Traumas and Posttraumatic Stress Disorder in a Community Population of Older Adolescents

/ Traumas and Posttraumatic Stress Disorder in a Community Population of Older Adolescents ROSE M. GIACONIA, PH.D., HELEN Z. REINHERZ, Sc.D., AMY B. SILVERMAN, B.A., BILGE PAKIZ, ED.M., ABBIE K. FROST, PH.D., AND ELAINE COHEN, PH.D.

ABSTRACT Objective: The prevalence of DSM-/II-R traumas and posttraumatic stress disorder (PTSD) and their impact on psy-

chosocial functioning were examined in a community population of older adolescents. Method: Subjects were 384 adolescents participating in an ongoing longitudinal study. When subjects were aged 18 years, the NIMH Diagnostic Interview Schedule, Version IIIR, was used to identify lifetime traumatic events and diagnoses of PTSD, major depression, phobias, and substance dependence. Behavioral, emotional, and academic functioning in later adolescence was evaluated through self-report measures and school records. Results: More than two fifths of adolescents experienced at least one DSM-/II-R trauma by age 18 years; PTSD developed in 14.5% of these affected youths or 6.3% of the total sample. Youths with PTSD demonstrated widespread impairment at age 18, including more overall behavioralemotional problems, interpersonal problems, academic failure, suicidal behavior, and health problems, as well as an increased risk for additional disorders. An equally striking finding was that youths who experienced traumas but did not develop PTSD also showed deficits in many of these areas when compared with their peers who had not experienced traumas. Conclusions: The substantial risk faced by youths in community settings for experiencing traumas and PTSD, along with associated impairments in later adolescence, underscores the need for programs of prompt intervention. J. Am. Acad. Child Ado/esc. Psychiatry, 1995,34,10:1369-1380. Key Words: trauma, PTSD, functioning, DSM-/II-R.

The introduction of posttraumatic stress disorder (PTSD) as a formal diagnostic category in DSM-III in 1980 stimulated renewed clinical and research interest in this disorder, especially its occurrence following a variety of traumas other than military combat (Helzer et al., 1987; McFarlane, 1991; Shore et al., 1986; Sutker et aI., 1991). Despite more than a decade of research using DSM-III and DSM-III-R criteria, little is known about the scope of traumatic experiences and PTSD among adolescents in community populations. Most prior research has focused on the emergence of PTSD or PTSD symptoms in groups who have already experienced specific traumas, such as survivors of natural disasters (Green et al., 1994; Shannon et al., 1994;

Accepted March 1, 1995. From the Early Adulthood Research Project, Simmons College School of Social Work. This research was supported by NIMH grant MH41569. Reprint requests to Dr. Giaconia, Simmons College School of Social Work, 51 Commonwealth Avenue, Boston, MA 02116.

0890-8567/95/3410-1369$03.00/0©1995 by the American Academy of Child and Adolescent Psychiatry.

Shore et aI., 1986), victims of sexual abuse (McLeer et aI., 1992) and crime (Kilpatrick et aI., 1987), and those witnessing or surviving mass shootings (North et al., 1994; Schwarz and Kowalski, 1991). The few investigations of PTSD in general community populations have been limited to cross-generational studies of adults aged 18 to over 90 (Davidson et aI., 1991; Helzer et al., 1987) or young adults in an urban area (Breslau et al., 1991). Information about the prevalence of traumas and PTSD in contemporary adolescent populations and their impact on later psychosocial functioning can alert clinicians and others working with adolescents to the level of risk faced by youths in community settings. Furthermore, an understanding of traumas and PTSD in adolescence can play an important role in developing early intervention and prevention strategies aimed at reducing long-term sequelae. The essential features for a diagnosis of PTSD according to DSM-III-R criteria are experiencing a distressing event outside the range of usual experience (such as serious threat or harm to oneself or witnessing

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:10, OCTOBER 1995

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GIA CONI A ET AI..

others being hun or killed) followed by at least six symptoms of at least 1 month 's duration from three symptom groups: (1) reexperiencing the traumatic event through flashbacks, intrusive thoughts, nightmares, or dreams; (2) numbing of responsiveness Ot avoidance of stimuli associated with the event; and (3) symptoms of arousal such as trouble concentrating or problems sleeping (American Psychiatric Association, 1987). There have been few community studies assessing the prevalence of a full range of traumas identified in DSM-III-R or the corresponding rates of PTSD associated with these diverse traumas. Recent community studies of young adults reported overall rates for experiencing any DSM-III-R trauma ranging from 39% (Breslau et al., 1991) to 84% (Vrana and Lauterbach, 1994). Lifetime prevalence rates of PTSD are substantially lower and have ranged from 1.0% to 1.3% (using DSM-III criteria) in the Epidemiologic Catchment Area (ECA) Program (D avidson et al., 1991; Hel zer et al., 1987) to 9.2 % (using DSM-III-R criteria) in adults aged 21 to 30 (Breslau et al., 1991). The need for studies of traumas and PTSD among contemporary adolescents in community populations is highlighted by growing evidence that cross-generational studies such as the ECA may mask a secular increase in exposure to traumas and PTSD (Cottler et al., 1992 ; Norris, 1992). These stu d ies may also underrepresent the level of risk for younger individuals because the retrospective reports of lifetime traumas by older respondents may reflect errors in recall about traumas and when they occurred (Norris, 1992). Recent studies of adults have demonstrated a differential risk for experiencing traumas and developing PTSD for males and females. Although males were rypically more likely to experience DSM-III or DSMfII-R traumas overall (Breslau et al., 1991 ; Norris, 1992; Vrana and Lauterbach, 1994), females exposed to traumas were mor e likely to meet all criteria for a PTSD diagnosis (Breslau et al., 1991; Cottier et al., 1992; Davidson et al., 1991). It remains to be shown whether this gender pattern holds true for adolescent populations. Studies of the impact of traumatic experiences and PTSD on psychosocial functioning provide compelling evidence of impairments in a variety ofdomains, including depressive and anxiety symptoms (Freeman et al., 1993; Saigh, 1988; Vrana and Lauterbach, 1994) ,

