The Impact of Childhood Exposure to a Natural
Disaster on Adult Mental Health: A 20-year
Longitudinal Follow-up Study of Children Exposed
to a Major Australian Bushfire
Thesis submitted for the degree of Doctor of Philosophy
by Miranda Van Hooff
August 2010
The University of Adelaide, Australia Centre for Military and Veterans’ Health School of Population Health and Clinical Practice
Table of Contents
List of Tables…………………………………………………………………………………xi
List of Figures………………………………………………………………………………..xv
Abstract……………………………………………………………………………………...xvi
Declaration………………………………………………………………………………….xix
Acknowledgements………………………………………………………………………….xx
1 Introduction...... 1
1.1 Aims of the Study ...... 5
1.2 Chapter Outline...... 6
2 Literature Review...... 8
2.1 Brief historical overview of the childhood disaster literature...... 8
2.2 The current state of the literature...... 9
2.3 Prevalence of disasters...... 10
2.4 Disasters defined...... 11
2.5 The normal/expected reaction of a child to a disaster...... 12
2.6 Risk and protective factors...... 13
2.6.1 Characteristics of the child...... 14
2.6.1.1 Developmental age...... 14
2.6.1.2 Sex...... 18
2.6.1.3 Ethnicity ...... 20
2.6.1.4 Pre-disaster functioning...... 20
2.6.1.5 Maternal and paternal mental health ...... 23
2.6.1.6 Prior trauma and PTSD ...... 24
2.6.1.7 Peri-traumatic response ...... 26
i 2.6.2 Disaster related factors...... 28
2.6.2.1 Whether the disaster was intentionally inflicted or not...... 28
2.6.2.2 Direct versus indirect exposure ...... 28
2.6.2.3 Associated level of disruption to housing and income...... 34
2.6.3 Injury, death and threat to family and friends...... 36
2.6.4 Parental reactions...... 38
2.6.5 Media exposure...... 41
2.6.6 Psychological resilience...... 43
2.6.7 Post-disaster treatment...... 46
2.6.8 Risk factor models ...... 48
2.7 Impact of methodology on disaster-related outcomes ...... 53
2.7.1 Choice of informant ...... 53
2.7.2 Time delay between disaster and assessment ...... 54
2.7.3 Representativeness of the sample ...... 56
2.7.4 Diagnostic issues in relation to PTSD ...... 57
2.7.5 Retrospective versus prospective study designs ...... 62
2.7.6 Method of assessing symptoms ...... 64
2.8 Disaster outcomes ...... 65
2.8.1 Physical/somatic symptoms...... 65
2.8.2 Decline in school performance ...... 67
2.8.3 PTSD...... 68
2.8.3.1 Onset duration and course ...... 68
2.8.3.2 PTSD symptom structure in children and DSM-V ...... 69
2.8.3.3 PTSD prevalence...... 70
2.8.4 Other psychopathology ...... 82
2.8.4.1 Depressive disorder ...... 82
ii 2.8.4.2 Anxiety disorders ...... 85
2.8.4.3 Substance use ...... 86
2.9 Mechanisms through which a disaster impacts on a child...... 93
2.9.1 Distortion of social networks...... 93
2.9.2 Increases risk for further trauma and PTSD ...... 94
2.9.3 Changes in the child’s view of themselves, others and the world ...... 94
2.10 Summary...... 95
3 The Original 1983 Studies ...... 96
3.1 The day of the fires ...... 96
3.2 The broad research agenda...... 96
3.3 The children’s study...... 97
3.3.1 Aims of the study...... 97
3.3.2 Description of the sample ...... 97
3.3.2.1 The bushfire survivors...... 97
3.3.2.1.1 Bushfire sample numbers...... 99
3.3.2.2 The original comparison sample ...... 99
3.3.2.2.1 Comparison sample numbers...... 100
3.3.3 Methodology:...... 100
3.3.3.1 Childhood measures – 1983-1985...... 101
3.3.3.1.1 Degree of disaster related personal and property loss ...... 101
3.3.3.1.2 Family functioning and maternal parenting style ...... 102
3.3.3.1.3 Maternal overprotection following the fires ...... 102
3.3.3.1.4 Posttraumatic phenomena in the children...... 103
3.3.3.1.5 Maternal post-trauma symptoms ...... 103
3.3.3.1.6 Rutter Child Behaviour Questionnaire ...... 103
3.3.4 Results:...... 105
iii 3.3.4.1 Study 1: The psychological impact of the fires...... 105
3.3.4.2 Study 2: Impact of the bushfire on family functioning ...... 107
3.3.4.3 Study 3: The relationship between posttraumatic symptoms and the
development of behavioural problems ...... 108
3.4 Conclusions:...... 109
4 Study Design and Methods...... 110
4.1 Ethics approval...... 110
4.2 Tracking of participants ...... 111
4.2.1 Creating a register of potential participants...... 111
4.2.2 The National Death Index (NDI) ...... 112
4.2.3 The Australian Electoral Commission (AEC) ...... 113
4.2.4 The South Australian Department of Births Deaths and Marriages (BDM) ...... 114
4.3 Recruitment and consent ...... 116
4.4 Assessment...... 117
4.4.1 Instruments...... 118
4.4.1.1 Demographics...... 118
4.4.1.1.1 Occupation ...... 118
4.4.1.1.2 Rural or urban status ...... 118
4.4.1.2 Lifetime exposure to trauma...... 119
4.4.1.3 Lifetime and current DSM-IV psychiatric disorder ...... 120
4.4.1.4 Lifetime and current DSM-IV PTSD ...... 121
4.4.1.4.1 Worst lifetime events...... 121
4.4.1.4.2 Ash Wednesday Bushfire...... 121
4.4.1.5 Current PTSD related distress ...... 122
4.4.1.6 Alcohol consumption and problem drinking...... 123
iv 5 Sample Description ...... 124
5.1 Introduction ...... 124
5.2 Sample composition ...... 124
5.2.1 The potential follow-up sample ...... 124
5.2.2 The actual follow-up sample...... 125
5.2.3 Withdrawals ...... 127
5.2.4 Participants who could not be contacted...... 127
5.2.5 Deceased ...... 128
5.3 Responders and non-responders...... 129
6 Impact of Childhood Exposure to a Natural Disaster on Adult Mental Health: 20- year Longitudinal Follow-up Study ...... 133
6.1 Commentary:...... 133
6.2 Introduction...... 134
6.3 Methodology...... 136
6.3.1 Sample...... 136
6.3.1.1 The bushfire exposed cohort ...... 136
6.3.1.2 The control sample...... 136
6.3.2 Instruments...... 137
6.3.2.1 Demographics...... 137
6.3.2.2 Adult psychiatric morbidity...... 138
6.3.2.3 Lifetime and current prevalence of bushfire related PTSD...... 139
6.3.2.4 Current self–reported levels of PTSD related distress ...... 140
6.3.2.5 Analysis...... 140
6.4 Results...... 141
6.4.1 Response rates...... 141
6.4.2 Responders and non-responders ...... 141
v 6.4.3 Demographic characteristics of the follow-up sample...... 142
6.4.4 Lifetime and current psychopathology ...... 147
6.4.5 Lifetime and current PTSD in relation to the bushfire ...... 150
6.4.6 Current bushfire-related distress...... 151
6.4.7 Alcohol consumption and problem drinking ...... 152
6.5 Discussion...... 152
7 Risk Factors for the development of post-disaster psychopathology Part 1: aims, literature and sample description ...... 156
7.1 Aims...... 156
7.2 Brief review of the background literature...... 159
7.2.1 Factor 1: Characteristics of the stressor...... 159
7.2.2 Factor 2: Characteristics of the child ...... 160
7.2.2.1 Sex...... 161
7.2.2.2 Age ...... 161
7.2.2.3 Pre-disaster functioning...... 161
7.2.3 Factor 3: Characteristics of the post-disaster environment...... 162
7.2.3.1 The child’s emotional and behavioural response to the disaster...... 162
7.2.3.2 Family functioning and home environment ...... 162
7.2.3.3 Parent reactions ...... 163
7.2.4 Factor 4: Additional lifetime trauma and psychopathology ...... 163
7.3 Methodology...... 164
7.3.1 Defining the sample ...... 164
7.3.1.1 Sample representiveness...... 164
7.3.1.2 Demographics at follow-up...... 169
7.4 Results ...... 173
7.4.1 Factor 1: Characteristics of the stressor...... 173
vi 7.4.1.1 Level of exposure to the Ash Wednesday bushfires ...... 173
7.4.2 Factor 2: Characteristics of the child at the time of fires...... 174
7.4.3 Factor 3: Characteristics of the post disaster environment ...... 174
7.4.3.1 Childhood emotional and behaviour problems ...... 174
7.4.3.2 Family functioning following the fires...... 183
7.4.3.2.1 Overprotective parenting ...... 183
7.4.3.2.2 Irritable distress in family ...... 183
7.4.3.2.3 Family involvement ...... 184
7.4.3.2.4 Maternal psychopathology...... 184
7.4.3.3 Post-traumatic symptoms following the fires...... 185
7.4.4 Factor 4: Lifetime trauma and psychopathology ...... 187
7.4.4.1 Lifetime trauma exposure...... 187
7.4.4.2 Posttraumatic Stress Disorder ...... 191
7.4.4.2.1 PTSD from the worst lifetime event ...... 191
7.4.4.2.2 Lifetime and current prevalence of bushfire related PTSD: ...... 192
7.4.4.2.3 Current self–reported levels of PTSD related Distress:...... 193
7.4.4.3 Other psychopathology...... 195
7.5 Summary of findings...... 199
7.5.1 Immediate post-disaster period...... 199
7.5.2 20-year follow-up data...... 201
8 Risk factors for the development of post-disaster psychopathology Part 2: results of
Univariate and Multivariate analyses...... 206
8.1 Introduction...... 206
8.2 Description of variables ...... 207
8.2.1 Predictor variables ...... 207
8.2.1.1 Factor 1: Characteristics of the stressor ...... 208
vii 8.2.1.2 Factor 2: Characteristics of the child at the time of the disaster ...... 208
8.2.1.3 Factor 3: Characteristics of the post-disaster environment ...... 209
8.2.1.3.1 Behaviour and emotional problems in the child ...... 209
8.2.1.3.2 Family functioning and home environment...... 209
8.2.1.4 Factor 4: Lifetime trauma and other psychopathology ...... 210
8.2.2 Outcome Variables...... 211
8.3 Statistics ...... 211
8.4 Prediction of lifetime bushfire-related DSM-IV PTSD...... 212
8.5 Prediction of lifetime DSM-IV PTSD from worst lifetime event...... 218
8.5.1 Univariate Model ...... 218
8.5.2 Multivariate Model ...... 218
8.6 Prediction of any lifetime DSM-IV disorder ...... 224
8.6.1 Univariate model...... 224
8.6.2 Multivariate Model ...... 225
8.7 Prediction of any lifetime DSM-IV depressive disorder ...... 231
8.7.1 Univariate model...... 231
8.7.2 Multivariate Model ...... 232
8.8 Prediction of any lifetime DSM-IV anxiety disorder (excl. PTSD) ...... 237
8.8.1 Univariate model...... 237
8.8.2 Multivariate model...... 238
8.9 Summary of findings...... 243
9 The stressor Criterion-A1 and PTSD: A matter of opinion?...... 251
9.1 Commentary...... 251
9.2 Introduction...... 252
9.3 Method ...... 256
9.3.1 Participants...... 256
viii 9.3.2 Measures ...... 258
9.3.2.1 Demographics...... 258
9.3.2.2 Lifetime exposure to traumatic events ...... 258
9.3.2.3 Lifetime PTSD ...... 259
9.3.3 Procedure ...... 260
9.3.4 Statistics ...... 261
9.4 Results...... 262
9.4.1 Categorisation of traumatic and non-traumatic events ...... 262
9.4.2 Prevalence of non-traumatic life, Criterion-A1 and equivocal events using the
different methods of categorisation ...... 264
9.4.3 Prevalence of PTSD for non-traumatic life events, Criterion-A1 events and
equivocal events using the different methods of categorisation...... 265
9.5 Discussion...... 268
10 Discussion and Conclusions ...... 279
10.1 Strengths of the study ...... 279
10.2 Limitations and methodological issues...... 282
10.3 Overall conclusions and findings from the study ...... 287
10.3.1 Demographics ...... 287
10.3.2 PTSD...... 288
10.3.3 Other psychopathology ...... 300
10.3.4 Lifetime trauma...... 307
10.4 Concluding comments ...... 310
References…………………………………………………………………………………..312
Appendices………………………………………………………………………………….328
A. DSM-IV Criteria for PTSD…………………………………………………………..328
ix B. Letter from the South Australian Births Deaths and Marriages Registration Office…………………………..………………………………………………….…331 C. Introduction Letter…………………………..……………………………………….333 D. Confirmation Letter…………………………..……………………………………...336 E. Information Sheet……………………………………………………………………339 F. Self-Report Measures………………………………………………………….…….342 G. Study Consent Form…………………………………………………………………354 H. Consent Form to Link with Medicare and Pharmaceutical Benefit Scheme Data…..356 I. Complaints Form ……………………………………………………………………359 J. Reminder Letter……………………………………………………………………...361 K. Declaration for Thesis Chapter 6…………………………………………………….363 L. Declaration for Thesis Chapter 9…………………………………………………….366
x List of Tables
Table 2.1: Lifetime prevalence of exposure to natural disasters in the general population.….10
Table 2.2: Comparison of ICD-10-DCR and DSM-IV criteria for PTSD…………………....59
Table 2.3: Prevalence of PTSD in children and adolescents following disaster exposure…...72
Table 2.4: Prevalence of anxiety, depression and substance use problems following childhood disaster exposure.…………………………………………………………..………………....88
Table 5.1: Details of the deceased participants (N=18)…………………………………..…129
Table 5.2: A comparison of responders and non-responders………………………………..131
Table 6.1: Flowchart of response rates……………………………………………………...142
Table 6.2: A comparison of demographics in the bushfire follow-up sample and the matched control group………………………………………………………………………………...144
Table 6.3: Lifetime and point (1-month) prevalence of DSM-IV disorders in bushfire survivors and controls……………………………………………………………………….147
Table 6.4: Number and proportion of participants satisfying each DSM-IV PTSD diagnostic criteria in relation to the bushfire and their worst lifetime event……………………………148
Table 6.5: Relative risk of lifetime and current PTSD in bushfire participants (in relation to the bushfire and a self nominated worst lifetime event) and control participants (in relation to a self nominated worst lifetime event)………………………………………………………149
Table 7.1: A comparison of demographic characteristics of participants in the longitudinal sample (N = 677) and not in the longitudinal sample (N = 334)……………………………166
xi Table 7.2: A comparison of adult demographics in the longitudinal bushfire group (N = 328) and control group (N = 349)…………………………………………………………….…..170
Table 7.3: Frequency and proportion of participants in the bushfire group reporting specific exposures to the Ash Wednesday bushfires…………………………………….……….…..175
Table 7.4 Proportion of children reporting each symptom type on the parent and teacher Rutter questionnaire…………………………………………………………………………177
Table 7.5: A comparison of Rutter summary scores in the bushfire and the control group...180
Table 7.6: A comparison of the number of cases on the parent Rutter questionnaire in the bushfire and the control group at first assessment…………………………………………..181
Table 7.7: A comparison of the number of cases on the parent Rutter questionnaire in the bushfire and the control group at first assessment (within group comparisons)………….…181
Table 7.8: A comparison of the number of cases on the teacher Rutter questionnaire in the bushfire and the control group at first assessment…………………………………………..182
Table 7.9: A comparison of the number of cases on the teacher Rutter questionnaire in the bushfire and the control group at first assessment (within group comparisons)…………….182
Table 7.10: A comparison of levels of irritable distress and family involvement in the bushfire group and the control group at first assessment……………………………………………..184
Table 7.11: Posttraumatic phenomena in children following the bushfires…………………186
Table 7.12: Lifetime trauma exposure, PTSD and the proportion of participants nominating each event as their worst lifetime event……………………………………………………..189
Table 7.13: Number of lifetime traumatic events in the bushfire and control group………..190
Table 7.14: Lifetime and 1 month prevalence of posttraumatic stress disorder in relation to the bushfire and a self-nominated worst lifetime event…………………………………………192
xii Table 7.15: Traumatic events and PTSD occurring prior to and after the Ash Wednesday Bushfires in the bushfire group (N = 328)…………………………………………………..193
Table 7.16: Current PTSD distress relating to the bushfire in the bushfire group (N = 280) and other events in the control group (N = 271)…………………………………………………195
Table 7.17: Lifetime and point (1-month) prevalence of DSM-IV anxiety, depressive and eating disorders in a longitudinal sample of bushfire survivors and controls……………….197
Table 8.1: Frequency and proportion of bushfire participants with PTSD (N=4) reporting specific exposures to the Ash Wednesday bushfires………………………………………..214
Table 8.2: Univariate (max N = 328) and multivariate (max N = 202) predictors of bushfire related PTSD in the bushfire group (where number of PTSD cases = 4 (1.23%)…………..216
Table 8.3: Univariate predictors of PTSD from the worst lifetime event in the whole sample (main effect) (N = 677), within the bushfire group (N = 328) and within the controls (N = 349)………………………………………………………………………………………….220
Table 8.4: Multivariate Predictors of ‘PTSD from Worst Lifetime Event’ in the Whole Sample (N = 430) (main effects only)………………………………………………………222
Table 8.5: Multivariate predictors of ‘PTSD from worst lifetime event’ in the whole sample (N = 430) and within the bushfire group and within the controls…………………………...223
Table 8.6: Univariate predictors of ‘any lifetime disorder’ in the whole sample (main effect) (N = 677), within the bushfire group (N = 328) and within the controls (N = 349)………...227
Table 8.7: Multivariate predictors of ‘any lifetime DSM-IV disorder’ in the whole sample (N = 430) (main effects only)…………………………………………………………………...229
Table 8.8: Multivariate predictors of ‘any lifetime DSM-IV disorder’ in the whole sample (N = 430) and within the bushfire group and within the controls………………………………230
xiii Table 8.9: Univariate predictors of ‘any lifetime depressive disorder’ in the whole sample (main effect) (N = 677), within the bushfire group (N = 328) and within the controls (N = 349)………………………………………………………………………………………….233
Table 8.10: Multivariate predictors of ‘any lifetime DSM-IV depressive disorder’ in the whole sample (N = 430) (main effects only)………………………………………………..235
Table 8.11: Multivariate predictors of ‘any lifetime DSM-IV depressive disorder’ in the whole sample (N=430) and within the bushfire group and within the controls……………..236
Table 8.12: Univariate predictors of ‘any lifetime anxiety disorder (excl. PTSD)’ in the whole sample (main effect) (N = 677), within the bushfire group (N = 328) and within the controls (N = 349)…………………………………………………………………………………….239
Table 8.13: Multivariate predictors of ‘any lifetime DSM-IV anxiety disorder (excl. PTSD)’ in the whole sample (N = 430) (main effects only)…………………………………………241
Table 8.14: Multivariate predictors of ‘any lifetime DSM-IV anxiety disorder’ in the whole sample (N=430) and within the bushfire group and within the controls……………………242
Table 9.1: Levels of agreement among ratings of non-traumatic life events and Criterion-A1 events based on the unanimous categorisation method……………………………………..263
Table 9.2: Numbers (proportions) of events classified as non-traumatic life, Criterion-A1 and equivocal using the different methods of categorisation……………………………………265
Table 9.3: Lifetime PTSD prevalence for non-traumatic life events (NT), Criterion-A1 events (Crit-A1) and equivocal events (E) using the different methods of categorization…………266
xiv List of Figures
Figure 5.1: Flow diagram of study participants involved in the study……………………..126
Figure 6.1 Pattern of Rutter symptoms reported by parents and teachers in the 15 months following the bushfire……………………………………………………………………...179
Figure 9.1: Prevalence of lifetime PTSD for specific event types using the unanimous categorisation method………………………………………………………………………267
xv Abstract
Background
On February 16 1983, several large-scale bushfires devastated substantial parts of Australia.
In the following two-years, McFarlane and colleagues examined the long-term psychological consequences of exposure to this bushfire in children. Eight hundred and six children attending school in an easily demarcated region of South Australia that was vastly devastated by the fires and 725 unexposed children were assessed. This thesis reports on the 20-year longitudinal mental health trajectories of this cohort of children. This study is the first to follow-up a large sample of childhood disaster survivors using a control sample recruited as children at the time of the original study
Sample:
Nine-hundred and eleven participants (540 (67%) bushfire survivors, and 471 (65%) controls) completed the follow-up assessment. The mean age of the bushfire sample at the time of the disaster was 8.44 years (3.23 to 13.49 years) and at follow-up was 28.64 years (23 to 34 years). The mean age of the control sample at the time of the disaster was 7.39 years (1.67 to
13.11 years) and at follow-up was 27.66 years (22 to 33 years).
Method:
Participants completed a 1-hour telephone interview examining lifetime and 1-month prevalence of DSM-IV disorder using the Composite International Diagnostic Interview
(CIDI) as well as a self-report booklet.
Miranda Van Hooff 2010 xvi
Results:
Bushfire survivors were at a slightly increased risk of developing a current DSM-IV disorder
(in particular a current DSM-IV anxiety disorder), as well as a lifetime DSM-IV anxiety disorder compared to the controls.
Seventy-five percent of the bushfire group still reported some degree of bushfire-related distress in the form of intrusion symptoms 20 years on, however the lifetime prevalence of bushfire-related PTSD was considerably lower than rates following other childhood disasters.
Only 6 (1.7%) of the bushfire survivors met lifetime DSM-IV PTSD criteria in response to the bushfire, compared to 27 (5.8%) of the control population who met PTSD in relation to their worst lifetime event.
Risk factor models for the development of lifetime depressive and anxiety disorders
(including bushfire-related PTSD and worst-event PTSD) were examined, with special consideration given to the relative contribution of characteristics of the disaster, child, and the post-disaster environment as well as additional lifetime trauma to the development of DSM-
IV psychopathology over time. The methodological limitations of current PTSD diagnostic criteria and assessment measures, as well as the implications of their use in longitudinal disaster research are comprehensively discussed.
Conclusion.
The present study, while acknowledging the detrimental impact of childhood disaster exposure on the development of long-term anxiety spectrum disorders, raises some important questions regarding the methodologies employed by previous longitudinal disaster studies.
The main challenge facing researchers is to begin to prioritise the disaster in the context of the other lifetime trauma so as not to overemphasise the contribution of this one discrete event to
Miranda Van Hooff 2010 xvii long-term psychosocial maladjustment. A focus on family intervention and reducing the risk of further traumatisation, in addition to the implementation of a long-term follow-up schedule for all childhood disaster survivors is recommended.
Miranda Van Hooff 2010 xviii
Declaration
This work contains no material which has been accepted for the award of any other degree or diploma in any university or other tertiary institution and, to the best of my knowledge and belief, contains no material previously published or written by another person except where due reference has been made in the text.
I give consent to this copy of my thesis when deposited in the University library, being made available for loan and photocopying, subject to the provisions of the Copyright Act 1968.
I acknowledge that copyright of the published works contained in this thesis as listed below resides with the copyright holders of these works:
McFarlane, AC and Van Hooff, M. (2009). Impact of childhood exposure to a natural disaster on adult mental health: 20-year longitudinal follow-up study. British Journal of Psychiatry, 195: 142-148. Van Hooff, M., McFarlane AC., Baur J., Abraham, M., Barnes DJ. (2009). The stressor Criterion-A1 and PTSD: a matter of opinion? Journal of Anxiety Disorders, 23(1): 77-86.
I also give permission for the digital version of my thesis to be made available on the web, via the University’s digital research repository, the Library catalogue, the Australasian Digital Theses Program (ADTP) and also through web search engines, unless permission has been granted by the University to restrict access for a period of time.
Miranda Van Hooff
I believe that this thesis is properly presented and conforms to the specifications for the degree of sufficient standard to be, prima facie, worthy of examination
Professor Alexander Cowell McFarlane Principal Supervisor
Miranda Van Hooff 2010 xix Acknowledgements
Firstly and foremost I would like to give a huge thank-you to my principal supervisor Professor Sandy McFarlane. His continual support, guidance and faith in me over the last 10 years have been invaluable. I would also like to thank him for providing me with the amazing opportunity to extend his early research on the Ash Wednesday Bushfires and for sharing his knowledge and expertise in the field of trauma and PTSD. Without the opportunities he has provided for me, I never would have reached the point I am in my research career today.
Thank-you also to Dr Chris Barton who kindly accepted to be my supervisor at such late notice. His input and constructive comments during the editing process were instrumental as was his willingness to read and review my entire thesis over the course of one week.
A huge thank-you also to my new work colleague and friend Dr Alan Verhagen for selflessly volunteering to take on the arduous task of reviewing parts of my thesis. His fresh eyes were able to pick up issues that my tired eyes could not see. I am extremely thankful for his input.
I would also like to thank Associate Professor Annette Braunack-Mayer for meeting with me regularly and keeping me on track during the final year of my candidature. Although I resisted for a long time, I now must admit that timelines are very important and helpful and possibly even crucial to completing a thesis, and I have Annette to thank for that.
I would also like to acknowledge the assistance of all staff at the CMVH, for their support and help throughout the last year. A special thank-you to Jenelle for her assistance with formatting and to Ashleigh for her editing expertise.
For her statistical expertise, I would like to thank Nancy Briggs from the Data Management and Analysis Centre (DMAC) at the University of Adelaide. Her statistical knowledge and expertise were invaluable.
I would like to thank the National Health and Medical Research Council for funding this project and the Australian Institute of Health and Welfare for providing me with the data matches I required. A special thank-you also to staff at the South Australian Births Deaths and Marriages Registration Office and the Australian Electoral Commission for assisting me
Miranda Van Hooff 2010 xx in contacting participants. Thank-you also to the teachers and headmasters of the eight primary schools involved in the study for meeting with me and assisting me with the initial data extraction.
I would also like to thank my family and friends particularly my mum and dad Brian and my husband Derek for their love and support. Despite the ups and downs, they have always been there to encourage me. Their faith in me has never wavered and I regularly drew strength from their belief in me. A huge thank-you to my husband Derek and my daughter Gracie for their tolerance and support and for making me want to achieve all that I can in life. To all of my friends, thank-you for your support, your concern and your prayers. It was wonderful knowing that you were all thinking of me and supporting me.
Finally I would like to give a huge thank-you to all of the participants in the study. The generous donation of their precious time as well as their openness, insight and willingness to share their experiences with me was critical to the study and I am extremely thankful to every-one involved.
Miranda Van Hooff 2010 xxi
1 Introduction
Disasters provide a major opportunity to investigate the impact of psychological trauma because at a given point in time a wide cross section of a population is exposed to the same event. As an event occurring at a distinct point of time, disasters have the potential to cause a range of physical and mental health problems. Furthermore, disaster exposure can exacerbate symptoms in individuals with pre-existing mental health problems, vulnerabilities and lifetime trauma. A unique combination of risk factors and psychopathology emerge in both children and adolescents following disasters. Thorough knowledge of these factors is instrumental to the development of future screening and intervention programs to meet the needs of disaster-affected children. The interplay between disaster exposure, prior lifetime trauma, and characteristics of the child is one of the main themes that will be addressed in this thesis. This will be performed using a conceptual risk factor model originally developed by
Korol, Green and colleagues (Green, Korol et al. 1991; Korol, Green et al. 1999) from data obtained in relation to the Buffalo Creek Dam collapse. This framework identifies four factors that have been reported in the wider disaster literature to influence children’s post-disaster reactions: (a) characteristics of the stressor (life threat and level of exposure to the disaster),
(b) characteristics of the child (demographics, pre-disaster functioning), (c) characteristics of the post-disaster environment (additional life events, parental reactions to the fire) and (d) the child’s efforts to process and cope with disaster-related distress. Drawing on this research, this thesis will extend this model by replacing the existing factor (d) with a new fourth factor comprising additional lifetime traumas and lifetime DSM-IV disorder to examine the strength of this model in predicting adult psychopathology following a bushfire.
Each year thousands of children and adolescents are affected by disasters of varying magnitudes across the globe. National studies performed in the US and Australia estimate the
Miranda Van Hooff 2010 1 lifetime prevalence of disaster exposure to range from 12% to 19% in adults (Kessler,
Sonnega et al. 1995; Breslau, Kessler et al. 1998; Creamer, Burgess et al. 2001) and 1.3% to
11.1% in children and adolescents (Giaconia, Reinherz et al. 1995; Copeland, Keeler et al.
