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Traumatic experiences and posttraumatic stress disorder among Chinese rural-to-urban migrant children
Journal of Affective Disorders 257 (2019) 123–129
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Research paper
Traumatic experiences and posttraumatic stress disorder among Chinese rural-to-urban migrant children Liang Yiminga,b, Zhou Yueyuea,b, Liu Zhengkuia,b, a b
T
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CAS Key Laboratory of Mental Health, Institute of Psychology, Beijing 100101, China Department of Psychology, University of Chinese Academy of Sciences, Beijing 100049, China
A R T I C LE I N FO
A B S T R A C T
Keywords: Traumatic experiences Posttraumatic stress disorder Migrant children China
Background: Children and adolescents are in the developmental periods with the highest risk of experiencing multiple types of traumatic experiences (TEs). Immigrant children are more likely than other children to be exposed to TEs and have a higher risk of mental health problems. However, no epidemiological study has reported the prevalence of TEs and the associated development of posttraumatic stress disorder (PTSD) among Chinese children. Methods: The present study focused on trauma exposure among rural-to-urban migrant Chinese children. A large-scale (N = 16,140) cross-sectional survey of rural-to-urban migrant workers’ children in grades 4 to 9 was conducted in Beijing. Lifetime exposure to accidents and injuries, interpersonal violence, and trauma within the social network or witnessing traumatic events were measured along with PTSD. Results: Nearly half of the participants (47.06%) had experienced TEs, and 6.68% of those children met the cutoff for PTSD. Trauma exposure was associated with gender, age, quality of life, parents’ marital status, caregivers before the child started school and father's education level. Overall, interpersonal violence was associated with the highest rates of PTSD, and disasters were associated with the lowest rates of PTSD. Limitations: The cross-sectional survey design limited the ability to document temporal ordering, and the assessment of lifetime TEs was based on retrospective recall. Conclusions: The present study is the first epidemiological study of TEs in Chinese rural-to-urban migrant children. TEs are potentially fairly common among this population. Interventions designed to prevent PTSD should target different TE types according to the victim's gender.
1. Introduction Most people are unavoidably exposed to traumatic experiences (TEs) at some point during their lifetime, and this exposure has been shown to negatively affect physical and mental health (Benjet et al., 2016; Liang et al., 2019; Liu et al., 2017). Prior work has indicated that adolescence is the developmental period with the highest risk of experiencing multiple types of TEs, such as accidents, injuries, interpersonal violence and many types of vicarious traumas (Finkelhor et al., 2009; Mclaughlin et al., 2013). Moreover, children and adolescents are also in a vulnerable developmental period because they lack effective coping skills to adapt to and recover from TEs; thus, they are more vulnerable to PTSD (Braun-Lewensohn, 2015). Therefore, it is important to understand the status quo of TEs and the associated development of PTSD in children and adolescents to prevent potential TE exposure and provide appropriate psychological services. However,
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evidence related to TEs and the associated development of PTSD among children and adolescents is insufficient. Both theoretical and empirical evidence suggests that the prevalence of TEs and PTSD varies widely across cultures (Benjet et al., 2016; Seedat et al., 2004). However, the available epidemiological data are predominantly from the USA. The prevalence of TEs is estimated to be 61.8% and 67.8% based on an American national sample of adolescents and a representative sample of the child population in western North Carolina, respectively (Copeland et al., 2007; Mclaughlin et al., 2013). The lifetime prevalence rates of PTSD among respondents in these two samples who were exposed to trauma were estimated to be 7.6% and 5.9%, respectively (Copeland et al., 2007; Mclaughlin et al., 2013). Higher trauma rates, estimated at 83.6%, were reported in a study of Kenyan and South African adolescents; additionally, there was a higher lifetime PTSD prevalence, estimated at 15.9%, among respondents exposed to trauma (Seedat et al., 2004). To our knowledge,
Corresponding author. E-mail address: [email protected] (Z. Liu).
https://doi.org/10.1016/j.jad.2019.07.024 Received 14 March 2019; Received in revised form 1 June 2019; Accepted 4 July 2019 Available online 05 July 2019 0165-0327/ © 2019 Elsevier B.V. All rights reserved.
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to an increased number of TEs, possibly because older children have more time to be exposed to TEs (Perkonigg et al., 2000; VaughnCoaxum et al., 2018). Children and adolescents in families with a lower socioeconomic status also tend to report more trauma exposure (Perkonigg et al., 2000; Vaughn-Coaxum et al., 2018). Most rural-tourban migrant children are born to lower socioeconomic status families, so trauma exposure among these children is worthy of attention. Family structure and the children's caregivers are determining factors of childadolescent trauma exposure: living with both biological parents has an important protective effect against traumatic events (Mclaughlin et al., 2013; Turner et al., 2007). Among rural-to-urban migrant children, a large proportion are left at home during early childhood when parents go out to work (Liu et al., 2009; Cheng et al., 2017). During this time, the child may be looked after by grandparents or other relatives. Whether early childhood caregivers are related to child-adolescent trauma exposure among migrant children is also worth discussing. The current study used a large-scale sample of rural-to-urban migrant children that included 16,140 migrant children in Beijing who migrated from almost every other region in China. The aim of the study was to describe the epidemiology of TE exposure and PTSD, including the prevalence of TE and PTSD, correlates of TE exposure and variations in the conditional risk of PTSD within a given TE exposure among these children and adolescents.
no epidemiological study has reported basic descriptive data on the prevalence of TE exposure and the associated development of PTSD among children and adolescents in an Asian culture. This serious gap in the literature needs to be addressed. Immigration is a common phenomenon around the world today, and rural-to-urban migration is an important type of immigration. In 2012, the number of rural-to-urban migrants reached approximately 230 million in China, accounting for 17% of China's total population (Cheng et al., 2017). Many migrant parents take their children to cities, and these children are called “rural-to-urban migrant children”. Previous research found that immigrant children are more commonly exposed to TEs: compared to children raised in the city, immigrant children experience more negative life events and witness more violence and gambling in their community (Cheng et al., 2017; Nöthling et al., 2017). Moreover, migration is a stress-inducing phenomenon that can cause a higher risk of mental health problems among migrants due to increased exposure to acculturative stressors or to unfamiliar environmental factors (Bhugra, 2004; Derluyn et al., 2008; Mclaughlin et al., 2013). Therefore, the prevalence of TEs and associated mental health problems among rural-to-urban migrant children is worthy of attention. However, to date, there has been no large-scale investigation of trauma exposure among immigrant children worldwide. Identifying which types of TEs present a higher conditional risk for mental health problems is another important issue. Previous research found that different types of TEs present different risks for the subsequent development of PTSD (Liu et al., 2017; Mclaughlin et al., 2013). Interpersonal violence, such as physical abuse and community and sexual violence, has consistently been regarded as the type of traumatic event linked to a higher risk of developing PTSD (Liu et al., 2017; Nöthling et al., 2017). Disasters, accidents and injuries have been found to present relatively low risks, and vicarious trauma exposure, such as hearing about or witnessing a traumatic experience, is associated with the lowest risk of developing PTSD (Lukaschek et al., 2013; Mclaughlin et al., 2013). Most conclusions regarding the risks associated with different types of TEs have been based on adults, and the PTSD criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) were developed mostly from the adult literature (Mclaughlin et al., 2013). How the different TEs that meet the DSM-IV A1 criterion affect children and adolescents deserves further exploration. Considerable gender differences regarding trauma exposure have been found in previous studies. Both the prevalence of specific types of TE and the probabilities of developing PTSD following different types of TE vary considerably according to gender (Nöthling et al., 2017; Perkonigg et al., 2000). Significant gender differences were observed in the types of TEs that occurred (Lukaschek et al., 2013; Perrin et al., 2014). Males were more likely to be victims of accidents and physical violence and were more likely to witness an injury or death, while females were more likely to be victims of rape and physical assault by romantic partners both as adult and adolescents (Lukaschek et al., 2013; Mclaughlin et al., 2013; Perrin et al., 2014). The results regarding the differences in sexual assault TEs between genders are mixed, and some scholars have noted that the inconsistent conclusions might be a result of cultural differences (Benjet et al., 2016; Mclaughlin et al., 2013; Seedat et al., 2004). More evidence from different cultures is needed. Gender differences also exist in PTSD risk. On the one hand, most studies have shown that females are more vulnerable to PTSD after experiencing the same traumatic event as males (Cheng et al., 2018; Liang et al., 2019). On the other hand, females are more likely to be victims of TEs with higher conditional risks for PTSD, such as rape and physical assault by romantic partners, which also leads to a higher prevalence of PTSD among females (Lukaschek et al., 2013; Mclaughlin et al., 2013). In addition to gender, other sociodemographic variables are associated with exposure to TEs among children and adolescents (Copeland et al., 2007; Mclaughlin et al., 2013). Age is an important factor related
2. Methods 2.1. Procedure and participants Fifty-eight schools in Beijing that had been established mainly for children of migrant workers were investigated. In total, 16,682 rural-tourban migrant children participated in the present study. The details of the school selection and sampling procedures are described elsewhere (Cao and Liu, 2015). Valid data were obtained from 16,140 (96.75%) children, and the excluded data were primarily omitted due to incomplete or inaccurate responses. The participants came to Beijing from 29 regions in mainland China, which covered almost all regions of mainland China. Data collection were collected within a school class, and the questionnaires were distributed and administered at each session by two assistant investigators who had received the same standardized instructions for carrying out the survey. Written informed consent was obtained from the participants and clearly indicated that they were not required to respond to any question if they did not wish to. Moreover, a statement approving this survey procedure was signed by the investigators and the school representatives, and the school administrators were fully briefed on the details of the investigative procedure, including the decision not to obtain parental consent because of the difficulties of contacting these children's parents or guardians. The study design and procedures were approved by the ethics review committee of the Institute of Psychology, Chinese Academy of Sciences. The sociodemographic characteristics of the study sample are presented in Table 1.