1370

behavior problems (McLeer et al., 1992; Saigh, 1988), social interaction problems (Davidson et al., 1991), poor school performance (Shannon et al., 1994), suicide attempts (Davidson er al., 1991) , and somatic complaints and sick days (Davidson et al., 1991; McFarlane, 1991; Rundell et al., 1989) . There is also strong evidence from both clinical and community studies that PTSD significantly increases the risk for experiencing other co-occurring disorders, especially major depression and alcohol or drug disorders (Breslau et al., 1991; Cottler et al., 1992; Davidson et al., 1991; Helzer et al., 1987; Keane and Wolfe, 1990; North et al., 1994; Rundell et al., 1989). The potential seriousness of traumas and PTSD documented by these studies underscores the need for examining their effects during the critical developmental period of adolescence. The current stu dy was designed to provide epidemiological information about exposure to traumas and PTSD in a community population of older adolescents. The threefold purpose was (1) to estimate the lifetime prevalence of traumatic events and PTSD overall and by gender; (2) to examine the relationship between the experience of traumas or a lifetime diagnosis of PTSD and current emotional, behavioral, social, and academic functioning at age 18; and (3) to assess the risk that traumas and PTSD posed for experiencing other DSM-III-R disorders.

METHOD Sample The 384 adolescents were particip ants in an ongoing longitudinal study that began in 1977 when subjects were 5 years old. Additional data collection waves occurr ed in 1981 (age 9), 1987 (age 15), and 1990 (age 18). Thi s report is based on the 1990 interviews with adolescents. The 1990 sample included 194 males and 190 females. M ost subjects were seniors in high school, with an average age of 17.9 . years. Almost all (99%) of the adolescents were white, and the socioeconomic status (SES) of their households was predom inately working class or lower-middle class (Reinherz er al., 1993a). T he original 1977 sample includ ed all youth s registering for kindergarten in one publi c school system who participated in statemand ated preschool testing of health, developmental, academic, and behavioral factors (N = 777) . T he school system was located in a predom inately white, working class community in the northeastern United States (Reinherz er al., 1993a ,b). Between 1977 and 1990, attrition occurred primarily in the early grades when students transferred from the publ ic school system to parochial schools; of the 763 enrolled in kindergarten (1978), 519 remained in the public schools for the grade 3 data collection (1981).

j . AM. ACAD. CHILD ADOLES C . PS YC HIA TRY, 34:10, OCTOB ER 199 5

TRAUMAS AN D I'TS D IN LATE ADOL ESC EN C E

Later data collection waves at ages 15 (I987) and 18 (I 99 0) targeted the 519 youths rema ining in the public school system through 1981. In 1987. 404 or 78% of yourh s last interviewed in 1981 part icipated; subjects were lost in this 6-year interval because th ey either moved from the area or declined to participate furth er. In 1990 , 95% of th ose inte rviewed in 1987 (or 74% of the targeted 519 subjects who continu ed in publ ic schools) remained in th e study at age 18 (Reinherz et al., 1993a,b). Analyses at each major data collection wave examined wheth er part icipant s differed from subjects lost to follow-up on dem ographic, behavioral, or emo tional £1cto rs. In 1981 (age 9) the subjects who co nt inued to parti cipate did not differ from those lost from the origin al 1977 sample by gender. SES, or preschool measures of development. health , and behavior problems. In 1987 (age 15), participants were not significantly different from subjects lost on age 9 variables such as gend er, SES, anxiety, and attenti on problems. In 1990 (at age 18), part icipants did not differ from nonparticipants on age 15 variables. including gender. SES, family struc ture, academic problems. anxiety, and attention problems (Reinherz et al., 1993a,b) . Alth ough these analyses cannot verify that participants did not differ from nonpartic ipants in any other imp ortant areas, such as traum as experienced, these results strongly suggest that the 1990 sampl e was not seriously compromised by selective attrition.

1986 ), a 10-item self-report measure appropriate for high schoo lage youths. Problems with int erpersonal relation ship s were assessed by using a six-item scale created by project staff (Int erperson al Problems Scale); th e ado lescents were asked how often during th e past 6 months they had exper ienced problem s such as not having peop le to depend on or having difficulti es communicating with others (Reinherz er al., 1993a). Subjects also provided an overall ~,ati ng ~f , ~he!r "Phys},cal h~alrh in the past year as "Ex~ellent." Goo d , Fair, or Poor and the average number of SIck days per month in past year. Suicidal ideation and lifetime suicide attempts were assessed by DIS-IIIR item s " H ave you ever felt so low you thought about co mmitting suicide?" and " Ha ve you ever atte mpted suicide?" High school course grades. taken from school tran scripts, provided a non-self-report measure of academic performance. School suspensions or expulsions in th e past year were established from both school records and self-reports. Co-Occurring Lifetime and Active DSM-III-R Disorders. The DIS IIIR also assessed lifetime and current diagnoses and ages of onset for five other disorders that might co-occur with PTSD: major depression, simple phobia. social ph obia . alcohol dependence. and dru g dependence. Disorders were considered to be current (active) if subjects who met lifetime criteria for a diso rder reported experiencing any key symptom s within I year before the intervi ew (Rob ins et al., 199 I).

