of these children were subsequently relocated to boarding schools in Istanbul *Camlica and Darussafaka *by families and school officials, and these children were interviewed in their respective boarding schools. (Note that study psychiatrists were not involved in relocation decisions.) Subjects included 102 girls (64%) and 58 boys (36%). The mean age was 14.43 years (range 9 18). All participants were Turkish Muslims, from schools in economically deprived regions. The study sample had a greater proportion of girls. This has been due to a greater willingness of girls to participate in the study (as found by Pynoos et al.) and the fact that many boys have been in summer camps during the quake [11]. The research team consisted of a psychiatrist and three psychologists, all native speakers of Turkish. They travelled from Istanbul to Adapazari, and frequently slept overnight in the Guest House of the Istanbul University in Sapanca. The University provided the transportation. Measures Self-report questionnaire. The research team constructed a 20-item questionnaire including demographic characteristics and a list of earthquake-related events. Data on age, gender, ethnic and religious background, occupation of parents,
192
A. Eks¸i et al.
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
and whereabouts during the quake were collected. Students were asked to review a list of nine events (identified in research studies with child survivors of earthquakes in Turkey, Armenia, Greece, Taiwan, and Japan). These yesno questions asked if the subject: (1) experienced any kind of serious danger (e.g., being trapped in rubble); (2) witnessed death and extreme suffering; (3) was injured; (4) had a family member injured; (5) had a family member die; (6) had another significant person die; (7) had their house destroyed; (8) moved to a tent camp or relative’s home; or (9) was placed in a boarding school.
Anxiety tests. The State-Trait Anxiety Inventory (STAI) (17) was administered in the classrooms. The STAI consists of 20 items to assess state anxiety (unpleasant emotional arousal in face of threatening demands or dangers) and 20 items to assess trait anxiety (which reflects the existence of stable individual differences in the tendency to respond with state anxiety in the anticipation of threatening situations). All tests were standardised [18] and have been widely used on Turkish subjects. Validity and reliability studies relating to the Turkish language and culture suggest their validity in Turkish populations [19]. The findings are briefly presented in Table I.
Individual interview. Psychiatric interview of each study participant was conducted by a trained psychiatrist in a 1-hour interview, held in a private room. These were scheduled to accommodate student and researcher availability and were conducted between 6 and 20 weeks post-quake. The interviews focused on recent quake experiences, pre-quake and post-quake circumstances, psychological state of students, complaints, and psychiatric symptomatology. The psychiatrist questioned each student in relation to previous life and pre-existing family problems, such as if anyone was physically or psychologically ill or recently died or if subject had previously experienced maltreatment or abuse or any kind of serious problem prior to the quake. When the subject answered ‘‘yes’’ to any of these questions, he/she was reported as having a pre-quake problem. Students were encouraged to talk freely about whatever had happened during and after the quake, concerning themselves, families, other significant people, homes, and attitudes and behaviour of parents/other adults. Their initial responses reported on the questionnaire were helpful in indicating which events had to be discussed in more detail. Depending on how the interview progressed, the clinician moved on to direct questions, taking care not to lead the discussion to specific answers.
Students also were questioned in relation to postdisaster circumstances (such as family reaction to the quake and boarding school placement), their recent stressful experiences, and complaints and psychiatric symptomatology. The goal of the assessment was to determine how children had coped with their experiences, what they had thought about what had happened to them, and how they viewed their current experiences. When talking about parents’ response to the quake, if students described symptoms of panic, wailing, praying, fainting, and other behaviour, the clinician interpreted this as an extreme parental reaction. Past research indicates that survivors may review and judge their own conduct, thus feelings of guilt and inferiority are practically universal. In this study, some students described strong feeling that the quake was punishment for some kind of sin, such as not practising religious orders, masturbating, or not being able to save loved ones. These were interpreted as quake-related feelings of guilt or blame. As Rutter [20] remarked, free descriptions in answer to open-ended questions provide accounts of behaviour that are most accurate and least prone to distortion; but these tend to be very lacking in detail, so it was necessary to follow with more specific questions. Considering that children are open to influence of suggestion, tend to overestimate or deny symptoms, or may become disturbed when speaking about the traumatic experience, it was important for the clinician to be sensitive to the cues provided by subjects. Assessing children who were bereaved by the traumatic disaster needed very careful handling, and every step was taken to gather accurate data in a professional manner.
