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Mental health problems among children and adolescents experiencing two major earthquakes in remote mountainous regions: A longitudinal study
Mental Health Problems among Children and Adolescents Experiencing two Major Earthquakes in Remote Mountainous Regions: A Longitudinal Study Wanjie Tang, Jingdong Zhao, Yi Lu, Tingting Yan, Lijuan Wang, Jun Zhang, Jiuping Xu PII: DOI: Reference:
S0010-440X(16)30436-9 doi: 10.1016/j.comppsych.2016.09.004 YCOMP 51742
To appear in:
Comprehensive Psychiatry
Please cite this article as: Tang Wanjie, Zhao Jingdong, Lu Yi, Yan Tingting, Wang Lijuan, Zhang Jun, Xu Jiuping, Mental Health Problems among Children and Adolescents Experiencing two Major Earthquakes in Remote Mountainous Regions: A Longitudinal Study, Comprehensive Psychiatry (2016), doi: 10.1016/j.comppsych.2016.09.004
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Mental Health Problems among Children and Adolescents Experiencing two Major Earthquakes in Remote Mountainous Regions: A Longitudinal
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Wanjie Tang M.D., Ph.D.,abc Jingdong Zhao Ph.D.,a Yi Lu Ph.D.,a Tingting Yan M.D.,
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Ph.D.,cd Lijuan Wang M.D., Ph.D.,e Jun Zhang M.D., Ph.D., c* Jiuping Xu Ph.D. a*
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Institute of Emergency Management and Reconstruction in Post-disaster, Sichuan University,
Chengdu, China b
Centre for Educational and Health Psychology, Sichuan University, Chengdu, China
Mental Health Center, State Key Lab of Biotherapy, West China Hospital, Sichuan University,
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c
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Chengdu, China
School of Post-disaster Reconstruction and Management, Sichuan University, Chengdu, China
e
Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People’
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d
*
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Hospital, Chengdu China
J. Xu and J. Zhang contributed equally to the work and are joint corresponding authors.
Correspondence to J. Xu : Institute of Emergency Management and Reconstruction in Post-disaster Sichuan University No. 24, South Section 1, Yihuan Road Wuhou District, 610065, Chengdu, Sichuan, P. R. China Tel: +86- 02885415143 E-mail: [email protected]
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Mental Health Problems among Children and Adolescents Experiencing two Major Earthquakes in Remote Mountainous Regions: A Longitudinal
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Study
Wanjie Tang M.D., Ph.D.,abc Jingdong Zhao Ph.D.,a Yi Lu Ph.D.,a Tingting Yan M.D.,
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Ph.D.,cd Lijuan Wang M.D., Ph.D.,e Jun Zhang M.D., Ph.D., c* Jiuping Xu Ph.D. a*
a
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Institute of Emergency Management and Reconstruction in Post-disaster, Sichuan University,
Chengdu, China b
Centre for Educational and Health Psychology, Sichuan University, Chengdu, China
Mental Health Center, State Key Lab of Biotherapy, West China Hospital, Sichuan University,
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c
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Chengdu, China
School of Post-disaster Reconstruction and Management, Sichuan University, Chengdu, China
e
Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People’
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d
*
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Hospital, Chengdu China
J. Xu and J. Zhang contributed equally to the work and are joint corresponding authors.
Correspondence to J. Xu : Institute of Emergency Management and Reconstruction in Post-disaster, Sichuan University, Chengdu, China, Email: [email protected]; or to J. Zhang, Mental Health Center, State Key Lab of Biotherapy, West China Hospital of Sichuan University, Chengdu, China, Email: [email protected]
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Abstract
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Objective: Millions of children were exposed to major earthquake in China, with serious psychological and developmental consequences. To obtain accurate rate of post-disaster
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related disorder and identify predictors may help inform post-disaster rescue and rehabilitation efforts. The present longitudinal study explored correlations of demographic and socioeconomic characteristics of juvenile survivors of the Ya’an and Wenchuan
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earthquakes in China with their trajectories of post-disaster related disorder.
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Methods: A total of 435 Chinese children and adolescents who survived the 2013 Ya’an earthquake were recruited from six primary, secondary and high schools in Baoxing County.
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All survivors were assessed at 12 months after the disaster, when a trained psychiatrist
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assessed mental health problems in a face-to-face structured interview, and 153 survivors were followed up at 30 months after the earthquake via telephone. Results: The 12-month assessment indicated a post-traumatic stress disorder (PTSD) prevalence of 43.9% as well as depression (20.9%) or the criteria for both PTSD and depression (18.2%), the other disorder (0.9%). The 30-month assessment indicated that 15.7% of subjects met the criteria for PTSD, 21.6% met the criteria for depression. No subjects met the criteria for other affective or anxiety disorders. Significant predictors of PTSD and depression were death in the family, previous earthquake experience, a poor parent-child relationship and economic pressure or poverty.
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Limitations: Clinical interview face to face is quite different from via telephone and the attrition rate in the longitudinal cohort is high, which would directly affect our results of the
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assessment.
Conclusions: PTSD and depression may be as prevalent and persistent in disaster victims
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in China as elsewhere, and high co-comorbidities remains poorly understood. Although many adolescents recover over time, some exhibit chronic, delayed-onset PTSD and
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depression, especially those with poor relationships with their parents or those living in precarious economic conditions. Family-based therapy may be needed to support child and adolescent trauma survivors in order to prevent mental illness.
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Key words: PTSD; depression; longitudinal studies; clinical interview; adolescent survivors
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1. Introduction
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Just five years after the Wenchuan earthquake (8.0 on the Richter scale) struck southwest China in 2008, the region was hit by the Ya’an earthquake (7.0 on the Richter
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scale), which caused 217 deaths and 11,470 injuries, of which more than 968 were serious.
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At the earthquake’s epicenter in Baoxing County, just 82 km south of Wenchuan, 99% of houses were severely or completely destroyed, infrastructure was severely damaged, and schools were demolished. This vast devastation exposed children and adolescents to a wide variety of stressors, including threats to physical and psychological security, loss of loved ones, exposure to dead bodies and community disruption.
Natural disasters have been associated with a range of psychopathologies in survivors, including is post-traumatic stress disorder (PTSD), depressive disorder, and other disorder [1, 2] .
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However, the precise prevalence of PTSD among children and adolescents is still unclear. A previous meta-analysis of 34 studies involving 2,697 individuals suggests a rate of 36% [3].
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Past studies have also reported prevalence of 21% and 60% at 4-6 weeks and 6 months after earthquakes [4, 5]. Moreover, another study has demonstrated a PTSD diagnosis in
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30.7% of the adolescents 21 months after a major earthquake in Italy, and a diagnosis of partial PTSD in a further 31.4% of these subjects [6]. A cross-sectional study revealed that
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64.8% of children had significant symptoms of PTSD 18 months after the 2005 Kashmir earthquake in Pakistan [7]. A recent study has also found the high prevalence of probably 50% of severe post-traumatic symptoms in school-age children one year after the
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earthquake in Haiti [8]. The study by Kadak and his colleague suggested 40.69% of the
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adolescents reported severe levels of PTSD symptoms 6 months after the 2011 Van earthquake in Turkey [9]. In contrast, in a longitudinal study, the prevalence of PTSD
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symptoms after Hurricane assessed at 8 and 15 months were only 13% and 7%,
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respectively [10]. In addition, one Wenchuan earthquake study indicated that the rates of PTSD symptoms were 9.7%, 1.3% and 1.6% at the 6-, 12- and 18-month follow-ups, respectively [11]. These differences in prevalence may reflect the different intensities of the disasters involved and the different time points when subjects were assessed post-trauma. Another obstacle to reliably assessing post-disaster psychopathology is the reliance in the literature on self-report questionnaires to screen for psychological distress, usually administered by laypersons or well-trained research assistants [11-13]. More reliable information may come from studies based on clinical interviews with trained psychiatrists.
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Potential predictors of trauma-related disorders have also been extensively investigated. Previous work suggests that proximity to the epicenter of a disaster as well as the magnitude
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of the disaster reliably predict PTSD in children and adolescents [14, 15]. Several additional predictors of PTSD in children have been proposed, including low social support, fear during
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trauma, perceived life threat, social withdrawal, comorbid psychological problems, poor family functioning, and distraction [16]. However, little is known about how stressful
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experiences are transformed into maladaptive trauma-related disorders in child and adolescent survivors, or about factors that may render individuals more susceptible to such disorders longitudinally. Therefore more study is needed into possible predictors of
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trauma-related disorders among child and adolescent survivors in a relatively long period
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after the trauma.
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Together, there are very little systematic studies for trauma and disaster research, while
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we are the majority of the world’s population. The present study aimed to deepen insights into the prevalence, course, and predictors of PTSD, depression and other mental health problems in children and adolescents who survived the 2013 Ya’an earthquake and, in many cases, the 2008 Wenchuan earthquake. Subjects were analyzed at 12 and 30 months after the Ya’an earthquake in a clinical interview conducted by a trained psychiatrist. This allowed us to document the course of psychological distress in survivors, in contrast to most previous studies based on cross-sectional analysis. Possible correlations of demographic, economic and family factors with risk of post-traumatic psychopathology were explored.