2007). A significant proportion of these participants will develop persistent mental health problems such as posttraumatic stress disorder (PTSD), depression and anxiety. Longitudinal studies in children have reported lifetime PTSD rates of between 32% and 51.5% (Green,
Grace et al. 1994; Yule, Bolton et al. 2000; Morgan, Scourfield et al. 2003), post-disaster rates of depressive disorders ranging from 33% to 46% (Green, Grace et al. 1994; Bolton,
O'Ryan et al. 2000; Morgan, Scourfield et al. 2003) and post-disaster rates of anxiety disorders (excluding PTSD) ranging from 41% to 61% (Bolton, O'Ryan et al. 2000; Morgan,
Scourfield et al. 2003). This variation in prevalence was partly due to the different methodologies employed in these studies, such choice of instrument, choice of informant, and time that has passed between disaster and follow-up assessment.
In both adults and children, the psychological response to a disaster is mediated strongly by the nature of their exposure, including their physical proximity to the trauma, life threat and degree of physical injury, bereavement associated with injury or death to loved ones and short and long-term disruptions to housing, income and community (Pfefferbaum 2005). In children and adolescents, the developmental age of the child can further amplify the disaster experience by limiting the child’s ability to effectively process the severity and implications of the event. Consequently young children in particular rely very strongly on their parents to keep them safe and to gauge the degree of risk associated with a particular event, often mimicking the adult’s reactions to the disaster. This innate drive to seek safety from parental figures highlights the importance of this attachment relationship during times of extreme stress. Attachment theory states that this innate method of protecting offspring from predators is most strongly elicited at times of extreme stress, sickness or fear (Bowlby 1979).
Miranda Van Hooff 2010 2
Consequently, parents’ own reactions to a disaster can have strong implications for how well a child adjusts in the recovery period (Winje and Ulvik 1998). Shattered assumptions about safety as well as parent’s own level of distress can inhibit them from adequately addressing the needs of their children (McFarlane 1987; Wooding and Raphael 2004).
A large number of studies have followed up disaster-affected populations over time. However only a small proportion of these studies have examined the complete longitudinal trajectories of these populations from childhood to adulthood (Green, Grace et al. 1994; Yule, Bolton et al. 2000; Morgan, Scourfield et al. 2003). Similarly whilst large population based studies have followed childhood populations into adult life (Fergusson and Horwood 2001; Koenen,
Moffitt et al. 2008) few of these studies have specifically focused on the role of traumatic stressors in this relationship and the impact this has on their adult functioning. This study will address an important issue: the fact that a number of these young adults will have experienced other significant traumatic experiences in their lifetime. Several recent studies have highlighted the role of cumulative trauma exposure on the development of subsequent psychopathology in adults (Bremner, Southwick et al. 1993; Zaidi and Foy 1994; Breslau,
Chilcoat et al. 1999). However few studies have addressed this issue in childhood disaster survivors (Garrison, Weinrich et al. 1993; Pfefferbaum, North et al. 2003; Chemtob, Nomura et al. 2008; Mullett-Hume, Anshel et al. 2008). This study provides a unique opportunity to add to this emerging branch of knowledge by examining the moderating role of lifetime trauma on the prevalence of mental health problems following a traumatic event occurring in childhood.
This longitudinal study examines the long-term mental health outcomes of a community sample of Australian adults who were exposed to a major bushfire disaster while attending primary school in the south east of South Australia in 1983. The study reported here is the 4th
Miranda Van Hooff 2010 3 phase of a longitudinal study, which commenced in 1983, two months following the Ash
Wednesday Bushfires.
In the original study, Sandy McFarlane and Beverly Raphael (McFarlane, Policansky et al.
1987) surveyed both the parents and teachers of 808 children attending schools within the area that had been burnt in the fires. In the region, in the order of 120,000 hectares of agricultural land had been destroyed, fourteen people had been killed and 359 individual farms totally or partially destroyed. As well, a further 40 homes had been completely destroyed.
The bushfire-affected sample was compared with a group of 734 children with an age range of 5 to 12 from another rural community, Naracoorte, unaffected by the disaster. The area was chosen because it had a similar social and economic structure to the fire-affected region.
The methodology of the original study involved sampling the population on three separate occasions, two (phase 1), eight (phase 2) and twenty-six (phase 3) months after the fire.
Questionnaires to parents and teachers (Rutter, Tizard et al. 1970) were administered on each occasion to document potential changes in emotional and behavioural functioning in the children as a result of the bushfire. As well, the two-month questionnaire documented the impact of the disaster on the children and their parents. The eight and the twenty-six month questionnaires monitored the continuing impact of the disaster. Finally this study examined the child’s health, school attendance and educational performance.
The present study tracked this same group of participants into adulthood, approximately 20 years after their initial exposure to the disaster. A register of all 1531 participants was compiled using data from the original questionnaires and archived school admission records.
Miranda Van Hooff 2010 4
Current contact information was obtained through the State Department of Births, Deaths and
Marriages, the Australian Electoral Commission, and an online telephone directory. A
National Death Registry was used to identify the deceased. Initial contact with the participants was by letter, followed by a telephone call. Survey methods included a 1-hour telephone interview examining lifetime and 1-month point prevalence rates of DSM-IV disorder using a computerised version of the fully structured, standardised and comprehensive Composite
International Diagnostic Interview (CIDI 2.1-Auto). A self-report booklet examining demographics, current bushfire related distress, and alcohol consumption was completed by each participant. A detailed history of lifetime traumatic events occurring both before and after the bushfire was also obtained.
1.1 Aims of the study
In light of this background literature, this thesis will investigate the adult psychiatric outcomes of childhood exposure to a major Australian bushfire in the context of other lifetime trauma by utilising an unexposed control sample recruited at the time of the initial disaster.
Embedded within this study design are three specific aims:
1. To provide an unbiased estimate of the conditional risk of DSM-IV PTSD, depressive
disorder and anxiety disorder in adults 20 years following exposure to a bushfire
disaster in childhood;
2. To examine the predictive role of lifetime traumatic events, disaster exposure, and
characteristics of the child and the post-disaster environment in the development of
lifetime DSM-IV PTSD, depressive disorder and anxiety disorder using a validated
conceptual framework;
Miranda Van Hooff 2010 5
3. To examine the effects that survey methodology, specifically event categorization and
Criterion A1 event selection has on trauma and PTSD prevalence.
1.2 Chapter outline
This thesis is organised into ten chapters. Chapter 2 reviews the literature on the longitudinal outcomes of exposure to a disaster in childhood and adolescence beginning with a brief historical overview of the childhood disaster literature. This is followed by a discussion of the various risk and protective factors associated with poor adjustment, and the prevalence of physical and mental health problems emerging as a consequence of the disaster. A significant proportion of this chapter also addresses the impact of methodology on both posttraumatic stress disorder and trauma rates.
Chapter 3 provides a detailed summary of the phases 1, 2 and 3 that preceded the current study. These phases were undertaken in the first two years immediately following the Ash
Wednesday Bushfires. The chapter outlines both the scientific findings from these early studies as well as the methodology and measures utilised.
Chapter 4 provides a detailed outline of the current study design and methodology including a description of the measures used in this study.
Chapter 5 provides a detailed description of the sample and includes information pertaining to demographic characteristics, response rates and sample composition.
Chapter 6 is a paper that has been recently published in the British Journal of Psychiatry:
(McFarlane, AC and Van Hooff, M. (2009). Impact of childhood exposure to a natural
Miranda Van Hooff 2010 6 disaster on adult mental health: 20-year longitudinal follow-up study. British Journal of
Psychiatry, 195: 142-148). This paper addresses the combined role of disaster exposure and the impact of post-disaster behavioural problems on lifetime and current prevalence of DSM-
IV anxiety, depressive and eating disorders assessed 20 years following the disaster.
Chapter’s 7 and 8 provide a detailed investigation into the predictors of poor long-term psychological functioning following exposure to the bushfires in childhood using an established framework. Chapter 7 provides an overview of the sample in relation to the key risk factors used in the predictive model in both the bushfire and control group. Chapter 8 examines the relative contribution of each of these longitudinal risk factors in the development of post-traumatic stress disorder as well as other anxiety and depressive disorders. At the end of each of these two chapters a summary of findings provides an overview of the results presented in each chapter.
Chapter 9 is a paper recently published in the Journal of Anxiety Disorders (Van Hooff, M.,
McFarlane AC., Baur J., Abraham, M., Barnes DJ. (2009). The stressor Criterion-A1 and
PTSD: a matter of opinion? Journal of Anxiety Disorders, 23(1): 77-86. This paper highlights the subtle complexities inherent in posttraumatic stress disorder’s stressor criterion (A1), demonstrated through a detailed examination of the impact that event categorisation has on prevalence rates of trauma and PTSD, which is relevant to all studies incorporating an evaluation of lifetime trauma.
Chapter 10 provides a critical examination and discussion of the findings of this thesis in the context of the published literature. Implications for future research are discussed in detail, together with a detailed summary of the strengths and weaknesses of the study.
Miranda Van Hooff 2010 7
2 Literature review
2.1 Brief historical overview of the childhood disaster literature
Historically, there has been a paucity of research into the psychosocial impact of disasters on children. Prior to 1980 this was due to the absence of an established diagnostic category to label and cluster observed symptoms. In addition, at this time there was a universal tendency for researchers and health professionals to rely on parent and teachers’ reports of children’s symptoms, which mistakenly minimised the emotional reactions of children as mild and transient. The earliest reported study of children’s response to disaster was conducted by
Perry et al (1956) and involved following up children (aged 1 to 15) who experienced a fatal tornado while attending a movie theatre. Parents described their children as presenting with five typical symptoms: (1) increased dependence on parents and reluctance to be away from them, (2) nightmares, (3) specific fears of trauma related stimuli, (4) behavioural and skill regression and (5) tornado themes in play (Perry, Silber et al. 1956; Vogel and Vernberg
1993). Following a cyclone in Oregan US in 1962, children aged from infancy to 8 years old behaved in ways that directly reflected their parents’ reactions to the trauma, whereas ten to
13 year olds responded with “much excitement with exclamations of joy”, displaying no signs of fear or anxiety (Crawshaw and Beaverton 1963). Based on such early work it was concluded that children’s disaster reactions are generally transient and milder than one might expect (Garmezy and Rutter 1985; Vogel and Vernberg 1993).
During the years 1972 to 1983, the longitudinal nature of symptoms became evident in research following up childhood survivors of the 1966 collapse of the coal mining tip in
Aberfan, Wales (Lacey 1972), the 1972 collapse of a mining dam and resultant flood in
Buffalo Creek (Gleser, Green et al. 1981), and the 1976 Chowchilla school kidnapping (Terr
1979; Terr 1983; Vogel and Vernberg 1993). A more detailed account of these events will be
Miranda Van Hooff 2010 8 presented later in this chapter. Not only did these studies highlight the persistent nature of posttraumatic symptoms over time, they were the first studies to recognise that children like adults have the capacity to experience symptoms of a severe magnitude.
Since the inclusion of posttraumatic stress disorder (PTSD) as a diagnostic category in the third revision of Diagnostic and Statistical Manual of Mental Disorder (DSM-III) (American
Psychiatric Association 1980), research into post-traumatic reactions in children has increased significantly. However it was not until the publication of the DSM-IV that PTSD symptoms specific to children were formally acknowledged and documented (Appendix A). Prior to this the DSM-III-R included specific features relating to children (for example, frequent somatic complaints, beliefs in omens that predicted the trauma) however these symptoms were not included as part of the diagnostic criteria (Vogel and Vernberg 1993).
2.2 The current state of the literature
There are a number of published studies reporting the long-term psychological outcome of exposure to disaster in childhood. These studies cover a broad range of natural and man-made disasters including floods (Earls, Smith et al. 1988), earthquakes (Goenjian, Pynoos et al.
1995; Hsu, Chong et al. 2002) cyclones (Milne 1977), hurricanes (Shaw, Applegate et al.
1996; La Greca, Silverman et al. 1998; Goenjian, Molina et al. 2001), lightening strikes
(Dollinger 1985), a dam collapse (Honig, Grace et al. 1993; Green, Grace et al. 1994), shipping disasters (Bolton, O'Ryan et al. 2000; Udwin, Boyle et al. 2000; Yule, Bolton et al.
2000), kidnappings (Terr 1983), school shootings (Brener, Simon et al. 2002), terrorist attacks
(Pfefferbaum, Nixon et al. 1999; Pfefferbaum, Nixon et al. 1999), sniper attacks (Nader,
Pynoos et al. 1990), bus crashes (Pynoos, Frederick et al. 1987; Tyano, Iancu et al. 1996) and
Miranda Van Hooff 2010 9 war (Winje and Ulvik 1998; Sack, Him et al. 1999; Dyregrov, Gjestad et al. 2002). Few of these studies, however, have followed these cohorts into adulthood.
2.3 Prevalence of disasters
As shown in Table 2.1, US and Australian national studies estimate the lifetime prevalence of disaster exposure to range from 12% to 19% in adults (Kessler, Sonnega et al. 1995; Breslau,
Kessler et al. 1998; Creamer, Burgess et al. 2001) and 1.3% to 11.1% in children and adolescents (Giaconia, Reinherz et al. 1995; Copeland, Keeler et al. 2007). Studies conducted in Chile, Germany and Switzerland report much lower rates of between 0% and 8%
(Perkonigg, Kessler et al. 2000; Hepp, Gamma et al. 2006; Zlotnick, Johnson et al. 2006).
Table 2.1: Lifetime prevalence of exposure to natural disasters in the general population
Study Sample Age Range Prevalence Kessler et al. (1995) Representative national 15 to 54 years Males 18.9% sample of 5877 US persons Females 15.2% (National Co-morbidity Study) Breslau et al. (1998) Community sample of 2181 18 to 45 years Total 16.6% adults from US (Detroit Area Survey of Trauma)
Creamer et al. (2001) Australian national sample of 16 to 85 years Males 19.9% 10641 adults (Australian Females 12.7% National Survey of Mental Health and Wellbeing)
Giaconia et al. (1995) 384 north eastern US Mean 17.9 years Total 1.3% adolescents participating in ongoing longitudinal study
Hepp et al. (2006) Representative sample of 367 40 to 41 years Males 0% adults from Zurich Females 0.23% Switzerland (The Zurich Cohort Study)
Copeland et al. (2007) Representative population Up to 16 years Total 11.1% sample of 1420 children from US: North Carolina (The Great Smoky Mountains Study)
Zlotnick et al. (2006) Representative sample of 2390 15 to 64 years Males 8% adults from Chile Females 5.6%
Perkonigg et al. (2000) Representative sample of 3021 14 to 24 years Total 0.5% persons in Munich, Germany Males 0.6% Females 0.4%
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2.4 Disasters defined
The types of events that qualify as a disaster vary considerably between studies. This may explain some of the discrepancy in the rates of exposure reported in different populations.
Some studies base their definition on the geographical area destroyed as well as the overall impact of the event on a particular community. Others definitions require there to be loss of life and for the event to be restricted in time (Neria, Nandi et al. 2008).
Hagan (2005) defines a disaster as a “calamitous event that generally involves injury or loss of life and destruction of property. These events are traumatic and customarily outside the scope of normal human experience; thus they are likely to involve psychological as well as physical injury” (Hagan 2005, page 787). In an early report aimed to educate psychologists on the needs of children following a disaster, Vogel and Vernberg (1993) define a disaster as follows:
Events that are relatively sudden, highly disruptive, time-limited (even
though the effects may be longer), and public (i.e. affecting children from
more than one family). This includes acts of human violence, such as
sniper shootings; effect of natural forces, such as hurricanes and
earthquakes; and failures of technology or results of human error, such as
plane crashes and toxic contamination (Vogel and Vernberg 1993, p 465).
Hoven and colleagues suggest 5 main classifications of disasters that have been shown to exert “deleterious” “unpredictable” and “pronounced” effects on children (Hoven, Duarte et al. 2003). These are 1) natural disasters (such as hurricanes, tornadoes, cyclones, earthquakes, or floods); 2) large-scale human induced accidents (such as the sinking of the Jupiter, the
Aberfan Disaster, Challenger Space Shuttle Disaster, Buffalo Creek Dam Collapse); 3) spree
Miranda Van Hooff 2010 11 shootings (school shootings, sniper attacks); 4) war and 5) terrorism (Oklahoma city bombing, Bali bombings, World Trade Centre Attacks) (Hoven, Duarte et al. 2003). These disasters can be further differentiated based on their origin (natural or man-made) and motivation (accidental, ideological, political, or driven by individual needs) (Hoven, Duarte et al. 2003). Vogel and Vernberg (1993) exclude family violence, such as physical and sexual abuse, political violence and warfare, as these acts are often confounded by repeated exposures or performed by a family member or close associate which are associated with their own unique patterns of response. For the purpose of this thesis, the term disaster will herein be defined according to Vogel and Vernberg’s definition above.
2.5 The normal/expected reaction of a child to a disaster
It is important to differentiate between the typical expected reaction of a child to a disaster and the behaviour and adjustment reactions that deviate from normal. Transient mild stress reactions should be expected following a disaster, due to disruptions to the child’s life. It is when these symptoms persist for a month or more that long-term adverse outcomes normally occur (Hagan 2005).
As outlined by Hagan (2005), independent of a child’s age, there are number of universal stages every child goes through in response to a disaster. Stage 1 is characterised by reactions of fright, disbelief, denial, grief and feelings of relief if loved one’s have not been harmed.
These reactions typically occur in the immediate aftermath of the disaster (American
Academy of Pediatrics Work Group on Disasters 1995; Hagan 2005). The second stage occurring a few days to several weeks after the disaster may involve regressive behaviours and symptoms of emotional distress such as anxiety, sadness and depressive symptoms, hostility and aggression toward others, apathy, withdrawal, sleep disturbances, somatisation,
Miranda Van Hooff 2010 12 pessimistic thoughts of the future, and play demonstrating themes related to the traumatic event. Fears of trauma related stimuli, for instance, fears of water in those who been exposed to a flood, loud noises, or of the event recurring are also a salient feature. These are normal expected reactions and should not be expected to last more than 2 weeks (American Academy of Pediatrics Work Group on Disasters 1995; Schonfeld 2002; Hagan 2005).
For many childhood disaster survivors, symptoms peak immediately after the disaster and then decline over time. A proportion of children however will go on to develop a diagnosable disorder such as PTSD, generalised anxiety disorder, panic disorder or depression (Stage 3)
(American Academy of Pediatrics Work Group on Disasters 1995; Hagan 2005). These children are frequently those who exhibit symptoms for more than one month following the disaster (Hagan 2005). They are also the children who are at the highest risk of adverse outcomes in adulthood.
2.6 Risk and protective factors
Children are inherently resilient (Hagan 2005). However, there are a number of factors, which influence how a child responds to a disaster that can lead to highly variable psychological outcomes both in the short and long-term.
For example, Lubit et al (2003) identify 14 factors that effect the impact of trauma on children: temperament; prior history of trauma; child’s psychological strengths; separation of child from parents during and after trauma; parent’s level of stress and ability to respond to their child’s needs; how quickly the child was brought to a safe place following the trauma; parent’s ability to maintain normal rules and routines; prior history of threats to parent child attachment such as parental separation or illness; what the child saw (death or grotesque
Miranda Van Hooff 2010 13 images); whether the disaster was an act of nature or caused by a person; if the child heard unanswered screams for help; whether the child feared for his or her life, or that of a loved one; whether the child was in danger; unexpectedness and duration of the disaster, and if the child felt guilty over acts of omission or commission (Lubit, Rovine et al. 2003). A number of these factors are discussed in more detail in the remainder of this chapter.
2.6.1 Characteristics of the child
2.6.1.1 Developmental age
Developmental age plays a significant role in their reactions to trauma. The way a child perceives, responds and processes a disaster is determined largely by the developmental age of that child through an integration of biological, emotional and behavioural systems within each child (McDermott and Palmer 2002).
During the preschool years, due to their inability to sufficiently verbalise their fears and concerns, children often use play and drawings to continually re-enact and process the event - drawing pictures or playing games with frightening trauma-related themes (Perry, Silber et al.
1956). Such play may indicate underlying psychopathology or it may be part of the recovery process whereby the child is using play to process the enormity of the event. Play that is overly repetitive and lacks positive progression may represent a deeper underlying problem
(Terr 1981; Vogel and Vernberg 1993). Children’s active imaginations may also cause them to apply human characteristics to inanimate objects, transferring their trauma related fears to items in their immediate household environment such as a vacuum cleaner or other appliance.
For children in this age group, comprehension of the magnitude of the disaster is very limited and behaviour problems are more often than not brought about by the destruction of routine and loss of loved ones than the actual disaster itself (American Academy of Pediatrics Work
Miranda Van Hooff 2010 14
Group on Disasters 1995; Hagan 2005). Such children may also perceive that the event was caused through their own actions and blame themselves for what has occurred, due to their egocentric view of the world (Deering 2000). Symptoms usually present as isolated behavioural problems (Green, Korol et al. 1991) and can comprise of episodes of aggression
(such as increased temper tantrums), fears, somatic complaints, eating problems, separation anxiety, behavioural and skill regression particularly enuresis, thumb sucking, crying, whining, wanting things immediately, hyperactivity and clinging (Gleser, Green et al. 1981;
Deering 2000; Hagan 2005). Sleep problems including reluctance to sleep alone and problems falling asleep are often exacerbated by sleep terrors and nightmares in children of this age group (Swenson, Saylor et al. 1996). In fact sleep problems were the most commonly reported symptom by parents of children exposed to the 1989 Loma Prieta earthquake, with 78% of parents reporting this problem (Ponton, Bryant et al. 1991).
For school aged children, regressive behaviours such as separation anxiety, brought about by the fear of death or injury to close family members, are common. Unlike, pre-verbal children however, school children have the ability to discuss their feelings and the cognitive ability to attempt to rationalise what has happened to them. This can sometimes help or hinder the recovery process. For example, school age-children can often become obsessed with details of the disaster, which can cause them to constantly revisit the traumatic memory through repetitive retelling of events (Lubit, Rovine et al. 2003). In a similar way to pre-school children, the emotional feelings of school aged children are often reflected through play, with disaster affected children more likely to exhibit aggressive behaviours and play games with trauma related themes (Terr, Bloch et al. 1999; Hagan 2005). McFarlane (1987) identified this behaviour in his original study of the Ash Wednesday Bushfire cohort. In this study an association was found between the children playing games about the fire and lack of maternal coping in relation to the fire. McFarlane suggests that play may represent the child’s attempt
Miranda Van Hooff 2010 15 to work through an event that had undermined their mother’s role as mediator between the child and danger and therefore serves an adaptive function. Children in this age group are also extremely vulnerable to the reactions of their parents and may mimic parental behaviours, using the response of their parents to gauge the seriousness of the event. Typical reactions in school age children include depression, anxiety, hyper-vigilance, irritability, fears, distractibility and concentration problems, decreased school performance (attention and learning problems), sleep difficulties (including nightmares), social withdrawal, apathy and oppositional behaviour (Terr, Bloch et al. 1999; Deering 2000; Lubit, Rovine et al. 2003;
Hagan 2005). Brener et al (2002) reported a dramatic increase in children missing school because of safety concerns following the Columbine school shootings.
In adolescents, impulsive acts of antisocial behaviour are a common response to a disaster as are symptoms of depression, apathy, withdrawal, social isolation, somatisation, irritability, decreased academic performance, sleep difficulties, and interpersonal conflicts. Younger adolescents may exhibit regressive behaviours such as bed wetting, separation anxiety and tantrums (Deering 2000). Adolescents exposed to a disaster often become preoccupied with omens relating to the disaster and may continue to focus on identifying possible warning signs for future events (Lubit, Rovine et al. 2003).
In relation to psychological morbidity, significant age-related effects where age is “a proxy marker for a range of more specific developmental issues such as cognitive style, language, social and peer orientation and biological change” (McDermott and Palmer 2002, p 755), have been observed following a range of different disasters. Most studies report that younger children are more likely than older children to exhibit symptoms of PTSD and other post- disaster psychopathology (Kar, Mohapatra et al. 2007; Piyavhatkul, Pairojkul et al. 2008).
This pattern of symptom presentation has been observed following hurricanes (Shannon,
Miranda Van Hooff 2010 16
Lonigan et al. 1994), cyclones (Milne 1977), tsunamis (Piyavhatkul, Pairojkul et al. 2008) and the World Trade Centre attack (increased rates of PTSD, separation anxiety and agoraphobia)
(Hoven, Duarte et al. 2005). Other studies have reported no relationship between age and the development of post disaster psychopathology (Pynoos, Frederick et al. 1987; Shaw,
Applegate et al. 1995; Vijayakumar, Kannan et al. 2006).
McDermott and Palmer (2002) examined the role of developmental age on depression and anxiety in 2379 school children and adolescents following a bushfire in New South Wales in
1994. They found a relationship between both school grade and depression and school grade and anxiety symptoms. Depression scores were highest in children from the lower grades suggesting that depressive symptoms may be an inherent part of a young child’s disaster response, which is strongly influenced by the degree of perceived loss in the child. Symptoms of PTSD, however, were highest in those from the middle grades (grades 7 to 9) suggesting that in addition to not being equipped with the effective cognitive coping strategies of the adolescents, these children are too old to have been protected by the close physical proximity of the parent at the time of the disaster (McDermott and Palmer 2002).
Green, Korol et al (1991) in their follow-up of 179 children 2 years following the Buffalo
Creek Dam collapse reported fewer PTSD symptoms (in particular denial symptoms) in the children in the youngest age group. They attributed this low rate of symptoms to an inability of the younger children to fully conceptualise and understand the trauma relying more on their parent’s behaviour/symptoms to guide them in their response which essentially protects these children from risk (Green, Korol et al. 1991).
Godeau, Vignes et al (2005) examined the presence of symptoms consistent with PTSD in adolescents directly and indirectly exposed to a major industrial accident in Toulouse France.
Miranda Van Hooff 2010 17
Nine months following the disaster 38.6% of directly exposed students still exhibited symptoms of PTSD, with a higher proportion of 17 year old children compared to those aged
11 to 15 meeting cut-offs for PTSD on the Impact of Events Scale-Revised (IES-R) (Godeau,
Vignes et al. 2005).
John et al (2007) followed up 502 children and adolescents (5 to 18 years of age) from three rural communities in India devastated by the 2004 Tsunami. PTSD was most severe and prevalent in adolescents (age 12 to 18) compared to the younger children. One study by
Giannopoulou et al (2006) identified avoidance symptoms as the PTSD symptom group most susceptible to age related differences following an earthquake, with younger children reporting significantly more avoidance symptoms than older children (Giannopoulou,
Strouthos et al. 2006). In addition younger children reported significantly more symptoms of separation anxiety, generalised anxiety and social phobia than older age groups.
2.6.1.2 Sex
In the literature, it is generally accepted that females report more severe posttraumatic stress reactions and are at a greater risk of developing PTSD than males following a range of disasters occurring in childhood (Goenjian, Pynoos et al. 1995; Goenjian, Walling et al. 2005)
Girls tend to display more internalising behaviours such as anxiety and depression (Winje and
Ulvik 1998) as well as elevated intrusion scores compared to boys following a disaster (Winje and Ulvik 1998; Giannopoulou, Strouthos et al. 2006) with the most highly exposed females reporting the most distress overall (Tyano, Iancu et al. 1996). This trait of emotional expression in females may be a consequence of ongoing socialisation experiences that encourage females to display their emotional reactions to the death of others and threats to their physical integrity (Milgram, Toubiana et al. 1988).
Miranda Van Hooff 2010 18
Boys on the other hand, typically display externalising behaviours that are antisocial, violent
(including vengeful thoughts), or aggressive and in general take longer to recover (Hoven,
Duarte et al. 2005; Lengua, Long et al. 2005; Roussos, Goenjian et al. 2005).
Three months following Hurricane Hugo, for example, while males reported experiencing anhedonia, memory difficulties and attention problems (symptoms related to cognitive and behavioural factors), females reported symptoms associated with emotional processing, including being upset with thoughts of the hurricane, having repetitive thoughts, fear of reoccurrence, emotional isolation, emotional avoidance, emotional numbing, being easily startled, guilt, avoidance of reminders and somatic symptoms (Shannon, Lonigan et al. 1994).