The Clinician-Administered Post-Traumatic Stress Disorder Scale (CAPS). The psychiatrist administered the adult version of CAPS [21] during or at the end of the interview. (The Child CAPS was not standardised at the time.) CAPS is one of the most frequently used measures of PTSD, and it has been translated into Turkish and standardized. Validity and reliability studies in relation to the Turkish language and culture have been performed [22]. CAPS consists of 17 items in three clusters: ‘‘B’’ measures the extent to which the traumatic event is re-experienced; ‘‘C’’ measures the extent to which the subject avoids stimuli associated with the trauma; and ‘‘D’’ measures the extent of hyperarousal. The severity and frequency of each symptom are recorded separately. Severity is rated from 0 / asymptomatic to 4 /extreme, and frequency is rated from 0/never to 4 /every day. A symptom is considered present if its severity is at least 1 and its frequency is at least 2. For a diagnosis of PTSD, an
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Risk for PSD in child quake survivors 193 individual must have at least one symptom in cluster B (re-experiencing), three from cluster C (avoidance), and two from cluster D (hyper-arousal). To meet DSM-IV criteria for PTSD, symptoms in each of the three domains must not only be present but must also be severe enough to cause substantial impairment in social, academic, or interpersonal domains.
females served as the reference category for gender, and ‘‘absence of condition’’ served as the reference category for the other dichotomous variables. In the subset of 96 children with PTSD, 45 (47%) also had depression. For this reduced sample, we used correlation to identify significant correlates of concurrent depression and entered those into a onestage binary logistic regression model.
Analysis
Results
SPSS (Statistical Package for Social Sciences) software was used to manage and analyze data. Twosided, independent-sample t -tests and chi-square tests were used to compare differences in continuous and categorical variables, respectively. Correlation was used to test age differences in characteristics of the sample, as well as to identify variables within categories that were highly inter-correlated. Binary logistic regression was used to examine independent predictors of PTSD and depression in the full sample. In accordance with our conceptual framework, variables that may predict the development of PTSD and depression were organized into three categories: (1) pre-quake factors; (2) event factors; and (3) postquake response factors. Within each category, we checked for inter-correlation of variables, which guided the dropping of some variables from subsequent multivariate analyses. We found that two variables ‘‘child in serious danger’’ and ‘‘lived in tent camp’’ inter-correlated with many of the other variables (r /0.30), and they were omitted from further analysis. Because diagnosis could be related to timing of the psychiatric interview (conducted between 1 and 5 months post-quake), we also included a variable termed ‘‘weeks post quake’’ as a predictor. We used logistic regression to test 14 variables as predictors of PTSD and depression. Variables were entered in four blocks: (1) pre-quake factors, including four variables gender, age, trait anxiety score, and pre-existing family problems (1 /yes, 0/no); (2) event factors (including six dichotomous variables) witnessed death, personally injured, family member injured, lost family member, lost other significant person, and house destroyed; (3) response (post-quake) factors (including three dichotomous variables) an extreme reaction of the adult family members (including wailing, praying, fainting, or panic), quake-related feelings of guilt or blame, and relocation of child to a boarding school; and (4) weeks since quake . This procedure yields odd ratios with 95% confidence intervals for each variable. Factor blocks were entered sequentially, and at each step differences in the 2 log likelihood values were checked against chi-square tables to see if the addition of the new block of variables improved model fit. When used as categorical predictors,
As shown in Table I, the children were severely affected by the earthquake. Specifically, 78% of children reported being in serious danger during the quake, 50% witnessed death and extreme suffering of other human beings, 14% reported personal injury, 35% reported injury of a family member, 24% experienced death of a family member, 43% experienced the death of a significant other, and 84% had their house destroyed. As a result, 63% of families lived in a tent camp, and 18% of children were sent to a boarding school. Clinical diagnosis showed that 96 students (60%) met the full criteria of PTSD on DSM-IV, and 49 students (31%) had major depression. The mean total CAPS score was 42.13 for the sample. A few differences were seen by gender or age (Table I). For example, a significantly larger proportion of boys was injured than girls, and girls were more likely to have lived with the family in a tent camp. A larger proportion of girls reported preexisting family problems. Younger children were more likely than older children to have been injured, have a family member die, or be placed in boarding school. Mean weeks between the quake and the psychiatric interview was significantly greater for girls and older children. Boys had higher mean CAP total scores, and greater proportions of boys had PTSD and depression diagnoses compared to girls. A depression diagnosis was negatively correlated with age. Table II displays comparisons between children with and without PTSD and with and without depression. Variables associated with PTSD included male gender, the witnessing of death and suffering, losing a family member, moving to a tent camp, having a parent with an extreme reaction to the quake, feeling quake-related blame or guilt, and fewer weeks from the quake. Variables associated with depression include male gender, younger age, higher Trait and State anxiety scores, being injured in the quake, losing a family member, being relocated to tent camp or boarding school, and feeling quake-related blame or quilt. Findings from the binary logistic regression modelling for PTSD are shown in Table III. Considering just the pre-quake factors (Model 1), the findings suggest that boys were more likely than girls to develop PTSD. When event factors were considered