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2. Methods 2.1. Participants
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This longitudinal study included Chinese children and adolescents who survived the 2013 Ya’an earthquake. Sampling was conducted in the six biggest schools including two
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primary, two secondary and two high school in Baoxing County. The total number of students in the six schools was about 220, 250, 1200, 700, 1280 and 1500, respectively. The
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local government and outside assistance took about two years after Ya’an earthquake to rebuild these schools. We randomly selected two classes per grade within each school. The
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number of each class ranged from 10 to 55 people.
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This project was approved by the Research Ethics Committee of Sichuan University, the Research Ethics Committee of the West China Hospital of Sichuan University, the Education
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Bureau of Baoxing County and has therefore been performed in accordance with the ethical
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standards laid down in the 1964 Declaration of Helsinki and its later amendments. In accordance with Chinese law, consent for this study was obtained from the subjects themselves as well as from the local education authority and the school administrators; parental consent was also required. Before each data collection session, participants were informed that their participation was voluntary and they had the right to withdraw from the study at any time without penalty.
The initial assessment was conducted between April 2, 2014 and May 10, 2014, approximately 12 months after the earthquake. Subjects were given a self-report
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questionnaire about the disaster experience, difficulties, which also included questions on demographic characteristics. In some cases, investigators helped the subjects (grade 3 to 6)
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complete the questionnaire because of their young age. After subjects completed the questionnaire, they underwent a clinical interview to assess the presence and severity of
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DSM-IV symptoms of PTSD, depression and other mental disorder. At 30 months after the earthquake, between October 11, 2015 and November 17, 2015, parents of subjects or
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caregiver were contacted by telephone, the follow-up procedure was explained to them, and the parents or caregiver gave oral consent for their children to participate. Subjects then completed the questionnaire about difficulties from 12 to 30 months and clinical interview via
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telephone; this assessment was identical to that conducted at 12 months, except that
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2.2. Measures
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subjects were not asked to assess their experience during the earthquake.
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Demographic data included age, gender, ethnic group, and school grade. Exposure to the Ya’an earthquake was measured using a self-report binary scale (yes/no) to assess whether the respondent (a) felt scared that he or she would die; (b) was in serious danger, such as because he or she was trapped or struck; (c) was seriously injured; (d) saw someone in serious danger, such as because he or she was trapped or struck; (e) witnessed someone being seriously injured; (f) witnessed someone getting buried or saw a dead body; (g) witnessed someone being killed; or (h) lost a family member. Respondents were asked about their life and experiences after the Ya’an earthquake, including difficulties at home, difficulties at school and poverty. They were also asked whether they had experienced the
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2008 Wenchuan earthquake.
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Subjects underwent a structured clinical interview based on the Kiddie Schedule for Affective Disorders and Schizophrenia (Kiddie-SADS-Present and Lifetime Version;
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K-SADS-PL, Version 1.0 of October 1996) [17] that shows good reliability and validity repeatedly used in Chinese sample [18-20] to screen mental health problems. A diagnosis
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was determined using DSM-IV criteria by combination of the KSADS and the Structured Clinical Interview for DSM-IV Childhood Diagnoses [2]. All three psychiatrists who can fluently speak both Mandarin Chinese and the local Sichuan dialect had at least 5 years of
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experience in general psychiatric practice. We conduct a between-interviewer agreement
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test before the formal interview until had 100% agreement in judging whether symptoms were present. In the formal interview, two psychiatrists co-interviewed the first ten subjects
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and attained between-interviewer agreements between 90% and 100%. For anything more
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complex, we discussed in group supervision. At the 12-month assessment, participants were interviewed by two psychiatrists (Jun Zhang and Tingting Yan) to screen for psychiatric disorders. At the 30-month assessment, participants were interviewed by telephone by two other psychiatrists (Jun Zhang and Wanjie Tang), and investigators helped to complete questionnaires about difficulties.
At the 12-month assessment, we advised subjects who met the criteria for PTSD or depression to take propranolol when they experienced PTSD symptoms and to engage in more physical exercise. These subjects’ parents or caregivers and teachers were also
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advised to devote more time and attention to helping the subjects cope with post-traumatic
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stress.
2.3. Data analysis
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Data were analyzed using SPSS 16.0 (IBM, Chicago, IL, USA). We used univariate descriptive statistics to evaluate participant characteristics and trauma exposure, as well as
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determine prevalence of symptoms of anxiety, depression, and PTSD. Chi-squared tests were used to assess the significance of inter-group differences in categorical variables, while t tests were used to assess inter-group differences in continuous variables.
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Regression analysis was used to assess bivariate associations between traumatic
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symptoms (anxiety, depression and PTSD) and each of the other variables. Logistic regression was performed to identify independent predictors of PTSD and other traumatic
3. Results
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symptoms. The threshold of significance was defined as p < 0.05.
3.1. Sample characteristics and trauma exposure Twelve classes of 460 students were selected to screen. Finally, a total of 435 Han Chinese children and adolescents were accepted to assess at 12 months after the earthquake and 153 were assessed again at 30 months after the earthquake (Table 1). The remaining subjects were not interviewed because the telephone number was no longer correct or was inactive (n = 156); because the parents refused to consent to follow up (n = 92); or because they did not answer the telephone (n = 34). In the longitudinal cohort of 153
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subjects who were assessed twice, 88 (57.5%) were female and the median age was 14
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years (mean, 13.7; SD, 2.3; range, 8-18 years).
To clarify the effect for missing data, we used chi-squared analysis to compare the PTSD
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and depression prevalence rates between group differences in the 12 month cohort for subjects followed up and those missed. There was no significant difference in PTSD
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(χ2=0.951; df =1; p=0.363) and depression (χ2=0.062; df=1; p=0.902) prevalence rates between these two groups, respectively, indicating that the attrition was unrelated to PTSD and
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depression and the data were missing randomly [21].
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All information about subjects’ self-report experiences of the Ya’an earthquake exposure was obtained at the 12-month assessment. Of the 435 participants, 92% directly witnessed
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traumatic events during the earthquake. Most (375, 86.2%) experienced extreme fear,
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several directly witnessed someone getting killed (58, 13.3%) or witnessed someone seriously injured (71, 16.3%), and relatively small numbers suffered serious physical injuries (11, 2.5%), lost a family member (40, 9.2%) or witnessed someone getting buried or saw a dead body (27, 6.2%). Types of experiences during the earthquake and difficulties afterwards are shown in Table 2 for the entire cohort at 12 months and for the longitudinal cohort that completed both the 12- and 30-month assessments. There were no significant gender difference among exposure and difficulties of child and adolescent survivors.
3.2. Prevalence of Mental Health Problems
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Mental health problems in child and adolescent survivors diagnosed by Psychiatrist using the Clinical Interview at two time points are shown in Table 3. At 12 months, based on
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structured clinical interview according to DSM-IV criteria, 191 subjects (43.9%) were diagnosed with PTSD, 91 (20.9%) with depressive disorders, 2 (0.45%) with panic disorder,
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1 (0.22%) with generalized anxiety disorder, and 1 (0.22%) with obsessive compulsive disorder. Among them, 108 (24.8%) subjects were PTSD-only, 12 (2.8%) depression-only,
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79 (18.2%) comorbid symptoms of PTSD and depression. None of the subjects met the criteria for other affective or anxiety disorders at this assessment and none of them reported
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suicidal behavior.
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Prevalence of PTSD and depression at 30 months was also assessed in the longitudinal cohort of 153 subjects. A total of 24 subjects (15.7%) met the criteria for PTSD and 33
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(21.6%) for depression. Among them, 11 (7.2%) subjects were PTSD-only, 20 (13.1%)
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depression-only, 13 (8.5%) comorbid symptoms of PTSD and depression. None of the subjects met the criteria for other mental health problems at 30-months assessment and no gender effects were found.
3.3. Predictors of Mental Health Problems Binary logistic regression was conducted to identify potential predictors of PTSD and depression (Table 4) respectively at 12 and 30 months after the earthquake. In the entire cohort assessed at 12 months, several factors were found to predict PTSD: exposure to the 2008 Wenchuan earthquake (OR 67.54, 95%CI, 22.93–198.96, p < 0.001), witnessing
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someone getting killed (OR 9.72, 95%CI 1.70–55.60, p = 0.011), and depression (OR 6.15, 95%CI 2.89–13.07, p < 0.001). Several factors were also found to predict depression:
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exposure to the 2008 Wenchuan earthquake (OR 4.92, 95%CI 1.52–15.95, p = 0.008); losing a family member (OR 2.27, 95%CI 1.05–4.93, p = 0.037); and experiencing PTSD
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(OR 5.92, 95%CI 2.81-12.48, p < 0.001).