In another study of hurricane survivors, Shaw et al (1996) found that although both males and females reported symptoms of anxiety and depression, only the males exhibited a significant increase in behavioural problems such as withdrawal, social problems and attention problems
(Shaw, Applegate et al. 1996). These sex specific patterns of behaviour appear to remain consistent over time. Green et al (1994) reported that females victims scored higher on anxiety, social isolation, depression, intrusion and avoidance than males victims 17 years following the Buffalo Creek Dam collapse (Green, Grace et al. 1994).
Nevertheless, sex has not always been a consistent factor in childhood response to trauma.
Some childhood disaster studies show no relationship between sex and the development of post-disaster psychopathology (Shaw, Applegate et al. 1995; La Greca, Silverman et al. 1996;
La Greca, Silverman et al. 1998; Kolaitis, Kotsopoulos et al. 2003; Vijayakumar, Kannan et al. 2006; Spell, Kelley et al. 2008).
Miranda Van Hooff 2010 19
2.6.1.3 Ethnicity
In comparison to sex and developmental age, the impact of ethnicity on disaster outcome has received very little attention in both the child and adult literature. The few studies that have investigated the role of ethnicity in childhood disaster victims have reported contradictory results mainly due to difficulties in isolating the effects of ethnicity from the confounding effects of socioeconomic status, particularly income and prior trauma exposure (Spell, Kelley et al. 2008). For example, studies following up survivors of a hurricane and the World Trade
Centre attacks, have found that African American children are more likely than Caucasian children to report anhedonia, attention problems, omens, avoidant symptoms, depression, anxiety, conduct problems, reckless behaviour, post-traumatic stress symptoms as well as a decline in their symptoms from time 1 to time 2 (Shannon, Lonigan et al. 1994; La Greca,
Silverman et al. 1996; La Greca, Silverman et al. 1998). Other studies, however, have reported no such ethnic differences (Pfefferbaum, Doughty et al. 2002; Costa, Weems et al.
2009). Despite this contention, it is generally accepted that it is the ethnic groups who have minority status that are at a greater risk of developing problems.
2.6.1.4 Pre-disaster functioning
Level of functioning prior to the disaster is an important determinant of disaster outcome in both children and adults. Children with anxiety and depressive symptoms that pre-date the disaster are at an increased risk of developing PTSD, generalised anxiety disorder and depressive disorder following subsequent disaster exposure (Lonigan, Shannon et al. 1994; La
Greca, Silverman et al. 1998; Hock, Hart et al. 2004). Studies following up hurricane survivors have found that a child’s level of trait anxiety is a stronger predictor of PTSD symptoms than the actual level of exposure to the hurricane (Lonigan, Shannon et al. 1994).
La Greca et al (1998) examined the combination of disaster exposure and pre-disaster
Miranda Van Hooff 2010 20 behavioural functioning on the development of PTSD in children exposed to Hurricane
Andrew. Children rated as more anxious, more inattentive and who had poor academic skills
15 months prior to the disaster reported more symptoms post hurricane, suggesting that such children may have greater difficulty coping and adjusting to the post-hurricane environment due to increased arousal. Anxious children pre-hurricane also reported more posttraumatic stress symptoms at the 7-month follow-up and were less likely to show a decline in symptoms from three to seven months, indicating that pre-disaster anxiety symptoms may also impede recovery (La Greca, Silverman et al. 1998). This finding of increased PTSD rates and lack of decline of symptoms in children with pre-disaster trait anxiety was replicated in a recent study following up youths after Hurricane Katrina (Weems, Pina et al. 2007) and in a study of youths following the Northridge Earthquake in Los Angeles (Asarnow, Glynn et al. 1999).
Asarnow et al (1999), however, reported no relationship between other types of psychiatric disorder specifically pre-earthquake depression and disruptive behaviours and PTSD one year after the earthquake (Asarnow, Glynn et al. 1999).
Developmental epidemiological research has made a significant contribution to the field of trauma and PTSD by demonstrating a significant association between early childhood factors such as pre-trauma psychopathology, family psychiatric history and general childhood adversity and the development of PTSD. Koenen et al (2007) examined 1037 adults who had been followed up since birth until age 26 as part of the Dunedin Multidisciplinary Health and
Development Study. They showed an increased risk of trauma and PTSD in those with the following three characteristics: externalising problems in childhood (such as difficult temperament, antisocial behaviour and hyperactivity- all of which are characterised by poor impulse regulation), family history of mental-health problems (maternal self-reported distress) and a history of family adversity (including the loss of a parent). Low IQ, childhood antisocial behaviour and poverty in childhood were also associated with an increased risk for
Miranda Van Hooff 2010 21
PTSD at both 26 and 32 years of age (Koenen, Moffitt et al. 2007). In a similar study Storr et al (2007), using a prospective study design, followed up a community sample of children from 6 years of age to young adulthood in order to ascertain the impact of early cognitive ability, behaviour problems and emotional problems on the risk of exposure to traumatic events with and without PTSD. Children displaying aggressive behaviour and children with reading problems were at an increased risk of experiencing assaultive type traumas but not
PTSD. Youths who rated themselves as having depressive or anxious feelings were at a greater risk of developing PTSD if they were exposed to trauma (Storr, Ialongo et al. 2007).
These results have important implications for studies following up disaster populations from childhood to adulthood as they suggest a pre-morbid vulnerability. Unstable early household environments sensitise individuals to the adverse effects of later stressors, consequently impacting on PTSD prevalence rates. They also imply a more general association between childhood psychopathology and the onset of PTSD following trauma, which may not be specific to disaster exposure.
Other aspects of pre-disaster functioning that have been shown in the literature to impact on disaster response in children include the number and type of prior traumatic events (Pynoos,
Frederick et al. 1987), social relationship difficulties, medical problems (Udwin, Boyle et al.
2000), and feelings of upset in the week prior to the disaster (Lengua, Long et al. 2005).
Children with poor social support, a shy and fearful temperament, or who have experienced previous losses are also at an increased risk of morbidity (Earls, Smith et al. 1988; Hagan
2005). Pynoos et al (1987) for instance reported renewed thoughts and images of prior traumatic events in exposed children following a sniper attack at their school.
Miranda Van Hooff 2010 22
2.6.1.5 Maternal and paternal mental health
Twin and family studies suggest a small but significant relationship between mental health problems in family members and the development of PTSD and other poor psychological outcomes in children following trauma, particularly interpersonal violence (Laor, Wolmer et al. 2001; Linares, Heeren et al. 2001; Ozer, Best et al. 2003; Keane, Marshall et al. 2006;
Self-Brown, LeBlanc et al. 2006). For instance, maternal psychopathology has been reported to both diminish the significance of the relationship between community violence and early childhood behaviour problems as well as increase the risk for PTSD following community violence in adolescents whose mothers reported high levels of PTSD (Linares, Heeren et al.
2001; Self-Brown, LeBlanc et al. 2006). These studies support a reciprocal relationship between the child’s symptoms and the parents, whereby the behaviour of the child who is affected by the parent, goes on to negatively impact the parent’s ability to effectively parent
(Spell, Kelley et al. 2008).
Vijayakumar et al (2006) examined this relationship in children exposed to a Tsunami and reported that family psychopathology influenced the development of affective problems one year following the disaster (Vijayakumar, Kannan et al. 2006). A second study by Spell et al
(2008) found that maternal psychological distress and PTSD correlated with children’s internalising and externalising behaviour problems following Hurricane Katrina.
Few studies have focused on the effects of paternal psychopathology on children’s psychopathology following disasters. Kilic et al (2003) conducted the only study directly comparing maternal and paternal psychopathology. They examined the effects of maternal and paternal symptoms of PTSD, depression and anxiety on forty-nine children (aged 7 to 14) randomly chosen from among 800 families living in a survivor’s camp in Bolu Turkey following a major earthquake. In this study, paternal rather than maternal depression and
Miranda Van Hooff 2010 23
PTSD predicted children’s PTSD scores with paternal PTSD manifesting more symptoms of irritability and detachment than maternal PTSD. The authors suggest that such irritability and detachment may have interfered more directly with family life, through an increase in arguments which may have contributed to the development of PTSD symptoms in children
(Kilic, Ozguven et al. 2003).
2.6.1.6 Prior trauma and PTSD
A number of studies have reported elevated rates of prior trauma in adults with posttraumatic stress disorder (Bremner, Southwick et al. 1993; Zaidi and Foy 1994; Breslau, Chilcoat et al.
1999). These studies however are limited by their failure to examine how the individual responded to this prior trauma (Breslau, Peterson et al. 2008). Breslau et al (2008) addressed this limitation in a recent 10-year longitudinal study of 990 randomly selected adult members of a large US Health Maintenance Organization. They found an increased risk of PTSD associated with subsequent trauma only in those participants who had developed PTSD in response to prior trauma. Prior trauma alone however did not elevate one’s risk for PTSD following subsequent trauma. Consistent with previous research however, prior trauma alone did increase one’s risk for subsequent trauma (Breslau, Peterson et al. 2008).
Only a small number of studies have examined the relationship between prior trauma and
PTSD in children exposed to a disaster (Garrison, Weinrich et al. 1993; Pfefferbaum, North et al. 2003; Chemtob, Nomura et al. 2008; Mullett-Hume, Anshel et al. 2008). The earliest childhood disaster study to identify this link was a study by Garrison et al (1993) who examined a large sample of adolescents following Hurricane Hugo in 1990. Adolescents with prior trauma were more than twice as likely to develop PTSD. Prior trauma in this study however was limited to the year prior to the disaster. Pfefferbaum et al (2003) studied
Miranda Van Hooff 2010 24 children (between the ages of 9-17) 8-14 months following the 1998 bombing of the
American Embassy in Nairobi Kenya. Number of prior lifetime traumatic events and resulting
PTSD significantly predicted PTSD symptoms arising from the bombing itself (Pfefferbaum,
North et al. 2003).
Chemtob et al (2008) examined the combined effects of being exposed to the World Trade
Centre attacks and other lifetime traumatic events (excluding physical abuse, sexual abuse and domestic violence) on the behaviour of 116 pre-school children from Manhattan. They categorised children according to their level of exposure to the disaster. Children were classified as having a high intensity exposure if they directly witnessed or experienced one of the following events: either of the towers collapse, injured people, dead bodies or people jumping out of a building (Chemtob, Nomura et al. 2008). Remarkably, high intensity exposure to the World Trade Centre attacks had little impact on the behaviour of pre-school children who did not have other lifetime trauma. However, children with both high intensity exposure and history of other lifetime trauma manifested amplified behaviour problems and were at a greater risk of experiencing emotional reactivity (odds ratio OR = 4.7), anxiousness/depression (OR = 7.5), withdrawn behaviour (OR = 7.0) and sleep problems (OR
= 1.2). Children who had experienced high intensity exposure in combination with other trauma were over 21 times more likely to be emotionally reactive and anxious or depressed and 16 times more likely to have attention problems than children who had no other trauma or who were considered to have low intensity exposure to the WTC attacks.
Mullet-Hume et al (2008) replicated these findings in another study examining childhood survivors of the World Trade Centre Attacks. Utilising a sample of 204 students living in an impoverished immigrant community, they reported a different pattern of post-disaster response depending on both the number of prior lifetime traumas and the level of exposure to
Miranda Van Hooff 2010 25 the World Trade Centre attacks. For those with a low number of previous traumas, a significant dose-response pattern of PTSD symptoms emerged 2.5 years following the event.
However, for those with a medium to high number of prior traumas, the number of prior traumas rather than the level of exposure to the World Trade Centre attacks best predicted the severity of PTSD symptoms. The authors suggest that a history of multiple traumas is potentially a more potent risk for psychiatric impairment following subsequent disaster exposure than the level of exposure to the disaster itself.
Despite the research outlined, the question of whether prior trauma decreases (through desensitisation) or increases (through a general dose effect) vulnerability for psychopathology following a disaster remains unclear and requires further investigation (Neuner, Schauer et al.
2006). This is particularly relevant in populations experiencing high levels of community violence or where children experience other traumatic events.
2.6.1.7 Peri-traumatic response
The child’s initial response to the disaster either during or immediately afterwards has been reported to be an important predictor of long-term adjustment . Reactions manifested in separation anxiety (Nader, Pynoos et al. 1990; Terr, Bloch et al. 1999), mourning (Goenjian,
Pynoos et al. 1995; Tyano, Iancu et al. 1996), anxiety, depression, fear, guilt and amnesia
(Udwin, Boyle et al. 2000), guilt over acts of omission and/or commission (Goenjian, Pynoos et al. 1995), fear of death, level of panic (Udwin, Boyle et al. 2000), and emotions such as sadness, worry, and loneliness (Lonigan, Shannon et al. 1994) have been reported to influence not only the development of PTSD but also the onset, duration and severity of the disorder.
Pfefferbaum et al (2003) reported that children’s peri-traumatic response to the Oklahoma city bombing, for example, was the strongest predictor of PTSD seven weeks following the
Miranda Van Hooff 2010 26 disaster over and above the effects of physical exposure, relationship to direct victims, bomb related television viewing, worry and safety concerns. In this study the three most common peri-traumatic responses in children were fear that someone in the family would be hurt, feeling nervous and feeling afraid, with females and children with physical, interpersonal or television exposure most likely to feel this way (Pfefferbaum, Doughty et al. 2002;
Pfefferbaum, Sconzo et al. 2003).
McDermott et al (2005) conducted a follow-up study of 222 children and adolescents exposed to the Canberra Wildfires in 2003. They reported significantly higher mean PTSD scores in children who thought they or a family member might die, were close to flames or were home alone and in children who reported seeing flames than children who did not report these experiences (McDermott, Lee et al. 2005). Thienkrua et al (2006) examined multivariate predictors of PTSD and depression in 371 children aged 7 to 14 who had been exposed to the
2004 tsunami in Thailand. Having a delayed evacuation, feeling that lives of family or self was threatened and having felt extreme panic or fear were significantly related to PTSD, whereas feeling one’s or one’s family life is threatened predicted symptoms of depression.
Several studies have indicated that the way a child subjectively interprets the severity of a disaster are both age and sex dependant. Shannon, Lonigan et al (1994) in a 3 month follow- up of children and adolescents following Hurricane Hugo found that older children generally rated the hurricane as less severe, whereas younger children and females reported more home damage (Shannon, Lonigan et al. 1994). Pfefferbaum et al (2003) reported a similar finding in children exposed to 1998 American Embassy Bombing in Nairobi Kenya. In this study, females scored higher than males in terms of their peri-traumatic reaction to the bombing.
Peri-traumatic reaction to the bombing was the highest predictor of post-traumatic stress
Miranda Van Hooff 2010 27 symptoms in relation to the bombing however, only when post-trauma symptoms in relation to prior trauma was removed from the model (Pfefferbaum, North et al. 2003).
2.6.2 Disaster related factors
Longitudinal studies of childhood disaster survivors have indicated a number of disaster- related factors that influence the development and course of PTSD and other psychopathology.
2.6.2.1 Whether the disaster was intentionally inflicted or not
Human-caused disasters in which harm is intentionally inflicted on the victim by a perpetrator have been reported to cause more psychological problems than natural disasters (American
Academy of Pediatrics Work Group on Disasters 1995). Galea et al (2005) suggest that this may be due to difficulties associated with identifying those who are direct victims following a natural disaster. In contrast to human caused or technological disasters which are generally confined to smaller demarcated regions making direct victims easily identifiable, natural disasters often cause widespread damage to broad geographical areas (Galea, Nandi et al.
2005). Natural disaster studies therefore, typically include large samples of people from disparate communities both directly and indirectly affected by the disaster which has the potential to dilute the overall severity of the effect (Galea, Nandi et al. 2005).
2.6.2.2 Direct versus indirect exposure
Pfefferbaum (2005) identifies three forms of trauma exposure: (1) direct exposure, defined as the individual’s physical proximity to the trauma and degree of physical injury to self; (2) indirect exposure which is trauma resulting from an event occurring to a family member or
Miranda Van Hooff 2010 28 other close associate; and (3) secondary adversity and traumatic reminders which occur in the aftermath of the event (Pfefferbaum 2005). Indirect exposure incorporates the following types of events:
Distant trauma reaction to a real event observed at the time but from
a distant safe site), close call (near miss), indirect trauma (reaction to
an event not directly observable), vicarious trauma (reaction to a
highly threatening event that was not directly observable but was
nationally threatening), mass event (reaction to pending or possible
national or worldwide event), mass hysteria (reaction to a non-
specific threat with acquisition of symptoms through social means)
and copycatting (imitation of symptoms transmitted through social
means) (Pfefferbaum 2005).
Pfefferbaum’s research extends earlier work by Green (1982) following the Buffalo Creek dam collapse, which highlighted the importance of disaster type in defining outcome. Green distinguishes between ‘central’ disasters which have both an immediate impact phase in addition to long term disruptions to housing, income and community, and ‘peripheral’ disasters where the survivor’s own physical setting remains intact, allowing survivors to return to the safety of their unaffected home. This dichotomy will be discussed further in section 2.6.2.3.
Victims of a disaster are often exposed to the disaster event(s) both directly and indirectly, which can have a cumulative effect on PTSD and other post-disaster psychopathology. This pattern of psychopathology is more apparent in younger children than older children suggesting an interaction between age and level of exposure whereby younger children may be less effected by events that they do not directly experience themselves (Groome and
Miranda Van Hooff 2010 29
Soureti 2004). Godeau et al (2005), for example, conducted a 9-month follow-up study of
1477 adolescents exposed to a major industrial accident in Toulouse France in 2001. They divided the adolescents into two groups, those who were directly exposed (experienced household damage) and those who were indirectly exposed (lived in the region but not directly in the blast zone). Among the younger adolescents (aged 11 to 13) rates of PTSD were twice as high among those directly exposed to the explosion, with this ratio increasing to
4 times in 15 year olds with severe damage to home, personal injuries and injuries to family members being among the highest predictors of PTSD. Adolescents with both personal injuries (direct exposure) and with family members who were injured (indirect exposure) were more likely to have PTSD at nine months than adolescents reporting only one of these forms of exposure.
Several short-term follow-up studies have supported a ‘dose of exposure’ pattern of psychopathology, whereby the severity of the response is congruent with the child’s level of exposure to the disaster (Pynoos, Frederick et al. 1987; Nader, Pynoos et al. 1990; Pynoos,
Goenjian et al. 1993; Goenjian, Pynoos et al. 1995; Pfefferbaum, Nixon et al. 1999;
Pfefferbaum, Seale et al. 2000; Goenjian, Molina et al. 2001; Groome and Soureti 2004;
Goenjian, Walling et al. 2005; Hoven, Duarte et al. 2005; Vijayakumar, Kannan et al. 2006;
Chemtob, Nomura et al. 2008). Nader et al (1990), found that children most highly exposed to a sniper attack 14 months prior continued to report the event as an extreme stressor at the follow-up assessment together with a large number of intrusive and avoidance symptoms. In contrast, children who were the least exposed (for instance were not in the school grounds or in the vicinity of the shooting) had reassessed the threat and consequently reported fewer symptoms. Giannopoulou et al (2006) reported children directly exposed (living in epicentre) to a major earthquake in Athens reported more symptoms of anxiety but not depression than those in the indirect exposure group (Giannopoulou, Strouthos et al. 2006). PTSD in the direct
Miranda Van Hooff 2010 30 exposure group was most strongly predicted by greater perceived life threat, whereas in the indirect exposure group, the number of post-earthquake traumatic events was the strongest predictor (Giannopoulou, Strouthos et al. 2006). Tyano et al (1996) followed-up 389 children
(representing four levels of exposure) who were involved in a fatal bus accident in Israel seven years earlier. Children in the high exposure group (those on the bus) reported the highest levels of depression, phobic anxiety, number of PTSD symptoms and help seeking behaviour and the lowest levels of coping than children in the low exposure group who were not on the bus itself (Tyano, Iancu et al. 1996). In one of the longest follow-ups of adolescent survivors of a hostage situation, those suffering the most severe injuries reported the highest number of PTSD symptoms seventeen years later (Desivilya, Gal et al. 1996).
Other objective disaster related factors that have been shown to increase risk for PTSD and other post trauma psychopathology include; whether or not any injuries were sustained
(Green, Grace et al. 1994; Kolaitis, Kotsopoulos et al. 2003); loss of pets; being trapped/blocked in trying to escape (Green, Grace et al. 1994; Udwin, Boyle et al. 2000); the overall evacuation experience (McDermott and Palmer 2002); and seeing blood (Udwin,
Boyle et al. 2000). Severity of intrusion symptoms in particular are predicted by loss of pets, degree of warning, being blocked in trying to escape, and loss of family members or friends
(Green, Grace et al. 1994). Kolaitis et al (2003) found that children injured in an earthquake reported more intrusion and avoidance symptoms at 5 month follow-up than those who were not injured.
Indirect exposure to a disaster is also associated with its own dose of exposure pattern of psychopathology. Terr, Bloch et al (1999), for example followed up three groups of children with various levels of indirect exposure to the Challenger Space Shuttle Disaster. Results showed that the children who initially watched the event and who were most emotionally
Miranda Van Hooff 2010 31 involved exhibited the most symptoms. These symptoms included post-traumatic play and re- enactment such as drawings and play, more trauma related dreams, more clinging behaviour and more trauma-related fears.
Several studies have reported an interaction between sex, the level of disaster exposure and the nature of the post-disaster response. In the aftermath of a hurricane for example, males from a high impact school reported lower scores on the anxious/depressed scale of the
Teacher Report Form (TRF) compared to males from a the low impact school, whereas females from the high impact school reported lower mean scores on internalising, externalising, anxious, depressed, social problems, delinquent behaviour and aggressive behaviours (Shaw, Applegate et al. 1995). Roussos et al (1999) in one of the largest post- earthquake screenings of children and adolescents reported higher ratings of subjective exposure in females compared to males. However, they were unable to conclude whether this was due to the females experiencing more subjective fear or being more willing to talk about it.
Several studies have failed to find a dose of exposure pattern of response. Hoven et al (2005) followed up 8236 students exposed to the World Trade Centre attacks and found children attending schools in Ground Zero (the place closest to the attack) reported lower rates of mental disorder than children with family exposure only (family member injured or killed) and children attending school further away from the site of the bombing. The authors suggest that this may reflect the increased social support and mental health interventions provided to individuals in the direct impact zone following the disaster. Shaw et al (1995) reported no differences in PTSD severity between children (aged 6 to 11) from a high impact school and children from a low impact school 8 weeks following Hurricane Andrew. In fact, children from the low impact school had the same prevalence of mild to moderate PTSD as children
Miranda Van Hooff 2010 32 from the high impact school suggesting a strong effect of indirect exposure through avenues such as the media in the low exposure group. One study by Milgram et al (1987) following up seventh grade children exposed to a massive catastrophic school bus accident found no effect of level of exposure, with children on the school bus showing a similar level of symptoms as children who were elsewhere at the time. This result was attributed to treatment received in the aftermath of the accident which may have diminished the effects of the situational exposure (Milgram, Toubiana et al. 1988).
Seven years later Tyano et al (1996) followed up this same group of children and examined the effects of level of exposure to the accident on adult psychopathology. This time adults with the highest level of exposure to disaster when they were children (those on the school bus that collided with the train) reported the highest levels of somatisation, depression, phobic anxiety, psychotic symptoms as well as the highest number of PTSD symptoms. There were no significant differences between those with medium, low or no exposure. This result suggests that the treatment effects may only be short lived and that over time the level of exposure to the disaster becomes a more potent risk factor for long term maladjustment.
Neuner et al (2006) followed up 264 children and adolescents aged 8 to 14 years 3 to 4 weeks following a Tsunami in Sri Lanka and found no relationship between level of exposure to the
Tsunami (in terms of objective exposure variables) and PTSD. Garrison et al (1993) observed only a small although significant correlation between severity of disaster exposure and number of PTSD symptoms in a community sample of adolescents exposed to Hurricane
Hugo, with sex, other traumatic events occurring over the last 12 months and sex being stronger predictors of post-traumatic stress disorder (Garrison, Weinrich et al. 1993).
Desivilya et al (1996) found no relationship between degree of exposure to a terrorist hostage situation and number of traumatic stress symptoms 17 years later attributing this lack of effect to the restricted variation in exposure.
Miranda Van Hooff 2010 33
Finally, Chemtob et al (2008) followed up pre-school children 35 months following the
World Trade Centre attacks and found that those with high intensity exposure were at a significantly increased risk of being anxious /depressed (OR = 7.1) and to have sleep problems (OR = 7.2) compared to those with low intensity exposure. This effect however was attenuated when other lifetime trauma was taken into consideration, indicating that it may not be the level of exposure per se that led to elevated behaviour problems in this group but the combination of high intensity exposure and prior trauma that caused an increase in symptoms.
Mullet-Hume et al (2008), in a 2.5 year follow-up of 204 children from impoverished schools in and around Manhattan further supported this argument by showing that the number of direct exposures to the World Trade Centre attack only had a significant impact on PTSD symptomatology in children with the lowest number of other lifetime traumas.
2.6.2.3 Associated level of disruption to housing and income
Secondary adversities such as displacement and relocation of the family home, property and economic loss, family and social problems and disrupted interpersonal social support networks can serve to trigger and intensify symptoms due to their unremitting nature and impact on communality (Goenjian, Pynoos et al. 1995).
Lonigan et al (1994) showed a relationship between high-level home damage and continued displacement 3 months following Hurricane Hugo and the presence of re-experiencing symptoms of PTSD (repetitive, intrusive and upsetting thoughts and images) as well as attention problems. Being in a familiar location during the hurricane, however, also served as a protective factor against the development of PTSD. Dirkzwager et al (2006) reported relocation as a significant predictor of health problems in children aged between 4 and 18
Miranda Van Hooff 2010 34 years of age two years following a fireworks explosion. John et al (2007) in a six month follow-up of children and adolescents exposed to a Tsunami reported more property loss and loss of life in those falling in the severe PTSD range. Six months following an earthquake in
Athens, Kolaitis observed higher depression scores in children who had property damage compared to those who did not (Kolaitis, Kotsopoulos et al. 2003). Finally, Kar et al (2007) compared psychiatric morbidity in 268 children from high exposure areas (mean age 12.6) and 179 children from low exposure areas (mean age 13.6) who experienced a cyclone that devastated the East Coast of India in October in 1999. Compared to those from the low exposure group, children previously living in areas now submerged by seawater reported significantly higher rates of depressed mood (37.3% versus 14.5%), hopelessness (38.1% versus 10.1%) decreased interest in pleasurable activities (49.6% versus 5%), decreased social interaction (28.4% versus 4.5%), continuing fear that cyclone would happen again (60.4% versus 23.5%) and PTSD (43.7% versus 11.2%). Approximately one third of children reporting damage to their home or who had to stay away from home developed PTSD.
A recent study by Wickrama and Kaspar (2007) examined the interaction of Tsunami exposure (defined according to loss of lives and level of property destruction) and associated psychosocial losses (calculated in terms of displacement duration, social loss, family loss and mother’s depressive symptoms) on depressive and PTSD symptoms in 325 Sri Lankan adolescents. Using Structural Equation Modelling, Tsunami exposure and psychosocial losses significantly predicted both PTSD and depressive symptoms in adolescents. An increase in psychosocial losses however diminished the effects of the tsunami exposure indicating that losses occurring due to the tsunami exposure are mediated by how much this drains psychosocial resources. Strong parent-child relationships were observed to be a protective factor in this relationship, positively compensating to some degree for the losses experienced
(Wickrama and Kaspar 2007).
Miranda Van Hooff 2010 35
Other studies have shown no effect of forced relocation on rates of depression, PTSD and childhood behavioural problems (Najarian, Goenjian et al. 1996; Goenjian, Molina et al.
2001). Milne (1977) examined 649 children, 7 to 10 months following Cyclone Tracy in
Darwin, Australia and found that children who continued to reside with their family in the homes despite the surrounding area being devastated by the cyclone emerged with the least symptoms. Instead it was the non-returned evacuees who exhibited the most adverse outcomes especially in relation to schooling difficulties, fear of wind and rain, fear of jet aircraft noise and injuries (Milne 1977). The same result was reported in families following the Ash Wednesday Bushfires. In this study, families who were split up in the first three days following the fires (due to parents sending their children out of the district in order to allow them to concentrate on salvaging the property and disposing of injured stock) appeared to have more family problems in the long term. McFarlane suggests that this is due to the family being unable to share in their immediate reactions to the disaster (McFarlane 1987). The role of the family environment in the development of post-disaster psychopathology was emphasised in a recent school based study of children and adolescents following an earthquake in Greece. In this study, significant differences in PTSD and depression scores were reported between those who did and did not report difficulties at home since the earthquake (Roussos, Goenjian et al. 2005). In summary, the acute events which result in little or no disruption to the child’s home and social environment are least likely to cause long-term negative outcomes (Hagan 2005).