194
A. Eks¸i et al.
Table I. Characteristics of the total sample and by gender. Gender differences
Variable
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Pre-quake factors Mean age Male gender Trait anxiety score State anxiety score Preexisting family problemsa
Total sample (n/160)
Boys (n /58)
Girls (n/102)
14.43 (SD/2.12) 58 (36.3) 46.44 (SD/8.72) 45.91 (SD/9.46) 31 (19.4)
14.19 46.23 46.04 4 (6.9)
14.57 46.56 45.83 27 (26.5)
Age differences Significance probabilityb
1.09, 158, 0.23, 158, 0.14, 158, 9.07, 158,
0.28 0.82 0.89 0.003
Significance probabilityc
0.42, 0.11, 0.08, 0.12,
0.55 0.15 0.34 0.14
Event factors Child in serious dangera Child witnessed deatha Child injureda Family member injureda Family member dieda Other significant person dieda House destroyeda
125 80 23 36 39 68 134
(78.1) (50.0) (14.4) (35.0) (24.4) (42.5) (83.8)
2 34 13 22 16 27 47
(72.4) (58.6) (22.4) (37.9) (27.6) (46.6) (81.0)
83 46 10 34 23 41 87
(81.4) (45.1) (9.8) (33.3) (22.5) (40.2) (85.3)
1.73, 1, 0.19 2.71, 1, 0.10 4.78, 1, 0.03 0.34, 1, 0.56 0.51, 1, 0.48 0.61, 1, 0.43 0.49, 1, 0.48
0.01, 0.85 0.01, 0.99 0.14, 0.05 0.11, 0.10 0.31, 0.0001 0.07, 0.30 0.12, 0.08
Response factors Family lived in tent campa Placed in boarding schoola Family had extreme reactiona Child felt blame/guilta
101 30 50 21
(63.1) (18.8) (31.3) (13.1)
31 15 17 9
(53.4) (25.9) (29.3) (15.5)
70 15 33 12
(68.6) (14.7) (32.4) (11.8)
3.66, 1, 0.06 3.02, 1, 0.08 1.59, 1, 0.69 0.46, 1, 0.50
0.13, 0.29, 0.02, 0.01,
Weeks since quake
16.31 (SD/5.52)
14.41
17.39
CAPS B-cluster (range 2 37) C-cluster (range 0 48) D-cluster (range 0 32) Total score (range 2 111) PTSD Depressiona
15.86 (SD/8.11) 13.70 (SD/10.24) 12.31 (SD/8.84) 42.13 (SD/23.60) 96 (60.0) 49 (30.6)
17.96 15.60 12.73 46.99 41 (70.1) 25 (43.1)
14.67 12.62 12.07 39.35 55 (53.9) 24 (23.5)
3.38, 158, 0.001 2.51, 158, 0.01 1.78, 158, 0.08 0.45, 158, 0.65 1.99, 158, 0.05 4.33, 1, 0.04 6.67, 1, 0.01
0.07 0.0001 0.77 0.99
0.28, 0.001 0.09, 0.07, 0.12, 0.12, 0.09, 0.17,
0.28 0.37 0.15 0.13 0.21 0.02
a
Dichotomous variables were coded 1/condition present and 0/condition absent. Significance tests included unpaired t -tests for continuous variables and chi-squared tests for dichotomous variables; Reported are T-score or chi-square statistic, degrees of freedom, and p value. c Significance was tested using Pearson’s r between two continuous variables and Kendal’s tb between interval and dichotomous variables. These are reported, followed by the p values. b
(Model 2), the model fit improved; the witnessing of death was the only significant variable. Adding response factors (Model 3) again improved the fit, and extreme parental reaction was significant. The variable ‘‘time since quake’’ was not significant, nor did adding it improve the model. Thus, Model 3 provided the best fit, suggesting that children who developed PTSD were more likely to have witnessed death (OR /2.47) and have a parent display an extreme reaction (such as wailing, fainting, or panicking) to the quake (OR /3.45). Examining predictors of depression (Table IV), among pre-quake factors (Model 1), male gender, younger age, and higher Trait anxiety were significant. Entering the event factors (Model 2) improved model fit. Age was no longer a significant predictor, but male gender, higher trait anxiety score, being injured, and losing a family member all were significant. Adding the response factors (Model 3) and ‘‘weeks post quake’’ (Model 4) did not improve the model fit. Thus, Model 2’s fit was best, suggesting that children developing depression were more likely to be boys than girls (OR /4.48), to have a higher trait anxiety score (OR /1.12 for each