Measures At age 18 (I990 ), measures included (I ) struc tured clinical int erview to assess traum as. PT SD . and other psychiat ric disorders; (2) self-ad ministered. standa rdized questionnaires evaluating current fun ctioning; and (3) school record s of academic performance. Traumas and P TSD. The NIMH Di agnostic Interview Schedule, Version IIIR (DIS -III R) (Robins er al., 1989). adm inistered to the ado lescents by 10 trained interviewers with research and/or clinical experience (Rein herz er al., 1993a), ident ified the types of traum as experienced and provid ed a lifetim e diagnosis of PTSD acco rdi ng ro DSM-lll-R crireria, as well as age of on set and duration. Using the DIS-lIIR PTSD modul e. the interviewer prompts for traum atic event s with the following: "A few people have terrible experiences that most people never go thr ough-things like being att acked , being in a flood or fire or bad traffic accident, being thre atened with a weapon, or seeing someo ne being badly injured or killed. Did something like this ever happen to you?" (Robins et al., 1989). Up to three events are recorded and coded by interviewers , and follow-up questions about symp tom s. onset, and recency are asked about any reported events that can be classified as "qualifying trauma s." The II categories of qu alifying traumas include military combat. rape, physical assault, seeing so meo ne hurt o r killed, disaster, threat, narro w escape, sud den inju ry o r accident, receiving news of sudden death o r injury of someone close, other person 's experience, and an "other event " categoty . Event s such as enduri ng family problems. chronic illness. and events depicted in movies are excluded as qu alifying traumas.

Analyses Features of traum as and PT SD examined included (I) prevalence of each type of DSM-III-R trau matic event, (2) relationship between types of trauma and PT SD crit eria, and (3) duration and age of onset of PTSD. Gender differences in trauma s and PTSD were assessed through X' tests, and odds ratios (O Rs) summarized the relative risk faced by each gende r. To examin e the relat ionsh ip of traum as and PT SD to fun ctioning in late adolescence . thr ee grou ps were co mpared: (I) PT SD diagn osis (n ~ 24) (adolescents who mer all criteria for DSM-III-R lifetime diagno sis of PT SD by age 18); (2) trauma only (n ~ 141 ) (adolescents who experienced qu alifying traumas but did not meet all criteria for lifetim e PT SD diagn osis); and (3) no traum a (n = 219) (subjects not reporting any qualifying traumas). Results are reported for both genders combined because initial analyses showed no significant gender by group interactions for any of these functioning variables. One-way analyses of variance with Tukey posr hoc comparisons and X2 tests were th e primary analytic techniques for these gender-combined analyses, The numbers and types of co-occurring DSM-III-R disorders o n both lifetime and active (I-year) basis were also compared for these three groups (PTSD , trauma only. no trauma) using overall and pairwise X' tests. In addi tion, the seq uencing of on set (using self-reported age of onset) was exami ned for disorders that cooccurred with PTSD .

La te Adolescent FUllction ing. C u rre n t behav iora l, cmorioual , aca-

demi c, and social functi on ing at age 18 years was assessed th rou gh self-report measures and schoo l record s. O verall emotional and behavioral fun ctioning was evaluated by the Total Problems scale of th e Youth Self-Report (YSR) (Achenbach and Edelbrock, 1987). It was also determined whether ado lescents scored in the " clinica l range" ( Ts core of67 o r greater) o n two bro ad categories of behavior probl ems: externalizing (delinq uent, aggressive) and intern alizing (withd rawn, an xious-depressed, soma tic co mplaints). Self-esteem was measured by the Rosenb erg Self-Esteem Scale (Rosenberg,

J.

RESULTS Prevalence of Traumas and PTSD

More than two fifths of adolescents in this community sample experienced qualifYing traumas by age 18 (T able 1). Twenty-four adolescents met criteria for a lifetime diagnosis of PTSD, which represents 6.3 % of

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TABLE 1 Types of Traumas and Posttraumatic Stress Disorder (PTSD) Criteria Met

n

<)10"

Met Criterion B (Reexperiencing Trauma) (<)lob)

165 8 25 49 5 8 6 40

43.0 2.1 6.5 12.8 1.3 2.1 1.6 10.4

50 4 8

13.0 1.0 2.1

Experienced Trauma Type of Trauma Any trauma Rape Physical assault Seeing someone hun or killed Natural disaster Threat Narrow escape Sudden injury or accident News of other's sudden death/accident Other event Other's experience n

b

Met Criterion C (Avoidance or Numbing)

(<)lob)

Met All Criteria for PTSD Diagnosis (Lifetime) (<)lob)

56.4 87.5 56.0 61.2 40.0 50.0 66.7 62.5

40.2 87.5 52.0 36.7 40.0 12.5 50.0 42.5

14.5 50.0 12.0 8.2 0.0 0.0 0.0 12.5

56.0 100.0 37.5

42.9 100.0 37.5

14.0 50.0 12.5

(<)lob)

Met Criterion D (Increased Arousal) (<)10 b)

70.3 100.0 72.0 73.5 40.0 12.5 66.7 72.5

19.4 62.5 28.0 20.4 20.0 0.0 33.3 22.5

72.0 100.0 62.5

20.0 50.0 25.0

Met Criterion E (2: 1 Month's Duration)

Percentage of total sample (n = 384) who reponed experiencing this trauma. Percentage of those experiencing trauma who met criterion.