2.2. Measures 2.2.1. Demographics A questionnaire was devised to obtain demographic information, including age, gender, parents’ educational level (1 = primary school and below, 2 = junior high school, or 3 = high school and above), caregivers before primary school (1 = parents, 2 = grandparents, or 3 = other relatives), parents’ marital status (1 = first marriage, 2 = divorced, or 3 = remarried) and the children's quality of life (“How would you describe your quality of life in your new location?”, 1 = low, 2 = below average, 3 = average, 4 = above average, or 5 = high). 124
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types and accumulation of TE types the children reported. To estimate the conditional probability of PTSD among participants who were exposed to particular TEs using the method described for the WHO World Mental Health Surveys, a random TE was selected from the TEs experienced by participants who reported more than one type of TE (Liu et al., 2017; Rosellini et al., 2018). This method was suggested to be suitable for obtaining unbiased estimates of conditional risk (Liu et al., 2017; McLaughlin et al., 2013). The descriptive statistics of the random representative TEs were also computed. Second, a descriptive statistical analysis of TE type prevalence and cross-tabulation of the accumulation of TE types was conducted for the male and female samples to explore gender differences. Third, depending on the number of TE types experienced, we classified the accumulation of TE types as no trauma, low accumulation (from 1 to 3 TE types), moderate accumulation (from 4 to 6 TE types) and high accumulation (more than 6 TE types). Descriptive statistics for the demographic variables were computed according to each classification. Then, we investigated the associations between the TE types and PTSD. Of the 7595 respondents who reported having experienced TEs, 6482 (response rate of 85.35%) reported their PTSD symptoms. To investigate the potential impact of attrition, we tested the differences in the main demographic variables (gender, age, TE type and accumulation of TE types). The results showed that whether a participant responded or not was not significantly related to gender or TE type (all p > .297) but was significantly related to age and the accumulation of TE types (ps < 0.001). Younger respondents (Mnot response = 11.07, SD = 1.61 years; Mresponse = 11.55 SD = 1.79 years; T1596 = −8.98, p < .001) and respondents with a lower accumulation of TE types (Mnot response = 2.10, SD = 1.35; Mresponse = 2.32, SD = 1.47; T1595 = −5.05, p < .001) were more likely not to report their PTSD symptoms. The next analysis was conducted with the participants who experienced TEs and reported PTSD symptoms. The prevalence of PTSD in the sample with TE exposure and the prevalence of PTSD associated with the random representative TE were computed. Cross-tabulation was used to determine proportional differences in PTSD prevalence according to TE type. The PTSD prevalence was also computed for the 3 TE categories, and cross-tabulation was used to determine the proportional differences in PTSD prevalence according to TE category. To investigate the risk of developing PTSD among individuals who experienced various TE types, multiple logistic regression was conducted for the full sample according to PTSD status. Gender differences were also investigated for the associations of TE type with PTSD. To investigate gender differences in the risk of developing PTSD among individuals who experienced various TE types, a multiple logistic regression was conducted for the male and female samples separately.
Table 1 Sociodemographic characteristics of the rural-to-urban migrant children (n = 16,140). Sociodemographic characteristics
Category
N
Weighted%
Gender
Male Female 8–9 10 11 12 13–14 15–17 Primary school and below Junior high school High school and above Primary school and below Junior high school High school and above First marriage Divorced Remarried Parents Grandparents Other relatives
9247 6662 2081 4267 3678 2658 2472 818 4257
57.3 41.3 12.9 26.4 22.8 16.5 15.4 5.1 26.4
5860 3440 6355
36.3 24.3 39.4
4618 2077 14,737 473 638 12,544 3076 439
28.6 12.9 91.3 2.9 4.0 77.7 19.1 2.7
Age (years)
Father's educational level
Mother's educational level
Parental marital status
Caregivers before starting school
2.2.2. Traumatic experience history The lifetime exposure to traumatic events was assessed with the first part of the University of California at Los Angeles (UCLA) PTSD reaction index for the DSM-IV, revision 1 (UCLA PTSD-RI; Steinberg et al., 2004). This part of the index constitutes a brief lifetime trauma screening for 12 types of TEs that meet the DSM-IV A1 criterion, such as natural disaster, medical trauma and exposure to community violence and domestic violence. Because none of the children had experienced a war, we deleted the item “Being in a place where a war was going on around you”. Finally, 11 types of TEs were measured in the current study. Consistent with the classification used in most prior studies (McLaughlin et al. 2013; Vaughn-Coaxum et al., 2018), we grouped these events into three categories: (1) accidents and injuries (including 4 types: earthquakes, other disasters, accidents and painful medical treatments); (2) interpersonal violence (including 3 types: experiencing domestic violence, experiencing violence away from home and sexual harassment); (3) trauma within the social network or witnessing events (including 4 types: witnessing fighting at home, witnessing violence away from home, seeing a dead body and hearing about the death or injury of a loved one).
3. Results 2.2.3. PTSD The third part of the UCLA PTSD-RI for the DSM-IV was administered to measure PTSD symptoms (Steinberg et al., 2004). The children who reported experiencing one or more TEs continued to fill out this section, and the other children skipped this section because experiencing a traumatic event is a prerequisite for PTSD. This part of the index is a self-report scale used to assess PTSD symptoms in children and adolescents based on the following three criteria from the DSM-IV: reexperiencing, avoidance and hyperarousal. The items are scored on a 5point scale ranging from 0 (none of the time) to 4 (most of the time), and the children rated each item according to their situation during the past month. A cutoff of a total score of 38 or greater was considered to indicate PTSD (Rodriguez et al., 2001a, b). In the present study, the scale exhibited good internal consistency (Cronbach's α = 0.91).
3.1. Prevalence of TEs Nearly half of the participants (7594 of 16,140, 47.06%) reported having experienced TEs. The prevalence of each TE is shown in Table 2. The most common TEs were witnessing violence away from home (24.16%), seeing a dead body (15.72%) and experiencing domestic violence (13.98%). The least common TEs were experiencing other disasters (2.63%), earthquakes (2.74%) and sexual harassment (5.21%). Overall, TEs belonging to the category of trauma within the social network or witnessing events occurred most often, and TEs belonging to the category of accidents or injuries occurred the least often. The proportion of randomly chosen TEs is shown in Table 2. The distribution of the randomly chosen TEs was consistent with the original distribution, and the proportion of each TE was lower. The mean accumulation of TE types was 1.08 for the total sample and was 2.29 for the sample with traumatic experiences. Most of the participants (38.39% in the total sample) had an accumulation of 1 to 3 TE types (low accumulation), 8.47% of the children in the total sample reported
2.3. Data analysis Data analysis was conducted in IBM SPSS version 22.0. First, descriptive statistics were performed for the demographic variables, TE 125
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Table 2 Prevalence of different types of traumatic experiences.
Any type of TE Accidents/injuries
Interpersonal violence
Social network or witnessing events
Earthquake Disaster Accident Painful medical treatment Domestic violence Violence away from home Sexual harassment Seeing domestic violence Seeing violence out home Seeing a dead body Hearing about death or injury
Total (n = 16,140)% (SE)
Boys (n = 9247)% (SE)
Girls (n = 6662)% (SE)
Randomly Chose TE % (SE)
PTSD Prevalence% (SE)
47.06 (0.57) 2.74 (0.78) 2.63 (0.78) 5.40 (0.77) 11.75 (0.74)
49.76 (0.74) 2.96 (1.02) 2.91 (1.02) 6.25 (1.01) 13.26 (0.97)
42.98 (1.21) 2.33 (1.21) 2.18 (1.21) 4.05 (1.20) 9.56 (1.17)
47.06 (0.57) 1.13 (0.78) 1.04 (0.78) 2.16 (0.78) 5.26 (0.76)
6.68 4.24 5.37 6.82 6.57
13.98 (0.73) 7.55 (0.76)
15.75 (0.95) 9.25 (0.99)
11.42 (1.15) 5.03 (1.19)
5.68 (0.78) 2.73 (0.78)
7.89 (0.96) 9.74 (1.52)
5.21 (0.77) 8.22 (0.75)
6.32 (1.01) 8.25 (1.00)
3.54 (1.20) 8.02 (1.18)
1.92 (0.78) 3.08 (0.78)
13.28 (2.06) 7.57 (1.29)
24.16 (0.69)
25.29 (0.90)
22.46 (1.08)
12.31 (0.74)
4.33 (0.50)
15.72 (0.72) 10.40 (0.74)
17.03 (0.95) 10.43 (0.98)
13.79 (1.14) 10.28 (1.16)
7.61 (0.76) 4.13 (0.77)
5.80 (0.72) 8.64 (1.17)
(0.31) (1.57) (1.85) (1.44) (0.92)
more boys had a higher accumulation of TE types than girls, χ2(2, N = 7464) = 23.35, p < .001.
an accumulation of 4 to 6 TE types (moderate accumulation) and a small proportion (0.52% of the total sample) reported an accumulation of more than 6 TE types (high accumulation).
