Running head: CHILDHOOD PSTD AFTER NATURAL DISASTER

A Review of Factors Associated with the Development of Post-traumatic Stress Disorder in Children who have experienced a Natural Disaster Jo Friesen University of Calgary

CHILDHOOD PSTD AFTER NATURAL DISASTER A Review of Factors associated with the Development of Posttraumatic Stress Disorder in Children who have experienced a Natural Disaster Posttraumatic stress disorder (PTSD) is a potentially debilitating disorder that has a lifetime prevalence of 8% (American Psychological Association, 2000). Key diagnostic criteria include experiencing or witnessing a traumatic event, followed by symptoms related to the persistent reexperiencing of the event, avoidance of stimuli related to the event and increased arousal after the event. Unfortunately, children are not immune. Research shows that nearly two-thirds of children will experience at least one traumatic event prior to age 16 and of those, 13% will show some PTSD symptoms (Copeland, Keeler, Angold & Costello, 2007). While Copeland et al. (2007) found that less than .05% of children met the full criteria for PTSD diagnoses when experiencing their first trauma, subsequent traumas significantly increased the risk for developing PTSD. In fact, Catani, Jacob, Schauer, Kohila and Neuner (2008) found that of the children they studied, those who experience twenty-one or more past traumas, all developed PTSD. Children exposed to trauma are not only at risk for PTSD, but are also twice as likely to develop a psychological disorder than unexposed children are (Copeland et al., 2007) While the types of trauma that can trigger PTSD are vast, including witnessing violence, being the victim of abuse and severe illness or injury, the focus of this paper will be on PTSD in children following natural disasters. Natural disasters occur throughout the world, and usually without warning. They can leave death, destruction and chaos in their wake, and their effects on mental health can be similar to the consequences of war (Catani et al., 2008). Children are the most vulnerable during such an event (Demir et al., 2010), and experiencing a natural disaster has a negative effect on children in terms of their emotional and behavioural adjustment (Vijayakurmar, Kannon, Kumar, & Devarajan, 2006). PTSD symptoms may continue long after the disaster is over and symptoms include

CHILDHOOD PSTD AFTER NATURAL DISASTER nightmares, flashbacks, loss of interest, hyperarousal, regressive behaviors, somatic illnesses, school difficulties, specific fears and posttraumatic play, along with the development of anxiety and depressive disorders (Demir et al., 2010; Prinstein, La Greca, Vernberg, & Silverman, 1996). For children, the rates of PTSD after a natural disaster have been shown to be between 14-95% (Catani et al., 2008). Obviously, such a large range of prevalence rates needs to be investigated, which means that in addition to considering child risk and resiliency factors in understanding PTSD, it is important to also consider the cultural, ethnic, political and socio-economic factors that correspond to the affected region, and the severity and duration of the specific natural disaster and its aftermath. Discussion Following the 2004 Asian Tsunami, Catani et al. (2008) studied a group of children in Sri Lanka to determine what risk factors played a role in the development of PTSD. They found that a major predictor was prior trauma exposure, which in this group of children was most commonly violence within the home or war exposure (Catani et al., 2008). Other risk factors included their parents psychopathology, substance abuse (by family members), and socio-economic factors, such as unemployment, poverty and poor nutrition (Catani et al., 2008). In total, 30.4% of the children in the study met the full criteria for the disorder, with girls accounting for the largest percentage (Catani et al., 2008). In discussing their results, Catani et al. point to the importance of considering pre-disaster circumstances (in this case an ongoing war) and cultural factors (high rates of alcohol use and family violence) when assessing risk for PTSD after a natural disaster. In another study, this one conducted by Demir et al. (2010) after two earthquakes hit the Marmara region of Turkey in 1999, showed that of 321 children, 25.5% developed PTSD. Unlike Catani et al. (2008), they found no relationship between gender, but those who had lost a loved one

CHILDHOOD PSTD AFTER NATURAL DISASTER or whose homes were destroyed had the highest rates of PTSD (Demir et al., 2010). Of interest, Demir et al. found similar rates of PTSD in both the immediate quake zone and in children who were outside of the danger zone, but still felt the quake. They hypothesized that due to the high level of media coverage, the children outside the immediate danger zone who had felt the quake had assimilated the TV coverage into their own fear response (Demir et al., 2010). Like Catani et al (2008), this study demonstrated the need to consider the region and circumstances in which the disaster occurred, including what impact the infrastructure - or lack thereof may have had on PTSD rates (Demir et al., 2010). In this situation, there were high mortality rates, which were attributed in part to the social, political and economic conditions of the region (Demir et al., 2010). Following Hurricane Andrew, which hit Florida in 1992, Vernberg, La Greca, Silverman and Prinstein (1996) conducted research to test their integrative conceptual model of PTSD, which involved four primary factors: exposure to traumatic events, individual child characteristics, access to social support and childrens coping ability. Their results showed that only 14% of children expressed no PTSD symptoms, and 30% reported severe or very severe symptoms (Prinstein et al., 1996; Vernberg et al., 1996). They determined that 62% of PTSD symptoms could be accounted for by their model (Vernberg et al., 1996). They also found that exposure to traumatic events during the hurricane was the most critical factor in predicting symptoms, though they recognized that the type of exposure children experienced was itself related to other factors (such as social support and SES) (Vernberg et al., 1996). They found little evidence to support any ethnic differences (that could not be better accounted for by exposure), but as predicted, found that more girls were diagnosed than boys (Vernberg et al., 1996). Access to social support was shown to be positively correlated with the childs ability to cope effectively, and that parental support, including modeling coping behaviors, giving comfort and providing safety and security, was most