additional point), to have been injured (OR / 4.29), and to have lost a family member in the quake (OR /10.96). Within the subset of 96 children with PTSD (not shown in table), correlation analysis suggested that the 45 with concurrent depression were more likely to be male, have a high trait anxiety score, to have lost a family member, and to have been sent to boarding school. In one-model binary regression, three variables retained significance, including male gender (OR /2.88), to have a higher trait anxiety score (OR /1.08 for each additional point), and to have lost a family member in the quake (OR /6.85). Discussion Certainly the child’s subjective understanding of the traumatic event can be more important than the event itself. However, since Turkey is continuously under the threat of severe earthquakes, and risk factors for development of psychiatric disorders among Turkish children have not yet been studied, the aim of this study was to obtain information on
Risk for PSD in child quake survivors 195 Table II. Characteristics of the sample by PTSD and depression status. PTSDa
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Variable Pre-quake factors Male gender Mean age Trait anxiety score State anxiety score Preexisting problemsa Event factors Child in serious dangera Child witnessed death/sufferinga Child injureda Family member injureda Family member dieda Other significant person dieda House destroyeda Response factors Moved to tent or relative’s homea Placed in boarding schoola Extreme parental reactiona Child felt blame/guilta Weeks post-quake
Depression (n /49)
No depress. (n/111)
Significance Probability b
4.33, 1, 0.04 1.49, 158, 0.14 1.70, 158, 0.09 1.72, 158, 0.09 0.33, 1, 0.57
25 (51.0) 13.57 49.41 49.57 12 (24.5)
33 (29.7) 14.81 45.13 44.29 19 (17.1)
6.67, 1, 0.01 3.54, 158, 0.001 2.92, 158, 0.04 3.36, 158, 0.001 1.18, 1, 0.28
(79.7) (34.4) (10.9) (31.3) (15.6) (35.9) (85.9)
0.15, 1, 0.70 10.42, 1, 0.001 1.02, 1, 0.31 0.66, 1, 0.42 4.43, 1, 0.04 1.88, 1, 0.17 0.38, 1, 0.54
34 30 13 19 26 23 40
(69.4) (61.2) (26.5) (38.8) (53.1) (46.9) (81.6)
91 50 10 37 13 45 94
(82.0) (45.0) ( 9.0) (33.3) (11.7) (40.5) (84.7)
3.16, 1, 0.08 3.56, 1, 0.06 8.48, 1, 0.004 0.44, 1, 0.51 31.54, 1, 0.0001 0.57, 1, 0.45 0.23, 1, 0.63
(75.0) (15.6) (20.3) (20.3)
6.46, 1, 0.01 0.68, 1, 0.41 5.94, 1, 0.02 6.66, 1, 0.01
20 18 14 11
(40.8) (36.7) (28.6) (22.4)
81 12 36 10
(73.0) (10.8) (32.4) (9.0)
15.10, 1, 0.0001 14.99, 1, 0.0001 0.24, 1, 0.63 5.39, 1, 0.02
2.99, 158, 0.003
15.43
PTSD (n /96)
No PTSD (n /64)
41 (42.7) 14.31 47.39 46.95 20 (20.8)
17 (26.6) 14.73 45.02 44.35 11 (17.2)
74 58 16 36 29 45 79
(77.1) (60.4) (16.7) (37.5) (30.2) (46.9) (82.3)
51 22 7 20 10 23 55
53 20 37 18
(55.2) (20.8) (38.5) (21.7)
48 10 13 3
15.27
Depressiona
17.88
Significance Probability b
16.70
1.35, 158, 0.18
a
Dichotomous variables were coded 1 /condition present and 0/condition absent. Significance tests included unpaired t -tests for continuous variables and chi-squared tests for dichotomous variables; reported are T score or chi-square statistic, degrees of freedom, and p value. b
the occurrence of particular events and to examine risk factors for developing PTSD and depression. In the child psychiatric literature, rates of PTSD following natural disasters seem to be between 28 and 95%. Our finding of PTSD in 60% of children significantly affected by Turkey’s 7.4-magnitude earthquake in 1999 was lower than that found in several other studies of earthquakes of similar magnitude [5,9 12]. For example, after a quake in Armenia, when Grigorian assessed 179 subjects, 72% received a diagnosis of PTSD [9]. Goenjian evaluated 65 Armenian children and found that 85% met criteria for PTSD [10]. One and a half years after the Armenian disaster, 111 children were assessed by DSM-III-R criteria for PTSD, and 70.3% were given this diagnosis [11]. In Athens, a month after Greece’s quake, 115 children and their parents were investigated by several questionnaires, and it was found that 78% of the subjects had mild to severe PTSD symptoms [23]. Only a few studies found lower rate of PTSD than ours. For example, another severe quake occurred, just a month after Turkey’s quake, in Taiwan. Hsu et al. [7] investigated 323 students 6 weeks postquake and found only 21.7% with PTSD. Roussos et al. [14] studied 1,937 Greek students residing 10 km from the epicentre of the Athens quake and found a PTSD rate of 4.5%. Two studies among the Turkish adult survivors estimated PTSD rates of 42% within a month of the quake, 23% at 13 months, and 39% at 20 months post-quake [24,25].