2.6.3 Injury, death and threat to family and friends
Death or injury to a family member or friend, number of known deceased, and the stronger the relationships with the victims have been found to magnify symptoms in childhood disaster
Miranda Van Hooff 2010 36 survivors. (Pynoos, Frederick et al. 1987; Milgram, Toubiana et al. 1988; Nader, Pynoos et al.
1990; Pynoos, Goenjian et al. 1993; Green, Grace et al. 1994; Goenjian, Pynoos et al. 1995;
Winje and Ulvik 1998; Pfefferbaum, Nixon et al. 1999; Hsu, Chong et al. 2002; Piyavhatkul,
Pairojkul et al. 2008). Specifically, severity of intrusion symptoms are predicted by loss of a large number of family or friends (Green, Grace et al. 1994; Winje and Ulvik 1998). In contrast, severity of avoidance symptoms have been associated with any injury to family members or friends (Kolaitis, Kotsopoulos et al. 2003).
Pfefferbaum et al (1999) conducted an assessment of clinical needs in 3218 children in grades
6 through 12, who attended schools in the same district as the Oklahoma City Bombing.
Seven weeks following the bombing, posttraumatic stress symptoms scores were highest in children who had a sibling or parent injured or killed in the bombing (Pfefferbaum, Nixon et al. 1999).
In a second report by the same authors, youths bereaved as a result of the bombing were, at seven weeks, significantly more likely to report symptoms of arousal immediately following the bombing, to report worrying about family members and friends at the time of the incident, and to report that bombing changed things at home and school compared with non-bereaved youths. In fact, the total posttraumatic stress score, and scores on the avoidance and arousal subscales for those who lost an immediate family member were higher than all other groups.
In this study 40% of those who lost an immediate family member sought counselling in the seven weeks following the disaster (Pfefferbaum, Nixon et al. 1999). In a small sub-study of these victims Pfefferbaum and colleagues reported that children who had lost a friend reported significantly more symptoms than children that had lost an acquaintance
(Pfefferbaum, Doughty et al. 2002).
Miranda Van Hooff 2010 37
Lengua et al (2005) in a 6 month follow-up of 142 children exposed to the World Trade
Centre attacks reported that children who knew someone who died in attacks experienced the highest levels of posttraumatic stress symptoms, depression and anxiety (Lengua, Long et al.
2005). Goenjian et al (2009) followed up 92 children, six and a half years following the 1988
Earthquake in Armenia. In this study, losing a parent in the earthquake impacted heavily on depression scores but not PTSD scores at follow-up, with orphans having the highest depressions scores, followed in sequential order by those who lost a father, those who lost a mother and those who did not lose a parent. The authors conclude that higher depression scores related to the loss of a father compared to a mother reflect the greater economic loss experienced by these families due to the fathers being the main income earners in this community (Goenjian, Walling et al. 2009).
2.6.4 Parental reactions
Parents own reactions to a disaster can have strong implications for how well a child adjusts in the recovery period (Winje and Ulvik 1998). In the face of trauma, children depend almost entirely on their parents for emotional and psychological guidance and support. This can lead to a child’s sense of safety and security being shattered due to the realisation that their parents were unable to protect them or stop the disaster from happening (Wooding and Raphael
2004).
In situations where parents are not physically or emotionally available to the child to provide support, either because they are unable to recognise symptoms in their children due to their own distress or because they are too distressed to adequately address the problems in their children, children are forced to regulate their own emotions, which has the potential to magnify the traumatic experience and cause long term adverse effects. McFarlane (1987), for
Miranda Van Hooff 2010 38 example, found that posttraumatic symptoms in children 26 months following the Ash
Wednesday bushfires were predicted more by separation from the parents in the days immediately following the fire, continuing maternal preoccupation with the fires, and changed family functioning than the child’s level of exposure to the fire or degree of property loss.
Maternal overprotection in response to feelings of vulnerability, as well as irritability in the parents in this study further strengthened this interaction between parent and child symptomatology (McFarlane 1987).
Further complicating this issue is the inherent ability of children to rapidly alternate from negative mood states to happy playful moods. This can lead to parents, teachers and health care providers alike incorrectly assuming that the child has recovered or is not experiencing any residual effects of the disaster (Lubit, Rovine et al. 2003). In other circumstances parents have been found to deny the emotional impact of a disaster on their children (Burke, Borus et al. 1982).
A number of studies have supported the unique role of the parent in regulating children’s response to disasters. Green, Korol et al (1991) identified parental functioning as one of the most influential factors contributing to number of PTSD symptoms in both very young children and adolescents following the Buffalo Creek Dam collapse. In young children, this may be due to the child’s inability to fully comprehend the magnitude of the event and strong reliance on the parents for support. Adolescents, in contrast, merely due to their age and perceived level of responsibility in the family, may be the ones who are most likely to bear the brunt of parental stress and loss of functioning (Green, Korol et al. 1991). Swensen et al
(1996) identified maternal hurricane related distress to be the only significant predictor of post-hurricane behaviour problems in children exposed to Hurricane Hugo 14-months earlier accounting for 9% of the variance. Hock et al (2004) found that maternal worry after
Miranda Van Hooff 2010 39
September 11 predicted level of child’s fear, whereas early anxiety about being separated from the child was not (Hock, Hart et al. 2004).
Some studies have also supported a reciprocal relationship between symptoms in the child and parent. Winje et al (1998) in a follow-up of children involved in a serious bus accident, for instance found that the child’s intrusion score 1 year after the crash influenced the mother’s intrusion scores two years later, and that the mother’s early general psychological distress influenced the child’s later general psychological distress (Winje and Ulvik 1998).
McFarlane (1987) found that children’s exposure to a high degree of danger in the Ash
Wednesday Bushfires impacted on the level of family involvement 26 months following the fires.
In severe cases, parents may exacerbate symptoms in the child through their direct actions.
Children may become targets of the aggressive behaviours from parents in the aftermath of a disaster brought about by both the feelings of frustration, stress and powerlessness with events over which they have no control and disruption to normal social connections, which guide appropriate and inappropriate interpersonal interactions. This theory is supported by the work of Kotch et al (1995) who reported a significant relationship between social support and stress and mothers at risk of child maltreatment (Kotch, Browne et al. 1995). Curtis et al
(2000), examined child protective service records 1 year prior and 1 year after Hurricane
Hugo, the Loma Prieta Earthquake in California and Hurricane Andrew in Louisiana and reported an increase in rates of reported child abuse following two of the three disasters
(Hurricane Hugo and Loma Prieta Earthquake) (Curtis, Miller et al. 2000). In a separate study by Keenan et al (2004) rates of traumatic brain injury in children ≤ 2 years who had been admitted to one of nine hospitals in North Carolina, were compared with rates of TBI in the 1 year prior to Hurricane Floyd in North Carolina (Keenan, Marshall et al. 2004). Results
Miranda Van Hooff 2010 40 showed a fivefold increase in inflicted injury and a ten-fold increase for non-inflicted injury in the first 6 months following the hurricane in regions severely affected by the hurricane.
This rate of non-inflicted injury remained elevated until the end of the two-year follow-up period and may have been attributed to an increase risk of injury from environmental hazards related to the disaster as well as reduced supervision (Keenan, Marshall et al. 2004).
In contrast, the experience of a disaster can also intensify bonds within families, bringing extended family members closer to each other for support, with secure attachments between parents and children acting as a buffer against psychological harm (Wooding and Raphael
2004). Kolaitis et al (2003) reported no relationship between parental symptoms following a disaster and child psychopathology (Kolaitis, Kotsopoulos et al. 2003).
2.6.5 Media exposure
Children who are geographically remote from a disaster are not immune to the acute and chronic psychopathologies that follow. Several studies, for example, have implicated indirect television exposure to disaster as a risk factor for children’s reactivity, despite the fact that the
DSM-IV diagnosis of PTSD appears to preclude exposure via the media (Hagan 2005;
Pfefferbaum 2005). Other forms of disaster-related media such as evacuation notices (Breton,
Valla et al. 1993) and disaster warnings (Kiser, Heston et al. 1993), which notify the individuals of impending disasters, have also been reported to induce anticipatory stress reactions similar to PTSD. However, media coverage may act as a potential intervention strategy by providing warnings and forecasts that can subsequently limit the number of injuries and casualties and reduce the overall psychological impact on those exposed
(Dominici, Levy et al. 2005)
Miranda Van Hooff 2010 41
Pfefferbaum and colleagues examined PTSD symptoms in a group of youths who lived over
100 miles from Oklahoma City at the time of the 1995 bombing. They found a significant relationship between bomb related media exposure (print media and broadcast media) and
PTSD symptoms 2 years following the bombing, with print media being a stronger predictor than broadcast media (Pfefferbaum, Seale et al. 2000; Pfefferbaum, Nixon et al. 2001;
Pfefferbaum, Seale et al. 2003). This followed on from an earlier study conducted 7 weeks following the Oklahoma city bombing, which showed that children reporting “all” of their television viewing to be bomb related reported higher mean posttraumatic stress scores.
(Pfefferbaum, Nixon et al. 1999).
Studies following up children after the 9/11 World Trade Centre terrorist attack showed children who reported seeing at least three graphic images on television were 3 times more likely to have severe or very severe posttraumatic stress reactions 4 months after the attacks with increased television viewing in the days following 9/11 linked to an increase in symptoms (Fairbrother, Stuber et al. 2003; Kennedy, Charlesworth et al. 2004). Lengua et al
(2005) reported that parents who limited their children’s television viewing after the World
Trade Centre attacks had children who were less upset and reported less externalising behaviours after the attacks (Lengua, Long et al. 2005). They also reported that children who were exposed to more media coverage in the week following their interview (up to 2 months following the attacks) reported being more upset and worried about the attacks during the interview.
For some children media coverage of an event such as a disaster may serve as the primary source of exposure (Pfefferbaum 2005) and can consequently lead to the development of post- traumatic symptoms. For others, television coverage of the disaster may be therapeutic, by allowing children to process the trauma in a sequential manner, starting at the heroic rescue
Miranda Van Hooff 2010 42 following through to the rehabilitation of the community and the determination of survivors to recover (Pfefferbaum, Nixon et al. 1999). Pfefferbaum et al (1999) found that youths reporting the highest arousal following the Oklahoma city bombing were the ones who were most likely to saturate their television viewing time with bomb related images suggesting a link between level of arousal and attention to distressing images (Pfefferbaum, Nixon et al.
1999). In a 7 week follow-up of 2381 eighth graders exposed to the Oklahoma city bombings, bomb related television exposure emerged as one of the most important predictors of PTSD
(Pfefferbaum, Doughty et al. 2002).
2.6.6 Psychological resilience
Although most adults are exposed to at least one traumatic event in their lifetime (Kessler,
Sonnega et al. 1995), only a small proportion go on to develop PTSD. Considerable debate exists in relation to how such resilience in the face of trauma should be defined and quantified. Rutter (2007) describes resilience as:
The phenomena that some individuals have a relatively good outcome despite
suffering risk experiences that would be expected to bring about serious
sequelae. In other words it implies relative resistance to environmental risk
experiences, or the overcoming of stress or adversity (Rutter 2007, p 205).
In a recent review of resilience in children, Condly (2006) defines resilience as:
A person’s capacity for adapting psychologically emotionally and physically
reasonably well and without lasting detriment to self, relationships or personal
development in the face of adversity, threat or challenge (Condly 2006).
Miranda Van Hooff 2010 43
Collishaw et al (2007) incorporating a developmental and organizational framework states that:
Resilience is not seen as good fortune arising from chance encounters with a
supportive friend, peer or partner, but rather an ongoing process of developing
the competencies necessary to form, maintain and benefit from supportive
interpersonal relationships (Collishaw, Pickles et al. 2007, p 226).
In light of these definitions, several recent studies have attempted to delineate factors that promote resilience to psychopathology following childhood trauma. These factors incorporate a broad spectrum of domains including experiences that occur following the trauma (such as additional adversity), genetic predisposition, environmental risk, individual characteristics and experiences, co-morbid psychiatric impairment, interpersonal relationships and family and social support (Garmezy 1991; Collishaw, Pickles et al. 2007; Rutter 2007; Williams
2007). Collishaw et al (2007) followed up a community sample of adults from Isle of Wight from adolescence to middle age in order to examine predictors of resilience following childhood abuse. Defining resilience as the absence of psychopathology over the 30-year follow-up period, resilience was higher among participants who had caring parents, good quality peer relationships throughout life and stable adult love relationships. Abused participants with higher neuroticism scores and who reported experiencing a psychiatric disorder in adolescence were less likely to show resilience. Sex and adolescent cognitive ability, showed no relationship with resilience (Collishaw, Pickles et al. 2007). Other studies following up survivors of childhood maltreatment have reported an association between resilience and living in a low crime, socially cohesive neighbourhood (Jaffee, Caspi et al.
2007), being African American, being female, having a low rate of stressful life events, having a supportive partner in young adulthood, social role satisfaction and positive sense of community (Banyard and Williams 2007). Secure attachment patterns were associated with
Miranda Van Hooff 2010 44 resilience in highly exposed adults 18 months following the World Trade Centre attacks
(Fraley, Fazzari et al. 2006). Interestingly, in relation to stressful life events, DuMont et al
(2007) found that childhood survivors of maltreatment who became resilient only after adolescence had experienced more stressful life events, suggesting possible growth following additional trauma (DuMont, Widom et al. 2007). Growth in the face of trauma was previously reported in a study 2999 Israeli adolescents exposed to terrorism, whereby 75% of the sample
(predominantly religious adolescents and females) reported a sense of growth (Laufer and
Solomon 2006).
Operational definitions of resilience also vary considerably from study to study (DuMont,
Widom et al. 2007). Some studies define resilience as an absence of specific disorder such as
PTSD or a specific behaviour such as antisocial behaviour over a specified period of time.
(Bonanno, Galea et al. 2007; Collishaw, Pickles et al. 2007); (Jaffee, Caspi et al. 2007).
Others adopt a ‘summative’ approach to defining resilience that requires individuals to show competence across multiple domains over time and function at a level of an average child or adolescent (McGloin and Widom 2001; Banyard and Williams 2007; DuMont, Widom et al.
2007). Dumont et al (2007) for example defines resilience as successful achievement across 8 domains; (1) education, (2) psychiatric disorder, (3) substance abuse, (4) official reports of arrests, (5) self-reported violent behaviour, (6) employment, (7) homelessness and (8) social activity.
Based on advice from the World Health Organization following the tsunami in 2004,
Williams (2006, 2007) outlined 7 important actions that should be taken for children in the aftermath of trauma or disaster in order to promote resilience and recovery:
(1) Ensure infants/children remain close to their mothers/families; (2) ensure
adequate nutrition and meet all physical needs; (3) encourage and help families
Miranda Van Hooff 2010 45
to re-establish children’s previous routines with eating, playing, studying,
sleeping and interacting with others; (4) engage children in activities: drawing,
storytelling, drama, games (do not encourage too strongly children to express
disaster-related feeling; allow children control over the decision whether or not
to think about the trauma and to express feelings about it); (5) encourage the
families (in groups) to facilitate the play activities specially the group games of
the children; (6) advise families/community leaders to recommence teaching
school age-children until they are able to return to their usual schools; (7)
advise parents and families not to discourage children when they verbalise their
feelings (Williams 2007, p 273).
Along these same lines Madrid et al (2006) also makes a series of recommendations for promoting resilience in children and families based on her observations of the aftermath of
Hurricane Katrina. These include:
(1) Promoting some degree of control, empowerment, and normality; (2) rapid
family reunification; (3) helping families recognize strengths and resources; (4)
assisting evacuee integration into the community; (5) encouraging proactive
measures to cope with losses and changes; (6) providing ready access to basic
human needs; (7) treating individuals with respect and dignity and (8) making
sure that individuals with special needs are assisted in the most appropriate
way possible (Madrid, Grant et al. 2006, p S452).
2.6.7 Post-disaster treatment
Treatment received in the post-disaster environment has been reported in a small number of studies to significantly reduce rates and severity of disaster-related psychopathology such as
Miranda Van Hooff 2010 46 disaster related fears (Yule 1992), PTSD related distress (Yule 1992), number of PTSD symptoms and PTSD severity (Goenjian, Karayan et al. 1997; Goenjian, Walling et al. 2005), depression scores (Yule 1992; Goenjian, Walling et al. 2005), and trauma related symptoms
(Chemtob, Nakashima et al. 2002). Treatments administered to disaster exposed children have included trauma/grief focussed group and individual psychotherapy (Goenjian, Karayan et al.
1997; Goenjian, Walling et al. 2005), cognitive-behaviour therapy (Yule 1992; Cohen, Jaycox et al. 2009), narrative exposure therapy, mediation –relaxation techniques (Catani,
Kohiladevy et al. 2009) a combination of cognitive behavioural techniques and narrative strategies (Salloum and Overstreet 2008), psychosocial intervention (Chemtob, Nakashima et al. 2002) and a resilience and strength building oriented therapy (Berger and Gelkopf 2009).
As in adult populations, unless treatment is specifically offered however, only a small proportion of child or youth disaster victims will actively seek it. Seven weeks following the
Oklahoma City Bombing, for example, only 5% of 2720 middle and high school children indirectly exposed to the bombing had sought counselling. These children reported greater sensory exposure, stronger initial reactions, greater current post-traumatic stress, worry about safety and trouble handling demands than those who had not sought counselling.
Interestingly, only 15% of youths with a PTSD score in the clinical range had sought counselling (Pfefferbaum, Sconzo et al. 2003).
Detection and treatment of children with psychological problems is challenging in the post- disaster environment. In the immediate post-disaster phase, first responder volunteers and emergency service personnel are concerned with providing basic needs such as medical supplies, shelter, food and water, and are therefore not focussed on or equipped to address children’s symptoms of psychological distress (Cohen, Jaycox et al. 2009). As time goes on, there is an overwhelming demand on mental health services and psychosocial resources, limiting access to psychological services and reducing the availability of trained mental health professionals able to provide individual treatment to symptomatic children (Salloum and
Miranda Van Hooff 2010 47
Overstreet 2008; Cohen, Jaycox et al. 2009). Adding to these difficulties is the reluctance of disaster affected individuals to become involved in any kind of any kind of intervention or screening due to heightened sensitivity to perceived intrusiveness, fear of exploitation and reluctance to be reminded of disaster related loss (Chemtob, Nakashima et al. 2002). More specifically relating to funding, provisions are limited to outreach and education but not actual treatment (Cohen, Jaycox et al. 2009). For all of these reasons it is essential that psychological treatments for children are cost effective, pragmatic, able to treat a large number of affected children in a short period of time, are designed in such a way as to increase adherence, are culturally specific and are monitored for efficacy over time (Chemtob,
Nakashima et al. 2002; Salloum and Overstreet 2008; Catani, Kohiladevy et al. 2009). School based interventions on an individual or group level provide one solution to these problems providing treatment is conducted in a structured way by trained professionals. These treatments however are most efficacious when prior trauma is also examined and addressed
(Cohen, Jaycox et al. 2009).
2.6.8 Risk factor models
Remarkably few studies to date have incorporated the literature on risk factors in the development and examination of a multivariate risk factor model of psychopathology following childhood disaster exposure. This is despite the fact that a conceptual risk factor model was first developed by Korol, Green and colleagues (Green, Korol et al. 1991; Korol,
Green et al. 1999) as early as 1991 in relation to the Buffalo Creek Dam collapse. In this model four factors are identified as influencing children’s post-disaster reactions: (a) characteristics of the stressor (life threat and level of exposure to the disaster) (b) characteristics of the child (demographics, pre-disaster functioning) (c) characteristics of the post-disaster environment (additional life events, parental reactions to the fire) and (d) the
Miranda Van Hooff 2010 48 child’s efforts to process and cope with disaster-related distress. In the follow-up of Buffalo
Creek Dam survivors, life threat, sex (being female), parental psychopathology, and an irritable and/or depressed family atmosphere all contributed to the prediction of PTSD symptomatology in the children.
Vernberg et al (1996) later verified this conceptual model in 568 school-aged children exposed to Hurricane Andrew. They examined the relative predictive role of level of exposure
(number of loss/disruption events, perceived life threat, number of life threatening experiences), child demographics (sex, age ethnicity), social support and coping on posttraumatic stress symptoms 3 months following the Hurricane. Altogether, these factors accounted for 62% of the variance in PTSD scores, with each factor improving the overall prediction of PTSD. The level of exposure to the hurricane accounted for over half of the variance in PTSD scores alone.
Four months later, La Greca et al (1996) re-examined predictors of PTSD in this sample
(N=442) using the same predictive model with the addition of another variable: number of stressful recent life events. This time these variables accounted for 39.1% of the total variance in PTSD scores, with experiences involving perceived life threat being the strongest predictor supporting the relationship between high level exposure (in relation to life threat and loss/disruption) and poor outcome (La Greca, Silverman et al. 1996).
More recently, Pina et al (2008) adopted this model to examine predictors of PTSD, anxiety and depression in 46 youths exposed to Hurricane Katrina, modifying the variables slightly to include measures of discrimination as well as familial-, extra-familial-, and professional – support. Extra-familial social support predicted all three disorders, indicating that youth with
PTSD were also those most likely to seek help from friends, co-workers and church members.
Miranda Van Hooff 2010 49
Professional support only predicted PTSD, whereas avoidant coping style predicted both
PTSD and anxiety. Discrimination, familial social support and active coping did not emerge as significant predictors in any of the models. Results of this study however, should be considered with caution due to the small sample size. A modified version of this model will be used to examine the relative contribution of child and disaster related factors to PTSD and other psychopathology following the Ash Wednesday Bushfires in Chapters 7 and 8 of this thesis.
Using a similar model, Jensen et al (2009) examined the relationship between characteristics of the stressor, pre-existing child characteristics and the characteristics of the post-disaster environment and PTSD in Norwegian children who were tourists in Indonesia at the time of the 2004 tsunami. The only multivariate predictors of PTSD to emerge at 10 months were subjective distress and death of a family member. At the 2.5-year follow-up being female, receiving professional help and parental sick leave emerged as multivariate predictors of
PTSD. Further analysis indicated that parental sick leave in this instance represented a marker for parental health supporting the link between parental distress and pre-existing psychopathology and children’s reactions to a disaster (Jensen, Dyb et al. 2009).
Hsu et al (2002) reported a significant relationship between PTSD symptoms and physical injury in adolescent survivors of an earthquake in Taiwan (Hsu, Chong et al. 2002). Being trapped in rubble, injuries to family members, witnessing others being injured or killed, and destruction of household property however showed no association with PTSD symptoms.
Other studies examining multivariate risk factor models predicting the development of PTSD have discovered a different pattern of risk factors depending on whether you attempt to predict the duration or the severity of PTSD. Udwin et al (2000), for example, followed up
Miranda Van Hooff 2010 50
217 survivors of the 1988 sinking of the cruise ship Jupiter and found that while PTSD caseness was influenced by a range of ‘disaster related’ exposure variables, the duration and severity of the disorder was influenced primarily by ‘pre-disaster vulnerability factors’ rather than the actual level of exposure.
Twenty-four variables were found to be univariate predictors of PTSD caseness 5-8 years following the disaster. These included pre-disaster variables such as learning problems, refusal to attend school, truancy, contact with mental health professionals and violence at home; objective disaster related factors such as seeing blood, swimming ability, whether they were in the water, level of injuries and whether they were trapped; subjective disaster related variables such as fear of death, feelings of panic and fear; feelings in the aftermath of the disaster such as amnesia, feelings of fear and feelings of guilt and finally high scores on anxiety, PTSD, depression and coping measures within the first 5 months following the disaster. When these variables were entered into a multivariate logistic regression however only five risk factors emerged: seeing blood, being trapped by people/furniture, thinking they would not be able to escape, feeling panicked and high scores on 5-month anxiety screening questionnaires.
In contrast, univariate predictors of the duration of PTSD (two years or more) included pre- disaster reports of separation anxiety, poor or no swimming ability, amnesia, strong feelings of fear, perceived lack of assistance from the school, high depression and anxiety scores at 5 months, a large number of life events and poor coping at follow up. Predictors of duration of
PTSD emerging from the multivariate logistic regression were social relationship difficulties in childhood, medical problems/Illness in childhood, and 5-month depression scores.
Miranda Van Hooff 2010 51
Predictors of PTSD severity were similar to the predictors of duration and included characteristics of the child (problems with social relationships, learning problems, physical illness and retrospective diagnosis of separation anxiety), immediate post-trauma reactions characterised by amnesia, intense feelings of fear and low social support, high depression anxiety and PTSD scores at 5 months, a large number of negative life events, and problems coping. Multivariate predictors of PTSD severity were separation anxiety disorder in childhood, high 5-month depression scores, and perceived lack of assistance from the school in the aftermath of the disaster. All together these factors accounted for 32% of the variance.
Goenjian et al (2001) followed up 158 adolescents 6 months after Hurricane Mitch identified
4 predictors of the severity of PTSD. The strongest predictor of severity of PTSD was level of impact, which accounted for 47% of the variance followed by objective hurricane exposure features (such as injuries, death and damage), subjective hurricane experiences and current thoughts of revenge.
Vijayakumar et al (2006) reported a significant relationship between severity of disaster exposure and PTSD, somatic symptoms and anxiety, but not affective symptoms in children one year following the 2004 Tsunami. They used multiple regression to compare the relative contribution of family history of psychopathology and tsunami related factors to the development of affective and anxiety disorder. Severity of disaster exposure contributed more to the variance in PTSD symptoms and anxiety symptoms than family history of psychopathology, whereas the opposite emerged in relation to somatic and affective symptoms.
Miranda Van Hooff 2010 52
2.7 Impact of methodology on disaster-related outcomes
Longitudinal studies have several measurement advantages over other study designs. In the field of trauma they provide a unique opportunity to identify both potential risk factors in the development of adverse outcomes and provide valuable insights into protective factors that lead to positive adaptations within a disaster affected community. Additionally because longitudinal studies typically involve multiple assessments over time, such data is less vulnerable to the impact of historical events (Rutter 1994). Despite such strengths, methodological differences between longitudinal studies can impact on the rates of disaster– related psychopathology reported in the literature. Following is a brief summary of some of the methodological challenges facing longitudinal research on children.
2.7.1 Choice of informant
It is has been established in the literature that parents and teachers often underestimate the number and magnitude of posttraumatic symptoms in their children (McFarlane, Policansky et al. 1987; Earls, Smith et al. 1988; Yule, Udwin et al. 1990; Vogel and Vernberg 1993;
Lengua, Long et al. 2005). Further, parents report their children to have more symptoms than their teachers (McFarlane, Policansky et al. 1987; Yule, Udwin et al. 1990). A study by
Sawyer et al (1996) for example, showed that maternal reports of internalising and externalising problems in childhood at age 5 are more highly correlated with maternal reports of these same behaviours at age 11-12, than teacher and youth self reports (Sawyer, Mudge et al. 1996). This supports earlier work by Achenbach and colleagues 1987 who reported limited parent-child and teacher-child agreement on the child emotional and behaviour problems
(Achenbach, McConaughy et al. 1987). In general, the highest level of agreement between parents and teachers is for externalising problems as these symptoms are more easily and readily observed (Vogel and Vernberg 1993). Children, on the other hand are considered
Miranda Van Hooff 2010 53 better reporters of more internal problems such as anxiety and depression (Boer, Smit et al.
2009).
Earls et al (1988) interviewed 32 parent-child pairs one year after a severe flood in rural
Missouri. In general, parents assigned significantly less diagnoses to their children than the children assigned to themselves (1.22 diagnoses versus 2.0 diagnoses per child). Agreement was highest for attention deficit disorder and oppositional disorder and lowest for substance abuse and anxiety disorders (Earls, Smith et al. 1988).
Koplewicz et al (2002) reported inconsistent reports between parents and children in regards to changes in fear symptoms 3 to 9 months following the 1993 World Trade Centre bombing.
Parents but not children reported decline in fears from Time 1 to Time 2 (Koplewicz, Vogel et al. 2002).
A more recent study following up children and adolescents 3 to 7 months following Hurricane
Katrina reported no association between maternal reports of child internalising and externalising symptoms and Hurricane exposure, but higher maternal reports of these problems than child self report. The authors suggest that this was due to the mother’s own self-reported distress influencing their ratings. This is an important finding as it highlights one of the many factors that confound an informant’s report.