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When we conducted the binary logistic regression for 153 subjects at 30 months, we identified several predictors of PTSD: witnessing someone getting seriously injured (OR 15.53, 95%CI 3.77-63.96, p < 0.001), witnessing someone getting killed (OR 6.91, 95%CI
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1.77-26.93, p = 0.005), economic pressure or poverty (OR 6.15, 95%CI 1.72-21.97, p =
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0.005), and quarreling with parents or feeling neglected (OR 5.39, 95%CI 1.53-18.92, p = 0.009). We also identified several predictors of depression: witnessing someone getting
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buried or seeing a dead body (OR 8.13, 95%CI 1.44-45.93, p = 0.018), losing a family
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member (OR 13.25, 95%CI 2.59-67.77, p = 0.002), quarreling with parents or feeling neglected (OR 4.68, 95%CI 1.73-12.66, p = 0.002), and economic pressure or poverty (OR 9.03, 95%CI 3.19-25.57, p < 0.001). At both the 12- and 30-month assessments, subjects who met the criteria for PTSD or depression reported not having received any counseling or medication for earthquake-related stress. This is despite the fact that we advised such subjects at the 12-month assessment to take propranolol when they experienced severe PTSD symptoms. This reluctance to take medication may reflect shame at having a psychological disorder.
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4. Discussion This study extends the literature on the course of Mental Health Problems among
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Chinese children and adolescents at 12 and 30 months after two major natural disasters. In our cohort, post-traumatic stress reactions were quite common at 12 months after a major
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earthquake and decreased significantly from 12 to 30 months after the earthquake. Although the prevalence of depression fell slightly though not significantly from 12 to 30 months, about
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15% of samples developed depression between 12 and 30 months. Our data also demonstrated that symptoms of PTSD and depression were highly comorbid in our cohort both at two time points indicating that children and adolescent with comorbid symptoms may
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be a distinct high-risk group after disasters. Our results may help in the design of
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psychological rehabilitation and prevention strategies for adolescents after earthquakes.
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Published estimates of PTSD prevalence among children and adolescents at 1-2 years
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of a natural disaster vary from 1.3% [11] to 95% [14]. Estimates are similarly broad even specifically among child and adolescent survivors of the Wenchuan earthquake, ranging from 1.3% [11] to 82.6% [22]. The prevalence in our cohort at 12 months after the Ya’an earthquake was 43.9%. While it is difficult to compare our interview-based prevalence with prevalence determined from self-report questionnaires, our prevalence is similar to the 37.4% reported in a study of 2,299 child and adolescent survivors in Baoxing County just six months after the Ya’an earthquake [23]. On the other hand, our prevalence is substantially higher than estimates of 1.3% [11], 8.6% [24], 5.7% [25] and 13.5 % [26] among child and adolescent survivors of the Wenchuan earthquake. A recent meta-analysis of data from
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diagnostic interviews concluded that approximately 10% of children and adolescents
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develop PTSD after exposure to non-interpersonal trauma [27].
Several factors may explain the apparently higher PTSD prevalence in our cohort
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following the 2013 Ya’an earthquake. One factor is exposure to the 2008 Wenchuan earthquake; such previous exposure can increase a young person’s risk of developing
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PTSD following a subsequent traumatic event [16]. Another explanation may be differences among the PTSD screening instruments and associated cut-off values used which increased risk of assessment bias and reduce the reliability of prevalence estimates. A third factor may
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be differences in the sample populations, such as age, gender distribution and intensity of
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traumatic distress. For example, the study reporting a 12-month PTSD prevalence of only 1.3% [11] among Wenchuan adolescent survivors was based on students from one grade
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(grade 11) at one high school that did not experience any deaths of students or students’
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family members during the earthquake.
Longitudinal studies are essential for a better understanding of the psychopathology of earthquake-related disorders. Only a handful of studies have longitudinally examined PTSD symptomatology among child and adolescent survivors of the Wenchuan or Ya’an earthquakes [11, 23, 26, 28]. The drop in PTSD from 43.9% to 15.7% in our study is consistent with the natural progression of untreated PTSD but most studies indicate untreated PTSD converts to depression in children and adolescents [29, 30]. One factor that contributed to recovery may include the advice we gave to parents, school principals and
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teachers about how to help children deal with psychological distress or personal loss. Another factor may be the relatively efficient medical and emergency assistance response to
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the Ya’an earthquake, reflecting the lessons learned from the 2008 Wenchuan earthquake. Thus, we cannot rule out that at least some of our subjects recovered from PTSD naturally
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(without treatment), which would be important to investigate in order to establish whether
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early treatment leads to better outcomes than delayed or no treatment.
After PTSD, depression is the second most common psychopathological response after this earthquake. Approximately 20% of our cohort met the criteria for depression at 12 and
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30 months. The prevalence of depression in our cohort is within the wide range reported
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after the Wenchuan and other earthquakes, including a prevalence of probable depression of 42.5% at 12 months after the Wenchuan earthquake [24], prevalence of depressive
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symptoms of 19.5% at 10 months after the Wenchuan earthquake [31], a prevalence of
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46.21% of depression at 30 months after the Haiti earthquake, prevalence of 13.7% at 32 months after the 1999 Parnitha earthquake in Greece [32], and prevalence of 37.7% at 6 months after the Van earthquake in Turkish [33]. The fact that depression prevalence was lower in our cohort than in several other reports may reflect previous studies’ reliance on cut-off points on self-report depression questionnaires, which can lead to higher estimates of PTSD and depression than estimates based on clinical interviews [34]. At the same time, the discrepancy among our and previous studies likely also reflects the broad range of reported prevalence in the literature on child and adolescent survivors of traumatic events. A systematic review of such prevalence from nine studies based on diagnostic interviews
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reported a range from 1.6 to 33% [35]. This wide range may reflect heterogeneity in sample populations, type of screening instruments and follow-up time. Future studies are needed to
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better understand the course of depression after an earthquake.
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In our cohort, our data provide strong evidence that PTSD and depression can occur long after a disaster, and most of these co-morbidities recovered by 30 months after
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earthquake. Establishing whether PTSD and depression occur independently after trauma is difficult, in part because their causes and mechanisms appear to overlap [36]. Future studies should clarify how the independently diagnosed conditions of depression and PTSD may
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co-occur and interact in child and adolescent survivors after disasters.
We aimed to determine what specific aspects of trauma exposure may have contributed
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to PTSD or depression development in our cohort. We found that witnessing someone
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getting killed or witnessing someone seriously injured could predicted PTSD at 12 or 30 months, consistent with previous studies indicating that level of exposure to trauma could consistently predict subsequent PTSD symptoms [16, 37, 38]. Our study also identified economic pressure or poverty and quarreling with parents or feeling neglected as predictors of PTSD and depression at 30 moths. In our cohort, losing a family member or witnessing someone’s death during the earthquake were risk factors for depression at both 12 and 30 months, consistent with previous studies [25, 39]. These results are consistent with reports that disruption in social support networks after trauma are associated with psychopathology [38, 40]. Specifically, the family plays a major role in helping the child adjust to most forms of
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trauma. A poor relationship with parents and poverty may increase risk of psychological problems because these conditions are usually chronic and are associated with lower social
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support, self-esteem, and interest or participation in day-to-day activities [41, 42]. These results also suggest that the experience of fear that exceeds the coping ability of children
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and adolescents may increase risk of post-traumatic depression, perhaps by altering the
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normal fear circuitry [43] and impairing the process of fear extinction [44].
Results in our cohort are not consistent with previous reports that girls are more likely than boys to develop PTSD and depression after nature disasters [11, 37, 45]. It may be that
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gender is associated with PTSD or depression only following specific types of disaster, and
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that other variables mediate this association. For example, one meta-analysis indicated that gender may influence risk of PTSD or depression much more after interpersonal trauma
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than after a natural disaster [46]. Further study is needed to explore in detail the potential
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involvement of gender in post-traumatic psychopathology.
4.1 Conclusions and Limitations This study adds to the literature on earthquake-related PTSD and depression developmental trajectories and related predictors. The data also provide a window into the course of PTSD and depression in child and adolescent survivors. Nevertheless, the study has several limitations. Firstly, clinical interview face to face is quite different from via telephone, which would directly affect the results of the assessment and telephone interviews probably elicit a lower response rate than face-to-face surveys. Secondly, the
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attrition rate of this study is high, which lead to the small sample size of the longitudinal subgroup. Thus, our results should be interpreted in caution. In conclusion, despite these
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limitations, our results present very important and significant information about youths who have experienced two major earthquakes in remote mountainous regions. In areas such as
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this, there is normally very little professional participation; screening and diagnosis for PTSD and depression is very rare. To organize the materials and to present them for international
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publication is even rarer. Our effort made such an attempt which the world can have a better understanding of morbidity and comorbidity in the aftermath of major disasters.