the total sample and 14.5% of the 165 youths who experienced a qualifying trauma. With the notable exception of rape, there were few statistically significant differences among types of trauma in either the groups ofPTSD symptoms elicited or the risk posed for the subsequent development of PTSD (Table 1). Compared to all other traumas

Ages of Traumas and PTSD Onset and Duration

DSM-III-R traumas occurred by as early as age 14 for more than one fourth (26.8%) of the 165 affected adolescents; nearly 1 in 8 youths (12.2%) experienced these traumas before age 10. For the 24 adolescents who met all criteria for PTSD, the median age of onset of the disorder was 16, but the disorder developed

combined, adolescents who reported being raped were

in almost one third (29.2%) by age 14. The duration

8 times as likely to show symptoms of avoidance or numbing (OR = 8.02, X2 = 9.99, df = 1, P < .002), 12 times as likely to report that symptoms persisted for more than 1 month (OR = 11.51, X2 = 7.81, df= 1, P < .014), and 7 times as likely to meet all DSMlII-R criteria for a diagnosis of PTSD (OR = 6.85, X2 = 8.50, df = 1, P < .004). On average, youths reporting rape experienced nearly twice as many total lifetime symptoms as adolescents with all other traumas combined (means = 10.13 versus 5.48, t = 3.42, df = 163, P < .001). It is interesting that PTSD subsequently developed in two of the four adolescents whose traumas were coded as "other event," a rate comparable with that of rape. These other diverse events included parent being sent to prison, parent revealing a past suicide attempt, terminating a pregnancy, and events adolescents identified as terrible experiences but declined to describe ("can't talk about it").

of PTSD was substantial for these youths; for nearly two fifths (n = 9; 37.5%) PTSD symptoms lasted between 1 and 3 years.

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Gender Differences

Males and females were equally likely to have experienced a qualifying trauma (X 2 = .005, P < .94, not significant [NSJ) by age 18 (Table 2), and there were few differences in the types of traumas identified. Females were significantly more likely than males to report rape (4.2% versus 0%, X2 = 8.34, df = 1, p < .004) and receiving news of the sudden death or injury of someone close (16.8% versus 9.3%, X2 = 4.85, df= 1, P < .03), whereas males were more likely to recount that they had received threats (4.1% versus 0%, X2 = 8.00, df = 1, P < .005). There were no gender differences in the prevalence of other serious traumas, including physical assault, seeing someone hurt or injured, or experiencing a sudden injury or accident.

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TRAUMAS AND PTSD IN LATE ADOLESCENCE

TABLE 2 Prevalence of Traumas and Posttraumatic Stress Disorder (PTSD) by Gender Females (n = 190) % n

Males (n = 194) % n Experienced qualifying trauma Lifetime prevalence of PTSD If experienced trauma Met criterion B (reexperiencing trauma) Met criterion C (avoidance or numbing) Met crirerion D (increased arousal) Mer criterion E (2: I month's duration) Met all PTSD criteria

Odds Ratio (95% CI)" (Females:Males)

83 4

42.8 2.1

82 20

43.2 10.5***

1.02 (0.7-1.5) 5.59 (1.9-16.7)

48

57.8

68

82.9***

3.54 (1.7-7.3)

7

8.4

25

30.5***

4.76 (1.9-11.8)

40

48.2

53

64.6*

1.96 (1.1-3.7)

43 4

52.4 4.8

63 20

76.8** 24.4***

3.01 (1.5-5.9) 6.37 (2.1-19.6)

"CI = confidence inrerval. * p < .05; ** P < .01; *** P < .001, two-tailed.

Although males and females were equally likely to have experienced serious traumas, females were six times as likely to develop PTSD subsequently (Xl = 12.71, df = 1, P < .001). These marked gender differences in the likelihood of developing PTSD after trauma cannot be explained solely by differences in the types of traumas experienced by males and females; rather they reflect a consistent pattern by males to less frequently report every type of PTSD symptom group (Table 2). These results held true when examining traumas combined as well as individual traumas such as physical assault and seeing someone hurt or killed. Among the 24 youths who met all criteria for PTSD, however, there were no significant gender differences in duration and age of onset.

Relationship of Traumas and PTSD to Current Functioning

Higher SES youths (highest three Hollingshead categories) and lower SES youths (lowest two categories) (Hollingshead and Redlich, 1958) were compared on exposure to traumas. Results showed that higher SES

Adolescents with a lifetime diagnosis of PTSD demonstrated substantial and widespread impairment in almost every area of functioning examined at age 18; their functioning was unequivocally poorer than that of youths who had experienced no traumas (on 9 of 11 measures) and somewhat poorer than that of adolescents who had experienced traumas but did not meet full PTSD criteria (trauma-only group) (4 of 11 areas) (Tables 3 and 4). Also striking, but less pronounced, were the significant deficits shown by trauma-only youths compared to their peers without traumas (on 7 of 11 measures). These results held true for both males and females; earlier analyses showed no significant gender by group interactions for measures of adolescent functioning. PTSD versus No Trauma. Compared with adolescents who reported no DSM-III-R traumas (no-trauma group), youths with a lifetime diagnosis of PTSD reported significantly more overall problems on the

youths (42.1 %) were no more insulated from exposure

Total Behavior Problems scale of the YSR at age 18;

to traumas overall than their lower SES counterparts (44.5%) (Xl = 0.22, df= 1, P < .64, NS). Furthermore, higher SES youths were just as likely as lower SES youths to report serious specific traumas such as rape (2.1% versus 2.1 %, Xl = .05, df = 1, P < .99, NS) and physical assault (6.8% versus 6.3%, Xl = .05, p < .83, NS).

they were 4 times as likely to score in the clinical range on the YSR Internalizing Problems scale (Xl = 5.83, df = 1, P < .02) and 12 times as likely to reach clinical levels on YSR Externalizing Problems (X1 = 28.39, df = 1, p < .00l). Youths with a diagnosis of PTSD also reported significantly more problems in their interpersonal rela-

SES and Traumas

J.

AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 34:10, OCTOBER 1995

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GIACONIA ET AL.

TABLE 3 Psychosocial Functioning at Age 18 Years and Posttraumaric Stress Disorder (PTSD) and Traumas

Total Behavior Problems (YSR)b PTSD Trauma only No rrauma Inrerpersonal Problems PTSD Trauma only No trauma Self-Esteem (Rosenberg) PTSD Trauma only No trauma High school grade-poinr average PTSD Trauma only No trauma

Group Differences"

Mean

SD

FValue

56.08 51.10 48.38

9.72 8.45 8.16

11.61***

14.50 11.88 11.26

5.11 3.97 3.37

8.44***

P

30.75 32.09 32.71

5.40 4.02 4.22

2.78

None

1.97 2.18 2.45

0.86 0.80 0.74

7.67***

P
P > N,T T>N

> N,T

a Pairs of groups that differ significantly (p < .05) using Tukey post hoc tests. Groups: P = PTSD diagnosis (n = 24); T = trauma only (n = 141); N = no trauma (n = 219). b YSR = Youth Self-Report. *** p < .001, two-tailed.

tionships and were at substantially greater risk for suicidal thoughts (X 2 = 10.13, df = 1, P < .002) and suicide attempts. More than 1 in 6 PTSD youths, compared with less than 1 in 55 of the no-trauma group, reported at least one suicide attempt by age 18 (X2 = 14.96, df = 1, P < .001). Adolescents with PTSD also exhibited poorer wellbeing as evidenced by lower ratings of perceived health (X 2 = 14.64, df = 1, P < .001) and greater number of sick days per month (X 2 = 14.64, df = 1, P < .001). Their high school grade-point averages were significantly lower than those of no-trauma youths. PTSD versus Trauma Only. Youths with PTSD demonstrated significantly poorer functioning than their counterparts who had experienced traumas but did not develop PTSD on the YSR Total Problems and Interpersonal Problems scales. Youths with PTSD were also substantially more likely to score in the clinical range on both Internalizing (X 2 = 4.51, df = 1, P < .03) and Externalizing Problems (X 2 = 5.91, df = 1, P < .02). However, other key areas of late adolescent functioning such as academic performance, health, suicidal ideation, and suicide attempts did not differ significantly, suggesting that trauma-only adolescents were also at risk for problems in late adolescence.

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Trauma Only versus No Trauma. Although to a lesser degree than youths with PTSD, adolescents who experienced traumas but did not meet all criteria for PTSD showed important deficits in late adolescence when compared with their no-trauma peers. These trauma-only youths reported significantly more overall behavioral-emotional problems on the YSR and were nearly four times as likely to score in clinical range on Externalizing Problems (X 2 = 10.49, df = 1, P < .002). Trauma-only adolescents were also at higher risk for poor academic performance, suicidal ideation (X 2 = 4.60, df = 1, P < .03), suicide attempts (X 2 = 3.94, df = 1, p < .05), and poorer health (X2 = 8.75, df = 1, p < .003). Our preliminary analyses did not identify any significant gender by group (PTSD, trauma only, no trauma) interactions for measures oflate adolescent functioning. Additional analyses of just those youths who experienced traumas (83 males and 82 females) confirmed that males with traumas did not differ significantly from females with traumas on overall behavioral-emotional problems (t = 0.08, P < .94, NS), clinical levels of externalizing problems (X 2 = 0.04, df = 1, p < .86, NS), and suicidal behavior (X 2 = 0.27, P < .60, NS).

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TRAUMAS AND PTSD IN LATE ADOLESCENCE

TABLE 4 Functioning at Age 18 Years and Posttraumatic Stress Disorder (PTSD) and Traumas Aspect of Functioning

%

Clinical range on YSRc Internalizing Problems PTSD 16.75 Trauma only .0 No trauma 4.6 Clinical range on YSRc Externalizing Problems PTSD 33.3 Trauma only 13.5 No trauma 4.1 Thought about suicide PTSD 33.3 Trauma only 18.4 No trauma 10.5 Attempted suicide PTSD 16.7 Trauma only 5.7 No trauma 1.8 Rated health as "fair" or "poor" PTSD 37.5 Trauma only 21.3 No trauma 10.0 2: 3 Sick days/month in past year PTSD 25.0 Trauma only 12.2 No trauma 5.1 Suspended/expelled in past year PTSD 25.0 Trauma only 37.6 No trauma 26.9

SE

X'

Group Differences"

7.8 1.8 1.4

6.24*

P> N P>T

9.8 2.9 1.3

26.15***

P> N P>T T>N

11.67 (4.0-34.3) 3.21 (1.2-8.5) 3.63 (1.6-8.3)

9.8 3.3 2.1

11.20**

P> N T>N

4.26 (1.6-11.0) 1.93 (1.1-3.5)

7.8 2.0 0.9

13.20**

P> N T>N

ID.75 (2.5-46.3) 3.23 (1.0-10.9)

10.1 3.5 2.0

17.05***

P> N T>N

5.37 (2.1-13.7) 2.42 (1.3-4.4)

9.0 2.8 1.5

13.44**

P>N T>N

6.24 (2.1-18.9) 2.61 (1.2-5.8)

9.0 4.1 3.0

4.96

None

a Pairs of groups that differ significantly (p < .05) using Xl tests. Groups: P = PTSD diagnosis (n = 24); T N = no trauma (n = 219). b CI = confidence interval. cYSR = Youth Self-Report. * p < .05; ** P < .01; *** P < .001, two-tailed.