2.7.2 Time delay between disaster and assessment
In both children and adults the onset of morbidity varies from person to person (Wooding and
Raphael 2004). Some children may appear to cope well in the immediate aftermath of the disaster but develop an increasing number of symptoms in the following months and/or years
Miranda Van Hooff 2010 54
(McFarlane, Policansky et al. 1987). Others have a strong initial reaction, which naturally dissipates over time. The time at which an assessment is performed therefore has the potential to strongly impact on the prevalence of both PTSD and other post-disaster psychopathology.
The general consensus is that posttraumatic symptoms in both children and adults typically decline over time. Green et al (1987) in a 17 year follow-up of childhood survivors of the
Buffalo Creek dam collapse for instance, found a decrease in the severity of anxiety, belligerence, somatic concerns and agitation, but an increase in alcohol abuse, drug abuse and suicidal ideation over time (Green, Grace et al. 1994).
La Greca et al (1998) reported a different pattern of predictors in school children at 3 and 7 months following Hurricane Andrew. Severity of the posttraumatic reactions at 3 months was predicted by level of exposure to the hurricane (32% of the variance), level of pre-disaster anxiety (11% unique variance), pre-disaster levels of inattention (12% unique variance) and pre-disaster academic skills (14% unique variance). At 7 months however, pre-disaster levels of inattention and academic skills no longer played a role in predicting severity of PTS reaction (La Greca, Silverman et al. 1998), with level of exposure, pre-disaster levels of anxiety and ethnicity emerging as the sole predictors.
Winje et al (1998) followed up 11 sibling pairs (11 child passengers and their non-passenger siblings) and six single children 1 and 3 yrs following a major bus crash on August 15, 1988 in Norway. Result showed a significant decrease in intrusion and avoidance symptoms, anxiety, depression, headaches, concentration problems, memory problems and reduced school performance from 1 yr to 3 years, but no significant differences between the two groups in relation to the reduction in symptoms of tiredness, appetite problems, stomach pain and sleep problems.
Miranda Van Hooff 2010 55
2.7.3 Representativeness of the sample
The representativeness of the sample in longitudinal disaster studies can be influenced by a number of socio-demographic and health related factors such as age, sex, marital status, immigrant status, educational level and the sample type (clinical or community) (Dijkema,
Grievink et al. 2005). Specifically in disaster affected populations non-responders tend to be male, never married, to have a lower household income, to be depressed, distressed or to have more symptoms of PTSD than non-responders (Dougall, Herberman et al. 2000; Ginexi,
Weihs et al. 2000; Dijkema, Grievink et al. 2005; van den Berg, van der Velden et al. 2007).
Threat to life, level of trauma exposure, loss of property and injury however are generally found not to relate to attrition (Dijkema, Grievink et al. 2005; van den Berg, van der Velden et al. 2007), except in a recent study of adolescent survivors of a café fire in Volendam which found a higher rate of injury in those lost to follow-up (Reijneveld, Crone et al. 2003).
Green et al (1987) in a longitudinal follow-up of children exposed to Buffalo Creek dam collapse reported less symptomatology at the one month follow-up in participants who completed the 17 year follow-up assessment than those who did not complete the follow-up survey (Green, Grace et al. 1994). In contrast, Yule et al (2000) reported no differences between responders and non-responders on self reported symptomatology measured 5 months after a shipping disaster.
Ensuring that researchers use representative samples increases the accuracy of estimates of the prevalence and distribution of disorders in disaster affected communities (Norris 2006).
Miranda Van Hooff 2010 56
2.7.4 Diagnostic issues in relation to PTSD
There are currently two primary systems used to diagnose and classify PTSD symptoms, the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
(American Psychiatric Association 1994) and the tenth revision of the International
Classification of Diseases (ICD-10) (World Health Organization 1994). Although superficially, ICD-10 and DSM-IV criteria for PTSD appear similar, some important discrepancies between these two classification systems exist raising doubt as to whether they are assessing the same disorder (Table 2.2). The main divergences relate to Criteria C, where
DSM-IV requires actual avoidance or psychic numbing, compared to ICD-10, which allows either preferred or actual avoidance and Criterion F, the significant distress or impairment criteria which is completely omitted from ICD-10. Other discrepancies exist and can be reviewed in Table 2.2.
The effect of such differences can impact considerably on PTSD prevalence rates highlighting the difficulty in making cross study comparisons when different classification systems are used. Peters, Slade and Andrews (1999) for example, in a pilot study to the National Survey of Mental Health and Wellbeing in Australia identified over a two-fold increase in the 12- month prevalence of PTSD using ICD-10 criteria compared to DSM-IV criteria (3% in comparison to 6.9%) in a community sample of 1364 adults. The two major sources of this discrepancy were the inclusion of the significant distress or impairment criteria (Criteria F) and the general numbing of responsiveness criteria in DSM-IV (Criteria C), which decreased rates of PTSD (Peters, Slade et al. 1999). Following this, Peters et al (2006), using data from the Australian National Survey of Mental Health and Wellbeing (N=10641), examined the relationship between sex and ICD-10 and DSM-IV rates of PTSD. Replicating earlier findings, PTSD rates using ICD-10 were more than double those obtained using DSM-IV.
Interestingly females were twice as likely, compared to males, to be given a diagnosis of
Miranda Van Hooff 2010 57
PTSD using ICD-10-DCR criteria but not DSM-IV criteria, despite the absence of difference in symptom severity between the two sexs (Peters, Issakidis et al. 2006). This demonstrates a more pronounced effect of sex on PTSD prevalence rates when ICD-10-DCR criteria is used to diagnose PTSD, and suggests the need to exercise caution when interpreting sex differences using these criteria. Finally, Lehmann et al (unpublished manuscript), also utilizing data from the Australian National Mental Health and Wellbeing Survey reported a
12-month DSM-IV prevalence of PTSD of 1.3% compared to 3.3% using ICD-10, with a high prevalence of Axis 1 disorder associated with DSM-IV disorder.
Miranda Van Hooff 2010 58
Table 2.2: Comparison of ICD-10-DCR and DSM-IV criteria for PTSD (From Lehmann,
Mattiske and McFarlane, Manuscript in Preparation)
Miranda Van Hooff 2010 59
Further discrepancies also exist between earlier and later versions of the DSM and ICD.
Although PTSD was first acknowledged as a diagnostic category in DSM-III (American
Psychiatric Association 1980), it wasn’t until the publication of the DSM-IV that PTSD symptoms specific to children were formally acknowledged and documented. Research conducted prior to 1994 therefore utilised less stringent criteria to assess PTSD, which had the potential to inflate prevalence rates.
Early studies conducted in the 1970s and 1980s, for instance, were limited to reporting observations of behaviour due to the absence of diagnostic criteria. Milne (1977) examined
649 children aged 5 to 17 years, approximately 7 to 10months following Cyclone Tracy and
Miranda Van Hooff 2010 60 reported that children were more likely to present with fear conditioned responses such as fear of wind and rain (26%), fear of the dark (12%), fear of jet aircraft noise (11%) and clinging to the mother (9.4%) than regressive or aggressive behaviour (Milne 1977).
Terr and colleagues, in one of the most influential early studies on child disasters, followed up
25 school children over a total of 5 years, who were involved in the Chowchilla School Bus
Kidnapping on July 15, 1976. These children (aged 5 to14) exhibited a number of behaviours that were quite different from those previously reported in adults. Post-traumatic play and re- enactment was a common reaction in addition to time skew and a limited view of the future.
Interestingly, many children exhibited a profound embarrassment at being involved in the kidnapping due to feeling totally exposed, humiliated and vulnerable. All children reported kidnap related or other fears, and were able to provide a complete account of the event when asked, but would often forget subsequent symptoms and behaviours. This is in contrast to previously reported symptoms of traumatic amnesia, common to adult victims of trauma.
Other reported symptoms included conscious avoidance of trauma related thoughts, interview provoked anxiety which was displaced from the kidnapper to the psychiatrist, the reporting of omens which preceded the kidnapping, personality shifts, psycho-physiological re-enactment, distortion of the duration of time, and newly formed memories representing visual distortion of the trauma (Terr 1983).
Dollinger (1985) followed up 38 children (aged 11-12) exposed to a Lightening Strike while playing or observing a soccer match in South Illinois in 1980. A semi-structured interview with both parents and the children was conducted at 1, 9 months and two years following the disaster. The authors noted a significant remission in symptoms over the follow-up period with most children coping satisfactorily at by the nine-month follow-up assessment. At one month, eight children were rated as severely effected exhibiting a range of symptoms
Miranda Van Hooff 2010 61 including nocturnal enuresis, generalised anxiety, anxiety about weather conditions, sleeping problems and separation anxiety, seven children were rated as moderately effected (with symptoms such as storm related fears, separation anxiety, sleep problems, somatic complaints and crying spells, and 15 children were rated as slightly effected (apprehensive about storms, nightmares, stomach aches, bad dreams, fear of soccer practice). Eight children were relatively unaffected. At the nine month and two year follow-up, only 5 of the children had a pronounced fear of storms and only 3 children refused to play soccer, however 17 of the original 38 children still remained somewhat fearful (Dollinger 1985).
The differences in the way in which disorders are defined are relevant to longitudinal studies that examine the stability of symptoms over time, particularly in follow-up studies that are conducted following a major revision of diagnostic criteria for a particular disorder. In summary, therefore cross study comparisons of disaster related PTSD should consider the diagnostic system used before assumptions about PTSD prevalence can be made.
2.7.5 Retrospective versus prospective study designs
Due to the sudden and unpredictable onset of disasters, most longitudinal follow-up studies of both child and adult survivors employ a retrospective study design. Consequently it is important to understand and account for the bias that may influence recall of an event. Hardt and Rutter (2004) identify 5 potential reasons why retrospective recall is likely to be unreliable; (1) there is likely to be some degree of forgetting which may be influenced by what has happened subsequent to the event, (2) there is a general tendency to apply meaning to memories such that memories are unconsciously reconstructed according to what is socially desirable, what is demanded by the research setting, or what is expected of them by the investigator, (3) individuals are only able to recall what they found relevant or were aware
Miranda Van Hooff 2010 62 of at the time, (4) people generally cannot remember what happened during the first two years of their life, (5) what people remember (especially in relation to the specific details of the event) can be influenced by their mood state at the time of retrospective reporting (King, King et al. 2000; Hardt and Rutter 2004). The effects of mood state on recall of events has been reported in a recent study by Roemer et al (1998) who reported a relationship between PTSD symptoms in soldiers deployed on a peacekeeping mission in Somalia and their reports of specific war-related stressors and a study by Southwick et al (1997) who reported psychopathology at the time of assessment amplified one’s memory for traumatic events over time. Using a regression based cross-lagged analysis King et al (2000) provided some further support for this finding, reporting a slight amplification of trauma accounts attributable to
PTSD symptom severity in 2942 male and female 190/1991 Persian Gulf War veterans. They suggest that this amplification effect, albeit minimal, may be associated with re-experiencing symptoms of PTSD whereby the ongoing reliving of the event through intrusive thoughts cements the event in the individual’s memory (King, King et al. 2000).
Employing a longitudinal prospective study design however has its own limitations, for example, (1) some experiences may not be reported at the time they occur due to guilt or embarrassment, (2) measures used in the initial stages of the study may become outdated by the time the sample is followed up in later life, (3) rates of attrition can be high due to an inability to trace participants (4) retrospective reporting may still be required in order to provide details concerning what has happened since last assessment and (5) longitudinal data is very expensive to collect (Hardt and Rutter 2004).
In their review Hardt and Rutter conclude that retrospective reports of events such as childhood adversity is valid providing questioning is centred around the occurrence of the event rather than details of the event which require interpretation and appraisal on the part of
Miranda Van Hooff 2010 63 the individual. Reporting of adverse events therefore is likely to be more valid than recollections of more subtle aspects of family life. If anything, retrospective reports are likely to provide underestimates of the prevalence of adverse experiences rather than an overestimates which should be considered when conducting long-term follow-ups of disaster populations (Hardt and Rutter 2004).
2.7.6 Method of assessing symptoms
PTSD and other post-disaster psychopathology have been systematically examined in a number of ways ranging from structured diagnostic assessments performed in person or over the telephone to psychodynamic semi-structured interviews, which encourage the participant to make their own associations in order to assist in the generation of symptom profiles. Not surprisingly, problems arise when different methods elicit conflicting symptom patterns, subsequently altering PTSD and other psychiatric prevalence rates. Honig, Grace et al (1999) specifically tackled this issue in a recent paper comparing the Structured Clinical Interview for DSM-III (SCID) with videotaped semi-structured psychodynamic clinical interviews performed on a small group of adults exposed to the Buffalo Creek Dam collapse 20 years prior. Compared to the SCID, interviewing the participants in their own homes using a relatively unstructured interview format, elicited two-thirds more PTSD symptoms, the majority of which clustered around Criteria C avoidance, raising concerns about the reliability of structured assessments in detecting symptoms of this type. They suggest the need to incorporate semi-structured interviews in future disaster follow-ups in order to gain a more accurate representation of the toll paid by victims and their communities in the aftermath of such a devastating event (Honig, Grace et al. 1993; Honig, Grace et al. 1999).
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2.8 Disaster outcomes
2.8.1 Physical/somatic symptoms
Somatic complaints, most commonly headaches, stomach aches and/or nausea and respiratory problems have been reported in children exposed to a lightning strike incident (Dollinger
1985), a fatal school bus accident (Milgram, Toubiana et al. 1988), a sniper attack (Nader,
Pynoos et al. 1990), a school shooting (Schwarz and Kowalski 1991) and a hurricane
(Hensley and Varela 2008), with girls reporting more symptoms than boys (Hensley and
Varela 2008). In fact, in the early phases of the current study, McFarlane et al (1987) identified somatic complaints as one of the primary causes of school absences following the
Ash Wednesday Bushfires in 1983.
In Milne’s (1977) follow-up of childhood survivors of cyclone Tracy, for example, although less than 4% of children were injured in a cyclone, 9.2% were reported to have been temporarily effected by disease and infection at some point since the cyclone, which declined to 1.4% at the time of the interview. Terr (1983) observed a number of somatic symptoms in children following the Chowchilla school bus kidnapping such as bladder problems (20%), becoming overweight (8%), stomach aches especially when anxious (20%) and short stature
(4%). Nader et al (1990) reported children most highly exposed to a sniper shooting at their school reported significantly more somatic symptoms at both 6 and 12 months following the attack than children who were less exposed.
More recently, Winje et al (1998) reported that children involved in a major bus accident presented mostly with somatic symptoms three years following the accident, with the most common symptoms being tiredness (39.3%), headaches (25%) and appetite problems (21.4%)
(Winje and Ulvik 1998). These symptoms had remained relatively stable from 1 year to 3
Miranda Van Hooff 2010 65 years post-accident. Bromet et al (2000) followed up 300 children aged 10 to 12 exposed to the Chernobyl disaster while in utero or in infancy. Mothers of children, who had been evacuated from the site 11 years ago, reported significantly more somatic symptoms in their children than mothers of children who never lived in the contaminated region. In addition reports of somatic symptoms in the children were significantly related to the somatisation level in the mother. Reijneveld, Crone et al (2001) reported a 2.4% increase in somatic complaints in adolescents 5 months following the Volendam café fire.
Dirkzwager et al (2006) examined health problems in 1287 children (aged 4-18) before and after a fireworks explosion in the Netherlands in 2000. Two years following the disaster, victims reported a greater increase in musculoskeletal problems, gastrointestinal problems, anxiety, sleep and social problems to their family practitioners than controls (Dirkzwager,
Kerssens et al. 2006).
A higher than expected prevalence of asthma was reported in children 5 years and under following the World Trade Centre attacks, with new cases of Asthma being strongly attributed to dust cloud exposure (Thomas, Brackbill et al. 2008). Another study following up school-age children following Hurricane Katrina noted an association between children’s frequent complaints of headaches, nosebleeds, stomach aches and allergies (dermatological) and exposure to formaldehyde, a carcinogen which was found to be present in high levels in temporary housing provided by the government (Madrid, Sinclair et al. 2008). These studies highlight the role that the post-disaster physical environment in relation to debris and pollutants can impact on the physical health of disaster survivors independent of somatic symptoms, which may be related to stress.
Miranda Van Hooff 2010 66
Finally, adolescent survivors of the Volendam café fire displayed significantly more musculoskeletal and respiratory complaints compared to controls 1 year following the fire
(Dorn, Yzermans et al. 2008). These symptoms were not observed at later follow-up assessments, suggesting that somatic symptoms may be a transient response to trauma with insufficient severity to develop into long-term disease. Future studies should employ longer follow-up periods to adequately determine the total burden of these symptoms over time.
Although somatic symptoms frequently present for the first time in the aftermath of a disaster, the underlying cause of these symptoms is difficult to ascertain. Some researchers hypothesise that PTSD and somatic symptoms emerge from a shared psychological vulnerability
(Asmundson, Coons et al. 2002) such that children prone to anxiety are also at an increased risk of experiencing negative physiological reactions (Hensley and Varela 2008).
Alternatively complaining about somatic problems may serve as a means of obtaining attention from the parent and therefore may not be a true reflection of the child’s actual physical state. Overall, however, somatic complaints in children following disasters are associated with a range of poor social, emotional and academic outcomes (Hensley and
Varela 2008) and should be addressed in all childhood disaster studies.
2.8.2 Decline in school performance
Two studies have examined the impact of disaster exposure on school performance. Early reports on survivors of the Ash Wednesday Bushfires and the sinking of the cruise ship
Jupiter reported a decline in school performance in the two years following the disaster, compared to unexposed controls (McFarlane, Policansky et al. 1987; Tsui, Dagnwell and
Yule, unpublished manuscript; cited inVogel and Vernberg 1993).
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2.8.3 PTSD
2.8.3.1 Onset duration and course
It has been generally observed in the literature that post-trauma symptoms in childhood disaster survivors peak within 1 year of the event (Yule and Udwin 1991; Yule, Bolton et al.
2000) and then either slowly decline (Winje and Ulvik 1998) or remain stable over several years (Terr 1983; Green, Korol et al. 1991; Green, Grace et al. 1994). Shaw et al (1996), for example, reported a steady decline in PTSD symptoms in children from 2 to 8 months following a hurricane, but no further decline from 8 to 21 months, with this reduction being greater in males than females (Shaw, Applegate et al. 1996). PTSD symptomatology remained high at 21 months, with 70% of children continuing to report moderate to severe posttraumatic stress symptoms. Koplewicz et al (2002) suggests that the magnitude of decline in symptoms may depend however on who reporting the symptoms. In their follow-up study of children exposed to 1993 World Trade Centre attacks, for instance, a decline in fear was reported by parents but not by children themselves indicating an inconsistency between parent and child report (Koplewicz, Vogel et al. 2002).
Yule et al (2000) in a 5-8 year follow-up of adolescent survivors of the cruise ship Jupiter, for example, reported that most sufferers with PTSD (90%) developed the disorder within six months of the trauma, with a further 10% developing late onset PTSD 6 or more months following the trauma. Most commonly, survivors either had PTSD for a short period of less than a year (30.1% of PTSD sufferers) or for more than 5 years (26.1% of the survivors). Of those who met PTSD criteria at some point in the 5 to 8 year follow-up period, 32% met criteria for PTSD at the time of the follow-up assessment.
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La Greca et al (1996) followed up 442 3rd to 5th grade children 3, 7 and 10 months following
Hurricane Andrew and observed a steady decline in PTSD symptoms over this time period.
However, 12% of children continued to report severe to very severe symptoms and 75% continued to report re-experiencing symptoms, however 10 months post disaster.
2.8.3.2 PTSD symptom structure in children and DSM-V
Recent factor analytic studies of PTSD symptoms suggest a possible need to deviate from the traditional 3-factor model of PTSD utilised in the DSM-III-R, DSM-IV and ICD-10, especially when assessing PTSD in children and adolescents (Anthony, Lonigan et al. 1999;
Anthony, Lonigan et al. 2005). In their first paper, Anthony, Lonigan et al (1999) using confirmatory factor analysis examined PTSD dimensionality in a group of 5,664 child and adolescent survivors of Hurricane Hugo and proposed a three-factor model of PTSD that incorporates a distinction between active or effortful avoidance and passive or automatic avoidance. In this model, factor 1 is comprised of intrusive symptoms coupled with symptoms involving active avoidance of aversive stimuli, whereby trauma victims actively and purposefully avoid negative reactions by purposefully thinking, talking and behaving in ways that avoid reminders of the traumatic event. Factor 2 is characterised by emotional numbing along with passive avoidance of emotionally unrewarding activities, whereby the trauma victims automatically refrain from certain activities due to a sense of feeling numb and disinterested. Factor 3 is arousal and is consistent with current formulation of these criteria.
However, the results supported earlier research (Pynoos, Frederick et al. 1987; Sack, Seeley et al. 1997; Lonigan, Anthony et al. 1998) which found little diagnostic utility of PTSD arousal symptoms in children and adolescents and little qualitative differences between the presentation of PTSD symptoms in children and adolescents (Shannon, Lonigan et al. 1994).
The authors also suggest a need to consider anhedonia and learning/memory difficulties as
Miranda Van Hooff 2010 69 associated features of PTSD, rather than diagnostic indicators. This 3 factor model proposed by Anthony, Lonigan et al (1999) was further validated in childhood survivors of two hurricanes of different magnitudes, Hurricane Hugo and Hurricane Andrew (Anthony,
Lonigan et al. 2005). Results of this study suggest that children experiencing disasters of different severities exhibit very similar post-traumatic reactions. The authors conclude by advocating a re-conceptualisation of PTSD from a categorical taxonomy (PTSD/No PTSD) to a dimensional construct based on disturbance severity (Anthony, Lonigan et al. 2005).
Honig et al (1993) in the longitudinal follow-up of childhood survivors of the Buffalo creek disaster suggest that the presence or absence of residual PTSD might not be the only or the most valid measure of long-term impact of traumatic event, but rather the long term impact may be better discerned by “Patterns of Adaptation” which may have originated as coping responses to trauma and which evolve into a mechanism of defence (Honig, Grace et al.
1993).
2.8.3.3 PTSD prevalence
A large number of national mental health surveys have been conducted around the world that indicate that the lifetime prevalence of PTSD in adults is between 6% to 9% with a 12 month prevalence of approximately 3% (Helzer, Robins et al. 1987; Kessler, Sonnega et al. 1995;
Creamer, Burgess et al. 2001) (Kessler, Chiu, Demler, Merikangas, & walters, 2005).
Lifetime PTSD prevalence rates in children and adolescents are considerably lower ranging from 0.1% in children aged 9-13 to 6.4% in adolescents (Giaconia, Reinherz et al. 1995;
Cuffe, Addy et al. 1998; Copeland, Keeler et al. 2007) due to both reduced chance of cumulative exposure to trauma and an inherent resilience in children.
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This background prevalence of other trauma exposures and PTSD should be considered in all studies examining the prevalence of psychopathology following a disaster due to interactions that exist between pre-existing psychopathology and responses to subsequent trauma
(McFarlane, Van Hooff et al. 2009).
The prevalence of PTSD following disaster exposure in childhood is highly variable depending on disaster type, time since follow-up, method and assessment and instrument used to assess PTSD. Methodological differences between studies such as choice of informant, time of assessment, type of sample, diagnostic criteria used and method of obtaining symptoms also make it extremely difficult to accurately compare prevalence rates following different disaster types.
Table 2.3 reports PTSD prevalence derived from specific disaster populations. In line with
Neria et al. (2008) the term ‘prevalence’ as opposed to the term ‘incidence’ was used as most of the included studies fail to provide an assessment of disaster related PTSD in persons without a history of PTSD and therefore do not represent true ‘incidence’.
