Posttraumatic stress disorder in adolescents after Typhoon Morakot-associated mudslides

Journal of Anxiety Disorders 25 (2011) 362–368

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Journal of Anxiety Disorders

Posttraumatic stress disorder in adolescents after Typhoon Morakot-associated mudslides Pinchen Yang a , Cheng-Fang Yen a,b,∗ , Tze-Chun Tang a , Cheng-Sheng Chen a , Rei-Cheng Yang c , Ming-Shyan Huang d , Yuh-Jyh Jong c,e , Hsin-Su Yu f a

Department of Psychiatry, College of Medicine, Kaohsiung Medical University and Kaohsiung Medical University Hospital, Kaohsiung, Taiwan Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Pediatrics, College of Medicine, Kaohsiung Medical University and Kaohsiung Medical University Hospital, Kaohsiung, Taiwan d Department of Internal Medicine, College of Medicine, Kaohsiung Medical University and Kaohsiung Medical University Hospital, Kaohsiung, Taiwan e Department of Laboratory Medicine, College of Medicine, Kaohsiung Medical University and Kaohsiung Medical University Hospital, Kaohsiung, Taiwan f Department of Dermatology, College of Medicine, Kaohsiung Medical University and Kaohsiung Medical University Hospital, Kaohsiung, Taiwan b c

a r t i c l e

i n f o

Article history: Received 9 May 2010 Received in revised form 24 October 2010 Accepted 25 October 2010 Keywords: Epidemiology Natural disaster Post-traumatic stress disorder Adolescents

a b s t r a c t The aims of this study were to examine prevalence rate of post-traumatic stress disorder (PTSD), its associated factors and co-occurring psychological problems in a group of displaced adolescents 3 months following Typhoon Morakot in Taiwan. The relationship of trauma dimension and PTSD was also explored. A total of 271 adolescents who had been evacuated from their homes participated in this school-based survey. Adolescents were interviewed using the Mini-International Neuropsychiatric Interview for Children and Adolescents. Subjects themselves completed the following questionnaires: an inventory of exposure experiences to Typhoon Morakot, the Chinese version of Impact of Events Scale-Revised, the Center for Epidemiological Studies Depression Scale, and the Family APGAR Index. Teachers completed the Teacher’s Report Form in the Achenbach system of Empirically Bases Assessment. Results revealed that the prevalence of PTSD related to Typhoon Morakot was 25.8%. Adolescents who were female, had PTSD related to previous traumatic events before Typhoon Morakot, had more exposure experiences, were physically injured, or had family member in same household died or seriously injured were more likely to have the diagnoses of PTSD. Meanwhile, adolescents with PTSD had more severe depression, internalizing, externalizing, social, thought, and attention problems than those without PTSD. Our findings indicate that specialized trauma services are needed for these youngsters to lessen prolonged vulnerabilities. © 2010 Elsevier Ltd. All rights reserved.

1. Introduction There is a growing body of researches addressing the psychological sequelae of children and adolescents after traumatic events and disasters. Among them, readily identifiable or verifiable natural disasters such as hurricanes and earthquakes are more thoroughly studied traumas (Garrison, Weinrich, Hardin, Weinrich, & Wang, 1993; Garrison et al., 1995; Goenjian et al., 1995, 2001; Hsu, Chong, Yang, & Yen, 2002; Vernberg, Silverman, La Greca, & Prinstein, 1996; Weems et al., 2007) and post-traumatic stress disorder (PTSD) is the most common psychiatric disorder discussed. PTSD symptomatology may be different among children and adolescents depending upon the traumatic event itself, its severity, duration, and the child’s developmental age at the time of the trauma (Perrin, Smith, & Yule,

∗ Corresponding author at: Department of Psychiatry, Kaohsiung Medical University Hospital, 100 Tzyou 1st Rd., Kaohsiung City 807, Taiwan. Tel.: +886 7 3124941; fax: +886 7 3134761. E-mail address: [email protected] (C.-F. Yen). 0887-6185/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.janxdis.2010.10.010