PTSD, Traumas, and Risk for Other Lifetime Psychiatric Disorders

PTSD and Other Disorders. A lifetime diagnosis of PTSD by age 18 significantly increased the risk of experiencing other lifetime psychiatric disorders by late adolescence (Table 5). Youths with PTSD were seven times as likely as no-trauma youths (X 2 = 17.60, df = 1, P < .001) and four times as likely as traumaonly adolescents (X 2 = 8.97, df= 1, P < .002) to meet DSM-III-R criteria for at least one of five other disorders. Particularly striking was the relationship between PTSD and major depression. More than two fifths of adolescents with PTSD, compared with fewer than 8% of their peers, met criteria for major depression by age 18 (X2 = 31.42, df = 1, p < .001). The J.

Odds Ratio (95% CI)/' 4.18 (1.2-14.5) 3.83 (1.02-14.3)

=

trauma only (n = 141);

corresponding ages of onset ofPTSD and major depression for the 10 youths who had both disorders revealed that PTSD preceded or emerged at the same age as major depression in 70% of these cases. Also noteworthy was the association between PTSD and serious substance dependence. For more than two thirds (66.7%, n = 4) of the adolescents with cooccurring PTSD and drug dependence and almost half (45.5%, n = 5) with co-occurring PTSD and alcohol dependence, the onset of PTSD preceded or occurred at the same age as the substance disorder. Traumas and Other Disorders. Although the traumaonly group was at no greater risk for major depression or phobias than the no-trauma group, they were at substantially greater risk for alcohol dependence (X2 = 10.77, df = 1, P < .001) and drug dependence (X 2 = 14.63, df = 1, P < .001).

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GIACONIA ET AL.

TABLE 5 Lifetime and Current (One-Year) Prevalence Rates of Other DSM-III-R Disorders Lifetime Diagnosis

DSM-III-R Disorder

%

SE

Group Differences"

Major depression PTSD 41.7 10.3*** Trauma only 9.2 2.4 No trauma 5.9 1.6 Simple phobia PTSD 29.2 9.5** Trauma only 12.1 2.8 No trauma 8.7 1.9 Social phobia PTSD 33.3 9.8* Trauma only 11.3 2.7 No trauma 14.6 2.4 Alcohol dependence PTSD 45.8 10.4*** Trauma only 31.4 3.9 No trauma 16.6 2.5 Drug dependence PTSD 25.0 9.0*** Trauma only 14.9 3.0 No trauma 3.7 1.3 One or more disorders" PTSD 79.2 8.5*** Trauma only 46.1 4.2 No trauma 34.7 3.2 Two or more disordersb PTSD 45.8 10.4*** Trauma only 23.4 3.6 No trauma 12.3 2.2 Three or more disordersb PTSD 33.3 9.8*** Trauma only 7.1 2.2 No trauma 2.3 1.0

Current (One-Year) Diagnosis Odds Ratio (95% CI)

%

SE

Group Differences"

Odds Ratio (95% CI)

P>N P>T

11.32 (4.2-30.3) 7.03 (2.6-18.9)

29.2 7.1 4.6

9.5*** 2.2 1.4

P>N P>T

8.61 (2.9-25.5) 5.39 (1.8-16.0)

P>N P>T

4.33 (1.6-11.8) 3.00 (1.1-8.3)

29.2 10.6 7.8

9.5** 2.6 1.8

P>N P>T

4.89 (1.8-13.4) 3.46 (1.2-9.7)

P> N P>T

2.92 (1.2-7.4) 3.91 (1.4-10.6)

29.2 10.6 12.3

9.5* 2.6 2.2

P>N P>T

2.93 (1.1-7.7) 3.46 (1.2-9.7)

P> N T>N

4.25 (1.8-10.2) 2.30 (1.4-3.8)

37.5 10.1** 27.9 3.8 15.7 2.5

P>N T>N

3.23 (1.3-7.9) 2.08 (1.2-3.5)

P> N T>N

8.80 (2.7-28.1) 4.62 (2.0-10.7)

20.8 12.8 1.8

8.5*** 2.8 0.9

P>N T>N

14.14 (3.5-57.1) 7.87 (2.6-23.8)

P>N P>T T>N

7.15 (2.6-19.8) 4.44 (1.6-12.6) 1.61 (1.04-2.5)

75.0 41.8 31.5

9.0*** 4.2 3.1

P>N P>T T>N

6.52 (2.5-17.2) 4.17 (1.6-11.1) 1.56 (1.1-2.4)

P>N P>T T>N

6.02 (2.5-14.8) 2.77 (1.1-6.8) 2.17 (1.2-3.8)

41.7 10.3*** 21.3 3.5 9.6 2.0

P>N P>T T>N

6.73 (2.7-17.0) 2.64 (1.1-6.5) 2.55 (1.4-4.7)

P> N P>T T>N

21.40 (6.3-73.0) 6.55 (2.3-18.9) 3.27 (1.1-9.8)

20.8 3.5 0.9

P>N P>T

28.55 (5.2-157.2) 7.16 (1.9-27.0)

= confidence interval; PTSD = posttraumatic stress disorder. Pairs of groups that differ significantly (p < .05) using X2 tests. Groups: P N = no trauma (n = 219). b Not counting PTSD. * P < .05; **P < .01; *** P < .001, two-tailed.