CHILDHOOD PSTD AFTER NATURAL DISASTER important (Vernberg et al., 1996). Peers offered social support and teachers were able to provide security, return to routine and information all of which also was related to decreased severity of PTSD symptoms (Vernberg et al., 1996). PTSD Factors One of the factors related to the development and severity of PTSD symptoms that came up consistently across research was exposure to trauma. Studies have looked at the effect of prior traumatic exposure (Cohen et al., 2009; Catani et al., 2008) and the level of exposure during the event (Bui et al., 2010; Cohen et al. 2009). In both situations, more exposure was related to increased symptoms and severity. While an initial exposure to trauma led to few symptoms, there was a cumulative effect of additional trauma exposures, even if they type of trauma was unrelated (Catani et al., 2008). Cohen et al. (2009) found that even though some children rated a previous event as more traumatic than the current disaster event, it was the disaster event that triggered the PTSD symptoms. In these situations, careful assessment is important, if the true source of the trauma is to be understood and treated. During the disaster, greater exposure in terms of duration and severity, and witnessing loved ones in life threatening situations were key factors in predicting PTSD symptoms. Distress during the event, including levels of fear, helplessness and horror were predictors of later PTSD symptoms as well (Bui et al., 2010). Of note with regards to trauma exposure is the relationship between such exposure and other environmental and family conditions. For instance, it may be the case that factors (such as low SES or substance abuse) that contribute to or predict family violence, are the same that contribute to increased traumatic exposure during an event. Understanding the role exposure plays in predicting PTSD in children post-disaster allows for better screening and provides insight into ways in which PTSD in such situations could be prevented or minimized.

CHILDHOOD PSTD AFTER NATURAL DISASTER A second common factor was the effect of conditions specific to the affected regions. This included political, cultural, economic and geographic factors which all impacted how the ecological system functioned before, during and after the disaster (Betancourt & Khan, 2008). In general, the predictive nature of these factors was related to how they contributed to the stability of the region, which was related to PTSD symptomology (Demir et al., 2010). Just as each natural disaster is unique, so are the circumstances in which it occurred, and often what is left in its wake is ongoing chaos, including increase criminal behaviours, disruption of social networks, separation of families, overcrowding, secondary health issues and the interruption of regular service systems (Betancourt & Khan, 2008). After Hurricane Katrina, Weems et al. (2010) found that even as long as thirty months after the disaster, PTSD symptoms in youth had not reduced, in large part due to the reality that their living environments were still in chaos, and most systems had not returned to normal. Cohen et al., (2009) found that delayed evacuation after the Tsunami, meaning more time spent enduring poor conditions, predicted increased PTSD symptoms. After the Marmara earthquakes, the high mortality rates were linked directly to poor infrastructure, and with increased mortality rates came increased exposure to trauma for the many children involved (Demir et al., 2010). A large scale disaster interrupts the entire ecological system which can have lasting effects on the development of the children involved, and the uniqueness of each ecological system makes it difficult to avoid such disruptions in the face of disaster. A third factor that was addressed in many studies was individual child characteristics. In general, there is consistent support that girls are more likely to develop PTSD after a natural disaster, perhaps in part due to their greater tendency to internalize, and in some cultures, due gender roles and expectations (Demir et al., 2010; Vernberg et al., 1996). Younger children are more at risk than adolescents. Augustyn & Groves (2005) hypothesized this was due to a younger

CHILDHOOD PSTD AFTER NATURAL DISASTER childs inability to comprehend cause and effect, which made them feel more helpless and uncertain of how they could protect themselves. There has been little evidence that ethnicity is a factor, as most of the variance in rates can be accounted for due to other factors (such as poverty, ability to evacuate, and subsequent exposure to the disaster) (Vernberg et al., 1996). Also related to individual child characteristics are resiliency factors related to PTSD, including high intelligence, religious practice, loving parenting, sense of future, internal locus of control and good coping skills (Betancourt & Khan, 2008) . Pina et al. (2008) studied Hurricane Katrina survivors and compared children with avoidant coping behaviors (blame, anger, social withdrawal) and children who used active coping behaviours (cognitive restructuring, problem focused). They found that avoidant coping style helped to predict PTSD, but interestingly, active coping did not serve as a protective factor (Pina et al., 2008). They hypothesized this may be due to the nature of the situation, and whether active coping strategies were reasonable under the circumstances (Pina et al., 2008). Vernberg et al. (1996) found a high positive correlation between high levels of distress and a greater use of all coping mechanisms, with social withdrawal having the highest correlations with PTSD symptoms. Although the value and impact of positive coping skills may not be clearly determined yet by the research, the negative impact of poor skills, such as social withdrawal are well documented. A final factor that appeared across studies was the value of social support. After Hurricane Andrew, children with strong social support were able to cope more effectively, and their access to social services was a significant predictor of PTSD symptoms severity (Vernberg et al., 1996). In the wake of Hurricane Katrina, social support from sources outside of the family (teachers, friends, church members) predicted lower levels of PTSD symptoms, as did professional support (Pina et al., 2008). One difference between these two studies is that Vernberg et al. (1996) found that