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Acknowledgments
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This work was supported by grants to Dr. Wanjie Tang from the Young Teacher’s Fund of Sichuan University (2014SCU11066), the China Postdoctoral Science Foundation (0050207602056) and the
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Applied Psychology Research Center of Chengdu Medical College (CSXL-151203).
Conflict of interest
The authors declare that they have no conflict of interest.
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2011 Van earthquake. Comprehensive psychiatry. 2013;54:982-90.
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[15] Groome D, Soureti A. Post‐traumatic stress disorder and anxiety symptoms in children exposed to the 1999 Greek
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American Academy of Child & Adolescent Psychiatry. 1997;36:980-8. [18] Ma X, Liu X, Hu X, Qiu C, Wang Y, Huang Y, et al. Risk indicators for post-traumatic stress disorder in adolescents exposed to the 5.12 Wenchuan earthquake in China. Psychiatry Research. 2011;189:385-91. [19] Chong M-Y, Chan K-W, Cheng A. Substance use disorders among adolescents in Taiwan: prevalence, sociodemographic correlates and psychiatric co-morbidity. Psychological medicine. 1999;29:1387-96. [20] Wu GH-M, Chong M-Y, Cheng AT, Chen TH-H. Correlates of family, school, and peer variables with adolescent substance use in Taiwan. Social science & medicine. 2007;64:2594-600. [21] Rubin DB. Inference and missing data. Biometrika. 1976;63:581-92. [22] Zhang Y, Ho SM. Risk factors of posttraumatic stress disorder among survivors after the 512 Wenchuan earthquake in China. PLoS one. 2011;6:e22371. [23] Zhang J, Zhu S, Du C, Zhang Y. Posttraumatic stress disorder and somatic symptoms among child and adolescent survivors following the Lushan earthquake in China: A six-month longitudinal study. Journal of psychosomatic research. 2015;79:100-6. [24] Ying L-h, Wu X-c, Chen C. Prevalence and predictors of posttraumatic stress disorder and depressive symptoms among child survivors 1 year following the Wenchuan earthquake in China. European child & adolescent psychiatry. 2013;22:567-75. [25] Liu M, Wang L, Shi Z, Zhang Z, Zhang K, Shen J. Mental health problems among children one-year after Sichuan
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earthquake in China: a follow-up study. PloS one. 2011;6:e14706. [26] Fan F, Long K, Zhou Y, Zheng Y, Liu X. Longitudinal trajectories of post-traumatic stress disorder symptoms among adolescents after the Wenchuan earthquake in China. Psychological medicine. 2015;45:2885-96. [27] Alisic E, Zalta AK, Van Wesel F, Larsen SE, Hafstad GS, Hassanpour K, et al. Rates of post-traumatic stress disorder in
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[30] Kolaitis G, Kotsopoulos J, Tsiantis J, Haritaki S, Rigizou F, Zacharaki L, et al. Posttraumatic stress reactions among children following the Athens earthquake of September 1999. European Child & Adolescent Psychiatry. 2003;12:273-80. [31] Wang W, Fu W, Wu J, Ma X-c, Sun X-l, Huang Y, et al. Prevalence of PTSD and depression among junior middle school
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students in a rural town far from the epicenter of the Wenchuan earthquake in China. PloS one. 2012;7:e41665. [32] Goenjian AK, Roussos A, Steinberg AM, Sotiropoulou C, Walling D, Kakaki M, et al. Longitudinal study of PTSD, depression, and quality of life among adolescents after the Parnitha earthquake. Journal of affective disorders. 2011;133:509-15.
[33] McKercher C, Patton GC, Schmidt MD, Venn AJ, Dwyer T, Sanderson K. Physical activity and depression symptom profiles in young men and women with major depression. Psychosomatic medicine. 2013;75:366-74. [34] Myers K, Winters NC. Ten-year review of rating scales. II: Scales for internalizing disorders. Journal of the American
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overlapping symptoms in diagnostic comorbidity. The Journal of nervous and mental disease. 2001;189:548-51. [37] Alisic E, Jongmans MJ, van Wesel F, Kleber RJ. Building child trauma theory from longitudinal studies: A meta-analysis. Clinical psychology review. 2011;31:736-47.
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[38] Pine DS, Cohen JA. Trauma in children and adolescents: Risk and treatment of psychiatric sequelae. Biological psychiatry. 2002;51:519-31.
[39] Goenjian AK, Walling D, Steinberg AM, Roussos A, Goenjian HA, Pynoos RS. Depression and PTSD symptoms among bereaved adolescents 6½ years after the 1988 spitak earthquake. Journal of affective disorders. 2009;112:81-4. [40] Salmon K, Bryant RA. Posttraumatic stress disorder in children: The influence of developmental factors. Clinical psychology review. 2002;22:163-88. [41] Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research. Psychological bulletin. 2006;132:959. [42] Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®): American Psychiatric Pub; 2013. [43] Keding TJ, Herringa RJ. Abnormal structure of fear circuitry in pediatric post-traumatic stress disorder. Neuropsychopharmacology. 2015;40:537-45. [44] Pitman RK, Rasmusson AM, Koenen KC, Shin LM, Orr SP, Gilbertson MW, et al. Biological studies of post-traumatic stress disorder. Nature Reviews Neuroscience. 2012;13:769-87. [45] Giannopoulou I, Strouthos M, Smith P, Dikaiakou A, Galanopoulou V, Yule W. Post-traumatic stress reactions of children and adolescents exposed to the Athens 1999 earthquake. European Psychiatry. 2006;21:160-6. [46] Olff M, Langeland W, Draijer N, Gersons BP. Gender differences in posttraumatic stress disorder. Psychological bulletin. 2007;133:183.
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cohort
(12
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Entire months)
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Table 1. Demographic characteristics of Han Chinese child and adolescent survivors of the Ya’an earthquake, stratified by entire cohort evaluated at 12 months and a longitudinal subgroup evaluated at 12 and 30 months
N
%
65
42.5
88
57.5
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N
Variable Boy
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(n = 435)
%
Longitudinal subgroup (12 and 30 months)* (n = 153)
Mean
SD
13.7
2.3
8.3
8.1
2.0
182
41.8
Girl
253
58.2
Mean
SD
Age
14.
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0
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Grade
2.3 2.1
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*Age and grade refer to 12 months after the earthquake.
Table 2. Features of traumatic exposure of Han Chinese child and adolescent survivors of the Ya’an
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earthquake, stratified by entire cohort evaluated at 12 months and a longitudinal subgroup evaluated at 12 and 30 months a
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Feature During the earthquake
girl/boy(χ2) girl/boy(χ2)
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(N = 435) n (%) n (%)
Longitudinal subgroup* Longitudinal subgroup (12 months) (N = 153) (30 months) (N = 153) n (%) girl/boy(χ2)
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Entire cohort(12 months)
3(2.0)
2/1(0.09)
99(22.8)
58/41(0.01)
45(29.4)
25/20(0.179)
71(16.3)
34/37(3.68)
24(15.7)
12/12(0.781)
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6/5(0.061)
27(6.2)
13/14(1.186)
11(7.2)
4/7(2.316)
58(13.3)
34/24(0.006)
25(16.3)
14/11(0.058)
40(9.2)
23/17(0.008)
11(7.2)
7/4(0.146)
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Saw someone in serious danger Witnessing someone seriously injured Witnessing someone get buried Witnessing someone getting killed Lost a family member
11(2.5)
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Was seriously injured
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Was scared that he or she 375(86.2) 219/156(0.064) 139(90.8) 82/57(0.403) would die Was in serious danger 42(9.7) 21/21(1.272) 20(13.1) 13/7(0.441)
55/42(0.235)
Quarreling with parents or 28(6.4) 10/18(6.196) 18 (11.8) neglected Economic pressure or 241(55.4) 133/108(1.964) 57(37.4) poverty Difficulties at school:
7/11(3.117)
Disputes with classmates or 117(26.9) being bullied
14/14(0.94)
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Preexisting exposure to 2008 275(63.2) 154.121(1.435) 97(16.3) earthquake Difficulties since the Ya’an earthquake Difficulties at home
a
74/43(1.702)
28(18.3)
32/25(0.154)
36(23.5) 22/14(0.167) 50(32.7) 33/17(1.871) 27(17.6) 19/8(2.006)
There were no significant gender difference among exposure and difficulties of child and adolescent survivors. *Results refer to the subgroup of the entire cohort that was assessed at both 12 and 30 months
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Table 3. Mental Health Problems in child and adolescent survivors diagnosed by Psychiatrist using the Clinical Interview a
a
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PT
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Entire cohort (12 months) Longitudinal subgroup* Longitudinal subgroup (N = 435) (12 months) (N = 153) (30 months) (N = 153) n(%) girl/boy(χ2) n(%) 2 2 Diagnosis girl/boy(χ ) n(%) girl/boy(χ ) PTSD total 191(43.9) 114/77(0. 72(47.1) 44/28(0.48) 325) 24(15.7) 14/10(0.001) Depression total 91(20.9) 51/40(0.2 31(20.3) 15/16(1.53) 12) 33(21.6) 19/14(0.006) PTSD only 108(24.8) 68/40(1.3 43(28.1) 30/13(3.3) 61) 11(7.2) 8/3(1.032) Depression only 12(2.8) 7/5(0.001 2(1.3) 1/1(0.056) ) 20(13.1) 13/7(0.441) Comorbid PTSD and 79(18.2) 44/35(0.2 29(19.0) 14/15(1.44) 6/7 depression 41) 13(8.5) (0.843) Panic disorder Comorbid 2(0.45) 1/1 with PTSD Generalized anxiety disorder 1(0.22) 0/1 comorbid with PTSD Obsessive compulsive 1(0.22) 1/0 disorder comorbid with PTSD There were no significant gender difference among mental health problems of child and adolescent survivors. *Results refer to the subgroup of the entire cohort that was assessed at both 12 and 30 months.