2000). Most importantly, PTSD may influence the development of children and adolescents and their abilities to build relationships and cause prolonged vulnerability. Literature review revealed that the reported prevalence of PTSD-related syndromes after natural disasters greatly varied. For example, studies reported that the prevalence at 1 year following a natural disaster range from no syndrome after a flood (Earls, Smith, Reich, & Jung, 1988), to 3.8–6.2% after Hurricane Hugo (Garrison et al., 1993), 28.6% with mild to moderate PTSD following the Northridge Earthquake (Asarnow et al., 1999), and 30.6% with PTSD following a super-cyclone crisis in India (Kar et al., 2007). Variation in prevalence figures could be due to differences in assessment duration from the traumatic event and the various methodologies used. Also, it has been proposed that actual development of PTSD will depend on the interaction among vulnerability factors, resilience factors, etiologic and mediating factors from both environmental and individual dimensions (Foy, Madvig, Pynoos, & Camilleri, 1996). All pre-traumatic, traumatic, and post-traumatic factors can contribute to the development of PTSD. Common pretraumatic factors include individual characteristics such as age,

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gender, temperament, intelligence, personality and prior experience of trauma or severe stress just prior to the occurrence of a trauma (Asarnow et al., 1999; Green et al., 1991; Hsu et al., 2002; Shaw, Applegate, & Schorr, 1996). Nature and severity of exposure experience to the traumatic disaster was found to be significantly associated with the development of PTSD (Carr et al., 1997; La Greca, Silverman, Vernberg, & Prinstein, 1996). The level of family function was also reported to related to PTSD development (Vernberg et al., 1996). To examine the factors correlated with PTSD is beneficial to understand the developmental mechanism of PTSD and identify those who have a high risk to have PTSD for further intervention. Exposure to traumatic events has been linked not only to PTSD, but also to other types of psychological distress symptoms, including depression, anxiety, behavioral problems, inattention, suicidality and increased substance abuse (Goenjian et al., 2001; McDermott, Lee, Judd, & Gibbon, 2005; Rohrbach, Grana, Vernberg, Sussman, & Sun, 2009; Shannon, Lonigan, Finch, & Taylor, 1994; Thienkrua et al., 2006). Hence, it will be important to have a comprehensive screening for psychiatric problems in children after a major disaster so that interventions can be properly targeted. Typhoon Morakot together with the mudslides and floods it caused was the deadliest typhoon-related disaster to impact Taiwan for the past 50 years. The storm caused catastrophic havoc, leaving 650 people dead and roughly US$3.3 billion in damages. On August 7, 2009, Typhoon Morakot made landfall in central Taiwan and the next day the storm emerged back over the waters of the Taiwan Strait, and most areas in southern Taiwan recorded heavy rainfall peaking at 2777 mm (109.3 in.). Extreme amounts of rain caused severe flooding throughout southern Taiwan and triggered enormous mudslides in mountainous areas. Rescue crews had to evacuate people by helicopter, with more than 14,000 residents trapped in buried villages cut off by the mudslides and flooding in steep mountainous areas. Due to the terrifying mudslides, nearly all of the inhabitants experienced direct threats to their lives, and the majority of their homes were buried by several meters of mud; hence people living in these two townships were relocated from the mountains to other locations on the plains in the aftermath of the storm. The Taiwanese government arranged several military camps as shelters for the villagers, and they were taken in as family units. Adolescents who were in grades 7–9 (N = 277) were allocated to three temporary boarding areas where they could continue to receive formal education in a group setting. The majority of them lived in group dormitories and visited family members only on weekends. As part of a public health emergency response, the aims of this study were to examine (1) the prevalence rate of PTSD related to Typhoon Morakot, (2) the associations between PTSD related to Typhoon Morakot and various factors such as demographic characteristics, exposure experience of Typhoon Morakot, prior PTSD, and perceived family function, and (3) co-occurring psychological problems (depression, psychological distress, and behavioral problems) in the group of displaced at-risk adolescents 3 months following Typhoon Morakot in Taiwan.