Naturally differences in rates of PTSD depend on various factors, such as when the study is performed and which criteria of DSM (III, III-R or IV) and assessment methods are used. For example, Wang et al. examined the effects of diagnostic criteria on the frequency in two groups after an earthquake in North China [26]. The rate of PTSD was 24.2% by using DSM-IV criteria and 41.4% by using DSM-III-R criteria. The authors concluded that introduction in DSM-IV of a criterion requiring clinically significant distress or impairment in functioning for a diagnosis of PTSD was a major contributor to the lower rate of DSM-IV PTSD. In our study, we rigorously followed the requirements for a diagnosis of PTSD that symptoms must be severe enough to cause substantial distress-impairment. Thus, caution should be used in comparing rates of post-disaster PTSD, taking care to note which criteria were used. Discrepancies are also attributable to magnitude and place of disaster and number of casualties. Looking at risk factors for developing PTSD, age and gender have been considered in many studies. Much of the psychiatric literature suggests that being female is a risk factor for developing PTSD, although a few investigators have found no significant association between gender and PTSD reactions [7,8,11]. In our study, gender was not a predictor of PTSD when other variables were controlled for. Some studies have found that age of a child significantly affects development of PTSD
196
A. Eks¸i et al.
Table III. Predictors of PTSD (n/160). Model 1 Pre-quake factors OR (95% CI)
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Pre-quake factors Male gendera Age Trait anxiety score Preexisting family problemsa
2.21 0.87 1.03 1.50
Model 2 Pre-quake/event factors OR (95% CI)
(1.07 4.50)b (0.74 1.03) (0.99 1.08) (0.63 3.58)
Event factors Child witnessed death/sufferinga Child injureda Family member injureda Family member dieda Other significant person dieda House destroyeda
1.95 0.90 1.03 1.60
(0.92 4.15) ( 0.74 1.09) (0.99 1.08) (0.64 4.00)
2.80 1.28 1.12 1.47 1.36 1.34
(1.34 5.84)c (0.44 3.73) (0.50 2.50) (0.56 3.87) (0.67 2.77) (0.45 3.95)
Response factors Extreme parental reactiona Child felt blame or guilta Child relocated to boarding schoola
Model 3 Pre-quake/event/ response factors OR (95% CI)
1.95 0.88 1.04 1.38
(0.89 4.27) (0.71 1.08) (0.99 1.08) (0.53 3.59)
2.53 1.60 1.01 1.38 1.51 1.47
(1.17 5.48)c (0.52 4.92) (0.43 2.39) (0.47 4.05) (0.72 3.19) (0.46 4.77)
3.36 (1.45 7.76)c 3.53 (0.93 13.45) 0.90 (0.30 2.69)
a
1.66 0.90 1.04 1.45
(0.74 3.76) (0.73 1.11) (0.99 1.09) (0.56 3.80)
2.47 1.57 1.04 1.21 1.55 1.22
(1.14 5.37)b (0.50 4.89) (0.44 2.45) (0.40 3.67) (0.73 3.30) (0.36 4.07)
3.45 (1.48 8.06)c 2.83 (0.72 11.12) 0.99 (0.33 3.05) 0.94 (0.87 1.02)
Weeks post-quake 2 log likelihood Difference between successive models Degrees of freedom
Model 4 All factors/weeks post quake OR (95% CI)
204.55
192.73 11.82b 6
180.26 12.47c 3
177.95 2.31 1
Dichotomous variables with 0 (condition absent) as reference group. p B/0.05; cp B/0.01.
b
symptoms; however, these findings have not always been consistent [6]. Instead, the witnessing of death and suffering was found to be a significant risk factor for the development of PTSD. Indeed, when the quake suddenly occurred at 03:00 h, adolescents (mostly boys) participated in rescue efforts; thus they witnessed death and suffering at home or next-door. Many other subjects were exposed to very dramatic scenes in the streets. Exposure to traumatic images was also regarded as a risk by some other investigators [1,2,6 8,12,15,16,27]. About a third of the children reported that parents and other adult figures exhibited extreme reactions during and following the quake, and this was found to be a significant risk factors for the development of PTSD. This included parents who became selfabsorbed with crying, wailing, or praying loudly, and these reactions likely increased children’s feelings of insecurity, fright, helplessness, and anxiety. Certainly children and their parents respond to each other’s stress, and parents serve as role models for coping [1 3,5,7]. Events that initially are not perceived as threatening and/or frightening may become so after observing the panic reactions of parents or teachers. This was seen in another study with Turkish earthquake child survivors, which found that negative effects on children were more pronounced when their fathers became irritable and detached [28]. Thus, the ability of the family to remain calm and reassuring may be a key factor in preventing PTSD.