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Table 4. Logistic regression to identify risk factors of PTSD and depression in child and adolescent survivors at 12 or 30 months after the Ya’an earthquake
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12 months
30 months
OR 95%CI P OR 95%CI P Variable Preexisting 67.540 22.928-198.958 <0.001 ------exposure to 2008 Wenchuan earthquake Witnessing 9.715 1.698-55.598 0.011 6.905 1.770-26.932 0.005 someone getting killed Witnessing ------15.530 3.770-63.964 <0.001 someone getting seriously injured Economic pressure ------6.153 1.724-21.968 0.005 or poverty Quarreling with ------5.386 1.534-18.916 parents or feeling neglected 0.009 Depression 6.149 2.892-13.072 <0.001 ------Depression Preexisting exposure to 4.92 ------2008 Wenchuan earthquake 3 1.519-15.954 0.008 Witnessing someone ------1.438-45.931 0.018 being buried or saw a dead body 8.128 Lost a family member 2.27 1.05-4.925 2.591-67.766 0.002 4 0.037 13.251 Quarreling with ------1.728-12.664 0.002 parents or feeling neglected 4.678 Economic pressure or ------3.190-25.566 poverty 9.031 <0.001 PTSD 5.92 ----3 2.811-12.482 <0.001 ---
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PTSD
S0010-440X(16)30436-9 doi: 10.1016/j.comppsych.2016.09.004 YCOMP 51742
To appear in:
Comprehensive Psychiatry
Please cite this article as: Tang Wanjie, Zhao Jingdong, Lu Yi, Yan Tingting, Wang Lijuan, Zhang Jun, Xu Jiuping, Mental Health Problems among Children and Adolescents Experiencing two Major Earthquakes in Remote Mountainous Regions: A Longitudinal Study, Comprehensive Psychiatry (2016), doi: 10.1016/j.comppsych.2016.09.004
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Mental Health Problems among Children and Adolescents Experiencing two Major Earthquakes in Remote Mountainous Regions: A Longitudinal
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Study
Wanjie Tang M.D., Ph.D.,abc Jingdong Zhao Ph.D.,a Yi Lu Ph.D.,a Tingting Yan M.D.,
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Ph.D.,cd Lijuan Wang M.D., Ph.D.,e Jun Zhang M.D., Ph.D., c* Jiuping Xu Ph.D. a*
a
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Institute of Emergency Management and Reconstruction in Post-disaster, Sichuan University,
Chengdu, China b
Centre for Educational and Health Psychology, Sichuan University, Chengdu, China
Mental Health Center, State Key Lab of Biotherapy, West China Hospital, Sichuan University,
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c
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Chengdu, China
School of Post-disaster Reconstruction and Management, Sichuan University, Chengdu, China
e
Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People’
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d
*
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Hospital, Chengdu China
J. Xu and J. Zhang contributed equally to the work and are joint corresponding authors.
Correspondence to J. Xu : Institute of Emergency Management and Reconstruction in Post-disaster Sichuan University No. 24, South Section 1, Yihuan Road Wuhou District, 610065, Chengdu, Sichuan, P. R. China Tel: +86- 02885415143 E-mail: [email protected]
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Mental Health Problems among Children and Adolescents Experiencing two Major Earthquakes in Remote Mountainous Regions: A Longitudinal
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Study
Wanjie Tang M.D., Ph.D.,abc Jingdong Zhao Ph.D.,a Yi Lu Ph.D.,a Tingting Yan M.D.,
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Ph.D.,cd Lijuan Wang M.D., Ph.D.,e Jun Zhang M.D., Ph.D., c* Jiuping Xu Ph.D. a*
a
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Institute of Emergency Management and Reconstruction in Post-disaster, Sichuan University,
Chengdu, China b
Centre for Educational and Health Psychology, Sichuan University, Chengdu, China
Mental Health Center, State Key Lab of Biotherapy, West China Hospital, Sichuan University,
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c
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Chengdu, China
School of Post-disaster Reconstruction and Management, Sichuan University, Chengdu, China
e
Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People’
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d
*
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Hospital, Chengdu China
J. Xu and J. Zhang contributed equally to the work and are joint corresponding authors.
Correspondence to J. Xu : Institute of Emergency Management and Reconstruction in Post-disaster, Sichuan University, Chengdu, China, Email: [email protected]; or to J. Zhang, Mental Health Center, State Key Lab of Biotherapy, West China Hospital of Sichuan University, Chengdu, China, Email: [email protected]
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Abstract
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Objective: Millions of children were exposed to major earthquake in China, with serious psychological and developmental consequences. To obtain accurate rate of post-disaster
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related disorder and identify predictors may help inform post-disaster rescue and rehabilitation efforts. The present longitudinal study explored correlations of demographic and socioeconomic characteristics of juvenile survivors of the Ya’an and Wenchuan
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earthquakes in China with their trajectories of post-disaster related disorder.
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Methods: A total of 435 Chinese children and adolescents who survived the 2013 Ya’an earthquake were recruited from six primary, secondary and high schools in Baoxing County.
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All survivors were assessed at 12 months after the disaster, when a trained psychiatrist
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assessed mental health problems in a face-to-face structured interview, and 153 survivors were followed up at 30 months after the earthquake via telephone. Results: The 12-month assessment indicated a post-traumatic stress disorder (PTSD) prevalence of 43.9% as well as depression (20.9%) or the criteria for both PTSD and depression (18.2%), the other disorder (0.9%). The 30-month assessment indicated that 15.7% of subjects met the criteria for PTSD, 21.6% met the criteria for depression. No subjects met the criteria for other affective or anxiety disorders. Significant predictors of PTSD and depression were death in the family, previous earthquake experience, a poor parent-child relationship and economic pressure or poverty.
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Limitations: Clinical interview face to face is quite different from via telephone and the attrition rate in the longitudinal cohort is high, which would directly affect our results of the
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assessment.
Conclusions: PTSD and depression may be as prevalent and persistent in disaster victims
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in China as elsewhere, and high co-comorbidities remains poorly understood. Although many adolescents recover over time, some exhibit chronic, delayed-onset PTSD and
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depression, especially those with poor relationships with their parents or those living in precarious economic conditions. Family-based therapy may be needed to support child and adolescent trauma survivors in order to prevent mental illness.
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Key words: PTSD; depression; longitudinal studies; clinical interview; adolescent survivors
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1. Introduction
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Just five years after the Wenchuan earthquake (8.0 on the Richter scale) struck southwest China in 2008, the region was hit by the Ya’an earthquake (7.0 on the Richter
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scale), which caused 217 deaths and 11,470 injuries, of which more than 968 were serious.
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At the earthquake’s epicenter in Baoxing County, just 82 km south of Wenchuan, 99% of houses were severely or completely destroyed, infrastructure was severely damaged, and schools were demolished. This vast devastation exposed children and adolescents to a wide variety of stressors, including threats to physical and psychological security, loss of loved ones, exposure to dead bodies and community disruption.
Natural disasters have been associated with a range of psychopathologies in survivors, including is post-traumatic stress disorder (PTSD), depressive disorder, and other disorder [1, 2] .
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However, the precise prevalence of PTSD among children and adolescents is still unclear. A previous meta-analysis of 34 studies involving 2,697 individuals suggests a rate of 36% [3].
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Past studies have also reported prevalence of 21% and 60% at 4-6 weeks and 6 months after earthquakes [4, 5]. Moreover, another study has demonstrated a PTSD diagnosis in
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30.7% of the adolescents 21 months after a major earthquake in Italy, and a diagnosis of partial PTSD in a further 31.4% of these subjects [6]. A cross-sectional study revealed that
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64.8% of children had significant symptoms of PTSD 18 months after the 2005 Kashmir earthquake in Pakistan [7]. A recent study has also found the high prevalence of probably 50% of severe post-traumatic symptoms in school-age children one year after the
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earthquake in Haiti [8]. The study by Kadak and his colleague suggested 40.69% of the
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adolescents reported severe levels of PTSD symptoms 6 months after the 2011 Van earthquake in Turkey [9]. In contrast, in a longitudinal study, the prevalence of PTSD
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symptoms after Hurricane assessed at 8 and 15 months were only 13% and 7%,
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respectively [10]. In addition, one Wenchuan earthquake study indicated that the rates of PTSD symptoms were 9.7%, 1.3% and 1.6% at the 6-, 12- and 18-month follow-ups, respectively [11]. These differences in prevalence may reflect the different intensities of the disasters involved and the different time points when subjects were assessed post-trauma. Another obstacle to reliably assessing post-disaster psychopathology is the reliance in the literature on self-report questionnaires to screen for psychological distress, usually administered by laypersons or well-trained research assistants [11-13]. More reliable information may come from studies based on clinical interviews with trained psychiatrists.