2. Methods 2.1. Setting and subjects A total of 277 adolescents who had been evacuated from their homes after the Typhoon Morakot were invited to participate in this school-based survey. This study was undergone in the classrooms three months following the mudslides disaster. The Institutional Review Board (IRB) of Kaohsiung Medical University approved the study. The IRB agreed to the use of passive consent from parents

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for their child’s participation for several reasons. First, this study not only surveyed participants’ psychological well-being but also provided further intervention for those who were identified as having psychological disturbances. Second, adolescents could make the decision to complete the anonymous questionnaire by themselves. Third, adolescents’ parents could receive results of the assessment and work together with mental health professionals and school teachers to improve the adolescents’ mental health. Fourth, this survey did no harm to the participants. Fifth, the IRB agreed that results of this study would be beneficial to the adolescents. Before conducting the study, we prepared a leaflet explaining the purpose and procedure of this study. Students took the leaflet home on the weekend for their parents to inspect. If the parents disagreed with the study, they could tell their children to directly refuse to participate. Written informed consent was also obtained from the students themselves before the study began. 2.2. Assessment and survey instruments Subjects were assessed using the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) (Sheehan et al., 1998). The MINI-KID is a semi-structured interview schedule based on criteria of the DSM-IV (American Psychiatric Association, 1994) that assesses 24 child and adolescent psychiatric disorders and suicide risk. The MINI-KID generates reliable and valid psychiatric diagnoses for children and adolescents (Sheehan et al., 2010). Substantial to excellent MINI-KID to a structural interview (i.e., the Schedule for Affective Disorders and Schizophrenia for School Aged Children—Present and Lifetime Version) concordance was found for syndromal diagnoses of any mood disorder, any anxiety disorder, any substance use disorder, any behavioral disorder, and any eating disorder (kappa = 0.56–0.87). Sensitivity was substantial (0.61–1.00) for fifteen kinds of DSM disorders. Specificity was excellent (0.81–1.00) for 18 disorders and substantial (>0.73) for the remaining. Due to time limitations and the purpose of this study, the PTSD module of the MINI-Kid was used for the interviews. In addition to PTSD related to Typhoon Morakot, we also assessed PTSD related to previous traumatic events other than Typhoon Morakot. Fifteen psychiatric staff, including two senior board-certified child psychiatrists, five psychiatrists, five clinical psychologists, and three psychiatric nurses participated as interviewers. All of them have years of clinical experience in adolescent and adult psychiatry. Before conducting the diagnostic interview for the adolescents experiencing Typhoon Morakot, all interviewers received comprehensive training to use the MINI-KID. First, all interviewers attended a workshop for the MINI held by the Taiwanese Society of Psychiatry. The workshop introduced the MINI’s concepts, contents, and principles of use and included a video-recorded case interview using the MINI for attendants to rate the diagnoses. Second, two senior board-certified child psychiatrists (P.Y. and C.F.Y.) conducted a seminar for other interviewers to introduce the MINI-Kid modules. Third, each interviewer conducted a diagnostic interview of an adolescent using the PTSD module of the MINI-Kid under the supervision of a child psychiatrist (C.F.Y.) and then received his feedback for modifying the interview. Last, the inter-rater diagnostic reliability among the 15 interviewers was examined using six tape-recorded MINI-Kid case interviews. The kappa for PTSD ranged 0.67–1, which indicated good inter-rater diagnostic reliability. All subjects were asked to complete three self-report questionnaires as below: The Inventory of Exposure Experience to Typhoon Morakot: This 6-item inventory was adapted from the inventory used for the adolescent victims of Taiwan Earthquake in 1999 (Hsu et al., 2002).