8.5*** 1.6 0.6

Note: CI

a

=

PTSD diagnosis (n

=

24); T

=

trauma only (n

=

141);

As shown in Table 5, a lifetime diagnosis of PTSD not only enhanced the risk for other disorders on a lifetime basis, but also substantially raised the risk for these disorders to be active within the past year.

shown that traumatic experiences and PTSD were strongly associated with a variety of difficulties in psychosocial functioning in late adolescence, including an increased risk for other co-occurring disorders. Our findings also pointed to important gender differences in response to traumatic events.

DISCUSSION

Prevalence of Traumas and PTSD

Our results demonstrated the substantial risk faced by youths in community settings for experiencing a range of DSM-III-R traumas. More importantly, it was

More than two fifths (43%) of adolescents in this working class community had experienced at least one lifetime DSM-III-R trauma by age 18 years, a rate

PTSD and Risk for Active Disorders

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TRAUMAS AND PT SD IN LATE ADOLES CEN CE

similar to that (39%) reported in a community study of older respondents (aged 21 to 30 years), also using the DIS-IIIR (Breslau et al., 1991). Although other community studies using different methods of assessing DSM-III-R traumas (checklists rather than the openended DIS-IIIR probe) have reported higher lifetime rates for adults and college undergraduates (Norris, 1992; Vrana and Lauterbach, 1994), our finding is striking because it demonstrates the sizable risk faced by contemporary youths in non urban community settings for experiencing events they perceive as "terrible experiences that most people never go through." The potential seriousness of these traumas is bolstered by our additional findings of a strong link between traumas and later psychosocial impairment. Twenty-four or 6.3% of adolescents in the current study met all DSM-III-R criteria for a lifetime diagnosis of PTSD, a rate somewhat lower than the 9.2% identified in a community study of young adults in an urban setting (Breslau et al., 1991), but in excess of the rate of 1.0% to 1.3% reported in the ECA community studies of adults aged 18 to over 90 (Davidson et al., 1991; Helzer et al., 1987). As noted earlier, these crossgenerational ECA studies may underrepresent traumas and PTSD in contemporary adolescents because they may mask a secular increase in traumas and PTSD and because the retrospective reports of older subjects may reflect errors in recall about when traumas occurred (Cottier et al., 1992; Norris, 1992). Trauma Type and PTSD Symptoms and Diagnosis

In the present study rape, compared with all other traumas combined, presented an 8- to 12-fold risk for meeting some individual PTSD criteria and a 7-fold risk for meeting all DSM-llI-R criteria for PTSD. This finding parallels that of other researchers who documented the relatively higher risk for PTSD or PTSD symptomatology faced by rape or sexual assault victims compared with those experiencing other traumas (Breslau et al., 1991; Helzer er al., 1987; Kilpatrick

a wide range of traumatic events, including those that do not involve direct violence or physical harm, to evoke PTSD symptoms and associated later problems. These findings also point to the importance of investigating factors other than type of trauma itself that may influence the likelihood of developing PTSD, such as characteristics of youths and their family environments. Traumas, PTSD, and Late Adolescent Functioning

Compared with all other adolescents, the 24 youths with a lifetime diagnosis of PTSD were at the greatest disadvantage in almost all late adolescent developmental tasks; they displayed clinical levels of both internalizing and externalizing behavior problems, performed more poorly academically, reported alarming rates of suicidal ideation and attempts, and had more interpersonal problems and more somatic complaints. An equally striking finding was that experiencing traumas, even in the absence of meeting all DSM-llI-R criteria for PTSD, carried significant risk for impairment in later adolescence. These findings are supported by prior studies that have shown traumatic events or PTSD to be associated with poor outcomes in many domains, including behavior problems (McLeer et al., 1992; Saigh, 1988), social interaction problems (Davidson et al., 1991), poor school performance (Shannon et al., 1994), suicide attempts (Davidson et al., 1991), and somatic complaints and sick days (Davidson et al., 1991; McFarlane, 1991; Rundell et al., 1989). Our results documenting the magnitude of problems at age 18 associated with traumas and PTSD are particularly compelling in light of the fact that many youths experienced these traumas or developed PTSD by as early as age 14. Thus, traumatic events experienced in childhood and early adolescence may have long-term effects in late adolescence and beyond. PTSD and Other Disorders

Compounding the other serious social, emotional,

er al. , 1987; Vrana and Lauterbach, 1994).

and academic difficulties at age 18 faced by adolescents

There were few diffetences among other types of traumatic events and the risk for the development of PTSD. It is noteworthy that "other events" such as a parent being sent to prison or a parent revealing a past suicide attempt produced the same rate of PTSD as actually being raped. Thus, those who work with adolescents should not underestimate the potential of

with PTSD was their substantially heightened risk for additional co-occurring DSM-llI-R disorders, on both a lifetime basis and within the past year. Four of five adolescents with PTSD met criteria for at least one additional disorder and more than two fifths had two or more other lifetime disorders. Although prior research in both clinical and community samples of older

] . AM . ACAD. CHILD ADOLE SC . PSYCHIATRY, 34:10, OCTOB ER 19 95

1377

GIACONIA ET AL.