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Potential predictors of trauma-related disorders have also been extensively investigated. Previous work suggests that proximity to the epicenter of a disaster as well as the magnitude
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of the disaster reliably predict PTSD in children and adolescents [14, 15]. Several additional predictors of PTSD in children have been proposed, including low social support, fear during
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trauma, perceived life threat, social withdrawal, comorbid psychological problems, poor family functioning, and distraction [16]. However, little is known about how stressful
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experiences are transformed into maladaptive trauma-related disorders in child and adolescent survivors, or about factors that may render individuals more susceptible to such disorders longitudinally. Therefore more study is needed into possible predictors of
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trauma-related disorders among child and adolescent survivors in a relatively long period
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after the trauma.
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Together, there are very little systematic studies for trauma and disaster research, while
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we are the majority of the world’s population. The present study aimed to deepen insights into the prevalence, course, and predictors of PTSD, depression and other mental health problems in children and adolescents who survived the 2013 Ya’an earthquake and, in many cases, the 2008 Wenchuan earthquake. Subjects were analyzed at 12 and 30 months after the Ya’an earthquake in a clinical interview conducted by a trained psychiatrist. This allowed us to document the course of psychological distress in survivors, in contrast to most previous studies based on cross-sectional analysis. Possible correlations of demographic, economic and family factors with risk of post-traumatic psychopathology were explored.
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2. Methods 2.1. Participants
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This longitudinal study included Chinese children and adolescents who survived the 2013 Ya’an earthquake. Sampling was conducted in the six biggest schools including two
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primary, two secondary and two high school in Baoxing County. The total number of students in the six schools was about 220, 250, 1200, 700, 1280 and 1500, respectively. The
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local government and outside assistance took about two years after Ya’an earthquake to rebuild these schools. We randomly selected two classes per grade within each school. The
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number of each class ranged from 10 to 55 people.
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This project was approved by the Research Ethics Committee of Sichuan University, the Research Ethics Committee of the West China Hospital of Sichuan University, the Education
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Bureau of Baoxing County and has therefore been performed in accordance with the ethical
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standards laid down in the 1964 Declaration of Helsinki and its later amendments. In accordance with Chinese law, consent for this study was obtained from the subjects themselves as well as from the local education authority and the school administrators; parental consent was also required. Before each data collection session, participants were informed that their participation was voluntary and they had the right to withdraw from the study at any time without penalty.
The initial assessment was conducted between April 2, 2014 and May 10, 2014, approximately 12 months after the earthquake. Subjects were given a self-report
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questionnaire about the disaster experience, difficulties, which also included questions on demographic characteristics. In some cases, investigators helped the subjects (grade 3 to 6)
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complete the questionnaire because of their young age. After subjects completed the questionnaire, they underwent a clinical interview to assess the presence and severity of
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DSM-IV symptoms of PTSD, depression and other mental disorder. At 30 months after the earthquake, between October 11, 2015 and November 17, 2015, parents of subjects or
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caregiver were contacted by telephone, the follow-up procedure was explained to them, and the parents or caregiver gave oral consent for their children to participate. Subjects then completed the questionnaire about difficulties from 12 to 30 months and clinical interview via
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telephone; this assessment was identical to that conducted at 12 months, except that
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2.2. Measures
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subjects were not asked to assess their experience during the earthquake.
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Demographic data included age, gender, ethnic group, and school grade. Exposure to the Ya’an earthquake was measured using a self-report binary scale (yes/no) to assess whether the respondent (a) felt scared that he or she would die; (b) was in serious danger, such as because he or she was trapped or struck; (c) was seriously injured; (d) saw someone in serious danger, such as because he or she was trapped or struck; (e) witnessed someone being seriously injured; (f) witnessed someone getting buried or saw a dead body; (g) witnessed someone being killed; or (h) lost a family member. Respondents were asked about their life and experiences after the Ya’an earthquake, including difficulties at home, difficulties at school and poverty. They were also asked whether they had experienced the
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2008 Wenchuan earthquake.
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Subjects underwent a structured clinical interview based on the Kiddie Schedule for Affective Disorders and Schizophrenia (Kiddie-SADS-Present and Lifetime Version;
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K-SADS-PL, Version 1.0 of October 1996) [17] that shows good reliability and validity repeatedly used in Chinese sample [18-20] to screen mental health problems. A diagnosis
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was determined using DSM-IV criteria by combination of the KSADS and the Structured Clinical Interview for DSM-IV Childhood Diagnoses [2]. All three psychiatrists who can fluently speak both Mandarin Chinese and the local Sichuan dialect had at least 5 years of
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experience in general psychiatric practice. We conduct a between-interviewer agreement
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test before the formal interview until had 100% agreement in judging whether symptoms were present. In the formal interview, two psychiatrists co-interviewed the first ten subjects
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and attained between-interviewer agreements between 90% and 100%. For anything more
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complex, we discussed in group supervision. At the 12-month assessment, participants were interviewed by two psychiatrists (Jun Zhang and Tingting Yan) to screen for psychiatric disorders. At the 30-month assessment, participants were interviewed by telephone by two other psychiatrists (Jun Zhang and Wanjie Tang), and investigators helped to complete questionnaires about difficulties.
At the 12-month assessment, we advised subjects who met the criteria for PTSD or depression to take propranolol when they experienced PTSD symptoms and to engage in more physical exercise. These subjects’ parents or caregivers and teachers were also
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advised to devote more time and attention to helping the subjects cope with post-traumatic
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stress.
2.3. Data analysis
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Data were analyzed using SPSS 16.0 (IBM, Chicago, IL, USA). We used univariate descriptive statistics to evaluate participant characteristics and trauma exposure, as well as
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determine prevalence of symptoms of anxiety, depression, and PTSD. Chi-squared tests were used to assess the significance of inter-group differences in categorical variables, while t tests were used to assess inter-group differences in continuous variables.
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Regression analysis was used to assess bivariate associations between traumatic
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symptoms (anxiety, depression and PTSD) and each of the other variables. Logistic regression was performed to identify independent predictors of PTSD and other traumatic
3. Results
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symptoms. The threshold of significance was defined as p < 0.05.
3.1. Sample characteristics and trauma exposure Twelve classes of 460 students were selected to screen. Finally, a total of 435 Han Chinese children and adolescents were accepted to assess at 12 months after the earthquake and 153 were assessed again at 30 months after the earthquake (Table 1). The remaining subjects were not interviewed because the telephone number was no longer correct or was inactive (n = 156); because the parents refused to consent to follow up (n = 92); or because they did not answer the telephone (n = 34). In the longitudinal cohort of 153
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subjects who were assessed twice, 88 (57.5%) were female and the median age was 14
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years (mean, 13.7; SD, 2.3; range, 8-18 years).
To clarify the effect for missing data, we used chi-squared analysis to compare the PTSD
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and depression prevalence rates between group differences in the 12 month cohort for subjects followed up and those missed. There was no significant difference in PTSD
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(χ2=0.951; df =1; p=0.363) and depression (χ2=0.062; df=1; p=0.902) prevalence rates between these two groups, respectively, indicating that the attrition was unrelated to PTSD and
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depression and the data were missing randomly [21].
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All information about subjects’ self-report experiences of the Ya’an earthquake exposure was obtained at the 12-month assessment. Of the 435 participants, 92% directly witnessed
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traumatic events during the earthquake. Most (375, 86.2%) experienced extreme fear,
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several directly witnessed someone getting killed (58, 13.3%) or witnessed someone seriously injured (71, 16.3%), and relatively small numbers suffered serious physical injuries (11, 2.5%), lost a family member (40, 9.2%) or witnessed someone getting buried or saw a dead body (27, 6.2%). Types of experiences during the earthquake and difficulties afterwards are shown in Table 2 for the entire cohort at 12 months and for the longitudinal cohort that completed both the 12- and 30-month assessments. There were no significant gender difference among exposure and difficulties of child and adolescent survivors.