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Subjects were asked whether they were physically injured, had household destruction, had the experience of being trapped, witnessed others being seriously injured or killed, and had the injury or death of close family members with whom they did or did not live at the time of Typhoon Morakot. The Chinese version of Impact of Events Scale-Revised (IES-R): The 22-item IES-R assessed three of the most commonly reported psychological response patterns associated with trauma, i.e., intrusive experience, avoidant behaviors, and hyperarousal symptoms (Weiss & Marmar, 1997). The original Impact of Event ScaleRevised was translated into Chinese and the comparability of content was verified through back-translation procedures and the reliability of the Chinese version had been verified (Wu & Chan, 2003). Participants were asked how much they were distressed or bothered by the difficulties related to Typhoon Morakot during the past week, for example: “Any reminder brought back feelings about it (Item 1)”. The degree of psychological distress was assessed on a 5-point scale, ranging from the absence of a symptom (0) to maximum symptomatology (4). The sum of all the scores was taken to indicate the severity of the psychological reactions to Typhoon Morakot. The Center for Epidemiological Studies Depression Scale (CES-D): The 20-item Mandarin-Chinese version (Chien & Cheng, 1985) of the CES-D (Radloff, 1977) is a self-administered evaluation scale assessing frequency of depressive symptoms in the preceding week, for example: “I was bothered by things that usually don’t bother me” (Item 1). The degree of depression was assessed on a 4-point scale, with scores ranging from 0 (none or very few) to 3 (always). The original CES-D was translated into Chinese and the comparability of content was verified through back-translation procedures. Higher CES-D scores indicate more severe depression. The Cronbach’s alpha for the CES-D used in Taiwanese adolescents was 0.93 and two-week test–retest reliability (r) was 0.78 (Yen, Ko, Yen, & Cheng, 2008). Family APGAR Index: The 5-item Family APGAR measures participants’ perceived family support in the domains of adaptation, partnership, growth, affection, and resolve (Chau, Hsiao, Huang, & Liu, 1991; Smilkstein, 1978). In this study we specifically asked the subjects to rate the emotional, communicative, and social interactive relationships between the respondent and his or her family in the preceding three months, for example: “I find that my family accepts my wishes to take on new activities or make changes in my lifestyle”. The four-point response scales reflect the frequency which ranges from never to always. High total scores indicate good perceived family function. The Cronbach’s ˛ in the present study was 0.836, and the 2-week test-retest reliability was 0.72 in a previous study on Taiwanese adolescents (Ko, Yen, Liu, Huang, & Yen, 2009). We also invited the teachers of the participating students to complete the Chinese version of the Teacher’s Report Form (CTRF) in the Achenbach system of Empirically Bases Assessment (Achenbach & Rescorla, 2007) according to the status of the students in the preceding 2 months. The C-TRF was translated from the English version of the TRF by using standard forward, backward and pretest-step methods (Chen, Huang, & Chao, 2009). The C-TRF consists of 113 behavior/emotional items. The problem items were scored 0 if not true, 1 if somewhat true or sometimes true, and 2 if very true or often true. The factor analysis yielded eight syndromes, including Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule Breaking Behavior, and Aggressive Behavior. Internalizing problems were composed of Anxious/Depressed, Withdrawn/Depressed, and Somatic Complaints. Externalizing problems were composed of Rule Breaking Behavior, and Aggressive Behavior. The total scores of the items on each syndrome were

transformed into T-score, and the higher T-score indicated the more severe behavioral problems. A previous study found that the internal consistency and 1-month test-retest reliability of the C-TRF were satisfactory for Taiwanese adolescents (Yang, Soong, Chiang, & Chen, 2000). 2.3. Procedures and statistical analysis Researchers explained the purposes and procedures of this study to the students in class, emphasizing respect for their privacy, and encouraged them to participate. Then the students were invited to complete the questionnaires. Meanwhile, all consenting students received a face-to face diagnostic interview using the PTSD module of MINI-KID to ascertain status of diagnosis. All participating students received a gift that was worth US$ 10 at the end of the assessment. Teachers of the participating students were invited to complete the C-TRF while blinded to the results of the diagnostic interviews and students’ self-reported questionnaires. The prevalence rate of PTSD related to Typhoon Morakot was first analyzed among the participating adolescents, then the possible associated factors of PTSD related to Typhoon Morakot were examined using three models of logistic regression analysis estimated with Wald’s 2 and the odds ratio (OR). In Model 1, the association of PTSD related to Typhoon Morakot with sociodemographic characteristics (gender, age, and current living status), perceived family function as reported by the APGAR, and PTSD related to previous traumatic events were examined. In Model 2, total numbers of exposure experience to Typhoon Morakot was added to examine its association with PTSD related to Typhoon Morakot. In Model 3, six types of exposure experience to Typhoon Morakot were added to examine their associations with PTSD related to Typhoon Morakot. Differences in levels of depressive scores as reported by the CESD, psychological distress as reported by the C-IES-R, and T-scores of the teacher-rating behavioral symptoms were examined between those with and without PTSD related to Typhoon Morakot using ttests. Because multiple comparisons were conducted, a two-tailed p value of <0.005 was considered statistically significant. The associations of depression and behavioral problems with PTSD related to Typhoon Morakot and number of exposure experience were further examined using two multiple regression analysis models to control for the confounding effects of gender and age. A two-tailed p value of <0.05 was considered statistically significant. 3. Results 3.1. Characteristics of subjects In total, 271 students (97.8%) completed all questionnaires and the interview. There was no difference in the gender ratio (2 = 1.033, p > 0.05) between the groups who participated and those who did not participate in this study (n = 6, 4 boys and 2 girls). However, those who did not participate were older than those who participated in this study (Z of Mann–Whitney U test = −2.645, p < 0.01). Among the 271 participating students, 124 (45.8%) were boys and 147 (54.2%) were girls, with a mean age of 13.4 years (standard deviation = 1.0 years, range: 12–15 years). Most of students (89.7%) were living in the temporary school dormitory and had family reunions only in weekend. 3.2. Prevalence of PTSD and exposure experiences Results of diagnostic interview based on the PTSD module of the MINI-KID indicated that 70 (25.8%) adolescents were diagnosed as having PTSD related to Typhoon Morakot, as well as 8 adolescents