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Table 2.3: Prevalence of PTSD in children and adolescents following disaster exposure
Author Disaster Age Number of Time PTSD Prevalence of PTSD (Year) Grade at Participants After Measure Time of at Follow-up Disaster Disaster
Spree Shootings
(Pynoos, Sniper attack 5 to 13 yrs 159 1 mth PTSD At follow-up: Frederick et in schoolyard Reaction 38.4%: moderate or severe al. 1987) Feb 24, 1984 Index PTSD symptoms 22%: mild symptoms of PTSD 39.6%: no PTSD
(Nader, Sniper attack 5 to 13 yrs 100 14 mths PTSD At follow-up: Pynoos et in schoolyard Reaction 74% of most highly al. 1990) Feb 24, 1984 Index exposed group had PTSD symptoms at follow-up 81% of those not directly exposed continued to report no symptoms
Large Scale Human Induced Incidents
(Green, Buffalo 2 to 15 yrs 179 2 years DSM-IIIR At follow-up: Korol et al. Creek Diagnosis 37% probable PTSD 1991) Dam collapse from Psychiatric Reports
(Green, Buffalo 2 to 15 yrs 135 14 years SCID At follow-up: Lindy et al. Creek 23% 1990) Dam collapse Since disaster: 63%
(Green, Buffalo 2 to 15 yrs 99 17 years IES At follow-up: Grace et al. Creek Dam 7%: met criteria for flood 1994) Collapse related PTSD February 26, 4%: met criteria for non- 1972 flood PTSD
Any time since disaster: 32%: met criteria for flood related PTSD 6%: met criteria for non- flood related PTSD
(Milgram, Major school Grade 7 108 (on bus) 1 week Pynoos At 1 week: Toubiana et bus accident 302 (on 2nd 9 months post- 42.9% minimal PTSD al. 1988) in Israel, bus) traumatic 15.6% mild PTSD June 11, 265 (other stress 29.3% moderate PTSD 1985 schools) reaction 12.2% severe PTSD scale At 9 months: 44.0% minimal PTSD 17.2% mild PTSD 28.0% moderate PTSD 10.8% severe PTSD
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Author Disaster Age Number of Time PTSD Prevalence of PTSD (Year) Grade at Participants After Measure Time of at Follow-up Disaster Disaster (Winje and 1988 Bus Mean age 28 1 year IES At 1 year follow-up : Ulvik 1998) Crash in approx 12 3 years 82.2% medium to high Norway Aug levels of intrusion 15, 1988 75% medium to high levels of avoidance
(Yule, Sinking of 11-17 217 17–25 CAPS At Follow-up: Bolton et al. the cruise years + 29 did part years 17.5% 2000) ship ‘Jupiter’ (Mean: (Mean: 21 Oct, 1988 14.7 years) 21.3 Any time since disaster: years) 51.5%
(Morgan, 1966 Aberfan 4 to 11 yrs 41/145 33 years CIDI- At follow-up: Scourfield Disaster (Mean Auto 29% met criteria for PTSD et al. 2003) 7.73 yrs) IES-R 25% experienced at least (score of one symptom of PTSD in 35 or the last 2 weeks above denotes Post disaster/lifetime: PTSD) 46% met criteria for PTSD
(Godeau, Explosion of 11-17 577 9 months SCW- At follow-up: Vignes et al. Chemical years PTSD 38.6% of directly exposed 2005) Factory in children Toulouse France, Sep 21, 2001
(Godeau, Explosion of 11-17 577 (directly 9 months SCW- Directly exposed children Vignes et al. Chemical exposed PTSD at follow-up: 2005) factory children) IES-R 47.3% of 11 year olds (AZF) in 900 (non 40.4% of 13 year olds Toulouse directly 16.7 % of 15 year olds France, Sep exposed 41.9 % of 17 year olds 21, 2001 children) Indirectly exposed children at follow-up: 23.4% of 11 year olds 20.5% of 13 year olds 4.4 % of 15 year olds
Natural Disasters - Earthquakes
(Pynoos, Earthquake 8 to 16 111 18 mths Clinical At follow-up: Goenjian et Spitak years Interview 70.27% PTSD al. 1993) Armenia, DSM-III-R 91.4% of children from Dec 7, 1988 Spitak met criteria for PTSD 90.9% of children from Gumri met criteria for PTSD 37.2% of children from Yereven met criteria for PTSD
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Author Disaster Age Number of Time PTSD Prevalence of PTSD (Year) Grade at Participants After Measure Time of at Follow-up Disaster Disaster
(Najarian, Earthquake 11 to 13 25 30 mths DICA-R At follow-up: Goenjian et Spitak yrs 32% of children remaining al. 1996) Armenia, in earthquake city met Dec 7, 1988 criteria for PTSD 28% of relocated children met criteria for PTSD 4% of comparison sample
(Goenjian, Earthquake 218 1.5 years CPTSD- At follow Up: Pynoos et Spitak RI (cut- 95% of children from al. 1995) Armenia off score Spitak met criteria for 1988 of 40 PTSD indicates 71% of children from PTSD) Gumri met criteria for PTSD 26% of children from Yereven met criteria for PTSD
(Asarnow, Earthquake, 8 to 18 66 12 mths PTSD-RI At follow-up: Glynn et al. Northridge, years 28.6% mild to moderate 1999) Los Angeles, PTSD Jan 17, 1994
(Hsu, Taiwan 12-14 323 6 weeks SCL-90-R At follow-up: Chong et al. Earthquake years ChIPS 21.7% Earthquake 2002) September Exposure 21, 1999, Inventory
(Kolaitis, Earthquake Grades 115 6 months CPTSD- At follow-up: Kotsopoulos Athens, 4 to 6 RI 78% Severe PTSD et al. 2003) Greece, Sep IESR symptoms 7, 1999 16.5% moderate PTSD symptoms 23.5% mild PTSD symptoms
(Roussos, Earthquake 9-18 years 1937 3 months PTSD-RI At follow-up: Goenjian et Ano Liosia, (cut-off 4.5% al. 2005) Greece, Sep of 38) 7, 1999 DSM-IV
(Giannopoul Earthquake 9-17 years 2037 6 to 7 CRIES- At follow-up: ou, Athens, months 13 (cut 35.7% of directly exposed Strouthos et Greece, Sep off of 17) group met criteria for al. 2006) 7, 1999 PTSD 20.1% of indirectly exposed group met criteria for PTSD
(Parvaresh Earthquake Primary 433 4 months Yule At follow-up: and Bam, 2003 and high PTSD 36.3% adolescents over 15 Bahramnezh school Measure 51.6% children below 15 ad 2009) children
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Author Disaster Age Number of Time PTSD Prevalence of PTSD (Year) Grade at Participants After Measure Time of at Follow-up Disaster Disaster
Natural Disasters – Hurricanes/Cyclones
(Shannon, Hurricane 9 to 19 5687 3 months RI At follow-up: Lonigan et Hugo, Sep years 5.42% al. 1994) 21, 1989
(Garrison, Hurricane 11-17 1264 1 year DSM-IIIR At follow-up: Bryant et al. Hugo, Sep years 5% 1995) 21, 1989
(Shaw, Hurricane 6 to 11 144 8 weeks PTSDRI Children from hi-impact Applegate Andrew, Aug years 32 weeks TRF school at the 8 week et al. 1995) 24, 1992 follow-up: 14.9% doubtful to mild 29.8% moderate 55.3% severe to very severe
At 32 week follow-up: 10.6% doubtful to mild PTSD 51.1% moderate PTSD 38.3% severe to very severe PTSD
(Vernberg, Hurricane Grades 568 3 months RI At follow-up: Silverman Andrew, Aug 3 to 5 30% mild PTSD et al. 1996) 24, 1992 26% moderate PTSD 25% severe PTSD 5% very severe PTSD
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Author Disaster Age Number of Time PTSD Prevalence of PTSD (Year) Grade at Participants After Measure Time of at Follow-up Disaster Disaster
(La Greca, Hurricane Grades 442 3 months PTSDRI At 3mth follow-up: Silverman Andrew, Aug 3 to 5 7 months 13.8% doubtful PTSD et al. 1996) 24, 1992 10 mths 30.3% mild PTSD 26.7% moderate PTSD 25.3% severe PTSD 3.8% very severe PTSD 39.1% met criteria for all 3 symptom clusters At 7mth follow-up: 23.3% doubtful PTSD 35.1% mild PTSD 23.3% moderate PTSD 15.2% severe PTSD 3.2% very severe PTSD 24% met criteria for all 3 symptom clusters At 10mth follow-up: 31% doubtful PTSD 35.5% mild PTSD 20.8% moderate PTSD 11.1% severe PTSD 1.6% very severe PTSD 18.1% met criteria for all 3 symptom clusters
(Shaw, Hurricane 6 to 11 30 21 mths PTSD-RI At follow-up: Applegate Andrew, Aug 70% demonstrated et al. 1996) 24, 1992 moderate to very severe post-traumatic stress symptoms
(La Greca, Hurricane Grades 4, 92 (3 mths) 7 months PTSD-RI At initial assessment: Silverman Andrew, Aug 5, 6 74 (7 mths) Doubtful PTSD (40% at 3 et al. 1998) 24, 1992 months) Mild PTSD (27% at 3 months) Moderate PTSD (20% at 3 months) Severe to very severe PTSD (13% at 3 months)
At follow-up assessment: Doubtful PTSD (54% at 7 months) Mild PTSD (35% at 7 months Moderate PTSD (8% at 7 months) Severe to very Severe PTSD (3% at 7 months)
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Author Disaster Age Number of Time PTSD Prevalence of PTSD (Year) Grade at Participants After Measure Time of at Follow-up Disaster Disaster (Goenjian, Hurricane Approx 13 158 6 months Child At follow-up: Molina et Mitch Oct- years PTSD 90% most devastated al. 2001) Nov 1998 Reaction region (Posoltega) Checklist 55% 2nd most devastated region (Chinandega) 14% least devastated (Leon)
(Kar, Cyclone 7 to 17 447 1 year Clinical At follow-up: Mohapatra Orissa India, years Exam 30.6% of all exposed et al. 2007) Oct, 1999 children had PTSD 13.6% had sub-syndromal PTSD 43.7% of children in HE group had PTSD 11.2% of children in LE group had PTSD
(Spell, Hurricane 8 to 16 260 3 to 7 UCLA At follow-up: Kelley et al. Katrina New years months PTSD-RI 11% with PTSD 2008) Orleans, Aug, 2005
(Hensley Hurricane 6th and 7th 302 5 to 8 RI At follow-up: and Varela Katrina New Grade months Doubtful PTSD (28.8%) 2008) Orleans, Mild PTSD (33.8%) Aug, 2005 Moderate PTSD (24.5%) Severe (10.3%) Very severe PTSD (2.3%)
(Pina, Hurricane Mean age 46 6 to 7 PTSD At follow-up: Villalta et Katrina New 11.43 months Checklist 23.9% in the clinical range al. 2008) Orleans, years for PTSD Aug, 2005
Natural Disasters – Tsunami
(Thienkrua, Tsunami 7 to 14 371 2 months UCLA At 2 month follow-up: Cardozo et Dec, 2004 years 9 months PTSD-RI 6% to 13% al. 2006) Thailand At 9 month follow-up: 10% among children in camps
(Neuner, Tsunami 8 to 14 264 3 to 4 UCLA At follow-up: Schauer et Dec, 2004 Sri years weeks PTSD-RI 4.6% to 8.5% met criteria al. 2006) Lanka for non-tsunami related PTSD 13.9% to 38.8% met criteria for tsunami related PTSD
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Author Disaster Age Number of Time PTSD Prevalence of PTSD (Year) Grade at Participants After Measure Time of at Follow-up Disaster Disaster (Wickrama Tsunami 12 to 19 325 Not DSM-IV At follow-up and Kaspar Dec, 2004 Sri years specified Diagnostic 40.9% Interview 2007) Lanka items
(John, Tsunami Dec 5 to 18 502 2 months IES-8 At initial assessment: Russell et 2004, India years 6 months (cut off 70.7% acute PTSD al. 2007) of 17 ) At follow-up: 81.6% (includes 10.9% delayed onset PTSD)
(Piyasil, Tsunami Dec Kindergarten 1 year:1364 1 year Psychiatrist At 1year follow-up: Ketuman et 2004, through grade 3years: 45 2 years Assessed 10.4% had PTSD 9 PTSD al. 2007; Thailand 3 years At 2year follow-up Piyasil, 7.6% Ketumarn et At 3 year follow-up: al. 2008; 11.1% of those with PTSD Ularntinon, at 1 year met criteria for Piyasil et al. PTSD 2008)
(Piyavhatkul, Tsunami Dec 1 to 18 94 10 mths DSM-IV At follow-up: Pairojkul et 2004, years Checklist 33% PTSD al. 2008) Thailand of PTSD Sympto ms
(Jensen, Tsunami Dec 6 to 17 10 months: 133 10 mths UCLA At 10 month follow-up: Dyb et al. 2004, 2.5 years: 104 2.5 years PTSD-RI 0.01% (2 people) 2009) Norwegian At 2.5 year follow-up: Tourists 0%
Natural Disasters – Bushfire
(McDermott Canberra 8 to 18 222 6 months PTSD-RI At follow-up: , Lee et al. Wildfires 50.2% doubtful PTSD 2005) 28.6% mild PTSD 21.1% moderate PTSD 7.5% severe PTSD 1.5% very severe PTSD
Terrorism
(Desivilya, Terrorist 14 to 23 59 17 years DSM-III At follow-up Gal et al. Hostage yrs symptoms 39% 1-4 symptoms of 1996) Situation in PTSD 1974 52% 5-8 symptoms of PTSD 9% at least 9 symptoms of PTSD
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Author Disaster Age Number of Time PTSD Prevalence of PTSD (Year) Grade at Participants After Measure Time of at Follow-up Disaster Disaster (Vila, School 6 to 9.5 26 2 months DSM-IV Any time since disaster: Porche et al. Hostage years 4 months Diagnosis 27% 1999) Situation 7 months IES-R France, Dec 18 mths 3, 1995
(Koplewicz, World Trade Grades 22 3 months PTS-RI At 3 month follow-up: Vogel et al. Centre 2 to 5 9 months (severe 23% mild PTSD 2002) Attacks, Feb or very Symptoms 26, 1993 severe 41% moderate PTSD symptom Symptoms s denote 14% severe PTSD PTSD symptoms caseness) 4% very severe PTSD symptoms At 9 month follow-up: 32% mild PTSD symptoms 41% moderate PTSD symptoms 14% severe PTSD symptoms 0% very severe PTSD symptoms
(Hoven, World Trade Grades 8236 6 months DISC At follow-up: Duarte et al. Centre 4 to 12 10.6% (Probable) 2005) Attacks, Sep 11, 2001
(Lengua, World Trade 9 to 13 151 6 months CPSS At follow-up: Long et al. Centre 8% 2005) Attacks, Sep 11, 2001
(Scrimin, Terrorist 6 to 14 22 3 months UCLA At follow-up: Axia et al. Hostage PTSD 77.3% full PTSD 2006) situation, Index for 22.7% sub-clinical PTSD Beslan DSM- 27.3% moderate PTSD Russia, Sep IV-TR 72.7% severe PTSD 1, 2004
War
(Kinzie, Pol Pot 8 to 12 40 4 years DIS At follow-up: Sack et al. Regime in since DSM-III- 50% 1986) Cambodia leaving R 1975 to 1979 Cambodia
(Kinzie, Pol Pot 8 to 12 27 7 years DSM-III- At follow-up: Sack et al. Regime in since R 48% 1989) Cambodia leaving Clinical 1975 to 1979 Cambodia interview
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Author Disaster Age Number of Time PTSD Prevalence of PTSD (Year) Grade at Participants After Measure Time of at Follow-up Disaster Disaster (Nader, Kuwaiti 8 to 21 51 < 4 mths CPTSD- At follow-up: Pynoos et children in RI 4 % no PTSD al. 1993) Gulf War, 29% mild PTSD 1991 40% moderate PTSD 31% severe PTSD
(Sack, Adolescent 6 to 12 1984: 46 5 years DICA At initial assessment: 50% Clarke et al. Survivors of 1987: 30 8 years At first follow-up: 48% 1993) Pol Pot 1990: 31 11 years At second follow-up: 34% Khymer Rouge Regime in Cambodia (1975-1979) now in the US
(Savin, Sack Pol Pot Approx 5 99 Approx DICA At follow-up: et al. 1996) Regime in to 12 in 13 years 31.3% Cambodia 1979 since Since disaster: 1975 to 1979 1979 37.3% Now Thailand Refugees (Laor, Gulf War and 3 to 5 107 30 mths CPTSD- Displaced children at Wolmer et scud missile RI follow-up: al. 1997) attacks Jan 19.6% doubtful symptoms 1991 35.3% mild symptoms 37.3% moderate symptoms 7.8% severe
Un-displaced children at follow-up: 33.3% doubtful symptoms 35.1% mild symptoms 28.1% moderate symptoms 3.5% severe
(Sack, Him Pol Pot 8 to 12 27 7 years DICA 7 years since end of et al. 1999) Regime in 10 years DSM-III- exposure : Cambodia 16 years R 48% 1975 to 1979 since Now US leaving 10 years since end of Refugees Cambodi exposure: a 38%
16 years since end of exposure: 35%
(Thabet and Palestinian 6 to 11 234 6 months CPTSD- At initial assessment (6 Vostanis Children years (at 6 18 RI months following end of 2000) living in months months conflict): Gaza Strip after end 40.6% moderate to severe of conflict) PTSD reactions
At follow-up: 10% moderate to severe
Miranda Van Hooff 2010 80
Author Disaster Age Number of Time PTSD Prevalence of PTSD (Year) Grade at Participants After Measure Time of at Follow-up Disaster Disaster PTSD reactions
(Dyregrov, 1991 Gulf 6 to 17 94 6 months IES At 6 month follow-up: Gjestad et War 12 84% al. 2002) months 24 At 12 month follow-up: months 88% At 24 month follow-up: 78%
Notes: CIDI-Auto, Composite International Diagnostic Interview-Auto (Computerised Version); IES-R, Impact of Events Scale Revised; SCID, Structured Clinical Interview for DSM-III; IES, Impact of Events Scale; CAPS, Clinician Administered PTSD Scale; SCW-PTSD, Symptoms consistent with PTSD; DICA, Diagnostic Interview for Children and Adolescents; DICA-R, Diagnostic Interview for Children and Adolescents-Revised; CPTSD-RI, Child Posttraumatic Stress Disorder Reaction Index; PTSD-RI, Posttraumatic Stress Disorder Reaction Index; CRIES-13, Children’s Revised Impact of Events Scale; SCL-90-R, Symptom Checklist-90 revised; ChIPS, Child’s Interview for Psychiatric Symptoms; RI, Reaction Index for Children; TRF, Teacher Report Form; UCLA PTSD-RI, University of California Los Angeles Posttraumatic Stress Disorder Reaction Index; DISC, Diagnostic Interview Schedule for Children; CPSS, Child PTSD Symptom Scale.
Miranda Van Hooff 2010 81
A number of studies have also examined the types of PTSD symptoms that are most prevalent following childhood exposure to a disaster The most common PTSD symptoms reported 33 years following the Aberfan Disaster, for example, were: pictures about it popped into my mind (54%), I thought about it when I didn’t mean to (49%), other things kept making me think about it (46%) and I avoided letting myself get upset when I thought about it (44%).
One year after a Hurricane in South Carolina, the most commonly reported PTSD symptoms were detachment (36%) efforts to avoid thoughts or feelings associated with the hurricane
(36%), irritability/anger (25%) and physiological arousal (20%) (Garrison, Weinrich et al.
1993). Seventeen years following a hostage situation in Israel, the most commonly reported symptoms were hyper-alertness, avoidance of activities reminiscent of the trauma and sleep difficulties (Desivilya, Gal et al. 1996).
2.8.4 Other psychopathology
2.8.4.1 Depressive disorder
Although most childhood disaster literature has been dominated by the prevalence of PTSD, recent research has acknowledged the link between PTSD and depressive disorder (Kolaitis,
Kotsopoulos et al. 2003). In fact recent neuro-endocrine research has suggested that Cortisol levels are similar in trauma survivors with either PTSD alone or co-morbid PTSD/depression indicating that these disorders may be reflecting the same construct with the same set of non- biological predictors (O'Donnell, Creamer et al. 2004; Meewisse, Reitsma et al. 2007).
Goenjian et al (1995), for example, followed up children exposed to an earthquake in
Armenia and reported a significant correlation between post-trauma symptoms and depression with 75% of children with current PTSD also reporting a co-morbid depressive disorder. This relationship was strongest in those children who lived closest to the epicentre of the
Miranda Van Hooff 2010 82 earthquake suggesting a dose of exposure pattern of psychopathology for co-morbid PTSD
/depression in addition to PTSD alone (Goenjian, Pynoos et al. 1995). Goenjian et al (2001) replicated these findings in a 6-month follow-up of survivors of Hurricane Mitch. In this study 79% of children in the most effected region, 38% in the second most effected region and 8% of children in the least effected region reported both PTSD and depressive disorder at the 6-month follow-up assessment (Goenjian, Molina et al. 2001).
Hsu et al (2002) reported that adolescents meeting criteria for PTSD 6 weeks following an earthquake in Taiwan also reported higher scores on scales of depression, anxiety, panic, obsessive symptoms, hostility, paranoid ideation and psychotic symptoms compared to those without PTSD (Hsu, Chong et al. 2002). Roussos et al (2005) reported severity of depression to be the strongest predictor of PTSD scores in children and adolescents (aged 9-18) exposed to a major earthquake in Greece, accounting for 27% of the total variance.
Bolton et al (2000) in their study of adolescent survivors of a shipping disaster examined the level of association between PTSD and other anxiety disorders and depression. In this study, among survivors who had developed PTSD the prevalence of anxiety and affective disorders
(excluding social phobia, obsessive compulsive disorder and manic disorders) was higher compared to survivors who did not have PTSD. In addition, these individuals also reported significantly higher rates of anxiety disorders and depression than controls (over 80% who developed PTSD also suffered other disorders), whereas there were no differences between survivors without PTSD when compared with controls. This indicates a strong correlation between the development of PTSD and the development of other disorders. For example, 61 of the 74 (82.4%) survivors with major depression in the 5 to 8 year follow-up period also had developed PTSD (Bolton, O'Ryan et al. 2000).
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Kar et al (2007) in a 1-year follow-up study of children aged 7to 17 years exposed to a cyclone found 34.3% of children and adolescents with PTSD also had depression, compared to 19% in those without PTSD (Kar, Mohapatra et al. 2007).
Furthermore, Bolton et al (2000) examined the relationship between the onset and recovery of major depression in relation to PTSD. They found that most of the survivors who reported both major depression and PTSD (57/61 cases) in the 5-8 years following a shipping disaster developed major depression either at the same time (30%) or up to 6 years after they developed PTSD. Approximately one third (36.8%) of these 57 individuals had onset of major depression after recovery from PTSD highlighting PTSD as the precipitating disorder
(Bolton, O'Ryan et al. 2000).
While PTSD and co-morbid PTSD/depression however may be indistinguishable based on both their cortisol profile and their pattern of non-biological predictors, the existence of depression as a separate outcome in both long and short term follow-up studies of trauma survivors should not be overlooked. As can be seen in Table 2.4 for example, in addition to the number of short term disaster follow-up studies which have reported the prevalence of depressive disorders following disasters to range anywhere from 8 to 81%, long-term studies
(5 years or more) examining the post-disaster prevalence of depressive disorders have reported variable rates ranging from 33% following the Buffalo Creek Dam Collapse to 46% following the Aberfan Disaster (Green, Grace et al. 1994; Bolton, O'Ryan et al. 2000;
Morgan, Scourfield et al. 2003). Other studies on adult refugees exposed to war atrocities in
Cambodia and Afghanistan report major depression to effect between 29%-45% of survivors
(Hubbard, Realmuto et al. 1995; Mghir, Freed et al. 1995).
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2.8.4.2 Anxiety disorders
Unlike PTSD, there is a paucity of research into the relationship between other anxiety disorders and disasters due to their shared phenomenology (Sack, Clarke et al. 1993;
McFarlane, Van Hooff et al. 2009). Studies reporting the prevalence of other anxiety disorders following childhood disaster exposure typically present these findings in combination with prevalence of depressive disorders, therefore results of these studies have been combined in Table 2.4.
Long-term post-disaster rates of anxiety disorder are slightly higher than rates of depressive disorders and range from 41% (excl PTSD) following the sinking of the Jupiter to 61% following the Aberfan Disaster (Bolton, O'Ryan et al. 2000; Morgan, Scourfield et al. 2003).
Bolton and colleagues in a follow-up of survivors from a shipping disaster, for example, reported 24.1% of survivors met criteria for any type of anxiety disorder (Bolton, O'Ryan et al. 2000) (excluding PTSD) in the 1 month prior to assessment. Of the anxiety disorders assessed, specific phobia was the most prevalent, effecting 15.7% of survivors.
Interestingly, the development of fears/phobias following disaster exposure has been identified following a number of disasters (Dollinger 1985; Yule, Udwin et al. 1990; Kar,
Mohapatra et al. 2007). Although the children in these studies were not likely to become generally more fearful, they were significantly more likely to develop fears of stimuli resembling/relating to the event such as fear of death and dying, separation from parents, noise, fear of the unknown, fears of ships storms, water travel and fear of wind and rain. Yule,
Udwin et al (1990) suggests that this finding provides support for the conditioning theory of fears, whereby children’s fears develop as result of a learning experience such as traumatic experience. Interestingly, even when survivors of the Jupiter sinking no longer reported having PTSD symptoms, the rates of specific phobia remained more prevalent in this group
Miranda Van Hooff 2010 85 compared to the unexposed controls, highlighting the enduring nature of these symptoms even in the absence of PTSD.
Terr, Bloch et al (1999) provided further support for the relationship between childhood disaster exposure and specific phobia utilising a sample of children and adolescents following the 1986 Challenger Space Shuttle Explosion. In this study, 90% of latency aged children reportedly suffered from one or more Challenger specific fears 5-7 weeks following the explosion. These disaster-specific fears included fear of death or dying, fear of taking risks and fears of explosions, fires, space and airplanes (Terr, Bloch et al. 1999).
2.8.4.3 Substance use
There has been surprisingly little research conducted to date into the effects of childhood disaster exposure on substance use. This is despite the fact that there are now a number of published studies examining the association between substance use problems and other types of childhood traumas such as physical and sexual abuse (De Bellis 2002; Breslau, Davis et al.
2003; Kilpatrick, Ruggiero et al. 2003; McHugo, Caspi et al. 2005; Raghavan and Kingston
2006) as well as several studies examining the effects of disaster exposure on substance use in adult populations (Vlahov, Galea et al. 2002; Vlahov, Galea et al. 2004).
Only four studies have directly examined the relationship between disaster exposure and substance use and have produced conflicting results. Reijneveld et al (2003) reported that compared to adolescents from non-affected schools, adolescents from schools affected by the café fire in Volendam Holland reported a significant increase of alcohol use 5 months following the disaster with 7.3% reporting excessive drinking prior to the disaster compared to 74.7% at follow-up. The use of other drugs such as tobacco, marijuana, ecstasy and sedatives however did not rise (Reijneveld, Crone et al. 2003). At 12 months, the disaster-
Miranda Van Hooff 2010 86 affected group continued to report excessive alcohol use. The use of hypnotics and sedatives had also increased from pre-disaster (Reijneveld, Crone et al. 2005). Adding to these findings,
Schroeder and Polusny (2004) reported that higher posttraumatic stress scores following a tornado in Minnesota predicted adolescent’s level of alcohol consumption, even after controlling for level of exposure to the disaster (Schroeder and Polusny 2004).
In contrast, Morgan et al (2003) reported no significantly increased risk of developing substance misuse in adolescent survivors of a shipping disaster when examined 33 years post- trauma. More recently, Rohrbach et al (2009) reported no significant relationship between posttraumatic stress symptoms following a Hurricane and post-hurricane alcohol use, when both pre-hurricane alcohol use and hurricane exposure were controlled for. Instead, negative events occurring after the hurricane such as arguments with parents, family illness and financial problems were associated with increased use of illicit drugs and alcohol (Rohrbach,
Grana et al. 2009).
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Table 2.4: The prevalence of anxiety, depression and substance use problems following
childhood disaster exposure
Author Disaster Age/Grade Number of Time Measure Prevalence of Mental (Year) Participants After Health Problems at Follow- Disaster up
Large Scale Human Induced Incidents/Technological disasters
(Green, Buffalo 2 to 15 years 135 14 years SCID At follow-up: Lindy et al. Creek Dam 21% major depression 1990) Collapse 6% dysthymic disorder February 26, 2% panic disorder 1972 4% social phobia 15% simple phobia 18% generalised anxiety disorder 5% substance abuse
(Green, Buffalo 2 to 15 yrs 99 17 years SCID At follow-up: Grace et al. Creek Dam PEF 13% major depression 1994) Collapse SCL-90 7% alcohol abuse February 26, 3% current drug abuse 1972 Any time since disaster: 33% major depression 18% alcohol abuse 18% drug abuse
(Winje and 1988 Bus Mean age 28 1 year CAS At 1 yr follow-up: Ulvik Crash in approx 12 administer 78.5% marked anxiety 1998) Norway Aug years ed by a reaction 15, 1988 child 46.4% marked psychiatrist, depressive reaction
(Bolton, Sinking of 11 to 17 216 17 to 25 RECAP 5-8 yr Prevalence O'Ryan et the cruise years months SADS-L (Survivors v Controls) al. 2000) ship Specific phobia ‘Jupiter’ 21 (23.6% v 9.2%), Oct, 1988 Panic disorder (12% v 2.3%) Separation anxiety (6.8% v 0%) Generalised anxiety disorder (6.0% v 5.7%) Major depression (34.3% v 17.2%) Social phobia (5.1% v 2.3%) OCD (2.8% v 1.1%) Dysthymia (3.2% v 0.0%) Manic disorder (1.4% vs 0.0%)
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Author Disaster Age/Grade Number of Time Measure Prevalence of Mental (Year) Participants After Health Problems at Follow- Disaster up
Substance abuse (4.6% v 2.3%) Substance dependence (1.9% v 1.1%0 Anorexia nervosa (1.4% v 1.1%) Bulimia nervosa (0.5% v 2.3%) Any affective disorder (38.4% v 17.4%) Any anxiety disorder (excl. PTSD) (40.7% v 18.4%) Any disorder (excl. PTSD) (56.5% v 34.5%)
Current Psychopathology (Survivors v Controls) Specific phobia (15.7% v 6.9%), Panic disorder (2.8% v 1.1%) Separation anxiety (1.1% v 0%) Generalised anxiety disorder (3.7% v 1.2%) Social phobia (1.9% v 1.1%) OCD (1.9% v 0%) Major depression (2.8% v 2.3.%) Dysthymia (0% v 0%) Manic disorders (0.9% v 0%) Substance abuse (0% v 0%) Substance dependence (1.4% v 0%) Anorexia nervosa (0% v 0%) Bulimia nervosa (0% v 0%) Any affective disorder (3.7% v 2.3%) Any anxiety disorder (excl. PTSD) (24.1% v 9.2%) Any psychopathology (excl. PTSD) (26% v 10.3%)
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Author Disaster Age/Grade Number of Time Measure Prevalence of Mental (Year) Participants After Health Problems at Follow- Disaster up
Morgan, 1966 4 to 11 years 41/145 37 to 44 CIDI-Auto At follow-up: Scourfield Aberfan yrs GHQ 23% current case on et al. 2003) Disaster GHQ Post disaster/lifetime: 61% anxiety disorder 46% depressive disorder 5% substance misuse 83% any disorder including PTSD
(Reijnevel Volendam 12-15 yrs 81 5 months YSR At initial assessment pre- d, Crone et Café fire Specific disaster: al. 2003) January Questions 0% anxious or depressed 2001 about 10.3% excessive tobacco drinking and illicit drug use At Follow-up: 9.9% anxious or depressed 74.7% excessive drinking
Natural Disasters - Earthquakes
(Goenjian, 1988 Spitak 218 1.5 years DSRS At follow-up: Pynoos et earthquake Separation anxiety al. 1995) in Armenia disorder: 7.4% in Spitak, 5.9% in Gumri, 2.5% in Yereven
Depressive disorder: 76% Spitak, 50% Gumri, 28% Yereven
Any time since disaster: Separation anxiety disorder: 49% in spitak, 39% in Gumri and 23% in Yereven
(Kolaitis, Earthquake Grades 115 6 months CDI At follow-up: Kotsopoul Athens, 4 to 6 32% depression os et al. Greece, Sep, 2003) 1999
(Roussos, Earthquake 9-18 years 1937 3 months DSRS At follow-up: Goenjian Ano Liosia, 13.9% depression et al. 2005) Greece, Sep, 1999
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Author Disaster Age/Grade Number of Time Measure Prevalence of Mental (Year) Participants After Health Problems at Follow- Disaster up
Natural Disasters - Hurricanes
(Shaw, Hurricane 6 to 11 yrs 30 21 mths TRF At follow-up: Applegate Andrew, Indices of et al. 1996) Aug, 1992 psychopathology in girls and boys measured by the TRF significantly increased in the 19 months since last assessment.