3.3. Other demographic correlates of TE exposure 3.2. Gender differences in trauma exposure TE exposure was significantly related to gender, age, life quality, caregivers before starting school, parental marital status and father's education level (ps < .020). TE exposure was not significantly related to mother's education level (p = .535). The summary of demographic characteristics according to TE exposure is shown in Table 3. The results showed that children in the group with high accumulation of TE types group were older, F (3, 15,970) = 136.19, p < .001. Children in the high accumulation of TE types group also had lower life quality, F (3, 15,963) = 6.19, p < .001. Compared to children who were cared for their parents before starting school, a larger proportion of children whose caregivers before starting school were grandparents or other relatives had a higher accumulation of TE types, χ2(6,
Overall, the proportion of boys (49.46%) with trauma exposure was higher than that of girls (42.98%), χ2(1, N = 15,909) = 71.51, p < .001. The prevalence of each type of TE among boys and girls is shown in Table 2. The prevalence of all TE types was higher in boys than in girls. The types of TEs with large gender differences were experiencing an accident, experiencing a painful medical treatment, experiencing domestic violence, experiencing violence away from home, experiencing sexual harassment and seeing a dead body. These TE types with larger gender differences were mostly related to accidents or interpersonal violence. Gender differences in the accumulation of TE types are shown in Table 3. In the sample with traumatic experiences, Table 3 Summary of demographic correlates of TE exposure.
Gender: Male Female Age Life quality Caregivers before starting school: Parents Grandparents Other relatives Parents’ marital status: First marriage Divorced Remarried Father's education: Primary school or below Junior high school High school or above Mother's education: Primary school or below Junior high school High school or above
No trauma (n = 8545) N (%)
Low accumulation of TE types (n = 6196) N (%)
Moderate accumulation of TE types (n = 1315) N (%)
High accumulation of TE types (n = 84) N (%)
χ2 / F value
4646 (54.37%) 3799 (44.46%) 10.98 (1.57) 2.98 (0.80)
3686 (59.49%) 2414 (38.96%) 11.42 (1.74) 2.95 (0.84)
854 (64.94%) 429 (32.62%) 11.75 (1.87) 2.95 (0.91)
61 (72.62%) 20 (23.81%) 12.04 (1.99) 2.64 (1.17)
χ2 = 94.19⁎⁎
6862 (80.30%) 1459 (17.07%) 188 (2.20%)
4675 (75.45%) 1299 (20.97%) 190 (3.07%)
941 (71.56%) 303 (23.04%) 58 (4.41%)
66 (78.57%) 15 (17.86%) 3 (3.57%)
χ2 = 81.56⁎⁎
7906 (92.52%) 206 (2.41%) 290 (3.39%)
5612 (90.57%) 198 (3.20%) 281 (4.54%)
1148 (87.30%) 64 (4.87%) 64 (4.87%)
71 (84.52%) 5 (5.95%) 3 (3.57%)
χ2 = 44.81⁎⁎
2178 (25.49%) 3225 (37.74%) 2014 (23.57%)
1679 (27.10%) 2303 (37.17%) 1300 (20.98%)
376 (28.59%) 462 (35.13%) 278 (21.14%)
24 (28.57%) 36 (42.86%) 14 (16.67%)
χ2 = 20.89⁎⁎
3345 (39.15%) 2386 (27.92%) 1096 (12.83%)
2420 (39.06%) 1873 (30.23%) 812 (13.11%)
551 (41.90%) 336 (25.55%) 165 (12.55%)
39 (46.43%) 23 (27.38%) 8 (9.52%)
χ2 = 12.99*
Note:. ⁎⁎ p<.01. ⁎ p<.05. 126
F = 136.19⁎⁎ F = 6.19⁎⁎
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3.5. Gender differences in the associations of TE types with PTSD
N = 16,059) = 81.56, p < .001. Compared to children whose parents were in their first marriage, a larger proportion of children whose parents were divorced or remarried had a higher accumulation of TE types, χ2(6, N = 15,848) = 44.81, p < .001. A lower proportion of children whose fathers had a higher education level had a higher accumulation of TE types, χ2(6, N = 13,557) = 20.89, p < .001.
Overall, the PTSD prevalence among females with TEs (7.42%) was higher than that among males with TEs (6.16%). To explore gender differences in the associations of TE types with PTSD, we conducted multiple logistic regressions in the male and female samples separately. The results are shown in Table 4, and several gender differences were revealed. Overall, 8 TE types could predict PTSD among boys, and only 5 TE types could predict PTSD among girls. Specifically, accidents, painful medical treatments and seeing a dead body predicted PTSD in only the male sample, and 3 TE types in the interpersonal violence category had stronger associations with PTSD in the female sample. There were few gender differences in the prediction of PTSD based on witnessing domestic violence and hearing about the death or injury of a loved one. These results indicate that gender differences were present mainly in TE types related to accidents, injuries and interpersonal violence.
3.4. Prevalence of PTSD among children with TEs Four hundred forty-three children reached the cutoff score on the UCLA PTSD-RI. The prevalence of probable PTSD was 6.68% among the 6482 children who were exposed to any TE and reported their PTSD symptoms. Compared to being exposed to a single TE type, being exposed to multiple TE types strongly predicted higher rates of PTSD, χ2(3, N = 6482) = 231.75, p < .001. Among children with exposure to a single TE type, the prevalence of PTSD was 3.31%; the prevalence of PTSD was 5.72% among children with two or three TE types. The PTSD prevalence was 14.00% in children with a moderate accumulation of TE types (4–6 TE types) and 30.26% in children with a high accumulation of TE types (more than 6 TE types). Age was also related to PTSD symptoms (r = 0.07, p < .001); adolescents aged 14 to 17 years (M PTSD symptoms = 19.23, SD = 12.26) had more PTSD symptoms than children aged 8 to 10 years (M PTSD symptoms = 16.58, SD = 12.86) and children aged 11 to 13 years (M PTSD symptoms = 16.36, SD = 11.77). The prevalence of PTSD among randomly chosen TEs is shown in Table 2. A significant variation in PTSD prevalence was found across these 11 TEs, χ2(10, N = 6482) = 48.38, p < .001, with the highest PTSD prevalence rates associated with sexual harassment (13.28%), experiencing violence away from home (9.74%) and hearing about the death or injury of a loved one (8.64%) and the lowest PTSD prevalence rates associated with experiencing an earthquake (4.24%), witnessing violence away from home (4.33%) and experiencing other disasters (5.37%). The results showed that the TE types related to interpersonal violence were associated with a relatively higher PTSD prevalence, and the TE types related to disaster were associated with a relatively lower PTSD prevalence. Significant variation in PTSD prevalence was also found across three TE categories, χ2(2, N = 6482) = 22.09, p < .001, with the highest PTSD prevalence associated with interpersonal violence (9.39%). In addition, the PTSD prevalence associated with accidents/injuries was 6.21%, and the prevalence associated with violence within the social network or witnessing events was 5.80%. To further explore the risk of PTSD among various TE types, a multiple logistic regression was conducted in the whole sample with PTSD, and the outcome is shown in Table 4. The results showed that most TE types, excluding earthquakes, disasters and witnessing violence away from home, were predictive of PTSD.
4. Discussion The present study is the first epidemiological study of TEs in ruralto-urban migrant children and their association with PTSD in China. Our main findings were that (1) TEs were relatively common in ruralto-urban migrant children in China; (2) gender differences were present in trauma exposure and the associations of TE types with PTSD; (3) the TE types related to interpersonal violence were associated with the highest conditional risk for PTSD; and (4) TE exposure was related to some sociodemographic variables, including age, gender, caregivers before starting school, quality of life, parents’ marital status and father's education level. Nearly half (47.06%) of the rural-to-urban children in Beijing reported experiencing one or more TEs, indicating substantial trauma exposure during childhood and adolescence, and 6.68% of those exposed to trauma met the cutoff for PTSD. The TE prevalence estimate was lower than the estimates reported in recent American (61.8%−67.8%) and African studies of children and adolescents (83.6%; Copeland et al., 2007; Mclaughlin et al., 2013; Seedat et al., 2004). Specifically, in a comparison of the American samples and our sample, the rates of TEs related to disasters and accidents were much higher in the American samples, while the rate of TEs related to being beaten or physically hurt by a family member was higher in the Chinese sample. The TE rates among African children were higher than those among Chinese children for almost all types of TEs. These cross-cultural differences might be partly caused by the different data collection instruments used; however, they also reflect differences in living environments, such as public security and natural conditions. In the present study, a larger proportion of boys (49.76%) had
Table 4 Differential associations of TE types with PTSD and gender differences.