95% CI of OR

.745–1.389 1.361–5.134 .848–5.385 1.837–42.090 .917–1.076

1.715–51.340 1.008–5.007 .886–3.327 .680–3.665 .971–4.245 .900–3.843

OR

1.017 2.644 2.137 8.792 .993

9.383 2.247 1.717 1.579 2.030 1.859 6.666* 3.921* 2.566 1.131 3.540 2.806

Results of three models of logistic regression analysis examining the associations of PTSD related to Typhoon Morakot with sociodemographic characteristics, family function, types of exposure experience, and PTSD related to previous traumatic events were shown in Table 1. The results of Model 1 indicated that adolescents who were female or had PTSD related to previous traumatic events were more likely to have the diagnoses of PTSD related to Typhoon Morakot, while age, current residence and perceived family support were not associated with PTSD related to Typhoon Morakot. Results of Model 2 indicated that adolescents who had more numbers of traumatic exposure experiences to Typhoon Morakot were more likely to have the diagnoses of PTSD related to Typhoon Morakot. The results of Model 3 indicated that adolescents who were physically injured or had family member in same household died or seriously injured were likely to have the diagnoses of PTSD related to Typhoon Morakot. The gender of female and PTSD related to previous traumatic events before Typhoon Morakot remained significantly associated with PTSD related to Typhoon Morakot in Models 2 and 3.

.767–1.408 1.413–5.307 .736–4.395 2.022–47.121 .911–1.067 1.462–2.319

.012 8.238** 2.591 7.403** .029

3.3. Factors related to PTSD

1.039 2.739 1.798 9.760 .986 1.841

OR Wald 

(3.0%) having PTSD related to previous traumatic events before Typhoon Morakot. Fifteen percent of the adolescents had family member in the same household died or seriously injured, 28.4% had family member not in the same household who died, 19.2% of their homes were severely destroyed, 19.2% had been trapped in heavy mud, 13.7% witnessed others being dead or seriously injured, and 3.3% had physical injuries in Typhoon Morakot.

.061 8.907** 1.657 8.045** .128 26.888***

Wald 2 2

95% CI of OR

Model 3 Model 2

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.764–1.350 1.006–3.262 .918–4.845 1.409–27.857 .935–1.080 1.016 1.811 2.109 6.266 1.005

PTSD: post-traumatic stress disorder. * p < 0.05. ** p < 0.01. *** p < 0.001.

.011 3.917* 3.094 5.811* .016 Age Gender (0: boys, 1: girls) Currently living with families PTSD related to the events other than Typhoon Morakot Level of family function on the APGAR Number of exposure experiences Types of exposure experience Being physically injured Death or serious injury of family member in same household Death of family member not in same household Witness others dead or seriously injured Household destruction Experience of being trapped in heavy mud

Wald 

2

OR

95% CI of OR

3.4. Psychological problems co-occurring with PTSD

Model 1

Table 1 The association between PTSD related to Typhoon Morakot and demographic characteristics, family function, PTSD related to the events other than Typhoon Morakot, and exposure experience examined by logistic regression analysis.