CHILDHOOD PSTD AFTER NATURAL DISASTER parental support had the greatest impact, while Pina et al. (2008) found social support outside the home made more of a difference. One reason for this difference could be the unique nature of the Katrina disaster, including the large number of families that were separated and the high levels of trauma for the entire family after the event, perhaps leaving parents with fewer resources or higher stress levels (Kelley et al., 2010). Another reason could be that while parental support is a positive factor, it factored equally for both children with and without PTSD symptoms, thereby not registering a significant effect (Pina et al., 2008). In general, the usefulness of social support depends upon the source and the type of support offered, which considering the different variables involved, lends credence to the idea that having multiple sources of support, in a variety of places (home, school, community, church) is in the best interest of the child (Vernberg et al., 1996). After the Disaster Of course, research into the factors related to the development of PSTD in children following a natural disaster is done in order to understand how best to support those children and offer them the best hope for successful outcomes. For many disorders, one area to look into is prevention. In this case, it is obvious that natural disasters cannot be prevented, but in many cases the severity of them can be mitigated. As weve seen, PTSD rates are connected the severity of exposure and the chaos experienced in the aftermath, which are factors that can be at least partially controlled through planning and infrastructure. More emphasis, however, has been placed on screening and intervention for children immediately following the disaster. Early intervention is critical, since left untreated, children with high levels of immediate symptoms are twelve times more likely to develop sustained, severe, PTSD symptoms (Kelley et al., 2010). Experts recommend screening for both pre-existing child characteristics that are known to be risk factors and for those who were known to have high trauma

CHILDHOOD PSTD AFTER NATURAL DISASTER exposure during the event (Augustyn & Groves, 2005; Chembot, Nakashima & Carlson, 2002). One instrument that has been tested for use is the Child PTSD Symptom Scale (CPSS), which is a self-report instrument designed specifically for children, that maps directly onto the DSM-IV-TR criteria (Foa, Johnson, Feeny, & Treadwell, 2001). Initial studies have shown that it is both reliable and valid after an acute stressor, and adapts to a variety of individual and group settings (Foa et al., 2001). Intervention strategies stress the value of family and school based interventions. Family interventions are important, as this is where children spend the majority of their time, and support can help with adjustment as well as foster healthy relationships within the family (Gerwirtz, Forgatch, & Wieling, 2008). Family interventions also allow for individualized care. As the parents are trained and supported, they are better able to meet their childs individual needs (Gerwirtz, Forgatch, & Wieling, 2008). School based interventions meet the need for children to return to a stable, predictable routine, and offer opportunities for structured activities such as drawing, play therapy, dance and drama, which can be useful in helping children to process information (Vijayakurmar et al., 2006). There are challenges with all of these interventions. The treatment of psychological needs is often not a part of the initial response after a disaster, and changing that protocol taps into economic and political factors. One suggestion by Chembot et al. (2002) is to pre-train school and public health personnel, who would have a reasonable expectation to remain after the disaster and to be the first-responders to screen and begin to address the needs they find. Cohen et al. (2009) agreed that schools were a good venue, but that personnel were not prepared, and due to the unpredictable nature of natural disasters, training and preparation would essentially have to be universal for an event that may never occur. Despite the funding and logistical obstacles of

CHILDHOOD PSTD AFTER NATURAL DISASTER implementing immediate psychological intervention following a disaster, the need is still present and important. Conclusion Research into posttraumatic stress disorder in children who have experienced a natural disaster is a small, but growing field of study. There are many challenges in pursuing research in this area, including access to children in the wake of such a crisis, ethical considerations of conducting research during a crisis, cultural and ethnic differences, and having appropriate infrastructure in place to support the research design (Demir et al., 2010; Pina et al., 2008). Despite these obstacles, this remains an important field of study. The long-term effects of PTSD on a child are substantial and pervasive (Weems et al., 2010). There are risks to academic development, as children struggle with concentration and memory (Augustyn & Groves, 2005). Social development is hindered by withdrawal, anti-social behaviors, increased substance abuse and lack of interest in activities (Augustyn & Groves, 2005). Physical development is hampered by sleep difficulties, headaches, chronic pain and nightmares (Augustyn & Groves, 2005). Knowing the effects, it is easy to see the need for good screening methods and timely intervention in the wake of a natural disaster, which requires a thorough understanding of the factors that contribute to the development of PTSD in children following a natural disaster.

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