Earthquake Disaster Accident Painful medical treatment Domestic violence Violence away from home Sexual harassment Seeing domestic violence Seeing violence out home Seeing a dead body Hearing about death or injury
Total (n = 6482) B OR
95%CI
Boys (n = 3930) B OR
95%CI
Girls (n = 2440) B OR
95%CI
−.01 .07 .31* .40⁎⁎ .52⁎⁎ .47⁎⁎ .60⁎⁎ .47⁎⁎ .17 .39⁎⁎ .57⁎⁎
[0.67, 1.46] [0.72, 1.57] [1.04, 1.79] [1.21, 1.85] [1.36, 2.08] [1.27, 2.02] [1.41, 2.34] [1.26, 2.02] [0.97, 1.45] [1.20, 1.80] [1.42, 2.18]
.19 −.04 .42* .55⁎⁎ .29* .43⁎⁎ .55⁎⁎ .42* .09 .51⁎⁎ .58⁎⁎
[0.74, 1.96] [0.57, 1.62] [1.09, 2.14] [1.31, 2.27] [1.00, 1.79] [1.13, 2.08] [1.24, 2.41] [1.09, 2.10] [0.83, 1.44] [1.27, 2.18] [1.35, 2.38]
−.28 .23 .31 .16 .88⁎⁎ .69⁎⁎ .79⁎⁎ .47⁎⁎ .22 .26 .57⁎⁎
[0.38, 1.52] [0.68, 2.32] [0.85, 2.21] [0.82, 1.67] [1.74, 3.37] [1.36, 2.92] [1.44, 3.39] [1.12, 2.29] [0.91, 1.70] [0.93, 1.79] [1.27, 2.45]
0.99 1.07 1.36 1.50 1.68 1.60 1.81 1.60 1.19 1.47 1.76
Note:. ⁎⁎ p<.01. ⁎ p<.05. 127
1.21 0.96 1.53 1.73 1.34 1.53 1.73 1.52 1.09 1.66 1.79
.76 1.26 1.37 1.17 2.42 2.00 2.21 1.60 1.24 1.29 1.76
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experiencing/witnessing domestic violence and experiencing violence away from home. These results suggested that fathers with low education levels were more likely to be violent and live in communities in which the residents are more violent with their children (Leung et al., 2008). There are several limitations in the present study. First, the assessment of lifetime TEs was based on retrospective recall, which is subject to potential reporting bias. Second, PTSD was assessed by self-reported questionnaires rather than more sensitive clinical interviews. Moreover, some respondents with younger ages or a lower accumulation of TE types did not report their PTSD symptoms. Therefore, the PTSD prevalence reported in the results may be overestimated. Third, the crosssectional survey design limited the ability to document the temporal ordering of TEs and PTSD and potential risks. Finally, the current study lacked a comparison between rural-to-urban migrant children and local children. The lifetime history of TEs in local Chinese children remains unknown. Thus, we call for more research to investigate TEs among Chinese children. Despite these limitations, our study is the first to document the high prevalence of TEs in Chinese rural-to-urban migrant children. These findings also reveal effective ways to reduce PTSD in this population by both preventing vulnerable children from trauma exposure and delivering timely preventive interventions to children exposed to TEs associated with a high risk of PTSD. Boys and girls must be treated differently in clinical work due to gender differences in the associations between TE types and PTSD. Male victims of accidents and injuries and female victims of interpersonal violence should be the targets of interventions.
trauma exposure than girls (42.98%), and boys (1.18) had a greater accumulation of trauma types than girls (0.93). Among all types of TEs, boys had larger proportions of trauma exposure, especially for trauma types related to accidents and violence. This may be partly because males are more adventurous and more likely to engage in risky activities (Lukaschek et al., 2013). In addition, a larger proportion of boys experienced sexual harassment in our sample, which was inconsistent with the results of some studies (McLaughlin et al., 2013; Nöthling et al., 2017). On the one hand, the reason boys experience more sexual harassment in our study is that boys are more likely to report their real experiences (Leung et al., 2008). On the other hand, cultural differences may cause differences in results because the Chinese culture places a strong emphasis on female chastity, and girls receive more sex education during childhood so they can better protect themselves from sexual harassment (Benjet et al., 2016). The comparatively higher conditional probability of PTSD associated with TEs related to interpersonal violence among our samples is consistent with the findings of previous studies (Liu et al., 2017; McLaughlin et al., 2013), likely because perpetrators who intentionally inflict harm have a complex emotional effect on their victims (Nöthling et al., 2017; Wamser-Nanney et al., 2017). Sexual harassment, which had the highest conditional risk for PTSD among all types of TEs, often comes from someone the victim knows and trusts, which commonly leads to victims feeling shame and guilt and even thinking that they are not worthy of love (Bonanno et al., 2002; Filipas and Ullman, 2006). Sexual harassment is a mild type of sexual abuse, and other sexual abuse, such as rape, can have a more severe impact, which suggests that sexual abuse needs to be a high priority in clinical work, especially during childhood and adolescence. In addition to interpersonal violence, hearing about the death or injury of a loved one has a heavy impact on children. Previous studies have demonstrated that this type of TE is a common traumatic experience that accounts for a large number of PTSD cases (Breslau et al., 1998; McLaughlin et al., 2013). A notable gender difference in the associations of TE types with PTSD was also found: some TEs related to accidents and injuries were associated with PTSD only among boys, while the impact of interpersonal violence on PTSD was greater among girls. These findings also prompted us to attach different levels of importance to different types of traumatic events according gender. To better identify high-risk populations according to TEs, we examined demographic differences in the accumulation of TE types. The results indicated that trauma exposure was associated with gender, age, quality of life, caregivers before starting school, parents’ marital status and father's education level. The number of cumulative TE types increased with age, which might be a result of increased exposure time (Vaughn-Coaxum et al., 2018). PTSD symptoms are also related to age; older adolescents have more PTSD symptoms than younger children, which might be partly due to cumulative trauma exposure. Therefore, those involved in clinical work with children and adolescents with psychological problems must consider their trauma history, especially during adolescence. Children living in families with a lower quality of life also tend to report more trauma exposure, which might be due to the lack of basic services and security facilities in the communities where they have lived. More importantly, children whose caregivers before they started school were not their parents and children who did not live with both biological parents experienced more TEs, which reflects the importance of parental supervision. Previous studies have indicated that family structure is a determinant of child-adolescent TEs (Mclaughlin et al., 2013). Children who lack parental supervision are more likely to be exposed to threatening situations and maltreatment from other, nonrelated adults at home. However, for most migrant children, parental supervision is relatively lacking, which is also an important reason to focus on the TE of this group. In addition, TEs were shown to be more common among children and adolescents whose fathers had lower educational levels. Further data analysis found that the father's education level was significantly associated with
CRediT authorship contribution statement Liang Yiming: Data curation, Formal analysis, Methodology, Writing - original draft, Writing - review & editing. Zhou Yueyue: Methodology, Writing - review & editing. Liu Zhengkui: Conceptualization, Investigation, Project administration, Resources, Supervision. Conflicts of interest The authors have no conflicts of interest to declare. Funding This work was supported by the programs of Pioneer Initiative of the Chinese Academy of Sciences, Feature Institutes Program (TSS2015-06) and Consulting and Appraising Project of Chinese Academy of Sciences (Y7CX134003). Acknowledgments We extend our sincere gratitude to Dr. Jin Cheng for her comments on an earlier version. Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jad.2019.07.024. References Benjet, C, Bromet, E, Karam, EG, Kessler, RC, McLaughlin, KA, Ruscio, AM, et al., 2016. The epidemiology of traumatic event exposure worldwide: results from the world mental health survey consortium. Psychol. Med. 46, 327–343. Bhugra, D., 2004. Migration and mental health. Acta Psychiatr. Scand. 109, 243–258. Bonanno, G.A., Keltner, D., Noll, J.G., Putnam, F.W., Trickett, P.K., LeJeune, J., Anderson, C., 2002. When the face reveals what words do not: facial expressions of emotion, smiling, and the willingness to disclose childhood sexual abuse. J. Pers. Soc. Psychol.