(Goenjian, Hurricane Approx 13 158 6 months DSRS At follow-up: Molina et Mitch Oct- years Depressive disorder: al. 2001) Nov 1998 81% most devastated region 51% 2nd most devastated region 29% least devastated region
(Spell, Hurricane 8 to 16 years 260 3 to 7 BASC-2 At follow-up: Kelley et Katrina New months 13% self reported al. 2008) Orleans, internalising problems Aug, 2005 18% mother-reported internalising symptoms 13% mother-reported externalising symptoms
Natural Disaster – Tsunami
(Thienkrua Tsunami 7 to 14 years 371 2 months Birleson At 2 month follow-up: , Cardozo Dec, 2004 9 months Depression 5 to 11% with depression et al. 2006) Thailand self-rating At 9 month follow-up: scale 12% depression among children in camps
(Piyavhatk Tsunami 1 to 18 years 94 10 mths Psychiatrist At follow-up: ul, Dec 2004, Interview 9.6% major depressive Pairojkul Thailand episode et al. 2008) 9.6% chronic adjustment disorder 3.2% separation anxiety disorder
Terrorism
(Hoven, World Trade Grades 8236 6 months DISC At follow-up: Duarte et Centre 4 to 12 8.1% major depression al. 2005) Attacks, Sep (probable) 11, 2001 10.3% generalised anxiety (probable) 12.3% separation anxiety (probable) 8.7% panic disorder (probable) 14.8% agoraphobia
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Author Disaster Age/Grade Number of Time Measure Prevalence of Mental (Year) Participants After Health Problems at Follow- Disaster up (probable) 28.6% any anxiety/depressive disorder (probable) 12.8% conduct disorder (probable) 4.5% alcohol abuse/dependence (probable)
War
(Kinzie, Pol Pot 8 to 12 40 4 years SADS At follow-up: Sack et al. Regime in since 53% depressive disorder 1986) Cambodia leaving 12.5% major depression 1975 to 1979 Cambodia 8% panic disorder Now US 18% generalised anxiety refugees disorder
(Kinzie, Pol Pot 8 to 12 27 7 years DSM-III-R At follow-up: Sack et al. Regime in since clinical 41% major depression 1989) Cambodia leaving interview 1975 to 1979 Cambodia
(Sack, Adolescent 6 to 12 1984: 46 5 years DICA Unipolar Depression: Clarke et Survivors of 1987: 30 8 years 1984: 50% al. 1993) Pol Pot 1990: 31 11 years 1987: 41% Khymer 1990: 6% Rouge Regime in Anxiety Disorder: Cambodia 1984: 18% (1975-1979) 1987: 3% now living 1990: 6% in the US
(Savin, Pol Pot Approx 5 to 99 Approx SADS At follow-up: Sack et al. Regime in 12 in 1979 13 years 68.7% 1996) Cambodia since In past: 1975 to 1979 1979 36.4% Now Refugees in Thailand
(Sack, Him Pol Pot 8 to 12 27 7 years DICA 7 years since end of et al. 1999) Regime in 10 years DSM-III-R exposure : Cambodia 16 years 41% depression 1975 to 1979 since 10 years since end of leaving Now US exposure: Cambodia Refugees 7% depression 16 years since end of exposure: 14% depression
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Author Disaster Age/Grade Number of Time Measure Prevalence of Mental (Year) Participants After Health Problems at Follow- Disaster up (Thabet Palestinian 6 to 11 years 234 6 mths Rutter A2 At initial assessment: and Children (at 6 months 18 mths Parent 26.9% cases on parent Vostanis living in after end of Scale Rutter 2000) Gaza Strip conflict) Rutter B2 43.6% cases on teacher Teacher Rutter scale At follow-up: 20.9% cases on parent Rutter 31.8% cases on teacher Rutter
Notes: SCID, Structured Clinical Interview for DSM-III; PEF, Psychiatric Evaluation Form; SCL-90, Symptom Checklist; CAS, Child Assessment Scale; RECAP, Retrospective Experiences and Child and Adolescent Psychopathology; SADS-L, Schedule for Affective Disorders and Schizophrenia Lifetime Version; CIDI-Auto, Composite International Diagnostic Interview (computerised version); GHQ, General Health Questionnaire; YSR, Youth Self Report Form; DSRS, Depression Self Rating Scale; CDI, Children’s Depression Inventory; TRF, Teacher Report Form; BASC-2, Behaviour Assessment System for Children- 2nd edition; DISC, Diagnostic Interview Schedule for Children; SADS, Schedule for Affective Disorders and Schizophrenia
2.9 Mechanisms through which a disaster impacts on a child
Lubit, Rovine et al (2003) identifies three unique mechanisms through which a disaster
impacts on a child, (1) distortion of social networks, (2) increased risk for further trauma and
PTSD and (3) changes in the child’s view of themselves, others and the world.
2.9.1 Distortion of social networks
The first mechanism is through the disruption and distortion of the child’s social networks,
which prevent children from participating in normal age appropriate behaviours (such as
social interaction with peers, academic success). This can contribute to social withdrawal,
irritability and regressive behaviours which has the potential to permanently hinder them both
socially and academically and resulting in them lacking the relevant skills to succeed in
everyday life (Lubit, Rovine et al. 2003).
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2.9.2 Increases risk for further trauma and PTSD
Children exposed to traumatic events such as disasters are also more vulnerable to experiencing further trauma and PTSD due to an induced sense of learned helplessness
(brought on by excessive arousal and subsequent numbing) in combination with a sensitisation of their neuro-chemical systems. (Lubit, Rovine et al. 2003). In fact, stress hormones have a profound impact on the developing brain of a child affecting patterns of myelination, neurogensis, synaptogenesis and neural morphobiology (Lubit, Rovine et al.
2003) which later impacts on how stress is processed in these individuals.
This relationship between previous trauma and the risk of experiencing further traumatic events was prospectively examined in a group of 1698 adults followed up from the first grade at school. In this study, 82.5% of the young adults had experienced a traumatic event since the first grade, with high levels of aggressive/disruptive behaviour, reading readiness and concentration problems in the first grade predicting exposure to assaultive violence but not
PTSD. In comparison, children with high levels of depressed or anxious mood in the first grade were at an increased risk of developing PTSD upon exposure to a traumatic event but were not an increased risk of experiencing a traumatic event in the first place. Ability to read well, however, served as a protective factor against assaultive violence (Storr, Ialongo et al.
2007).
2.9.3 Changes in the child’s view of themselves, others and the world
Children are particularly vulnerable to the detrimental effects of trauma as it is in childhood that basic personality and views of the world are first formed. Disasters and other traumatic events occurring during this critical period of emotional development can permanently alter a
Miranda Van Hooff 2010 94 child’s perception of the world, specifically how safe, predictable and controllable their world is (Lubit, Rovine et al. 2003). The sense of powerlessness felt by children during a disaster can also damage self-esteem and sense of self-efficacy.
Disasters can cause children to question their parent’s ability to satisfy their emotional needs and protect them from danger consequently disrupting important attachment relationships which regulate and define future interpersonal relationships (Lubit, Rovine et al. 2003).
Children are often unable to identify, label, express, and cognitively process the disaster due to their lack of experience and exposure to such an overwhelming event. In response, children may lose the ability to appropriately distinguish and control affective states, which leads to poor impulse control and aggressive behaviour. For other children, the fear of the destructive power of aggression may inhibit the appropriate use of assertiveness later impacting on that individuals ability to achieve goals (Lubit, Rovine et al. 2003)
2.10 Summary
In summary there is a unique combination of risk factors and psychopathology that emerge in both children and adolescents following disasters. These risk factors in combination with the methodology employed to examine them play an important role in the development of PTSD and other types of post-trauma psychopathology. The following chapter provides a detailed outline of the Phases 1, 2, and 3 of the present study and includes details of both the findings of these studies and the measures used. The aims and hypotheses of this thesis will be outlined towards the end of this chapter.
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3 The original 1983 studies
3.1 The day of the fires
On February the 16th 1983, several large-scale bushfires devastated substantial parts of
Victoria and South Australia. One of the most vastly effected areas of South Australia was the farming region in the South East of the state, where an estimated 120,000 hectares of agricultural, pastoral and forest land were destroyed, 250 000 stock were injured or killed,
359 farms were fully or partially burnt, and 40 homes were completely destroyed. Fourteen people from the district were killed. There were reports of flames measuring 250 metres high and cyclonic strength winds of over 100km/hr which were strong enough to snap the trunks of radiata pines (McFarlane 1987).
3.2 The broad research agenda
Following the Ash Wednesday Bushfire in 1983, a research team from the Flinders Medical
Centre in South Australia headed by Sandy McFarlane surveyed three separate samples of
South Australian residents that were affected by the fires. The first study examined the prevalence and aetiology of emotional and behavioural problems in a group of primary school children from the south east of South Australia. The second body of research focussed on the aetiology and course of posttraumatic morbidity in a group of 469 fire fighters and the third study examined the prevalence of psychiatric disorder in adults registered as disaster victims by the Red Cross and the Department of Community Welfare in the 12 months following the fire.
At the time at which it was published, the research conducted by McFarlane and colleagues into the long term psychological sequelae of the Ash Wednesday bushfires was the first of its
Miranda Van Hooff 2010 96 kind to focus on a large scale bushfire/wildfire involving loss of life and destruction of homes
(McFarlane and Raphael 1984). Prior to that, research on fire-exposed populations was limited to the description of symptoms in individuals who had been trapped in places where fire had broken out such as in the Cocoanut Grove Nightclub (Cobb and Lindemann 1943), and the marine explosion on the Delaware river in 1957 (Leopold and Dillon 1963).
This literature review will focus primarily on the research conducted by McFarlane and colleagues on children from South East South Australia as this forms the baseline assessment for the current phase of data collection.
3.3 The children’s study
3.3.1 Aims of the study
The primary aim of this element of the study was to determine the rates of impairment in children following a major Australian bushfire using a standardised psychometric instrument
(Rutter, Tizard et al. 1970) that had previously been validated in an Australian population
(Connell, Irvine et al. 1982).
3.3.2 Description of the sample
3.3.2.1 The bushfire survivors
The original bushfire-affected cohort consisted of 808 children attending primary school in an easily demarcated region of South Australia that had been devastated by the Ash Wednesday
Fires on February 16th, 1983. These children were initially recruited by McFarlane and colleagues in the years 1983-1985 to investigate the longitudinal impact of the fires on the behaviour and functioning of children living in the bushfire-affected region. Children
Miranda Van Hooff 2010 97 attending one of six primary schools that serviced the bushfire affected region participated in the original study. These schools were Kangaroo Inn Area School, Kalangadoo Primary
School, Tarpeena Primary School, Nangwarry Primary School, Mt Burr Primary School and
Penola Primary School. The fires, encroaching on the school grounds, physically threatened all but one of these schools, Penola Primary School. This school was included as many children living in the fire affected region attended this school and therefore experienced a high level of exposure to the both the fires and the aftermath as a part of their daily family life.
Although all the children were exposed to the threat of death and personal loss, - experiencing forced evacuation from their schools/homes to escape perishing in the fires and witnessing the mass destruction and clean-up that followed, - different groups of children had different experiences depending on their physical proximity to the fires on that day, the degree of property and personal loss sustained by their family, and the overall resulting economic, financial and emotional hardship endured in the months following the fires. Some of the children were evacuated early and safely to nearby towns by family or friends and suffered no subsequent personal or property loss. Other children were trapped in their homes or in nearby evacuation points for hours, shrouded in darkness, listening to the wind howl and watching as the trees exploded into fireballs damaging and destroying their homes and property. Other children had experiences between these extremes, confounded additionally by the immediate and long-term reactions of family and friends, the death and injuries to family members, friends and pets and the subsequent psychological and financial pressure induced by the fires.
The majority of children involved in the study were separated from their parents or caregivers for a substantial amount of time on the day of the fires, which also contributed to the intensity of their experience. A more detailed account of the level of exposure to the fires and resulting behavioural changes in the follow-up cohort will be discussed in Chapter 7.
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3.3.2.1.1 Bushfire sample numbers
The first assessment (phase 1 of data collection) was conducted 2 months following the fires and included data on 520 bushfire-affected children. Two hundred and thirty five (43.2%) parents and 460 (88.5%) teachers completed questionnaires.
For the second assessment (phase 2 of data collection) which conducted 8 months following the fires, a number of schools in the region requested that children in the younger age groups
(5 and 6 year olds) also be included in the study therefore the total number of children involved increased to 808. Of these 808 children 467 (57.8%) parents and 719 (88.9%) teachers completed questionnaires.
The third assessment (phase 3), conducted 26 months following the fires was associated with a significant decline in participant numbers. Two of the primary schools in the bushfire- affected region had a change of headmaster during the interim period between assessment 2 and 3 and no longer wished to participate. In addition, the children from the two highest grades had moved on to high school, making these children more difficult to locate. These two factors in combination reduced the maximum number of potential teacher ratings to 365.
The 26-month sample of parent reports however was increased to 434 as a result of interviewers individually approaching the parents of children from both of these schools and encouraging them to participate. Overall the 26-month return rate for parents and teachers remained unchanged at 55.5% (N=241) and 84.6% (N=309) respectively.
3.3.2.2 The original comparison sample
The comparison sample was recruited 16 months following the fires in the interim period between assessment phase 1 and 2 for the bushfire-affected group and were assessed at this one time point only. Seven hundred and thirty-four primary school children (aged 5 to 12)
Miranda Van Hooff 2010 99 from a nearby rural region in South Australia that was not devastated by the fires participated in the study. This area was chosen as it has similar social and economic structure to the bushfire affected area. (McFarlane, Policansky et al. 1987). The two schools attended by these children were Naracoorte Primary School and Naracoorte South Primary School.
3.3.2.2.1 Comparison sample numbers
The same methods of recruiting participants and distributing questionnaires as in the bushfire- affected group were adhered to with the comparison group, with parents and teachers of all
734 students being invited to participate. The response rate for parents and teachers was
76.4% (N=561) and 96.7% (N=710) respectively.
3.3.3 Methodology:
Consent for the children to participate in the original study was obtained from parents and/or teachers who signed a written consent form. Information was collected from parents and teachers who completed paper and pencil questionnaires at three time points 2, 8 and 26 months following the fires in the bushfire group, and one time point in the controls at 16 months.
In the bushfire group, the two-month questionnaire documented the degree of exposure and impact of the fires on both parents and the children. The 8 and 26-month questionnaires recorded the continuing impact of the disaster on the parents, child and family in relation to emotional and behavioural problems in the child and overall family functioning.
Questionnaires administered to parent and teachers of the comparison group documented emotional and behavioural problems in the child and family functioning in a group of children who were not directly exposed to the fires.
Miranda Van Hooff 2010 100
3.3.3.1 Childhood measures – 1983-1985
3.3.3.1.1 Degree of disaster related personal and property loss
Degree of Bushfire related loss (level of exposure to the bushfire) was assessed using a 14- item inventory administered to parents at either the 2-month or the 8-month follow-up assessment. Five of these items recorded the number of people known to the child’s family who were injured or killed in the fires (personal loss) and the remaining 9 questions focussed on the level of damage, destruction or threat to homes, motor vehicles, property affecting livelihood, as well as death and injury to stock and pets (property loss).
Using methodology originally outlined in McFarlane (1987) and employed in Tennant and
Andrews’ (1976) life events inventory, personal losses were weighted according to the nature of the relationship of the victim to the child and the severity of the loss (i.e. injury to mother, father or sibling=3, injury to grandparent or other relative=2, injury to parent’s or child’s own friend=1; death of mother, father or sibling= 6, death of grandparent or other relative=4, death of parent’s or child’s own friend =2). Weighted scores for all of these losses were then added to produce a measure of total personal loss.
Property loss items were weighted according to the amounts of practical assistance required to reparate for losses which was devised from a survey conducted on a special team of 20 bushfire relief workers appointed to assist the Ash Wednesday Bushfire victims in 1983
(McFarlane 1987) (i.e. house destroyed = 4, house damaged = 2, property effecting livelihood damaged or destroyed = 3, car damaged or destroyed =1, house threatened = 1, stock injured or killed = 1, pets injured or killed = 1). Following weighting, items in these subscales were summed to produce a measure of total personal and property loss.
Miranda Van Hooff 2010 101
3.3.3.1.2 Family functioning and maternal parenting style
A measure devised by McFarlane (1987) was used to measure family functioning/maternal parenting style at 8 and 26 months following the fire. This measure was specifically devised to examine family functioning following a natural disaster, and was developed through observation and consultation with disaster-exposed schools in the area, disaster victims, disaster services, as well as previous literature. At 8-months the questions were rated for the period since the Ash-Wednesday Bushfires and at 26-months for the 8 months prior to assessment. The mother mostly completed this measure.
The family functioning measure comprised 11 items, with 2 subscales (family irritable distress and family involvement). Irritable distress describes a pattern of family interaction characterised by irritability, fighting, emotional withdrawal, and loss of pleasure from shared activities. Involvement characterises families who had a better sense of their goals, were closer than before, talked over problems and were concerned about putting strain on each other. Each question was rated on a 3-point scale from 0 (does not apply) to 2 (certainly applies) with total scores ranging from 0 to 12 for irritability and 0 to 10 for involvement.
Both scales have acceptable internal reliability, and the factor structure suggested face validity and was very similar to that predicted by the question selection (McFarlane 1987).
3.3.3.1.3 Maternal overprotection following the fires
A two-item measure of maternal overprotection devised for the 8 and 26-month follow-up were utilised in the study. Overprotection was measured by adding the score of two questions, ‘Since the disaster, do you worry more about your children coming to harm?’ and
‘Do you need to know where your children are more than before?’ Each overprotection question was rated on a 3-point scale: from 0 (not at all), 1 (sometimes) to 2 (often) with
Miranda Van Hooff 2010 102 scores ranging from 0-6. Details of findings relating to this two-item measure have been published (McFarlane 1987).
3.3.3.1.4 Posttraumatic phenomena in the children
Posttraumatic Phenomena in the children 8 and 26 months following the fires was examined using four questions. Scoring followed the same pattern as the Rutter instrument (0 = doesn’t apply, 1= applies somewhat, 2 = certainly applies) with the last two responses indicating a positive response. Questions included in the parent questionnaire examined four types of symptoms: “1. Has dreams or nightmares about the fire, 2. At times plays games about the fire and paints pictures about it, 3. Is upset or worried by reminders of the fire (e.g., sirens, strong winds, etc.) and 4. Spontaneously talks about the fire. Scoring was based on both the sum of the responses to each of the PTSD questions (Range 0 to 8) as well as the proportion of children exhibiting at least one post-trauma symptom. Items were chosen based on available research reports at the time and the investigator’s clinical experience (McFarlane,
1987).
3.3.3.1.5 Maternal post-trauma symptoms
Two questions administered to parents at the 8 and 26 month follow-up assessment examined maternal wellbeing and the presence of intrusive phenomenology; (1) How have you been feeling in the last month; and (2) Do you still find unwanted thoughts and feelings about the fires pop into you mind? These questions will be examined as specific risk factors for adult psychopathology.
3.3.3.1.6 Rutter Child Behaviour Questionnaire
Childhood emotional and behavioural problems were assessed using the parent and teacher
Rutter Child Behaviour Questionnaire (Rutter, Tizard et al. 1970). Originally developed in the
Miranda Van Hooff 2010 103
UK in order to detect behavioural disturbances in large groups of children aged between nine and thirteen, this questionnaire enables both parents and teachers to rate their child on the presence or absence of a range of behaviours using a three point likert scale: 0 = does not apply, 1 = applies somewhat, 2 = certainly applies. Scores on each of the items are summed to produce a total behaviour score with a cut-off of 9 on the teachers scale and 13 on the parent’s scale indicating a behavioural disorder.
Each scale has two subscales: an antisocial/conduct disorder/disruptive/hostile-aggressive scale (5 items on parent scale, 6 items on teacher scale) and a neurotic/emotional disorder scale/anxious fearful scale (5 items on parent scale, 4 items on teacher scale). Children are classified as having a conduct type disorder if their total score exceeds or equals the cut-off and their conduct score is larger than their neurotic score. Children are classified as having an emotional disorder if their total score exceeds or equals the cut-off and their neurotic score is greater than their conduct score.
Using a cut-off of 13 on the parent scale and 9 on the teacher scale sensitivity and specificity is slightly higher for the parent scale than the teacher scale when compared with clinical assessment (sensitivity 55% compared to 53%; specificity 94% compared to 93%) (Rutter,
Tizard et al. 1970). Test-retest reliability over a period of up to six months, however, is generally higher for the teacher scale (0.62 to 0.89; (Rutter, Tizard et al. 1970; Fombonne
1989; Morita, Suzuki et al. 1990; Berg, Lucas et al. 1992) than the parent scale (0.63 to 0.75;
(Rutter, Tizard et al. 1970; Zimmermann-Tansella, Minghetti et al. 1978; Morita, Suzuki et al.
1990) partly due to influential effect of parents own psychiatric status and family size on parental ratings of child behaviour. Inter-rater reliability between mother and father ratings of child symptoms is adequate (r = 0.64) as are ratings between different teachers (0.73-0.79;
(Rutter, Tizard et al. 1970; Zimmermann-Tansella, Minghetti et al. 1978). An additional
Miranda Van Hooff 2010 104 hyperactive subscale, separate from the conduct/aggressive subscale and comprising 3 items is also supported by a number of studies (McGee, Williams et al. 1985; Morita, Suzuki et al.
1990). The main weaknesses of the Rutter measure are the reported limited agreement between parental, teacher and child reports of emotional and behavioural problems. In addition, teacher ratings are contingent on the degree of familiarity with the child, whether or not the behaviour presents itself in the classroom situation and the bias introduced by comparisons made with other children in the class. To counteract these limitations both the parent and teacher were utilized in the original study.
3.3.4 Results:
3.3.4.1 Study 1: The psychological impact of the fires
The first study published examined the psychological impact of the disaster on the bushfire- exposed children compared to a group of unexposed controls (McFarlane, Policansky et al.
1987). Two analyses were performed. The first involved contrasting the emotional and behavioural problems of bushfire-exposed children at 2, 8 and 26 months with emotional and behavioural problems in age and sex matched unexposed controls. The second analysis investigated the stability of emotional and behavioural problems over time in the children who had been surveyed on all three occasions. In this analysis, children who became new cases at 8 and 26 months but were not cases at 2months were compared with children who were never cases (McFarlane, Policansky et al. 1987).
Results of this study showed that both teacher and parent reports of behavioural problems in children were significantly lower at 2 months than at 8 months, with no change from 8 months to 26 months. This same pattern emerged in relation to parent Rutter caseness
Miranda Van Hooff 2010 105 whereas caseness on the teacher Rutter continued to increase over the 26-month period.
(McFarlane, Policansky et al. 1987).
Common predictors of caseness during the follow-up period included anger, neuroticism, lying, distractibility and restlessness. Interestingly, the absence of antisocial behaviour was also a predictor of caseness indicating that although the children may have been suffering symptoms they generally became more obedient in the immediate aftermath of the disaster.
A further examination of the social and educational consequences of the disaster showed that
17.6% of children were rated by their teachers to be underachieving at 8 months, and 24.5% at 26 months, with underachievers also scoring higher on the parent and teacher Rutter. Also the disaster group reported significantly more days absent from school than the comparison group, with common reasons including headaches, stomach-aches and feeling miserable and worried.
The overall prevalence of disorder in this sample of childhood bushfire survivors was lower than expected, with more parents than teachers rating the children as cases at each of the 3 time points (2 month parent cases: 6.6 to 7.8%; 2 month teacher cases: 1.8 to 3.9%; 8 month parent cases 16.8 to 20.4%; 8 month teacher cases 5.5 to 9.1%; 26 month parent cases 18.4 to
21.4%; 26 month teacher cases 10.6 to 11.4%). One explanation for the low teacher rates is the fact that a number of teachers had only known the students for 10-11weeks. Other possible explanations include the tendency of children to comply while in the school environment, the teachers’ tendency to deny the continuing effects of the disaster or an indication of the parents’ intolerance of the child’s normal behaviour patterns hence inflating their assessments of poor behaviour in their own children.
Miranda Van Hooff 2010 106
There was also a significant difference in the constellation of behaviours present in disaster exposed children and controls. Anger and phobic behaviours were significantly more prominent in the bushfire group than controls at 8 and 26 months and neurotic symptoms and somatic symptoms were more prevalent at 8 months as rated by the parents. Teachers noted a greater discrepancy between disaster survivors and controls at 2 months in relation to antisocial behaviour, neurotic behaviour, lie telling and degree of distractibility.
3.3.4.2 Study 2: Impact of the bushfire on family functioning
In a second study, McFarlane (1987) describes the longitudinal impact of the bushfire on levels of irritable distress (characterised by increased irritability, fighting, withdrawal, and decreased enjoyment with shared activities), involvement (level of closeness and shared goals) and parental overprotection in bushfire-affected families. This study followed up 235 families, 8 months (n=183) and 26 months following the fires (n=103) (McFarlane 1987).
The bushfire group reported significantly more irritable distress at 8 months and 26 months than the control group. In relation to ‘involvement’ the disaster group scored higher than the control group at 26 months only. There was no change in the levels of irritable distress or involvement in bushfire affected families between 8 and 26 months. Using multiple regression, the main predictors of irritable distress to emerge were disaster related variables such as continued maternal preoccupation with the fire, fear of future fires, the continuing effects of property loss and family separation in the first three days following the fires.
Predictors of family involvement following the fires were maternal post-traumatic imagery, and the level of direct exposure to danger in parents and children. Finally an examination of levels of parental overprotection revealed a significant relationship with level of family involvement but not levels of irritable distress. Overprotection in combination with
Miranda Van Hooff 2010 107 involvement was also associated with posttraumatic phenomena experienced by the mothers in the aftermath of the fires.
3.3.4.3 Study 3: The relationship between posttraumatic symptoms and the
development of behavioural problems
In a third study, McFarlane (1987) examined the prevalence of posttraumatic symptoms and their relationship to behaviour problems in all 808 children exposed to the fires. Four symptoms were examined; (1) having dreams or nightmares about the fire, (2) playing games or painting pictures about the fire, (3) feeling worried or upset upon reminders of the fire (i.e. sirens, strong winds) and (4) engaging in spontaneous conversation about the fire.
At 8 and 26 months the most common parent reported symptoms were ‘child talks about the fire’ (43.1% at 8month, 35.9% at 26months), and ‘reminders of the fire upset them’ (34.9% at
8months, 47.4% at 26 months). Interestingly the prevalence of teacher reported posttraumatic symptoms were much lower with the most common symptoms at 8 months being ‘plays or talks about the fire (6.1%), and at 26 months being ‘afraid of sirens’ (3.7%). This supports the findings of (McFarlane, Policansky et al. 1987), which showed lower teacher reported behaviour problems following the fires.
The prevalence of posttraumatic symptoms showed no significant reduction over time.
Overall, posttraumatic symptoms were most common in children rated as cases on the Rutter questionnaire, however such symptoms were also present in a number of children who did not exhibit behavioural disorders and therefore did not represent a unique relationship between posttraumatic symptoms and behavioural disorder. Parent-rated behaviours in the children accounted for a higher proportion of the variance in the posttraumatic phenomena at 26
Miranda Van Hooff 2010 108 months (26%) compared to 8 months (19%), with phobic symptoms being the strongest behavioural predictor, however the proportion of the variance accounted for was low.
Behavioural problems reported by teachers at 2 and 8 months and posttraumatic symptoms observed by parents at 8 months predicted posttraumatic symptoms at 26 months, suggesting a sensitisation effect brought about by the child’s initial reaction to the fire, whereby early symptoms of anxiety increase the likelihood of the child developing posttraumatic symptoms over time.
Predictors of posttraumatic symptoms in children at eight months included family being split up, parental exposure to the fires, age, changed family functioning, maternal intrusive thoughts and continuing unrepaired property damage at the time of assessment.
Predictors of post-traumatic symptoms at 26 months included, family being split up in the days following the fires, maternal fears of future fires (8 months), continuing loss of income from the fires at 8 months, intrusive thoughts of fire in the mother (at 26 months), life events in the preceding 18 months and family functioning (at 26 months).
3.4 Conclusions:
In summary, this sample of children exhibited a number of significant post-traumatic and behavioural problems that persisted at an assessment 26 months after the disaster. This thesis will attempt to ascertain whether these symptoms continue into young adulthood as well as the long-term consequences of experiencing these symptoms in childhood.