It is of interest that in this study group that included all subjects with adverse experiences, not all developed PTSD. It is likely that there were several protective factors that reduced risk for PTSD. One of them might have been the presence of supportive, protective parents/parent substitutes as, in the psychiatric interview, many children stated that they received psychological support, warmth, and encouragement from families or family-substitute relatives afterwards. In this study, depression was found in 31% of the subjects. Given the cross-sectional design of the study, we were unable to discern whether major depression predisposed children to developing PTSD or whether PTSD lowered resistance to depressive illness. However, the development of major depression was found among survivors of other earthquakes [1,9,12,13,15,16,24,25,29]. For example, in a study of the Armenia quake, it was found that 22% of victims had a major depressive disorder 3 6 months after the quake [17]. In Greece, one study estimated rates of clinical depression at 14% [14] and another study estimated rates of 32% [23]. Among adult survivors of Turkey’s 1999 earthquake, 18% were found to have major depression [25]. Krug et al indicated that after severe earthquakes, floods, and hurricanes, suicide rates increase [29]. In our study, risk factors of depression included male gender, higher trait anxiety score, death of a family member, and personal injury. Of these four variables, the first three also were predictors of
Risk for PSD in child quake survivors 197 Table IV. Predictors of depression (n/160). Model 1 Pre-quake Factors OR (95% CI)
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
Pre-quake factors Male gendera Age Trait anxiety Preexisting family problemsa
3.16 0.71 1.08 2.37
(1.40 7.13)c (0.59 0.86)c (1.03 1.13)c (0.91 6.21
Event factors Child witnessed death/sufferinga Child injureda Family member injureda Family member killeda Other significant person killeda House destroyeda
Model 2 Pre-quake/event factors OR (95% CI)
3.62 (1.40 9.37)c 0.86 (0.68 1.09) 1.11(1.05 1.18)c 2.35 (0.81 6.82) 1.58 3.80 1.11 9.87 0.78 1.36
(0.63 4.00) (1.16 12.89)b (0.43 2.88) (3.24 30.01)c (0.32 1.90) (0.42 4.41)
Response factors Extreme parental reactiona Child felt blame or guilta Child relocated to boarding schoola
Model 3 Pre-quake/event/ response factors OR (95% CI)
3.41 0.87 1.11 2.19
(1.31 8.86)b (0.68 1.12) (1.05 1.18)c (0.74 6.48)
4.48 0.82 1.12 2.27
(1.61 12.51)c (0.64 1.06) (1.05 1.18)c (0.75 6.84)
1.53 3.73 1.01 8.58 0.75 1.48
(0.60 3.91) (1.08 12.89)b (0.42 2.86) (2.69 27.39)b (0.30 1.86) (0.45 4.87)
1.67 4.29 1.14 10.96 0.70 1.93
(0.65 4.32) (1.19 14.87)b (0.43 3.02) (3.27 36.74)b (0.28 1.78) (0.56 6.67)
1.00 (0.38 2.62) 1.98 (0.61 6.47) 1.40 (0.40 4.85)
1.01 (0.39 2.64) 2.87 (0.79 10.43) 1.19 (0.34 4.18) 1.10 (0.99 1.21)
Weeks post-quake 2 log likelihood 164.79 Difference between successive models: Degrees of Freedom
Model 4 All factors/weeks post quake OR (95% CI)
136.59 28.20c 6
135.05 1.54 3
131.46 3.59 1
a
Dichotomous variables with 0 (condition absent) as reference group.
comorbid depression in the subsample of 96 children with PTSD. Because our study sample had a greater proportion of girls, we are cautious about pointing to gender as a factor in depression development. New findings from a study of National Institutes of Health showed that girls and boys have similar chances of developing symptoms of depression [30]. It is not surprising that higher trait anxiety score was a risk factor for depression, as many other studies have found that PTSD, anxiety and depressive reactions were highly inter-correlated [1,2,8,10,15,16]. For example, it was suggested that children with generalized anxiety disorder appear to be at significant risk for comorbid major depression [10]. Unlike Asarnow [5], who stated that level of trait anxiety appeared to be the single strongest risk for the development of severe PTSD, we did not find a significant association between PTSD and trait anxiety. Nor was trait anxiety score the most powerful predictor of depression. Rather, we found the major risk factor for depression to be death of a family member. In fact, a considerable number of research studies have found clinical symptoms of a major depressive episode in children after the death of a parent, and bereavement in childhood has been considered a potential risk factor for subsequent psychopathology [15,31 35]. For example, Weller et al. [31] found that 37% of bereaved children met criteria for depression 1 month after parental death. In another study it was indicated that severity of posttraumatic stress and depressive reactions were highly correlated, and
that extent of loss of family members was independently correlated with PTSD and depression [15]. Although only 14% of children in our study sustained significant injury, this appeared to be a predictor of depression. These injuries included fractured and crushed limbs, some of which became gangrenous and required amputation. A few students had Crush Syndrome and needed dialysis. Other investigators also have found that being physically injured was a major risk factor for PTSD and depression [7,24,35,36]. Stoddard reviewed 10 years of research on physical injuries and concluded that despite the high priority that injuries receive in paediatric research, psychiatric aspects are neglected; and there is a need for assessment and for planning of treatment based on severity of injury, comorbid psychopathology, bodily location and prognosis [36]. To control for timing of the psychiatric interview (conducted between 1 and 5 months post-quake), we tested the variable ‘‘weeks post-quake’’ as a predictor of diagnosis. Although, on average, children diagnosed with PTSD were interviewed closer in time to the quake than children without PTSD, this variable was not significant when entered into the logistic regression models. However, it is important to note that children diagnosed with PTSD and/or depression in this study were offered treatment through the Child Health Institude in Istanbul. Follow-up assessment 18 months later showed that 25 children who obtained treatment differed significantly from those who did not receive treatment on several variables: they had experienced more
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
198
A. Eks¸i et al.
traumatic quake-related events (4.9 vs. 3.9), were more likely to have been injured themselves, were more likely to have lost a family member, and were more likely to have a concurrent diagnosis of depression (80.0 vs. 28.6%). Follow-up assessment indicated that therapy helped children to overcome depression to some extent. Still, experience of trauma was associated with poor response in cases who lost parents and family integrity, who had somatic injury and boarding schooling. Follow-up findings, subject of another manuscript, suggested that symptoms of PTSD and depression were much reduced at 18 months, suggesting that for some, PTSD symptoms resolve with time.