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population study. Soc. Psychiatry Psychiatr. Epidemiol. 48, 525–532. Mclaughlin, K.A., Koenen, K.C., Hill, M.E.D., Petukhova, M., Sampson, M.N.A., Zaslavsky, A.M., et al., 2013. Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. J. Am. Acad. Child Adolesc. Psychiatr. 52, 815–830. Nöthling, J., Simmons, C., Suliman, S., Seedat, S., 2017. Trauma type as a conditional risk factor for posttraumatic stress disorder in a referred clinic sample of adolescents. Compr. Psychiat. 76, 138–146. Perkonigg, A., Kessler, R.C., Storz, S., Wittchen, H.U., 2000. Traumatic events and post‐traumatic stress disorder in the community: prevalence, risk factors and comorbidity. Acta Psychiatr. Scand. 101, 46–59. Perrin, M., Vandeleur, C.L., Castelao, E., Rothen, S., Glaus, J., Vollenweider, P., Preisig, M., 2014. Determinants of the development of post-traumatic stress disorder, in the general population. Soc. Psychiatry Psychiatr. Epidemiol. 49, 447–457. Rodriguez, N., Steinberg, A.S., Saltzman, W.S., Pynoos, R.S, 2001a. PTSD index: psychometric analyses of the adolescent version. In: Symposium Conducted at the Annual Meeting of the International Society for Traumatic Stress Studies. New Orleans, LA. Rodriguez, N., Steinberg, A.M., Saltzman, W.S., Pynoos, R.S., 2001b. Youth PTSD assessment: psychometric investigation of PTSD self-report instruments. In: 17th Annual ISTSS Meeting. New Orleans. Rosellini, A.J., Liu, H., Petukhova, M.V., Sampson, N.A., Aguilar-Gaxiola, S., Alonso, J., De Jonge, P., et al., 2018. Recovery from DSM-IV post-traumatic stress disorder in the WHO world mental health surveys. Psychol. Med. 48, 437–450. Seedat, S., Nyamai, C., Njenga, F., Vythilingum, B., Stein, D.J., 2004. Trauma exposure and post-traumatic stress symptoms in urban African schools: survey in Cape Town and Nairobi. Br. J. Psychiatry. 184, 169–175. Steinberg, A.M., Brymer, M.J., Decker, K.B., Pynoos, R.S., 2004. The university of California at Los Angeles post-traumatic stress disorder reaction index. Curr. Psychiatry Rep. 6, 96–100. Turner, H.A., Finkelhor, D., Ormrod, R., 2007. Family structure variations in patterns and predictors of child victimization. Am. J. Orthopsychiatr. 77, 282–295. Vaughn-Coaxum, R.A., Wang, Y., Kiely, J., Weisz, J.R., Dunn, E.C., 2018. Associations between trauma type, timing, and accumulation on current coping behaviors in adolescents: results from a large, population-based sample. J. Youth Adolesc. 47, 842–858. Wamser-Nanney, R., Howell, K.H., Schwartz, L.E., Hasselle, A.J., 2017. The moderating role of trauma type on the relationship between event centrality of the traumatic experience and mental health outcomes. Psychol. Trauma. 10, 499–507.
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Research paper
Traumatic experiences and posttraumatic stress disorder among Chinese rural-to-urban migrant children Liang Yiminga,b, Zhou Yueyuea,b, Liu Zhengkuia,b, a b
T
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CAS Key Laboratory of Mental Health, Institute of Psychology, Beijing 100101, China Department of Psychology, University of Chinese Academy of Sciences, Beijing 100049, China
A R T I C LE I N FO
A B S T R A C T
Keywords: Traumatic experiences Posttraumatic stress disorder Migrant children China
Background: Children and adolescents are in the developmental periods with the highest risk of experiencing multiple types of traumatic experiences (TEs). Immigrant children are more likely than other children to be exposed to TEs and have a higher risk of mental health problems. However, no epidemiological study has reported the prevalence of TEs and the associated development of posttraumatic stress disorder (PTSD) among Chinese children. Methods: The present study focused on trauma exposure among rural-to-urban migrant Chinese children. A large-scale (N = 16,140) cross-sectional survey of rural-to-urban migrant workers’ children in grades 4 to 9 was conducted in Beijing. Lifetime exposure to accidents and injuries, interpersonal violence, and trauma within the social network or witnessing traumatic events were measured along with PTSD. Results: Nearly half of the participants (47.06%) had experienced TEs, and 6.68% of those children met the cutoff for PTSD. Trauma exposure was associated with gender, age, quality of life, parents’ marital status, caregivers before the child started school and father's education level. Overall, interpersonal violence was associated with the highest rates of PTSD, and disasters were associated with the lowest rates of PTSD. Limitations: The cross-sectional survey design limited the ability to document temporal ordering, and the assessment of lifetime TEs was based on retrospective recall. Conclusions: The present study is the first epidemiological study of TEs in Chinese rural-to-urban migrant children. TEs are potentially fairly common among this population. Interventions designed to prevent PTSD should target different TE types according to the victim's gender.
1. Introduction Most people are unavoidably exposed to traumatic experiences (TEs) at some point during their lifetime, and this exposure has been shown to negatively affect physical and mental health (Benjet et al., 2016; Liang et al., 2019; Liu et al., 2017). Prior work has indicated that adolescence is the developmental period with the highest risk of experiencing multiple types of TEs, such as accidents, injuries, interpersonal violence and many types of vicarious traumas (Finkelhor et al., 2009; Mclaughlin et al., 2013). Moreover, children and adolescents are also in a vulnerable developmental period because they lack effective coping skills to adapt to and recover from TEs; thus, they are more vulnerable to PTSD (Braun-Lewensohn, 2015). Therefore, it is important to understand the status quo of TEs and the associated development of PTSD in children and adolescents to prevent potential TE exposure and provide appropriate psychological services. However,
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evidence related to TEs and the associated development of PTSD among children and adolescents is insufficient. Both theoretical and empirical evidence suggests that the prevalence of TEs and PTSD varies widely across cultures (Benjet et al., 2016; Seedat et al., 2004). However, the available epidemiological data are predominantly from the USA. The prevalence of TEs is estimated to be 61.8% and 67.8% based on an American national sample of adolescents and a representative sample of the child population in western North Carolina, respectively (Copeland et al., 2007; Mclaughlin et al., 2013). The lifetime prevalence rates of PTSD among respondents in these two samples who were exposed to trauma were estimated to be 7.6% and 5.9%, respectively (Copeland et al., 2007; Mclaughlin et al., 2013). Higher trauma rates, estimated at 83.6%, were reported in a study of Kenyan and South African adolescents; additionally, there was a higher lifetime PTSD prevalence, estimated at 15.9%, among respondents exposed to trauma (Seedat et al., 2004). To our knowledge,
Corresponding author. E-mail address: [email protected] (Z. Liu).
https://doi.org/10.1016/j.jad.2019.07.024 Received 14 March 2019; Received in revised form 1 June 2019; Accepted 4 July 2019 Available online 05 July 2019 0165-0327/ © 2019 Elsevier B.V. All rights reserved.
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to an increased number of TEs, possibly because older children have more time to be exposed to TEs (Perkonigg et al., 2000; VaughnCoaxum et al., 2018). Children and adolescents in families with a lower socioeconomic status also tend to report more trauma exposure (Perkonigg et al., 2000; Vaughn-Coaxum et al., 2018). Most rural-tourban migrant children are born to lower socioeconomic status families, so trauma exposure among these children is worthy of attention. Family structure and the children's caregivers are determining factors of childadolescent trauma exposure: living with both biological parents has an important protective effect against traumatic events (Mclaughlin et al., 2013; Turner et al., 2007). Among rural-to-urban migrant children, a large proportion are left at home during early childhood when parents go out to work (Liu et al., 2009; Cheng et al., 2017). During this time, the child may be looked after by grandparents or other relatives. Whether early childhood caregivers are related to child-adolescent trauma exposure among migrant children is also worth discussing. The current study used a large-scale sample of rural-to-urban migrant children that included 16,140 migrant children in Beijing who migrated from almost every other region in China. The aim of the study was to describe the epidemiology of TE exposure and PTSD, including the prevalence of TE and PTSD, correlates of TE exposure and variations in the conditional risk of PTSD within a given TE exposure among these children and adolescents.