3.2. Prevalence of Mental Health Problems
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Mental health problems in child and adolescent survivors diagnosed by Psychiatrist using the Clinical Interview at two time points are shown in Table 3. At 12 months, based on
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structured clinical interview according to DSM-IV criteria, 191 subjects (43.9%) were diagnosed with PTSD, 91 (20.9%) with depressive disorders, 2 (0.45%) with panic disorder,
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1 (0.22%) with generalized anxiety disorder, and 1 (0.22%) with obsessive compulsive disorder. Among them, 108 (24.8%) subjects were PTSD-only, 12 (2.8%) depression-only,
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79 (18.2%) comorbid symptoms of PTSD and depression. None of the subjects met the criteria for other affective or anxiety disorders at this assessment and none of them reported
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suicidal behavior.
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Prevalence of PTSD and depression at 30 months was also assessed in the longitudinal cohort of 153 subjects. A total of 24 subjects (15.7%) met the criteria for PTSD and 33
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(21.6%) for depression. Among them, 11 (7.2%) subjects were PTSD-only, 20 (13.1%)
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depression-only, 13 (8.5%) comorbid symptoms of PTSD and depression. None of the subjects met the criteria for other mental health problems at 30-months assessment and no gender effects were found.
3.3. Predictors of Mental Health Problems Binary logistic regression was conducted to identify potential predictors of PTSD and depression (Table 4) respectively at 12 and 30 months after the earthquake. In the entire cohort assessed at 12 months, several factors were found to predict PTSD: exposure to the 2008 Wenchuan earthquake (OR 67.54, 95%CI, 22.93–198.96, p < 0.001), witnessing
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someone getting killed (OR 9.72, 95%CI 1.70–55.60, p = 0.011), and depression (OR 6.15, 95%CI 2.89–13.07, p < 0.001). Several factors were also found to predict depression:
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exposure to the 2008 Wenchuan earthquake (OR 4.92, 95%CI 1.52–15.95, p = 0.008); losing a family member (OR 2.27, 95%CI 1.05–4.93, p = 0.037); and experiencing PTSD
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(OR 5.92, 95%CI 2.81-12.48, p < 0.001).
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When we conducted the binary logistic regression for 153 subjects at 30 months, we identified several predictors of PTSD: witnessing someone getting seriously injured (OR 15.53, 95%CI 3.77-63.96, p < 0.001), witnessing someone getting killed (OR 6.91, 95%CI
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1.77-26.93, p = 0.005), economic pressure or poverty (OR 6.15, 95%CI 1.72-21.97, p =
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0.005), and quarreling with parents or feeling neglected (OR 5.39, 95%CI 1.53-18.92, p = 0.009). We also identified several predictors of depression: witnessing someone getting
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buried or seeing a dead body (OR 8.13, 95%CI 1.44-45.93, p = 0.018), losing a family
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member (OR 13.25, 95%CI 2.59-67.77, p = 0.002), quarreling with parents or feeling neglected (OR 4.68, 95%CI 1.73-12.66, p = 0.002), and economic pressure or poverty (OR 9.03, 95%CI 3.19-25.57, p < 0.001). At both the 12- and 30-month assessments, subjects who met the criteria for PTSD or depression reported not having received any counseling or medication for earthquake-related stress. This is despite the fact that we advised such subjects at the 12-month assessment to take propranolol when they experienced severe PTSD symptoms. This reluctance to take medication may reflect shame at having a psychological disorder.
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4. Discussion This study extends the literature on the course of Mental Health Problems among
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Chinese children and adolescents at 12 and 30 months after two major natural disasters. In our cohort, post-traumatic stress reactions were quite common at 12 months after a major
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earthquake and decreased significantly from 12 to 30 months after the earthquake. Although the prevalence of depression fell slightly though not significantly from 12 to 30 months, about
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15% of samples developed depression between 12 and 30 months. Our data also demonstrated that symptoms of PTSD and depression were highly comorbid in our cohort both at two time points indicating that children and adolescent with comorbid symptoms may
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be a distinct high-risk group after disasters. Our results may help in the design of
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psychological rehabilitation and prevention strategies for adolescents after earthquakes.
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Published estimates of PTSD prevalence among children and adolescents at 1-2 years
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of a natural disaster vary from 1.3% [11] to 95% [14]. Estimates are similarly broad even specifically among child and adolescent survivors of the Wenchuan earthquake, ranging from 1.3% [11] to 82.6% [22]. The prevalence in our cohort at 12 months after the Ya’an earthquake was 43.9%. While it is difficult to compare our interview-based prevalence with prevalence determined from self-report questionnaires, our prevalence is similar to the 37.4% reported in a study of 2,299 child and adolescent survivors in Baoxing County just six months after the Ya’an earthquake [23]. On the other hand, our prevalence is substantially higher than estimates of 1.3% [11], 8.6% [24], 5.7% [25] and 13.5 % [26] among child and adolescent survivors of the Wenchuan earthquake. A recent meta-analysis of data from
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diagnostic interviews concluded that approximately 10% of children and adolescents
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develop PTSD after exposure to non-interpersonal trauma [27].
Several factors may explain the apparently higher PTSD prevalence in our cohort
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following the 2013 Ya’an earthquake. One factor is exposure to the 2008 Wenchuan earthquake; such previous exposure can increase a young person’s risk of developing
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PTSD following a subsequent traumatic event [16]. Another explanation may be differences among the PTSD screening instruments and associated cut-off values used which increased risk of assessment bias and reduce the reliability of prevalence estimates. A third factor may
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be differences in the sample populations, such as age, gender distribution and intensity of
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traumatic distress. For example, the study reporting a 12-month PTSD prevalence of only 1.3% [11] among Wenchuan adolescent survivors was based on students from one grade
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(grade 11) at one high school that did not experience any deaths of students or students’
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family members during the earthquake.
Longitudinal studies are essential for a better understanding of the psychopathology of earthquake-related disorders. Only a handful of studies have longitudinally examined PTSD symptomatology among child and adolescent survivors of the Wenchuan or Ya’an earthquakes [11, 23, 26, 28]. The drop in PTSD from 43.9% to 15.7% in our study is consistent with the natural progression of untreated PTSD but most studies indicate untreated PTSD converts to depression in children and adolescents [29, 30]. One factor that contributed to recovery may include the advice we gave to parents, school principals and
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teachers about how to help children deal with psychological distress or personal loss. Another factor may be the relatively efficient medical and emergency assistance response to
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the Ya’an earthquake, reflecting the lessons learned from the 2008 Wenchuan earthquake. Thus, we cannot rule out that at least some of our subjects recovered from PTSD naturally
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(without treatment), which would be important to investigate in order to establish whether
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early treatment leads to better outcomes than delayed or no treatment.
After PTSD, depression is the second most common psychopathological response after this earthquake. Approximately 20% of our cohort met the criteria for depression at 12 and
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30 months. The prevalence of depression in our cohort is within the wide range reported
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after the Wenchuan and other earthquakes, including a prevalence of probable depression of 42.5% at 12 months after the Wenchuan earthquake [24], prevalence of depressive
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symptoms of 19.5% at 10 months after the Wenchuan earthquake [31], a prevalence of
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46.21% of depression at 30 months after the Haiti earthquake, prevalence of 13.7% at 32 months after the 1999 Parnitha earthquake in Greece [32], and prevalence of 37.7% at 6 months after the Van earthquake in Turkish [33]. The fact that depression prevalence was lower in our cohort than in several other reports may reflect previous studies’ reliance on cut-off points on self-report depression questionnaires, which can lead to higher estimates of PTSD and depression than estimates based on clinical interviews [34]. At the same time, the discrepancy among our and previous studies likely also reflects the broad range of reported prevalence in the literature on child and adolescent survivors of traumatic events. A systematic review of such prevalence from nine studies based on diagnostic interviews
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reported a range from 1.6 to 33% [35]. This wide range may reflect heterogeneity in sample populations, type of screening instruments and follow-up time. Future studies are needed to
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better understand the course of depression after an earthquake.
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In our cohort, our data provide strong evidence that PTSD and depression can occur long after a disaster, and most of these co-morbidities recovered by 30 months after
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earthquake. Establishing whether PTSD and depression occur independently after trauma is difficult, in part because their causes and mechanisms appear to overlap [36]. Future studies should clarify how the independently diagnosed conditions of depression and PTSD may
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co-occur and interact in child and adolescent survivors after disasters.
We aimed to determine what specific aspects of trauma exposure may have contributed
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to PTSD or depression development in our cohort. We found that witnessing someone
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getting killed or witnessing someone seriously injured could predicted PTSD at 12 or 30 months, consistent with previous studies indicating that level of exposure to trauma could consistently predict subsequent PTSD symptoms [16, 37, 38]. Our study also identified economic pressure or poverty and quarreling with parents or feeling neglected as predictors of PTSD and depression at 30 moths. In our cohort, losing a family member or witnessing someone’s death during the earthquake were risk factors for depression at both 12 and 30 months, consistent with previous studies [25, 39]. These results are consistent with reports that disruption in social support networks after trauma are associated with psychopathology [38, 40]. Specifically, the family plays a major role in helping the child adjust to most forms of
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trauma. A poor relationship with parents and poverty may increase risk of psychological problems because these conditions are usually chronic and are associated with lower social
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support, self-esteem, and interest or participation in day-to-day activities [41, 42]. These results also suggest that the experience of fear that exceeds the coping ability of children
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and adolescents may increase risk of post-traumatic depression, perhaps by altering the
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normal fear circuitry [43] and impairing the process of fear extinction [44].