Statement of interest
Clinical implications
References
(1) This study suggests the need for disaster-related treatment interventions for children. Our study revealed that risk for developing PTSD and depression was increased for children who were injured, witnessed death, lost a family member, and had a parent with an extreme reaction.
[1] The Practice Parameters for the Assessment and Treatment of Children and Adolescents with PTSD. J Am Acad Child Adolesc Psychiatry 1998;37(suppl):10. [2] Pfefferbaum B. PTSD in children: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1997;36: 1503 11. [3] Yule W. Post-traumatic stress disorder. In: Rutter M, Taylor E, editors. Child and adolescent psychiatry, 4th ed. London: Blackwell Science; 2003. p 520 8. [4] American Psychiatric Association (APA) diagnostic and statistical manual of mental disorders. 4th ed (DSM- IV). Washington, DC: American Psychiatric Association; 1994. [5] Asarnow J, Glynn S, Pynoos R, Nahum J, Gutherie D, Cantwell DP, et al. When the earth stops shaking. J Am Acad Child Adolesc Psychiatry 1999;38:1016 23. [6] Green BI, Korol M, Grace MC, Vary MG, Leonard AC, Gleser GC, et al. Children and disaster: Age, gender and parental effects on PTSD symptoms. J Am Acad Child Adolesc Psychiatry 1991;30:945 51. [7] Hsu C, Chong M, Yang P, Yen C. PTSD among adolescent earthquake victims in Taiwan. J Am Acad Child Adolesc Psychiatry 2002;41:875 81. [8] Lonigan CJ, Shannon MP, Taylor CM, Finch AJ, Sallee FR. Children exposed to disaster: II. Risk factors for the development of post traumatic stress disorder symptomatology. J Am Acad Child Adolesc Psychiatry 1994;33: 94 105. [9] Grigorian HM. The Armenian earthquake. In: Austin LS, editor. Responding to disaster. Washington, DC: American Psychiatric Press; 1992. p 157 67. [10] Goenjian AK, Steinberg AM, Najarian LM, Fairbanks LA, Tadhjian M. Prospective study of PTSD, anxiety and depressive reactions after earthquake and political violence. Am J Psychiatry 2000;157:895 911. [11] Pynoos RS, Goenjian A, Tashian M, Karakashian M, Manjikian R. PTS reaction in children after the 1998 Armenian earthquake. Br J Psychiatry 1993;163:239 47. [12] Najarian LM, Goenjian AK, Pelcovitz D, Mandel F, Najarian B. Relocation after a disaster: Post traumatic stress disorder in Armenia after the earthquake. J Am Acad Child Adolesc Psychiatry 1996;35:374 83. [13] Armenian HK, Morikawa M, Melkonian AK, Hovanesian A, Akiskal K. Risk factors for depression in the survivors of the 1988 earthquake in Armenia. J Urban Health 2002;79(3): 373 82. [14] Roussos A, Goenjian AK, Steinberg AM, et al. Posttraumatic stress and depressive reactions among children and adolescents after the 1999 earthquake in Greece. Am J Psychiatry 2005;162:530 7. [15] Goenjian AK, Pynoos RS, Steinberg AM, Najarian LM, Asarnow JR, Karayan I, et al. Psychiatric comorbidity in
(2) The ability of the family to remain calm and reassuring is a key factor in preventing stress reactions in children following disasters. All parents and teachers should be educated to keep their reactions under control, as their fear responses will augment children’s fear responses and contribute in turn to the development of PTSD and depression. (3) Interventions for children and even for adolescents may be of limited effectiveness if the family is not considered as a whole. In fact, providing care and support to their overly stressed parents might be among the most effective ways to provide care and support for the children affected by disaster. Also critical are care and support for families who have members die in the disaster, including extended families that may have to step in to care for children who lose parents and guardians. Key Points
death of a family member, suggesting that these children should receive attention from mental health professionals. Other at-risk groups were males, children with high trait anxiety scores, and children injured in the quake
We thank to the Istanbul University Research Fund for financially sponsoring the technical analysis, Number 1398-05 052 000. We also thank the students who so generously gave up their time to participate in the study.