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Differences in the level of depression on the CES-D, psychological distress on the Chinese version of IES-R, and T scores of the teacher-rating behavioral symptoms between those with and without PTSD related to Typhoon Morakot examined using t tests are shown in Table 2. Results indicated that students with PTSD related to Typhoon Morakot had more severe depression on the CES-D and psychological distress on the Chinese version of IES-R than those without PTSD related to Typhoon Morakot. Meanwhile, those with PTSD related to Typhoon Morakot had more severe teacher-rating symptoms on Social Problems, Thought Problems and Rule Breaking Behavior and total C-TRF than those without PTSD related to Typhoon Morakot. Results of multiple regression analysis models examining the associations of depression and behavioral problems with PTSD related to Typhoon Morakot and number of exposure experience are shown in Table 3. The results of Model 1 indicated that after controlling for the effects of gender and age, adolescents who had PTSD related to Typhoon Morakot had more severe depression, internalizing, externalizing, social, thought, and attention problems than those who did not have PTSD related to Typhoon Morakot. Results of Model 2 indicated that more exposure experiences to Typhoon Morakot were significantly associated with more severe depression, internalizing, externalizing, social, and thought problems but not with attention problem. 4. Discussion This study found that 25.8% of adolescents had the diagnosis of PTSD related to Typhoon Morakot. Adolescents who were female, had PTSD related to previous traumatic events before Typhoon Morakot, had more exposure experiences to Typhoon Morakot, were physically injured, or had family member in same household died or seriously injured in Typhoon Morakot were more likely to have the diagnoses of PTSD related to Typhoon Morakot.

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Table 2 Severities of depression, disaster-related psychological distress, and T-scores of the teacher-rating behavioral symptoms between adolescents with and without PTSD related to Typhoon Morakot.

Depression on the CES-D Psychological distress on the C-IES-R T scores of the teacher-rating behavioral symptoms Anxious/depressed Withdrawn/depressed Somatic complaints Social problems Thought problems Attention problems Rule breaking behavior Aggressive behavior Total

PTSD (N = 70) mean (SD)

Non-PTSD (N = 201) mean (SD)

t

26.5 (10.6) 36.3 (16.9)

13.6 (8.0) 10.2 (9.0)

10.715** 16.254**

54.6 (5.8) 53.8 (5.0) 54.7 (6.8) 55.9 (6.5) 55.8 (7.7) 54.0 (4.8) 56.5 (6.8) 56.1 (5.8) 53.1 (8.3)

53.0 (5.0) 52.5 (4.4) 53.4 (6.4) 53.6 (5.8) 52.6 (5.4) 52.4 (5.0) 54.3 (5.6) 55.0 (6.0) 49.7 (8.0)

2.224 2.080 1.393 2.763* 3.848** 2.425 2.752* 1.364 2.999*

CES-D: Center for Epidemiologic Studies-Depression Scale; C-IES-R: Chinese version of Impact of Event Scale-Revised; PTSD: post-traumatic stress disorder. * p < 0.005. ** p < 0.001. Table 3 The associations of depression and behavioral problems with PTSD related to Typhoon Morakot and number of exposure experience examined by multiple regression analysis.a

Model 1 PTSD related to Typhoon Morakot Model 2 Number of exposure experiences a * ** ***

Depression

Internalizing problems

Externalizing problems

Social problems

Thought problems

Attention problems

Beta

t

Beta

t

Beta

t

Beta

t

Beta

t

Beta

t

.532

10.521***

.161

2.667**

.148

2.468*

.172

2.848**

.203

3.572***

.174

2.986**

.282

4.863***

.182

3.005**

.173

2.886**

.254

4.261***

.116

2.005*

.113

1.905

Controlling for the effects of gender and age. PTSD: post-traumatic stress disorder. p < 0.05. p < 0.01. p < 0.001.