adults confirms this finding (Breslau et al., 1991; Cottier et al., 1992; Davidson et al., 1991; Helzer et al., 1987; Keane and Wolfe , 1990; North et al., 1994; Rundell et al., 1989), it is noteworthy that even among our relatively young subjects there was such an extensive overlap of lifetime disorders. In addition, rates for co-occurring disorders active in the past year were almost as large as lifetime rates. Researchers investigating the comorbidity of PTSD and other disorders have noted the importance of examining whether the onset of PTSD precedes or follows other disorders with which it co-occurs (Cottier et al., 1992; Keane and Wolfe, 1990; Rundell ct al., 1989). The present study, by examining corresponding ages of onset, showed that PTSD usually preceded or occurred at the same age as depression for those adolescents with both disorders. Although our results cannot establish whether PTSD caused the subsequent depression, they strongly suggest that depression was less likely to be a predisposing risk for the development of PTSD, but more of a concomitant or consequence of PTSD. In contrast, for youths with co-occurring alcohol dependence and PTSD, the onset of alcohol dependence preceded the onset of PTSD in about half of the cases. Cottier et al. (I992) reported that among adults with both PTSD and substance abuse, substance use generally preceded traumas, that is, was a predisposing risk factor. Our findings suggest that while for many youths an alcohol disorder may serve as a risk for exposure to traumas and PTSD, for an almost equal number of adolescents PTSD precedes and enhances the risk for subsequent alcohol problems. Gender Differences

Second, we found that females who experienced traumas were six times as likely as their male counterparts with traumas to meet all DSM-III-R criteria for a diagnosis of PTSD. This greater risk for PTSD ,among females has been reported by other researchers (Breslau et al., 1991; Cottier et al., 1992; Green et al., 1994; Shannon et al., 1994) . In addition, we showed that these gender differences held true for every PTSD symptom group identified by DSM-III-R, as did Shannon et al. (I 994). Finally, our results suggest that even though males experiencing traumas were significantly less likely than their female counterparts to express symptoms ofPTSD or develop PTSD, they were just as prone to exhibit problems in other aspects oflate adolescent functioning. Thus, for boys the experience of traumatic events, even when not accompanied by DSM-III-R PTSD symptoms, may presage problems in later adolescence. Limitations

First, because the sample was predominantly white , working or middle class youths, results may not be generalizable to more racially and economically diverse groups . Second, information about traumas, PTSD symptoms, and ages of onset were all based on retrospective reports of adolescents at age 18 and may be subject to errors in recall, although this may be less problematic for our adolescent respondents than for older adults in prior community studies. Finally, our findings about the sequencing of onset of disorders that co-occurred with PTSD should be considered tentative until replicated by other studies ofadolescents, because they were based on fairly small numbers of youths who had both disorders and also relied on retrospective reports about ages of onset.

Contrary to the findings of others who reported a greater incidence of traumas in males (Breslau et al., 1991 ; Norris, 1992; Vrana and Lauterbach, 1994), the overall rates of experiencing traumas were the same for both males and females in this community sample. There were also few gender differences in rates of specific traumas, although rape was reported exclusively by females and threats were identified only by males in our sample. It is particularly noteworthy that girls in this community were at as great a risk for physical assault and witnessing violence as boys, whereas other researchers have found these traumas to occur more frequently in males (Fitzpatrick and Boldizar, 1993; Norris, 1992).

Our findings have a number of important societal and clinical implications. The most striking finding was the unexpected number and variety of traumas actively experienced or witnessed by this predominantly lower-middle class population of adolescents. It is possible that the current generation of youths has been exposed to many more instances of unusual and "terrible experiences" in our current violent society than generations of the recent past. Regardless of the etiology of this increase in reported violence to youths (Gentry and Eron, 1993; US Bureau

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AM . ACAD. CHILD ADOLESC . PSYCHIATRY, 34:10, OCTOBER 1995

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Clinical Implications

TRAUMAS AND I'TSD IN LATE ADOLESCENCE

of the Census, 1994), clinicians must be actively prepared to offer crucial prompt clinical aid. Today's young people, even in small towns and cities, may find their own war zones where they experience trauma requiring clinical response. The physician, nurse, and other health professionals seeing youths in an emergency ward or community office after a physical assault, accident, or rape must be prepared to offer counseling or prompt clinical referral. Best of all is the availability of psychiatric emergency personnel or crisis teams trained to work with youths who have experienced trauma. In particular, medical personnel at a variety of levels of training must be sensitized to the high-risk status of adolescent females who now experience physical traumas that were in the recent past believed to be confronted only by males. In addition, rape was found in the present study to present the highest risk of all traumas for the emergence of PTSD. Thus, adolescent girls appear to be at increased jeopardy for both the traditional risk of rape as well as other events previously considered to be primarily risks for males. Since not all victims of trauma are seen by the medical system, a challenge is faced by community caretakers who see youths in other settings. Counselors, teachers, and other responsible adults who are close to youths must be alert to emerging symptoms subsequent to trauma. Proactive programs of counseling must also be made available to youths who have been known to have witnessed a traumatic accident, suffered a major loss by death, or experienced the suicide of a peer. Such groups can both serve a supportive function and identify those most in distress who should be referred for clinical treatment. The importance of prompt intervention after trauma has been highlighted as key to the successful treatment of children and adolescents exposed to traumas (Bell and Jenkins, 1991). Such programs of prompt intervention may help to lessen the effects of severe traumas, forestalling the development of PTSD with its major negative sequelae.

Research Implications

The findings of our study need to be replicated in more ethnically and socioeconomically diverse groups to determine whether the findings of the universality of traumas experienced and their sequelae are also present. In addition, our results concerning the onset

of other disorders and the sequence of onset of specific disorders should be investigated in larger and more diverse groups. It would be valuable to establish, as shown in the present study, the increased likelihood of major depression after or concomitant with PTSD. Future studies with this community sample will investigate specific early health, behavioral, and familial factors that may predict the development of PTSD in vulnerable youths. Factors that protect youths exposed to trauma from the development of PTSD will also be examined and may offer insights with direct preventive implications.

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