no epidemiological study has reported basic descriptive data on the prevalence of TE exposure and the associated development of PTSD among children and adolescents in an Asian culture. This serious gap in the literature needs to be addressed. Immigration is a common phenomenon around the world today, and rural-to-urban migration is an important type of immigration. In 2012, the number of rural-to-urban migrants reached approximately 230 million in China, accounting for 17% of China's total population (Cheng et al., 2017). Many migrant parents take their children to cities, and these children are called “rural-to-urban migrant children”. Previous research found that immigrant children are more commonly exposed to TEs: compared to children raised in the city, immigrant children experience more negative life events and witness more violence and gambling in their community (Cheng et al., 2017; Nöthling et al., 2017). Moreover, migration is a stress-inducing phenomenon that can cause a higher risk of mental health problems among migrants due to increased exposure to acculturative stressors or to unfamiliar environmental factors (Bhugra, 2004; Derluyn et al., 2008; Mclaughlin et al., 2013). Therefore, the prevalence of TEs and associated mental health problems among rural-to-urban migrant children is worthy of attention. However, to date, there has been no large-scale investigation of trauma exposure among immigrant children worldwide. Identifying which types of TEs present a higher conditional risk for mental health problems is another important issue. Previous research found that different types of TEs present different risks for the subsequent development of PTSD (Liu et al., 2017; Mclaughlin et al., 2013). Interpersonal violence, such as physical abuse and community and sexual violence, has consistently been regarded as the type of traumatic event linked to a higher risk of developing PTSD (Liu et al., 2017; Nöthling et al., 2017). Disasters, accidents and injuries have been found to present relatively low risks, and vicarious trauma exposure, such as hearing about or witnessing a traumatic experience, is associated with the lowest risk of developing PTSD (Lukaschek et al., 2013; Mclaughlin et al., 2013). Most conclusions regarding the risks associated with different types of TEs have been based on adults, and the PTSD criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM) were developed mostly from the adult literature (Mclaughlin et al., 2013). How the different TEs that meet the DSM-IV A1 criterion affect children and adolescents deserves further exploration. Considerable gender differences regarding trauma exposure have been found in previous studies. Both the prevalence of specific types of TE and the probabilities of developing PTSD following different types of TE vary considerably according to gender (Nöthling et al., 2017; Perkonigg et al., 2000). Significant gender differences were observed in the types of TEs that occurred (Lukaschek et al., 2013; Perrin et al., 2014). Males were more likely to be victims of accidents and physical violence and were more likely to witness an injury or death, while females were more likely to be victims of rape and physical assault by romantic partners both as adult and adolescents (Lukaschek et al., 2013; Mclaughlin et al., 2013; Perrin et al., 2014). The results regarding the differences in sexual assault TEs between genders are mixed, and some scholars have noted that the inconsistent conclusions might be a result of cultural differences (Benjet et al., 2016; Mclaughlin et al., 2013; Seedat et al., 2004). More evidence from different cultures is needed. Gender differences also exist in PTSD risk. On the one hand, most studies have shown that females are more vulnerable to PTSD after experiencing the same traumatic event as males (Cheng et al., 2018; Liang et al., 2019). On the other hand, females are more likely to be victims of TEs with higher conditional risks for PTSD, such as rape and physical assault by romantic partners, which also leads to a higher prevalence of PTSD among females (Lukaschek et al., 2013; Mclaughlin et al., 2013). In addition to gender, other sociodemographic variables are associated with exposure to TEs among children and adolescents (Copeland et al., 2007; Mclaughlin et al., 2013). Age is an important factor related
2. Methods 2.1. Procedure and participants Fifty-eight schools in Beijing that had been established mainly for children of migrant workers were investigated. In total, 16,682 rural-tourban migrant children participated in the present study. The details of the school selection and sampling procedures are described elsewhere (Cao and Liu, 2015). Valid data were obtained from 16,140 (96.75%) children, and the excluded data were primarily omitted due to incomplete or inaccurate responses. The participants came to Beijing from 29 regions in mainland China, which covered almost all regions of mainland China. Data collection were collected within a school class, and the questionnaires were distributed and administered at each session by two assistant investigators who had received the same standardized instructions for carrying out the survey. Written informed consent was obtained from the participants and clearly indicated that they were not required to respond to any question if they did not wish to. Moreover, a statement approving this survey procedure was signed by the investigators and the school representatives, and the school administrators were fully briefed on the details of the investigative procedure, including the decision not to obtain parental consent because of the difficulties of contacting these children's parents or guardians. The study design and procedures were approved by the ethics review committee of the Institute of Psychology, Chinese Academy of Sciences. The sociodemographic characteristics of the study sample are presented in Table 1.
2.2. Measures 2.2.1. Demographics A questionnaire was devised to obtain demographic information, including age, gender, parents’ educational level (1 = primary school and below, 2 = junior high school, or 3 = high school and above), caregivers before primary school (1 = parents, 2 = grandparents, or 3 = other relatives), parents’ marital status (1 = first marriage, 2 = divorced, or 3 = remarried) and the children's quality of life (“How would you describe your quality of life in your new location?”, 1 = low, 2 = below average, 3 = average, 4 = above average, or 5 = high). 124
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types and accumulation of TE types the children reported. To estimate the conditional probability of PTSD among participants who were exposed to particular TEs using the method described for the WHO World Mental Health Surveys, a random TE was selected from the TEs experienced by participants who reported more than one type of TE (Liu et al., 2017; Rosellini et al., 2018). This method was suggested to be suitable for obtaining unbiased estimates of conditional risk (Liu et al., 2017; McLaughlin et al., 2013). The descriptive statistics of the random representative TEs were also computed. Second, a descriptive statistical analysis of TE type prevalence and cross-tabulation of the accumulation of TE types was conducted for the male and female samples to explore gender differences. Third, depending on the number of TE types experienced, we classified the accumulation of TE types as no trauma, low accumulation (from 1 to 3 TE types), moderate accumulation (from 4 to 6 TE types) and high accumulation (more than 6 TE types). Descriptive statistics for the demographic variables were computed according to each classification. Then, we investigated the associations between the TE types and PTSD. Of the 7595 respondents who reported having experienced TEs, 6482 (response rate of 85.35%) reported their PTSD symptoms. To investigate the potential impact of attrition, we tested the differences in the main demographic variables (gender, age, TE type and accumulation of TE types). The results showed that whether a participant responded or not was not significantly related to gender or TE type (all p > .297) but was significantly related to age and the accumulation of TE types (ps < 0.001). Younger respondents (Mnot response = 11.07, SD = 1.61 years; Mresponse = 11.55 SD = 1.79 years; T1596 = −8.98, p < .001) and respondents with a lower accumulation of TE types (Mnot response = 2.10, SD = 1.35; Mresponse = 2.32, SD = 1.47; T1595 = −5.05, p < .001) were more likely not to report their PTSD symptoms. The next analysis was conducted with the participants who experienced TEs and reported PTSD symptoms. The prevalence of PTSD in the sample with TE exposure and the prevalence of PTSD associated with the random representative TE were computed. Cross-tabulation was used to determine proportional differences in PTSD prevalence according to TE type. The PTSD prevalence was also computed for the 3 TE categories, and cross-tabulation was used to determine the proportional differences in PTSD prevalence according to TE category. To investigate the risk of developing PTSD among individuals who experienced various TE types, multiple logistic regression was conducted for the full sample according to PTSD status. Gender differences were also investigated for the associations of TE type with PTSD. To investigate gender differences in the risk of developing PTSD among individuals who experienced various TE types, a multiple logistic regression was conducted for the male and female samples separately.
Table 1 Sociodemographic characteristics of the rural-to-urban migrant children (n = 16,140). Sociodemographic characteristics
Category
N
Weighted%
Gender
Male Female 8–9 10 11 12 13–14 15–17 Primary school and below Junior high school High school and above Primary school and below Junior high school High school and above First marriage Divorced Remarried Parents Grandparents Other relatives
9247 6662 2081 4267 3678 2658 2472 818 4257
57.3 41.3 12.9 26.4 22.8 16.5 15.4 5.1 26.4
5860 3440 6355
36.3 24.3 39.4
4618 2077 14,737 473 638 12,544 3076 439
28.6 12.9 91.3 2.9 4.0 77.7 19.1 2.7
Age (years)
Father's educational level
Mother's educational level
Parental marital status
Caregivers before starting school
2.2.2. Traumatic experience history The lifetime exposure to traumatic events was assessed with the first part of the University of California at Los Angeles (UCLA) PTSD reaction index for the DSM-IV, revision 1 (UCLA PTSD-RI; Steinberg et al., 2004). This part of the index constitutes a brief lifetime trauma screening for 12 types of TEs that meet the DSM-IV A1 criterion, such as natural disaster, medical trauma and exposure to community violence and domestic violence. Because none of the children had experienced a war, we deleted the item “Being in a place where a war was going on around you”. Finally, 11 types of TEs were measured in the current study. Consistent with the classification used in most prior studies (McLaughlin et al. 2013; Vaughn-Coaxum et al., 2018), we grouped these events into three categories: (1) accidents and injuries (including 4 types: earthquakes, other disasters, accidents and painful medical treatments); (2) interpersonal violence (including 3 types: experiencing domestic violence, experiencing violence away from home and sexual harassment); (3) trauma within the social network or witnessing events (including 4 types: witnessing fighting at home, witnessing violence away from home, seeing a dead body and hearing about the death or injury of a loved one).
3. Results 2.2.3. PTSD The third part of the UCLA PTSD-RI for the DSM-IV was administered to measure PTSD symptoms (Steinberg et al., 2004). The children who reported experiencing one or more TEs continued to fill out this section, and the other children skipped this section because experiencing a traumatic event is a prerequisite for PTSD. This part of the index is a self-report scale used to assess PTSD symptoms in children and adolescents based on the following three criteria from the DSM-IV: reexperiencing, avoidance and hyperarousal. The items are scored on a 5point scale ranging from 0 (none of the time) to 4 (most of the time), and the children rated each item according to their situation during the past month. A cutoff of a total score of 38 or greater was considered to indicate PTSD (Rodriguez et al., 2001a, b). In the present study, the scale exhibited good internal consistency (Cronbach's α = 0.91).