Meanwhile, adolescents who had PTSD related to Typhoon Morakot had more severe depression, internalizing, externalizing, social, thought, and attention problems than those who did not have PTSD related to Typhoon Morakot. Our findings regarding PTSD and comorbid conditions diagnosed in this group of displaced aboriginal adolescents three months after natural disaster bear further discussion. 4.1. Prevalence of PTSD The result of this study found that 25.8% of adolescents having PTSD 3 months after Typhoon Morakot, which is in line with Western trauma reports showing that a substantial proportion of adolescents were in need of post-disaster mental health intervention program. However, our PTSD rate was higher than that of the 1999 Greece post-earthquake school-based mental health survey which was also done 3 months after natural disaster. In the 1999 post-earthquake study, PTSD Reaction Index was used to evaluate 1937 students and the estimated PTSD rate was reported to be 4.5% (Roussos et al., 2005). Differences in assessment methods, characteristics of subjects and nature of disasters might partially account for this reported difference. Of the subjects in this current study, 208 (75.1%) were aboriginal adolescents from the aboriginal tribe of Bunun. Aboriginals in Taiwan consist of 13 different tribes and accounted for approximately 2% of the population in Taiwan (Ministry of Interior, Taiwan, 2009). Average household income of aborigines is far below that of the average for Taiwanese farmers (Directorate-General of Budget Accounting and Statistics, Taiwan, 2009), and there is also health inequality reported between the aborigines and the rest of Taiwanese, with an average life expectancy 6–8 years shorter than that of the general population (Council of Indigenous People,

Taiwan, 2004). Nowadays, many young Bunun have moved into metropolitan regions for employment in industrial factories, and the elderly who have remained in the isolated mountainous hometown are farmers and become the main caretakers of the children and adolescents. Previous American studies have suggested that aboriginal adolescents have more serious mental health problems than adolescents from the main culture (Duclos et al., 1998; Jones, Dauphinais, Sack, & Somervell, 1997). A Taiwanese adolescent life satisfaction survey has also reported that dissatisfaction with one’s current life among aboriginal adolescent was higher than that of Taiwanese mainstream adolescents, and the percentage of aboriginal adolescent bothered by daily life distress was higher than that of adolescents in the general population (Peng, Wu, Lin, Shiao, & Lyu, 2006). High rate of PTSD after a natural disaster in this study further highlighted that adolescents living in the mountainous areas are at a disadvantaged position for health. Future longitudinal follow-up study to evaluate the developmental course of PTSD will be warranted in this group of aboriginal adolescents. 4.2. Factors related to PTSD Our results indicated that adolescents who were female, were physically injured in this disaster, had family member in the same household died or seriously injured were more likely to develop PTSD related to Typhoon Morakot. These findings were consistent with previous Western reports (Hoven et al., 2005). Nevertheless, we did not explore all the important related factors of PTSD previously mentioned in western studies. For example, parental traumatization may in itself have an effect on child mental health. Unique to childhood/adolescent PTSD etiology is the positive correlation between children’s symptoms and trauma-related