/
/
/
/
/
/
/
/
/
/
. Of the 160 students, 60% met the diagnostic criteria for PTSD on CAPS. Considering the magnitude and damage by the earthquake, it does not seem to be as high as that reported in some other studies. According to the logistic regression analysis, significant risk factors for PTSD development were witnessing death and having parents exhibit extreme reactions. The ability of the family to remain calm and reassuring may be a key factor in preventing PTSD . Our study revealed that 31% had Major Depression on DSM IV. This rate was higher than other studies. The most powerful predictor was
/
/
/
/
/
/
/
/
/
/
Risk for PSD in child quake survivors 199 children after the 1988 earthquake in Armenia. J Am Acad Child Adolesc Psychiatry 1995;34(9):1174 84. Kilpatrick DG, Ruggiero KJ, Acierno R. Witnessing violence and risk of PTSD, major depression, substance abuse/ dependence, and comorbidity: Results from the National Survey of Adolescents. J Consult Clin Psychol 2003;71: 692 700. Spielberger C. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Presss; 1983. Oy B. Children’s Depression Inventory: Validity and reliability study (In Turkish). Turk J Psychiatry 1991;2:132 6. Ozusta, S. Cocuklar icin durumluk-surekli kaygi envanterini uyarlamasi. Gecerlik-guvenirlik calismasi. 1993. Basilmamis yu¨ksek lisans tezi (In Turkish). Rutter M, Yule W. Applied scientific thinking in clinical assessment. In: Rutter M, Taylor E, editors. Child and adolescent psychiatry, 4th ed. London: Blackwell Science; 2003. p 103 16. Blake DD, Weathers FW, Nagy LM. A clinician administered rating scale for assessing current and lifetime PTSD (The CAPS-I). Behav Ther 1990;13:187 8. Aker T, Ozeren M, Basoglu M. Klinisyen Tarafindan Uygulanan TSSB Olc¸eg˘i. TSSB-O. Gecerlik-Guvenirlik C ¸ alismasi. Turk Psikiyatri Derg 1999;10:286 93 (in Turkish). Kolaitis G, Kotsopoulos J, Tsiantis J, Haritaki S, Rigizou F, Zacharaki L, et al. Post traumatic stress reactions among children following the Athens earthquake of September 1999. Eur Child Adolesc Psychiatry 2003;12(6):273 80. Altindag A, Ozen S, Sir A. One-year follow-up study of post traumatic stress disorder among earthquake survivors in Turkey. Compr Psychiatry 2005;46:328 33. Salcioglu E, Basoglu M, Livanou M. Long-term psychological outcome for non-treatment seeking earthquake survivors in Turkey. J Nerv Ment Dis 2003;191(3):154 60. Wang X, Gao L, Shinfuku N, Zhang H, Zhao C, Shen Y. Longitudinal study of earthquake related PTSD in a /
[16]
/
/
[17] [18]
/
[19]
Int J Psych Clin Pract Downloaded from informahealthcare.com by York University Libraries on 07/07/14 For personal use only.
[20]
[21]
/
[22]
[23]
/
/
[24]
/
[25]
/
[26]
/
[27]
/
/
/
/
/
[28]
/
/
[29]
/
/
[30]
[31]
/
/
/
[32]
/
[33]
/
[34]
/
/
randomly selected community sample in North China. Am J Psychiatry 2000;157:1260 6. Jaycox LH, Stein BD, Kataoka SH, Wong M, Fink A, Escudero P, et al. Violence exposure, post traumatic stress disorder and depressive symptoms among recent immigrant school children. J Am Acad Child Adolesc Psychiatry 2002; 41:1104 10. Kilic EZ, Ozquven H, Sayil I. The psychological effects of parental mental health on children experiencing disaster: The experience of Bolu earthquake in Turkey. Fam Process 2003;42:485 95. Krug EG, Kresnow M, Peddicord JP, Dahlberg LL, Powell KE, Crosby AE, et al. Suicide after natural disasters. New Engl J Med 1998;338(6):373 8. National Institute of Mental Health. Evidence based mental health. Vol. 9. London: BMJ Publishing Group; 2006. p 30 1. Weller RA, Weller EB, Fristad MA, Bowes JM. Depression in recently bereaved children. Am J Psychiatry 1991; 148(11):536 40. Birmaher B, Ryan ND, Williamson DE, Brent DA, Kaufman J. Childhood and adolescent depression: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1996;35: 1575 83. Dowdney L, Wilson R, Maughan B, Allerton M, Schofield P, Skuse D. Psychological disturbance and service provision in parentally bereaved children. Br Med J 1999;319:354 7. Cerel J, Fristad M, Verducci J, Weller R, Weller E. Childhood bereavement: Psychopathology in the 2 years postparental death. J Am Acad Child Adolesc Psychiatry 2006; 45(6):681 90. Vehid H, Alyanak B, Eksi A. Suicide ideation after the 1999 earthquake in Marmara, Turkey. Tohoku J Exp Med 2006; 208:19 24. Stoddard F, Saxe G. Ten-year research review of physical injuries. Research update reviews. J Am Acad Child Adolesc Psychiatry 2001;40(10):1128 45. /
/
/
/
[35]
/
/
[36]
/
/