3.1. Prevalence of TEs Nearly half of the participants (7594 of 16,140, 47.06%) reported having experienced TEs. The prevalence of each TE is shown in Table 2. The most common TEs were witnessing violence away from home (24.16%), seeing a dead body (15.72%) and experiencing domestic violence (13.98%). The least common TEs were experiencing other disasters (2.63%), earthquakes (2.74%) and sexual harassment (5.21%). Overall, TEs belonging to the category of trauma within the social network or witnessing events occurred most often, and TEs belonging to the category of accidents or injuries occurred the least often. The proportion of randomly chosen TEs is shown in Table 2. The distribution of the randomly chosen TEs was consistent with the original distribution, and the proportion of each TE was lower. The mean accumulation of TE types was 1.08 for the total sample and was 2.29 for the sample with traumatic experiences. Most of the participants (38.39% in the total sample) had an accumulation of 1 to 3 TE types (low accumulation), 8.47% of the children in the total sample reported
2.3. Data analysis Data analysis was conducted in IBM SPSS version 22.0. First, descriptive statistics were performed for the demographic variables, TE 125
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Table 2 Prevalence of different types of traumatic experiences.
Any type of TE Accidents/injuries
Interpersonal violence
Social network or witnessing events
Earthquake Disaster Accident Painful medical treatment Domestic violence Violence away from home Sexual harassment Seeing domestic violence Seeing violence out home Seeing a dead body Hearing about death or injury
Total (n = 16,140)% (SE)
Boys (n = 9247)% (SE)
Girls (n = 6662)% (SE)
Randomly Chose TE % (SE)
PTSD Prevalence% (SE)
47.06 (0.57) 2.74 (0.78) 2.63 (0.78) 5.40 (0.77) 11.75 (0.74)
49.76 (0.74) 2.96 (1.02) 2.91 (1.02) 6.25 (1.01) 13.26 (0.97)
42.98 (1.21) 2.33 (1.21) 2.18 (1.21) 4.05 (1.20) 9.56 (1.17)
47.06 (0.57) 1.13 (0.78) 1.04 (0.78) 2.16 (0.78) 5.26 (0.76)
6.68 4.24 5.37 6.82 6.57
13.98 (0.73) 7.55 (0.76)
15.75 (0.95) 9.25 (0.99)
11.42 (1.15) 5.03 (1.19)
5.68 (0.78) 2.73 (0.78)
7.89 (0.96) 9.74 (1.52)
5.21 (0.77) 8.22 (0.75)
6.32 (1.01) 8.25 (1.00)
3.54 (1.20) 8.02 (1.18)
1.92 (0.78) 3.08 (0.78)
13.28 (2.06) 7.57 (1.29)
24.16 (0.69)
25.29 (0.90)
22.46 (1.08)
12.31 (0.74)
4.33 (0.50)
15.72 (0.72) 10.40 (0.74)
17.03 (0.95) 10.43 (0.98)
13.79 (1.14) 10.28 (1.16)
7.61 (0.76) 4.13 (0.77)
5.80 (0.72) 8.64 (1.17)
(0.31) (1.57) (1.85) (1.44) (0.92)
more boys had a higher accumulation of TE types than girls, χ2(2, N = 7464) = 23.35, p < .001.
an accumulation of 4 to 6 TE types (moderate accumulation) and a small proportion (0.52% of the total sample) reported an accumulation of more than 6 TE types (high accumulation).
3.3. Other demographic correlates of TE exposure 3.2. Gender differences in trauma exposure TE exposure was significantly related to gender, age, life quality, caregivers before starting school, parental marital status and father's education level (ps < .020). TE exposure was not significantly related to mother's education level (p = .535). The summary of demographic characteristics according to TE exposure is shown in Table 3. The results showed that children in the group with high accumulation of TE types group were older, F (3, 15,970) = 136.19, p < .001. Children in the high accumulation of TE types group also had lower life quality, F (3, 15,963) = 6.19, p < .001. Compared to children who were cared for their parents before starting school, a larger proportion of children whose caregivers before starting school were grandparents or other relatives had a higher accumulation of TE types, χ2(6,
Overall, the proportion of boys (49.46%) with trauma exposure was higher than that of girls (42.98%), χ2(1, N = 15,909) = 71.51, p < .001. The prevalence of each type of TE among boys and girls is shown in Table 2. The prevalence of all TE types was higher in boys than in girls. The types of TEs with large gender differences were experiencing an accident, experiencing a painful medical treatment, experiencing domestic violence, experiencing violence away from home, experiencing sexual harassment and seeing a dead body. These TE types with larger gender differences were mostly related to accidents or interpersonal violence. Gender differences in the accumulation of TE types are shown in Table 3. In the sample with traumatic experiences, Table 3 Summary of demographic correlates of TE exposure.
Gender: Male Female Age Life quality Caregivers before starting school: Parents Grandparents Other relatives Parents’ marital status: First marriage Divorced Remarried Father's education: Primary school or below Junior high school High school or above Mother's education: Primary school or below Junior high school High school or above
No trauma (n = 8545) N (%)
Low accumulation of TE types (n = 6196) N (%)
Moderate accumulation of TE types (n = 1315) N (%)
High accumulation of TE types (n = 84) N (%)
χ2 / F value
4646 (54.37%) 3799 (44.46%) 10.98 (1.57) 2.98 (0.80)
3686 (59.49%) 2414 (38.96%) 11.42 (1.74) 2.95 (0.84)
854 (64.94%) 429 (32.62%) 11.75 (1.87) 2.95 (0.91)
61 (72.62%) 20 (23.81%) 12.04 (1.99) 2.64 (1.17)
χ2 = 94.19⁎⁎
6862 (80.30%) 1459 (17.07%) 188 (2.20%)
4675 (75.45%) 1299 (20.97%) 190 (3.07%)
941 (71.56%) 303 (23.04%) 58 (4.41%)
66 (78.57%) 15 (17.86%) 3 (3.57%)
χ2 = 81.56⁎⁎
7906 (92.52%) 206 (2.41%) 290 (3.39%)
5612 (90.57%) 198 (3.20%) 281 (4.54%)
1148 (87.30%) 64 (4.87%) 64 (4.87%)
71 (84.52%) 5 (5.95%) 3 (3.57%)
χ2 = 44.81⁎⁎
2178 (25.49%) 3225 (37.74%) 2014 (23.57%)
1679 (27.10%) 2303 (37.17%) 1300 (20.98%)
376 (28.59%) 462 (35.13%) 278 (21.14%)
24 (28.57%) 36 (42.86%) 14 (16.67%)
χ2 = 20.89⁎⁎
3345 (39.15%) 2386 (27.92%) 1096 (12.83%)
2420 (39.06%) 1873 (30.23%) 812 (13.11%)
551 (41.90%) 336 (25.55%) 165 (12.55%)
39 (46.43%) 23 (27.38%) 8 (9.52%)
χ2 = 12.99*
Note:. ⁎⁎ p<.01. ⁎ p<.05. 126
F = 136.19⁎⁎ F = 6.19⁎⁎
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3.5. Gender differences in the associations of TE types with PTSD
N = 16,059) = 81.56, p < .001. Compared to children whose parents were in their first marriage, a larger proportion of children whose parents were divorced or remarried had a higher accumulation of TE types, χ2(6, N = 15,848) = 44.81, p < .001. A lower proportion of children whose fathers had a higher education level had a higher accumulation of TE types, χ2(6, N = 13,557) = 20.89, p < .001.
Overall, the PTSD prevalence among females with TEs (7.42%) was higher than that among males with TEs (6.16%). To explore gender differences in the associations of TE types with PTSD, we conducted multiple logistic regressions in the male and female samples separately. The results are shown in Table 4, and several gender differences were revealed. Overall, 8 TE types could predict PTSD among boys, and only 5 TE types could predict PTSD among girls. Specifically, accidents, painful medical treatments and seeing a dead body predicted PTSD in only the male sample, and 3 TE types in the interpersonal violence category had stronger associations with PTSD in the female sample. There were few gender differences in the prediction of PTSD based on witnessing domestic violence and hearing about the death or injury of a loved one. These results indicate that gender differences were present mainly in TE types related to accidents, injuries and interpersonal violence.
3.4. Prevalence of PTSD among children with TEs Four hundred forty-three children reached the cutoff score on the UCLA PTSD-RI. The prevalence of probable PTSD was 6.68% among the 6482 children who were exposed to any TE and reported their PTSD symptoms. Compared to being exposed to a single TE type, being exposed to multiple TE types strongly predicted higher rates of PTSD, χ2(3, N = 6482) = 231.75, p < .001. Among children with exposure to a single TE type, the prevalence of PTSD was 3.31%; the prevalence of PTSD was 5.72% among children with two or three TE types. The PTSD prevalence was 14.00% in children with a moderate accumulation of TE types (4–6 TE types) and 30.26% in children with a high accumulation of TE types (more than 6 TE types). Age was also related to PTSD symptoms (r = 0.07, p < .001); adolescents aged 14 to 17 years (M PTSD symptoms = 19.23, SD = 12.26) had more PTSD symptoms than children aged 8 to 10 years (M PTSD symptoms = 16.58, SD = 12.86) and children aged 11 to 13 years (M PTSD symptoms = 16.36, SD = 11.77). The prevalence of PTSD among randomly chosen TEs is shown in Table 2. A significant variation in PTSD prevalence was found across these 11 TEs, χ2(10, N = 6482) = 48.38, p < .001, with the highest PTSD prevalence rates associated with sexual harassment (13.28%), experiencing violence away from home (9.74%) and hearing about the death or injury of a loved one (8.64%) and the lowest PTSD prevalence rates associated with experiencing an earthquake (4.24%), witnessing violence away from home (4.33%) and experiencing other disasters (5.37%). The results showed that the TE types related to interpersonal violence were associated with a relatively higher PTSD prevalence, and the TE types related to disaster were associated with a relatively lower PTSD prevalence. Significant variation in PTSD prevalence was also found across three TE categories, χ2(2, N = 6482) = 22.09, p < .001, with the highest PTSD prevalence associated with interpersonal violence (9.39%). In addition, the PTSD prevalence associated with accidents/injuries was 6.21%, and the prevalence associated with violence within the social network or witnessing events was 5.80%. To further explore the risk of PTSD among various TE types, a multiple logistic regression was conducted in the whole sample with PTSD, and the outcome is shown in Table 4. The results showed that most TE types, excluding earthquakes, disasters and witnessing violence away from home, were predictive of PTSD.