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symptoms in their parents (Foy et al., 1996). However we did not explore parental trauma-related symptoms, nor did we investigate personal variables such as temperament, intelligence and personality on its association with PTSD development. This study found that PTSD related to previous trauma was associated with development of post-Typhoon Morakot PTSD. This finding was in line with the western reports of prior traumatic events to be vulnerability factors for future development of PTSD once they reach a certain threshold of trauma load (Hoven et al., 2005; Neuner et al., 2004). The implication of our finding is that the mudslides experienced by a significant proportion of the displaced adolescents will probably render them vulnerable to future PTSD when facing any new trauma. Interventions to mitigate the effects of Typhoon Morakot and its aftermath have therefore become more important in these adolescents. Previous western studies have also demonstrated that there is a relationship between level of exposure to September 11, World Trade Center Attack and likelihood of child anxiety/depressive disorders in the community (Hoven et al., 2005). In addition, after a Hurricane disaster, severity of PTSD and depressive reactions and features of objective disaster-related experiences in children were shown to follow a “dose-of-exposure” pattern that was congruent with the rates of death and destruction in the heavily affected areas (Goenjian et al., 2001). The results of our models of logistic regression analysis were consistent with the above western findings in showing that the types and numbers of exposures experiences were associated with development of PTSD and depressive symptoms in at-risk adolescents. 4.3. Psychological problems co-occurring with PTSD Previous post-natural disaster studies in children/adolescents have reported elevated prevalence of depression which is frequently comorbid with PTSD. For example, high levels of depressive symptoms were reported among children and adolescents 1.5 and 3 years after the Spitak earthquake in Armenia (Goenjian et al., 1997) and 6 months after Hurricane Mitch in Nicaragua (Goenjian et al., 2001). Clinical depression rate in adolescents 3 months after a natural disaster has been reported to be as high as of 13.8% (Roussos et al., 2005). Several researchers also noted an increase in levels of depression over time among adolescents with chronic PTSD (Goenjian et al., 2005). Hence, our finding of significantly higher depressive scores in adolescents with PTSD merits consideration. Depressive symptoms were probably due to multiple losses, including personal losses, loss of community, and ongoing living conditions. The present finding indicates that a significant number of adolescents will need further detailed exploration to see whether they have clinically diagnosable depression for which interventions targeting mood disorder will be warranted accordingly. Another important finding of this study was that adolescents who had PTSD related to Typhoon Morakot were found to have more severe depression, internalizing, externalizing, social, thought, and attention problems than those who did not have PTSD related to Typhoon Morakot by the teachers’ scorings in standardized questionnaires. After Typhoon Morakot, the adolescents were allocated to temporary boarding areas and the teachers accompanying them all day had become their temporary surrogate parents. Previous post-disaster studies have noted that adolescents with PTSD are not likely to seek treatment (Wu et al., 1999), nor do they spontaneously report their psychological reactions to the trauma (Wolfe, Sas, & Wekerle, 1994). Our findings implied that given an appropriate instrument, observation made by people who live with adolescents can be of paramount value in early identification of youngsters in need of mental health interventions after traumatic events.

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4.4. Limitations There were several limitations of our investigation which deserved attention. First, this study was conducted with the concentration on subgroups of interest (i.e. the displaced adolescents), and as such it has a limited generalizability than if the subjects had been drawn from representative samples of a given population. Nevertheless, the fact that our subjects were of a similar age, and were ethnically, culturally (i.e. of Taiwanese aboriginal tribe) and religiously homogeneous reduced the possibility of confounds and constitutes the strength of this survey. Second, we did not have pre-disaster data such as pre-existing mental and physical health condition, nature of other preexisting or concurrent significant life events independent and unrelated to mudslides, pre-disaster functioning, coping strategies and personality characteristics, of which can all be confounding factors leading to current mental health problems. Third, the ratings of mudslides-related stress were subjective and retrospective, raising concerns about bias related to current emotional functioning. 4.5. Conclusions During adolescence, youngsters are in the process of cognitive development that will lead to their ability to process complex and abstract ideas. From previous western studies we learned that trauma-related sequelae have adverse effects on adolescents’ future development, including conscience functioning, academic achievement, economic productivity, health, and the stability they bring to marriage, family life, and their societal role (Goenjian et al., 1999; Kessler, 2000; McFarlane, Policansky, & Irwin, 1987). However, the developmental period of adolescences is also a period of strength and resilience if we can identify the subjects with symptoms and provide properly targeted post-disaster mental health services. It is our belief that such a trauma-focused evaluation for displaced adolescents experiencing Typhoon Morakot in Taiwan is important, not only to assess their mental health, but for intervention and prevention issues as well. Findings in our assessment may provide a better understanding of post-disaster mental health problems among this group of displaced adolescents. Depending on the results of this current assessment, it may be critical that mental health services for these adolescents remain available for many years to come. Future research should emphasize the longitudinal assessments of the impacts of Typhoon Morakot disaster; also the focus should not only be on evaluation of development of psychiatric disease, but also on life aspirations of these adolescents and any possible adolescent risky behaviors which may alter their life trajectories. Declaration of potential conflicts of interests The authors report no competing conflicts of interest. Submission declaration The submitted work has not been published previously and it is not under consideration for publication elsewhere. Its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out. If accepted, it will not be published elsewhere in the same form, in English or in any other language, without the written consent of the copyright-holder. Acknowledgements This study was supported by grants (NSC98-2321-B-037-063 and NSC98-2410-H-037-005-MY3) from the National Science Council, Taiwan, ROC.

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