Results in our cohort are not consistent with previous reports that girls are more likely than boys to develop PTSD and depression after nature disasters [11, 37, 45]. It may be that
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gender is associated with PTSD or depression only following specific types of disaster, and
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that other variables mediate this association. For example, one meta-analysis indicated that gender may influence risk of PTSD or depression much more after interpersonal trauma
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than after a natural disaster [46]. Further study is needed to explore in detail the potential
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involvement of gender in post-traumatic psychopathology.
4.1 Conclusions and Limitations This study adds to the literature on earthquake-related PTSD and depression developmental trajectories and related predictors. The data also provide a window into the course of PTSD and depression in child and adolescent survivors. Nevertheless, the study has several limitations. Firstly, clinical interview face to face is quite different from via telephone, which would directly affect the results of the assessment and telephone interviews probably elicit a lower response rate than face-to-face surveys. Secondly, the
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attrition rate of this study is high, which lead to the small sample size of the longitudinal subgroup. Thus, our results should be interpreted in caution. In conclusion, despite these
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limitations, our results present very important and significant information about youths who have experienced two major earthquakes in remote mountainous regions. In areas such as
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this, there is normally very little professional participation; screening and diagnosis for PTSD and depression is very rare. To organize the materials and to present them for international
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publication is even rarer. Our effort made such an attempt which the world can have a better understanding of morbidity and comorbidity in the aftermath of major disasters.
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Acknowledgments
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This work was supported by grants to Dr. Wanjie Tang from the Young Teacher’s Fund of Sichuan University (2014SCU11066), the China Postdoctoral Science Foundation (0050207602056) and the
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Applied Psychology Research Center of Chengdu Medical College (CSXL-151203).
Conflict of interest
The authors declare that they have no conflict of interest.
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[39] Goenjian AK, Walling D, Steinberg AM, Roussos A, Goenjian HA, Pynoos RS. Depression and PTSD symptoms among bereaved adolescents 6½ years after the 1988 spitak earthquake. Journal of affective disorders. 2009;112:81-4. [40] Salmon K, Bryant RA. Posttraumatic stress disorder in children: The influence of developmental factors. Clinical psychology review. 2002;22:163-88. [41] Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research. Psychological bulletin. 2006;132:959. [42] Association AP. Diagnostic and statistical manual of mental disorders (DSM-5®): American Psychiatric Pub; 2013. [43] Keding TJ, Herringa RJ. Abnormal structure of fear circuitry in pediatric post-traumatic stress disorder. Neuropsychopharmacology. 2015;40:537-45. [44] Pitman RK, Rasmusson AM, Koenen KC, Shin LM, Orr SP, Gilbertson MW, et al. Biological studies of post-traumatic stress disorder. Nature Reviews Neuroscience. 2012;13:769-87. [45] Giannopoulou I, Strouthos M, Smith P, Dikaiakou A, Galanopoulou V, Yule W. Post-traumatic stress reactions of children and adolescents exposed to the Athens 1999 earthquake. European Psychiatry. 2006;21:160-6. [46] Olff M, Langeland W, Draijer N, Gersons BP. Gender differences in posttraumatic stress disorder. Psychological bulletin. 2007;133:183.
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cohort
(12
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Entire months)
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Table 1. Demographic characteristics of Han Chinese child and adolescent survivors of the Ya’an earthquake, stratified by entire cohort evaluated at 12 months and a longitudinal subgroup evaluated at 12 and 30 months
N
%
65
42.5
88
57.5
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N
Variable Boy
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(n = 435)
%
Longitudinal subgroup (12 and 30 months)* (n = 153)
Mean
SD
13.7
2.3
8.3
8.1
2.0
182
41.8
Girl
253
58.2
Mean
SD
Age
14.
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0
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Grade
2.3 2.1
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*Age and grade refer to 12 months after the earthquake.
Table 2. Features of traumatic exposure of Han Chinese child and adolescent survivors of the Ya’an
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earthquake, stratified by entire cohort evaluated at 12 months and a longitudinal subgroup evaluated at 12 and 30 months a
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Feature During the earthquake
girl/boy(χ2) girl/boy(χ2)
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(N = 435) n (%) n (%)
Longitudinal subgroup* Longitudinal subgroup (12 months) (N = 153) (30 months) (N = 153) n (%) girl/boy(χ2)
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Entire cohort(12 months)
3(2.0)
2/1(0.09)
99(22.8)
58/41(0.01)
45(29.4)
25/20(0.179)
71(16.3)
34/37(3.68)
24(15.7)
12/12(0.781)
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6/5(0.061)
27(6.2)
13/14(1.186)
11(7.2)
4/7(2.316)
58(13.3)
34/24(0.006)
25(16.3)
14/11(0.058)
40(9.2)
23/17(0.008)
11(7.2)
7/4(0.146)
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Saw someone in serious danger Witnessing someone seriously injured Witnessing someone get buried Witnessing someone getting killed Lost a family member
11(2.5)
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Was seriously injured
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Was scared that he or she 375(86.2) 219/156(0.064) 139(90.8) 82/57(0.403) would die Was in serious danger 42(9.7) 21/21(1.272) 20(13.1) 13/7(0.441)
55/42(0.235)
Quarreling with parents or 28(6.4) 10/18(6.196) 18 (11.8) neglected Economic pressure or 241(55.4) 133/108(1.964) 57(37.4) poverty Difficulties at school:
7/11(3.117)
Disputes with classmates or 117(26.9) being bullied
14/14(0.94)
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Preexisting exposure to 2008 275(63.2) 154.121(1.435) 97(16.3) earthquake Difficulties since the Ya’an earthquake Difficulties at home
a
74/43(1.702)
28(18.3)
32/25(0.154)
36(23.5) 22/14(0.167) 50(32.7) 33/17(1.871) 27(17.6) 19/8(2.006)
There were no significant gender difference among exposure and difficulties of child and adolescent survivors. *Results refer to the subgroup of the entire cohort that was assessed at both 12 and 30 months
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Table 3. Mental Health Problems in child and adolescent survivors diagnosed by Psychiatrist using the Clinical Interview a
a
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Entire cohort (12 months) Longitudinal subgroup* Longitudinal subgroup (N = 435) (12 months) (N = 153) (30 months) (N = 153) n(%) girl/boy(χ2) n(%) 2 2 Diagnosis girl/boy(χ ) n(%) girl/boy(χ ) PTSD total 191(43.9) 114/77(0. 72(47.1) 44/28(0.48) 325) 24(15.7) 14/10(0.001) Depression total 91(20.9) 51/40(0.2 31(20.3) 15/16(1.53) 12) 33(21.6) 19/14(0.006) PTSD only 108(24.8) 68/40(1.3 43(28.1) 30/13(3.3) 61) 11(7.2) 8/3(1.032) Depression only 12(2.8) 7/5(0.001 2(1.3) 1/1(0.056) ) 20(13.1) 13/7(0.441) Comorbid PTSD and 79(18.2) 44/35(0.2 29(19.0) 14/15(1.44) 6/7 depression 41) 13(8.5) (0.843) Panic disorder Comorbid 2(0.45) 1/1 with PTSD Generalized anxiety disorder 1(0.22) 0/1 comorbid with PTSD Obsessive compulsive 1(0.22) 1/0 disorder comorbid with PTSD There were no significant gender difference among mental health problems of child and adolescent survivors. *Results refer to the subgroup of the entire cohort that was assessed at both 12 and 30 months.
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Table 4. Logistic regression to identify risk factors of PTSD and depression in child and adolescent survivors at 12 or 30 months after the Ya’an earthquake
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12 months
30 months
OR 95%CI P OR 95%CI P Variable Preexisting 67.540 22.928-198.958 <0.001 ------exposure to 2008 Wenchuan earthquake Witnessing 9.715 1.698-55.598 0.011 6.905 1.770-26.932 0.005 someone getting killed Witnessing ------15.530 3.770-63.964 <0.001 someone getting seriously injured Economic pressure ------6.153 1.724-21.968 0.005 or poverty Quarreling with ------5.386 1.534-18.916 parents or feeling neglected 0.009 Depression 6.149 2.892-13.072 <0.001 ------Depression Preexisting exposure to 4.92 ------2008 Wenchuan earthquake 3 1.519-15.954 0.008 Witnessing someone ------1.438-45.931 0.018 being buried or saw a dead body 8.128 Lost a family member 2.27 1.05-4.925 2.591-67.766 0.002 4 0.037 13.251 Quarreling with ------1.728-12.664 0.002 parents or feeling neglected 4.678 Economic pressure or ------3.190-25.566 poverty 9.031 <0.001 PTSD 5.92 ----3 2.811-12.482 <0.001 ---
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PTSD