4. Discussion The present study is the first epidemiological study of TEs in ruralto-urban migrant children and their association with PTSD in China. Our main findings were that (1) TEs were relatively common in ruralto-urban migrant children in China; (2) gender differences were present in trauma exposure and the associations of TE types with PTSD; (3) the TE types related to interpersonal violence were associated with the highest conditional risk for PTSD; and (4) TE exposure was related to some sociodemographic variables, including age, gender, caregivers before starting school, quality of life, parents’ marital status and father's education level. Nearly half (47.06%) of the rural-to-urban children in Beijing reported experiencing one or more TEs, indicating substantial trauma exposure during childhood and adolescence, and 6.68% of those exposed to trauma met the cutoff for PTSD. The TE prevalence estimate was lower than the estimates reported in recent American (61.8%−67.8%) and African studies of children and adolescents (83.6%; Copeland et al., 2007; Mclaughlin et al., 2013; Seedat et al., 2004). Specifically, in a comparison of the American samples and our sample, the rates of TEs related to disasters and accidents were much higher in the American samples, while the rate of TEs related to being beaten or physically hurt by a family member was higher in the Chinese sample. The TE rates among African children were higher than those among Chinese children for almost all types of TEs. These cross-cultural differences might be partly caused by the different data collection instruments used; however, they also reflect differences in living environments, such as public security and natural conditions. In the present study, a larger proportion of boys (49.76%) had
Table 4 Differential associations of TE types with PTSD and gender differences.
Earthquake Disaster Accident Painful medical treatment Domestic violence Violence away from home Sexual harassment Seeing domestic violence Seeing violence out home Seeing a dead body Hearing about death or injury
Total (n = 6482) B OR
95%CI
Boys (n = 3930) B OR
95%CI
Girls (n = 2440) B OR
95%CI
−.01 .07 .31* .40⁎⁎ .52⁎⁎ .47⁎⁎ .60⁎⁎ .47⁎⁎ .17 .39⁎⁎ .57⁎⁎
[0.67, 1.46] [0.72, 1.57] [1.04, 1.79] [1.21, 1.85] [1.36, 2.08] [1.27, 2.02] [1.41, 2.34] [1.26, 2.02] [0.97, 1.45] [1.20, 1.80] [1.42, 2.18]
.19 −.04 .42* .55⁎⁎ .29* .43⁎⁎ .55⁎⁎ .42* .09 .51⁎⁎ .58⁎⁎
[0.74, 1.96] [0.57, 1.62] [1.09, 2.14] [1.31, 2.27] [1.00, 1.79] [1.13, 2.08] [1.24, 2.41] [1.09, 2.10] [0.83, 1.44] [1.27, 2.18] [1.35, 2.38]
−.28 .23 .31 .16 .88⁎⁎ .69⁎⁎ .79⁎⁎ .47⁎⁎ .22 .26 .57⁎⁎
[0.38, 1.52] [0.68, 2.32] [0.85, 2.21] [0.82, 1.67] [1.74, 3.37] [1.36, 2.92] [1.44, 3.39] [1.12, 2.29] [0.91, 1.70] [0.93, 1.79] [1.27, 2.45]
0.99 1.07 1.36 1.50 1.68 1.60 1.81 1.60 1.19 1.47 1.76
Note:. ⁎⁎ p<.01. ⁎ p<.05. 127
1.21 0.96 1.53 1.73 1.34 1.53 1.73 1.52 1.09 1.66 1.79
.76 1.26 1.37 1.17 2.42 2.00 2.21 1.60 1.24 1.29 1.76
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experiencing/witnessing domestic violence and experiencing violence away from home. These results suggested that fathers with low education levels were more likely to be violent and live in communities in which the residents are more violent with their children (Leung et al., 2008). There are several limitations in the present study. First, the assessment of lifetime TEs was based on retrospective recall, which is subject to potential reporting bias. Second, PTSD was assessed by self-reported questionnaires rather than more sensitive clinical interviews. Moreover, some respondents with younger ages or a lower accumulation of TE types did not report their PTSD symptoms. Therefore, the PTSD prevalence reported in the results may be overestimated. Third, the crosssectional survey design limited the ability to document the temporal ordering of TEs and PTSD and potential risks. Finally, the current study lacked a comparison between rural-to-urban migrant children and local children. The lifetime history of TEs in local Chinese children remains unknown. Thus, we call for more research to investigate TEs among Chinese children. Despite these limitations, our study is the first to document the high prevalence of TEs in Chinese rural-to-urban migrant children. These findings also reveal effective ways to reduce PTSD in this population by both preventing vulnerable children from trauma exposure and delivering timely preventive interventions to children exposed to TEs associated with a high risk of PTSD. Boys and girls must be treated differently in clinical work due to gender differences in the associations between TE types and PTSD. Male victims of accidents and injuries and female victims of interpersonal violence should be the targets of interventions.
trauma exposure than girls (42.98%), and boys (1.18) had a greater accumulation of trauma types than girls (0.93). Among all types of TEs, boys had larger proportions of trauma exposure, especially for trauma types related to accidents and violence. This may be partly because males are more adventurous and more likely to engage in risky activities (Lukaschek et al., 2013). In addition, a larger proportion of boys experienced sexual harassment in our sample, which was inconsistent with the results of some studies (McLaughlin et al., 2013; Nöthling et al., 2017). On the one hand, the reason boys experience more sexual harassment in our study is that boys are more likely to report their real experiences (Leung et al., 2008). On the other hand, cultural differences may cause differences in results because the Chinese culture places a strong emphasis on female chastity, and girls receive more sex education during childhood so they can better protect themselves from sexual harassment (Benjet et al., 2016). The comparatively higher conditional probability of PTSD associated with TEs related to interpersonal violence among our samples is consistent with the findings of previous studies (Liu et al., 2017; McLaughlin et al., 2013), likely because perpetrators who intentionally inflict harm have a complex emotional effect on their victims (Nöthling et al., 2017; Wamser-Nanney et al., 2017). Sexual harassment, which had the highest conditional risk for PTSD among all types of TEs, often comes from someone the victim knows and trusts, which commonly leads to victims feeling shame and guilt and even thinking that they are not worthy of love (Bonanno et al., 2002; Filipas and Ullman, 2006). Sexual harassment is a mild type of sexual abuse, and other sexual abuse, such as rape, can have a more severe impact, which suggests that sexual abuse needs to be a high priority in clinical work, especially during childhood and adolescence. In addition to interpersonal violence, hearing about the death or injury of a loved one has a heavy impact on children. Previous studies have demonstrated that this type of TE is a common traumatic experience that accounts for a large number of PTSD cases (Breslau et al., 1998; McLaughlin et al., 2013). A notable gender difference in the associations of TE types with PTSD was also found: some TEs related to accidents and injuries were associated with PTSD only among boys, while the impact of interpersonal violence on PTSD was greater among girls. These findings also prompted us to attach different levels of importance to different types of traumatic events according gender. To better identify high-risk populations according to TEs, we examined demographic differences in the accumulation of TE types. The results indicated that trauma exposure was associated with gender, age, quality of life, caregivers before starting school, parents’ marital status and father's education level. The number of cumulative TE types increased with age, which might be a result of increased exposure time (Vaughn-Coaxum et al., 2018). PTSD symptoms are also related to age; older adolescents have more PTSD symptoms than younger children, which might be partly due to cumulative trauma exposure. Therefore, those involved in clinical work with children and adolescents with psychological problems must consider their trauma history, especially during adolescence. Children living in families with a lower quality of life also tend to report more trauma exposure, which might be due to the lack of basic services and security facilities in the communities where they have lived. More importantly, children whose caregivers before they started school were not their parents and children who did not live with both biological parents experienced more TEs, which reflects the importance of parental supervision. Previous studies have indicated that family structure is a determinant of child-adolescent TEs (Mclaughlin et al., 2013). Children who lack parental supervision are more likely to be exposed to threatening situations and maltreatment from other, nonrelated adults at home. However, for most migrant children, parental supervision is relatively lacking, which is also an important reason to focus on the TE of this group. In addition, TEs were shown to be more common among children and adolescents whose fathers had lower educational levels. Further data analysis found that the father's education level was significantly associated with
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