Miranda Van Hooff 2010 109 4 Study design and methods
This study is the 4th phase of a longitudinal study, which commenced in 1983, two months following the Ash Wednesday Bushfires. The original studies assessed a cohort of bushfire survivors and controls on three separate occasions, two (phase 1), eight (phase 2) and twenty- six months (phase 3) following the fires. The methodology and results of these early studies have been outlined in Chapter 3. The present study involved a follow-up of this same group of participants into adulthood, approximately 20 years after their initial exposure to the disaster.
This chapter provides a detailed outline of the study design and methodology relating to the
4th phase of this longitudinal study. This extensive methods section includes details relating to ethics approval, tracking and recruitment of participants, and a description of the measures used. A description of the data that will be extracted and utilised from Phases 1, 2 and 3 of the study was described earlier in section 3.3.3.
4.1 Ethics approval
Due to the unique tracking requirements of the study, ethics approval was obtained from four independent Ethics Committees prior to commencement of the study:
1. The University of Adelaide Human Research Ethics Committee (HREC), the author’s
home institution.
2. The Department of Education Training and Development (DETE). Approval was
sought from this committee to enable the author to re-contact the primary schools, and
to request access to archived school admission records for the purpose of extracting
dates of birth for potential recruits.
Miranda Van Hooff 2010 110 3. The Australian Institute of Health and Welfare (AIHW), in order to obtain information
relating to cause and number of deaths which is stored in the National Death Index
(see section 4.2.2).
4. The Australian Electoral Commission (AEC), to gain access to residential addresses
stored in a confidential database of elector information (see section 4.2.3).
4.2 Tracking of participants
Tracking of the original participants was completed in four phases and involved cooperation and input from the eight primary schools involved in the original study, the National Death
Index (NDI) (Australian Institute of Health and Welfare), the Australian Electoral
Commission (AEC) and the Births, Deaths and Marriages Registration Office of South
Australia (BDM).
4.2.1 Creating a register of potential participants
A register of all potential participants was compiled using identifying data extracted from the original questionnaires and date of birth information obtained from archived school admission records on site at each of the eight primary schools. A total of 1531 participants, 806 of the original 808 children from the bushfire group and 725 of the 734 original participants from the control group were identified and included in the cohort to be traced. Two participants from the bushfire group and nine participants from the control group were excluded from the recruitment list due to the absence of any identifying data for these participants.
The South Australian Government Department of Education, Training and Development
Ethics Committee, with the support of the Principals at each of the eight primary schools, approved the study protocol. For the six schools in the bushfire-affected region, a list of
Miranda Van Hooff 2010 111 student names was faxed to each school and a school administration officer extracted the relevant dates of birth from archived school admission records. For the two schools in the comparison group - Naracoorte Primary School and Naracoorte South Primary, a large number of dates of birth were absent from our records, therefore the author travelled to the these schools to complete the extraction process.
4.2.2 The National Death Index (NDI)
Information for the 1531 members of the study cohort was then submitted to the National
Death Index, a database housed at the Australian Institute of Health and Welfare, which contains records of all deaths occurring in Australia since 1980. The NDI service provides information regarding the cause and date of death. For records to 1996, only the code for underlying cause of death is available. For records from 1997, the codes for the underlying cause of death and all other causes of death mentioned on the death certificate are available.
Information was submitted to the NDI to exclude the deceased from the recruitment list and to examine the survival rates and mortality outcomes associated with childhood exposure to the bushfire.
Details of potential participants were matched with Australian death records from their date of enrolment in the study. Deaths identified through the NDI were included in the study if the match was accepted as “likely to be a true match” (according to the NDI matching algorithm), or “a complete match” with the identifying information submitted from our files. Where there was an “attempted match” based on limited availability of identifying information, further validation was sought from friends of the deceased prior to the commencement of tracking.
The National Death Index is governed by the confidentiality legislation upheld by the
Australian Institute of Health and Welfare Act 1987 and was therefore approved by the
Miranda Van Hooff 2010 112 Australian Institute of Health and Welfare Ethics Committee prior to commencement of the study. A detailed account of participants who are deceased is provided in Chapter 5.
4.2.3 The Australian Electoral Commission (AEC)
Potential addresses for the remaining participants were obtained through the Australian
Electoral Commission’s (AEC) confidential database of elector information and were matched with a telephone number through an online telephone directory (the White Pages online – www.whitepages.com.au). Of the 1531 names submitted to AEC, 861 (56%) participants were matched with a current address. However, of those 861, only 357 (41.5%) of the original participants were matched with a current telephone number through the online directory.
Notably, information from the AEC was only made available to the author by virtue of the embodiment of the University of Adelaide as a “medical research institution” and was done so in strict accordance with a safeguard agreement signed by the study Chief Investigator to maintain the privacy of all electors involved. As a part of this agreement, no information provided by the AEC was to be made available to any third party or used for any other means other than to track research participants for the purposes of the present study. This agreement was strictly adhered to in the current study protocol. The one limitation of information stored by the AEC is that elector address information is stored according to the elector’s current surname. Therefore any participant who had changed their name since initial recruitment could not be located using this process.
Miranda Van Hooff 2010 113 4.2.4 The South Australian Department of Births Deaths and Marriages (BDM)
In the absence of a correct address match through the AEC, the author contacted the South
Australian Department of Births Deaths and Marriages in order to obtain a list of participants who may have changed their name. The ages of the follow-up sample ranged from 23 to 32 years and it was anticipated that a significant proportion of participants might have married in the 20 years since commencement of the study.
To protect the persons to whom the entries of the register relate from unjustified intrusion of their privacy, a restricted level of access to the change of name registry was granted by BDM on the provision that participants first consented to the release of their contact information to the author.
A list of 1175 participant names was thereby forwarded to BDM, of which 156 (13.3%)
(females only) were matched with the marriage register, and 14 (1%) were matched with the change of name registry. The author had contacted 51 of these individuals in this interim period, leaving 119 participants to be contacted by BDM.
Due to an impasse1 between the AEC and BDM, which failed to permit BDM direct access to the electronic version of the electoral role, a registrar from the Births Deaths and Marriages registration office searched the hard copy of the electoral role relating to all states and territories within Australia for each of the 119 participants.
Several names were matched with more than one address. Where this occurred, each address was documented and later used to track the participant. In total 110 names were matched with
1 The AEC is governed by the EAct, which limits access to the electronic copy of the role to “Medical Research Institutions” and other such organisations for the purpose of conducting medical research. Although BDM is a state government agency and is governed by National Privacy Legislation, it is not recognised by AEC as a “medical research institution’ and hence was not authorised to receive matched elector information from the AEC on behalf of the University of Adelaide. In the same way, BDM was restricted by National privacy legislation and would not authorise the AEC to have access to information stored in the Change of Name Registry for the purpose of tracing participants on behalf of the University of Adelaide. This lead to an impasse between these two agencies that could not be resolved. Miranda Van Hooff 2010 114 at least one address. Nine of the names could not be found on any of the electoral rolls within
Australia, suggesting that these participants may not have been enrolled to vote. Twenty-eight
(25.45%) of the 110 names on the electoral roll were matched based on their maiden name rather than their married name and contact details for these individuals were forwarded directly to the University.
The remaining 82 names and addresses were then entered by BDM into the White Pages online directory. Of these 82 names, 63 (76.83%) were successfully matched with a telephone number and 19 were not (23.17%).
These 63 participants were subsequently contacted first by letter (Appendix B) and then by phone by a registrar from BDM who requested their consent to pass on their contact information to our research team. Of these 63 potential participants, 40 gave their permission to be contacted.
Ten individuals expressed to BDM that they were not interested in participating in the study and refused to give their consent to being recontacted.
Finally, for the 19 individuals who were matched with an address but no phone number, BDM sent out a letter and information sheet requesting that each person ring the research team if they are interested in learning more about the study. None of these participants however contacted the research team directly.
Miranda Van Hooff 2010 115 4.3 Recruitment and consent
For participants with a current residential address, a letter (Appendix C) from the study coordinator was sent to introduce the study. This letter included both an email address and contact phone number for the research team.
One week following, a research psychologist telephoned the participant to explain the study in more detail and to request their permission to send them an invitation pack. A date to conduct the telephone interview was also booked with the participant for the following week.
The invitation pack consisted of a letter confirming their interview time and date (Appendix
D), an information sheet (Appendix E), a self-report questionnaire (Appendix F), a consent form to participate in the study (Appendix G), a consent form giving permission for their
Medicare and Pharmaceutical Benefit Scheme (PBS) information to be extracted from the
Health Insurance Commission (Appendix H) and a complaints form (Appendix I). A reply paid envelope was included in the pack to assist in the return of the consent forms and self- report booklet.
Minimums of ten consecutive attempts at phone contact were made to each participant prior to that participant being removed from the tracking list. These calls were made at various times of the day and days of the week. Written consent was obtained prior to commencement of the study with consent forms being returned by each participant in hard copy format. Each participant was asked to provide contact information for three of their closest friends or relatives to aid in their retention in the study and to provide avenues for future follow-up. In addition, each participant was asked to give verbal consent to be re-contacted again in the future for inclusion in further follow-up studies. For those who completed the interview component by were delayed in sending back their questionnaire booklet, a reminder letter was sent in the post (Appendix J).
Miranda Van Hooff 2010 116 4.4 Assessment
Assessment was conducted in two parts. In part one, participants were asked to complete a self-report booklet. Part two consisted of a one hour telephone interview with a research psychologist using the computerised version of the Composite International Diagnostic
Interview (CIDI), a fully structured, standardised and comprehensive interview for adults used to assess current and lifetime prevalence of mental disorders based on the Diagnostic and
Statistical Manual for Mental Disorders – 4th revision (DSM-IV) (CIDI-Auto, version 2.1)
(World Health Organisation 1997; World Health Organization Collaborating Centre for
Mental Health and Substance Abuse 1997).
Interviews were conducted by trained research psychologists with extensive experience in recruitment, telephone interviewing and psychological assessment. Each interviewer had completed a two-day intensive training program covering survey concepts and definitions, training in sensitivity and issues pertaining to privacy and confidentiality, conducted by the
University of Adelaide Department of Psychiatry. An instruction manual with specific question-by-question instructions on how to code and categorise the relevant psychiatric symptoms was given to each interviewer as a reference document.
A panel consisting of a psychiatrist, and three research psychologists reviewed scoring of structured interviews weekly to maintain a high level of inter-rater reliability.
A research assistant carefully checked all self-report booklets for missing data or inconsistencies on a daily basis and telephoned research participants in order to clarify responses or complete missing questions.
Miranda Van Hooff 2010 117 4.4.1 Instruments
4.4.1.1 Demographics
Demographic questions used in the follow-up study were derived from the 1997 Australian
National Survey of Health and Wellbeing (Australian Bureau of Statistics 1999) and are reported using standards employed by the Australian Bureau of Statistics (ABS) and the
Australian Institute of Health and Welfare (AIHW). All demographic questions were completed as part of the self-report booklet (Appendix F).
4.4.1.1.1 Occupation Occupations were categorised using the Australian Standard Classification of Occupations
(ASCO)(Australian Bureau of Statistics 1997) into nine groups based on the kind of work performed and the skill level involved; managers and administrators, professionals, associate professionals, tradespersons and related workers, advanced clerical and service workers, intermediate clerical, sales and service workers, intermediate production and transport workers, elementary clerical, sales and service workers, labourers and related workers.
4.4.1.1.2 Rural or urban status The proportion of participants residing in metropolitan, rural and remote locations in
Australia was determined using the Rural, Remote Metropolitan Area Classification (RRMA).
The RRMA classification gives an index of residential remoteness based on distance to service centres as well as distance from other people. The three zones utilised in the analysis were: Metropolitan [Capital cities, Other Metropolitan Centres (urban centre population ≥
100,000)], Rural [small to large urban centres with population range of 10,000 to 99, 999] and
Remote [remote centres (urban centre population 5,000 to 9,999), and other remote areas
(urban centre population < 5,000)].
Miranda Van Hooff 2010 118 4.4.1.2 Lifetime exposure to trauma
Lifetime exposure to trauma was examined using ten Criterion-A1 events from the CIDI-Auto
(World Health Organisation 1997). These events were direct combat, life-threatening accident, fire, flood or natural disaster, witnessed someone badly injured or killed, rape, sexual molestation, serious physical attack or assault, threatened with a weapon, held captive or kidnapped, tortured or victim of terrorists, and other stressful event. Seven additional events were also added to this list (domestic violence, witnessed domestic violence, threatened or harassed without a weapon, finding a dead body, witnessing someone suicide or attempt suicide, child physical abuse, child emotional abuse). These events were chosen based on the authors’ clinical and research experience with traumatised populations. Participants were asked whether they had experienced any of these events and whether they had ever experienced a great shock due to any of these events happening to someone close to them.
Each participant was then requested to nominate which of these events were their 3 worst events in the order of worst to third worst. Participants were then asked to provide a brief description of each of these events.
Events that were reported by participants in response to the category ‘any other stressful event’ were further categorised. If three or more participants reported a similar event the event was assigned its own category, leading to a further eight event categories (death of a loved one, loved one attempted or committed suicide, miscarriage, still birth, relationship problems or separation, parent divorce or leaving, job stressors, medical illness or complication experienced by a loved one). An ‘other’ category remained for the events that were reported by only one or two participants, such as death of a pet and abortion. Events were also divided into three broad categories: events that happened to self, witnessing an event that happened to another, and learning about an event happening to another.
Miranda Van Hooff 2010 119 4.4.1.3 Lifetime and current DSM-IV psychiatric disorder
Lifetime and 1-month point prevalence rates of DSM-IV (American Psychiatric Association
1994) disorder were assessed using the CIDI (World Health Organisation 1997). The CIDI was chosen in this study for three primary reasons; it is designed to be administered by lay interviewers, it is a widely used instrument in epidemiological surveys, and has previously been validated in a Australian population as part of the 1997 Australian National Mental
Health and Wellbeing Survey (Andrews and Peters 1998).
Studies have found that the CIDI has excellent inter-rater reliability, and satisfactory test- retest reliability and validity in Australia and a variety of other settings worldwide (Wittchen,
Robins et al. 1991; Andrews and Peters 1998).
DSM-IV disorders were sub-grouped into three categories: depressive disorders (major depressive disorder [single and recurrent], depressive disorder not otherwise specified, dysthymic disorder), anxiety disorders (panic disorder, panic with agoraphobia, agoraphobia, specific phobia [animal, environmental, situational, blood, other], social phobia, obsessive compulsive disorder, generalised anxiety disorder, anxiety disorder not otherwise specified) and eating disorders (anorexia nervosa, bulimia nervosa and eating disorder not otherwise specified).
Scoring was based on the standard CIDI scoring criteria - 0 ‘indeterminate diagnosis’, 1
‘criteria not met’, 3 ‘positive criteria met but exclusion not met’, 5 ‘All Diagnostic Criteria
Met’. Severity of disorder, age of onset and age of last episode were also recorded.
Participants were designated as having a ‘current diagnosis’ if they met all of the criteria for that disorder in the four weeks prior to their interview.
Miranda Van Hooff 2010 120 4.4.1.4 Lifetime and current DSM-IV PTSD
4.4.1.4.1 Worst lifetime events In assessing Posttraumatic Stress Disorder (PTSD), there were two major differences between the current study and other longitudinal studies of childhood disaster survivors. Firstly, in the current study, PTSD symptoms were examined in all participants (both bushfire survivors and controls) in relation to the event nominated by the participant to be their worst lifetime traumatic event. This is in contrast to other studies, which predominantly addresses the effects of the disaster in the exposed population and the worst lifetime traumatic event in the controls. Second, in the current study, the PTSD section of the CIDI was modified in order to evaluate PTSD symptoms for the three worst events (as opposed to only one event). This was undertaken for two reasons; (1) to investigate whether participants who fail to satisfy diagnostic criteria for their first (worst) event, can go on to qualify for PTSD based on their second or third worst event, and (2) to determine if the process of examining PTSD symptoms in relation to more than one event increases the lifetime and current prevalence of PTSD in relation to the bushfires.
4.4.1.4.2 Ash Wednesday Bushfire In addition to the assessment of PTSD in relation to the participant’s worst lifetime event, a more detailed examination of the prevalence of lifetime and current DSM-IV bushfire-related
PTSD was also undertaken using the CIDI. Using the worst event method employed in this study, bushfire survivors were questioned with specific reference to the Ash Wednesday
Bushfires if they nominated the bushfire as their worst lifetime event (Fire Group 1). If the bushfire survivors did not nominate the bushfire as their worst lifetime event, but instead nominated another event as their worst, PTSD symptom questions were asked in specific relation to this other event (Fire Group 2). A further group, Fire Group 3 was also constructed that consisted of bushfire survivors who nominated the bushfire as either their worst, second
Miranda Van Hooff 2010 121 or third worst lifetime event and therefore included all those in Fire Group 1 and those in Fire
Group 2 who nominated the bushfire as their second or third worst lifetime event. In total,
352 (69%) of those originally exposed to the bushfires were questioned as to whether they had experienced PTSD symptoms as a direct result of the bushfire at some point in their lives
(Fire Group 3). Bushfire survivors were sub-grouped in this way to maximise sample numbers for analysis of bushfire related PTSD.
4.4.1.5 Current PTSD related distress
Current distress associated with PTSD symptoms was examined using the self-report Impact of Events Scale – Revised (IES-R) (Appendix F). Adapted from the widely used Impact of
Events Scale (Horowitz, Wilner et al. 1979) the IES-R is a 22-item scale designed to assess how distressing each PTSD symptom has been during the past week. Each question is rated on a four-point scale ranging from 0 (not at all) to 4 (extremely), with scale scores being formed into three subscales reflecting intrusion (eight items), avoidance (eight items) and hyperarousal (6 items). Since its development in 1997, the IES-R has been psychometrically evaluated in a number of samples including an Australian sample of Vietnam Veterans seeking treatment for PTSD as well as a community sample of veterans with varying levels of trauma exposure (Creamer, Bell et al. 2003), a sample of women exposed to a natural disaster
(an ice storm) during or preceding pregnancy (Brunet, St-Hilaire et al. 2003) and a group of individuals who had experienced a serious motor vehicle accident (Beck, Grant et al. 2008).
Each of these efforts has examined the associated factor structure of the IES-R, with results ranging from poor (Creamer, Bell et al. 2003) to good support (Brunet, St-Hilaire et al. 2003) for the three scale structure with studies indicating a high degree of inter-correlation between these subscales (r’s = 0.52–0.87; (Creamer, Bell et al. 2003). The IES-R has good internal consistency, with alpha coefficients ranging from 0.79 to 0.94 for its 3 subscales and total
Miranda Van Hooff 2010 122 score (Weiss and Marmar 1997; Brunet, St-Hilaire et al. 2003; Creamer, Bell et al. 2003;
Beck, Grant et al. 2008), adequate test-retest reliability with correlation coefficients ranging from 0.71 to 0.94 for its 3 subscales and total score (Weiss and Marmar 1997; Brunet, St-
Hilaire et al. 2003) and adequate construct validity when correlated with the Posttraumatic
Checklist (Creamer, Bell et al. 2003).
To allow a direct comparison with a recent longitudinal study of disaster survivors (Morgan,
Scourfield et al. 2003), a score of 35 or above on this scale was used to define a case.
Symptom questions were anchored to the bushfire in the survivor group and their most stressful self-nominated life event in the controls.
4.4.1.6 Alcohol consumption and problem drinking
Alcohol consumption and problem drinking was examined using the Audit (The Alcohol Use
Disorders Identification Test) (Saunders, Aasland et al. 1993) a brief self-report screening instrument developed by the World Health Organization (WHO). Originally designed for use in health care settings, the version used in the current study has been modified for the
Australian context by the Centre for Drug and Alcohol Studies. This instrument consists of 10 questions to examine the quantity and frequency of alcohol consumption (questions 1 to 3), possible symptoms of dependence (questions 4-6), and the reactions or problems related to alcohol (questions 7-10) (range: 0-36). A score of 6 or more for women and 7 or more for men indicate a drinking problem. The Australian version of the AUDIT has been reported to have good internal consistency (α = 0.76) and high sensitivity for detection of drinking over
Australian recommended limits and for the detection of ICD-10 dependence but low specificity (Degenhardt, Conigrave et al. 2001).
Miranda Van Hooff 2010 123 5 Sample description
5.1 Introduction
This chapter is divided into two sections. Section one describes the sample composition including information about the potential follow-up sample, the actual follow-up sample, participants who withdrew or could not be contacted and participants who have died. Section two reports on the differences between responders and non-responders based on information collected in phase 1, 2 and 3 of the study.
All data reported in this chapter relates to participants assessed in the 4th phase of the study
(the 20-year follow-up assessment) and includes participants who completed either the interview or self-report measure. A detailed description of the sample composition of phases
1, 2 and 3 of the study was outlined in section 3.3.2. Further information relating to demographic characteristics are presented in Chapter 6.
5.2 Sample composition
5.2.1 The potential follow-up sample
The initial follow-up sample was comprised of 1531 (806 from the bushfire group and 725 from the comparison group) of the 1542 original study participants. The number of subjects involved in the study over the four phases of the study are summarised in Figure 5.1.
Identifying information and data was unable to be located for just 11 of the original study participants due to data storage problems and inaccurate school admission records. Two of the bushfire participants and nine children from the comparison group, were therefore removed from the follow-up sample due to insufficient identifying data.
Miranda Van Hooff 2010 5.2.2 The actual follow-up sample
Of the 806 participants in the bushfire group, 714 (88.6%) were re-contacted around the 20- year anniversary of the fires and were invited to participate in the study. Four hundred and forty (54.6%) of these participants completed the full follow-up protocol and a further 540
(67%) completed at least one part of the protocol.
Of the 725 participants in the control group, 622 (86%) participants were also re-contacted.
Three hundred and eighty-two participants (52.7%) completed the full follow-up study protocol and 471 (65%) completed at least one part of the protocol.
Miranda Van Hooff 2010
Assessment 1
Bushfire Survivors 2 months post bushfire 520 children aged 7-12
Comparison Group
288 children aged 5-6 join the study
Assessment 2 374
children 8 months post bushfire unable to Assessment 1 808 children aged 5-12 be contacted 16 months post due to 2 bushfire schools 734 socio- declining demographically to similar unexposed Assessment 3 participate children aged 5 to 12 26 months post bushfire
434 children aged 7-14 2 children
removed 9 children
from removed
follow-up from
sample due follow-up
to missing sample due
data to missing
data
Assessment 4 Assessment 2
20 years post bushfire 20 years post 806 children completing either bushfire assessment 1 or 2 725 children who have completed
Figure 5.1: Flow diagram of study participants involved in the study. The green box represents the current study.
Miranda Van Hooff 2010 5.2.3 Withdrawals
Considering the sensitive and personal nature of some of the assessment items and the time commitment required to complete the protocol, the withdrawal rate in this study was unexpectedly low. Only 8% of those contacted 20 years following the fires (N=111) withdrew or were withdrawn by the investigators once participant consent had been obtained. As anticipated, almost half (44%, N=39) of these participants withdrew due to the personal nature of the questions and a further 26% (N=23) of participants withdrew due to other time commitments. Sixteen participants (18%) withdrew without providing a reason, six (7%) participants withdrew on the basis that they could not see the relevance of the assessment questions, three (3%) participants withdrew due to an interviewer error, and one person withdrew because they felt they would not receive any personal benefit from participating.
Additionally a further 23 participants were withdrawn by the investigators due to repeated missed appointments.
5.2.4 Participants who could not be contacted
Overall the tracking method employed was highly successful given the large interval between assessments. Only 92 (11.4%) participants in the bushfire group and 103 (14.2%) of the comparison group were unable to be recontacted for follow-up. For most participants (N=158) this was due to the researchers being unable to track them using their previous identifying information. An additional six participants (3% of the entire sample) were located but could not be contacted by phone and did not respond to written correspondence, seven (4%) participants did not reply to repeated phone messages, nine (5%) participants were currently living overseas and could not be contacted through written correspondence, two (1%) participants were located, recruited and booked in for an interview but avoided repeated
Miranda Van Hooff 2010 attempts to be interviewed and finally 13 (7%) participants could not be located due to time and funding constraints.
The largest cause of attrition was from participants who were not interested in the study and who declined to participate upon first point of contact. In total 148 (9.7% of the entire follow- up sample), declined for this reason.
5.2.5 Deceased
Causes and rates of death in the study population were obtained through the Australian
National Death Index (NDI) and are presented in Table 5.1. Deaths were categorised according to the codes of death and hospitalisation from the International Classification of
Diseases (ICD) Version 9 (for deaths occurring prior to 1997) and version 10 (for deaths occurring from 1997 onwards).
Eighteen (1.1%) of the original 1531 study participants were identified and confirmed as deceased using the NDI. Details of the deceased participants are provided in Table 6. The most common causes of death in this population were motor vehicle accidents comprising
44% of all deaths, followed by suicide (22%). All but one motor vehicle victim was male. A comparison of mortality rates in the bushfire group and the comparison group found
2 significantly higher rates of mortality in those affected by the fires (χ 1= 4.62, p < .05).
Miranda Van Hooff 2010 Table 5.1: Details of the deceased participants (N=18)
Group ICD Code Cause of Death Age Sex
Bushfire E812.1 MVA – Passenger 10 M
Bushfire E816.0 MVA – driver 20 M
Bushfire E816.0 MVA – driver 25 M
Bushfire V89.2 MVA – unspecified 21 M
Bushfire V03.9 MVA - pedestrian 25 M
Bushfire V23.4 MVA - motorcycle rider 28 M
Bushfire V47.5 MVA – driver 29 F
Bushfire E953.0 SUICIDE – hanging 20 M
Bushfire X70 SUICIDE – hanging/strangulation/ suffocation 25 M
Bushfire X70 SUICIDE – hanging/strangulation/ suffocation 28 F
Bushfire E910.9 Accidental drowning and submersion 18 M
Bushfire C71.1 Malignant neoplasm of brain – frontal lobe 30 M
Bushfire C81.9 Malignant neoplasm of lymphoid, haematopoietic 27 F
and related tissue- Hodgkin’s disease, unspecified
Bushfire 161.9 Intra-cerebral hemorrhage, unspecified 28 F
Control E815.0 MVA - Driver 20 M
Control E955.1 Suicide – shotgun 17 F
Control E493.9 Asthma – chronic lower respiratory disease 13 M
Control G03.9 Meningitis, unspecified [arachnoiditis (spinal)] 30 F
Notes: MVA, Motor Vehicle Accident; ICD, International Classification of Diseases.
5.3 Responders and non-responders
A comparison of the 1011 responders and the 520 non-responders was carried out using data collected at phases 1-3 of the study and are presented in Table 5.2.
Miranda Van Hooff 2010 2 Non-responders were more likely to be male (χ 1=4.02, p = 0.04), to be from families with
2 2 three or more siblings (χ 1= 10.08, p = 0.04), and to have a disorder (χ 1 = 10.65, p = 0.001)
and higher mean scores (F1,1161 = 8.29, p = 0.004) as defined by teacher Rutter than responders.
Parental Rutter score and disorder categorisation showed a response by group interaction,
2 with responders in the bushfire group more likely than non-responders to have a disorder (χ 1
= 4.81, p = 0.03) (and a higher score, F1,773 = 6.62, p = 0.01) whereas responders in the control group were less likely to have a disorder (and had a lower score). In the bushfire group alone, non-responders were less exposed to the bushfire (in terms of death, injuries or property
damage) than responders (F1,512 = 9.08, p = 0.003).
Miranda Van Hooff 2010 Table 5.2: A comparison of responders and non-responders
Bushfire Control P-value Participant Overall Non- Bushfire Non- Control Non- P-value P-value Inter- Characteristic Responders Responders Responders Responders Responders Responders Response Group action
n=1011 n=520 n=540 n=266 n=471 n=254
Sex: 0.04 0.97 0.93
Male 507 (50.1) 289 (55.6) 270 (50.0) 148 (55.6) 237 (50.3) 141 (55.5)
Female 504 (49.9) 231 (44.4) 270 (50.0) 118 (44.4) 234 (49.7) 113 (44.5)
Age at bushfire 8.0 (2.3) 7.9 (2.4) 8.4 (2.3) 8.4 (2.4) 7.4 (2.1) 7.4 (2.3) 0.84 <0.0001 0.60 (years)
Number of 0.04 <0.0001 0.52 siblings:
Unknown 294 (29.1) 164 (31.5) 194 (35.9) 104 (39.1) 100 (21.2) 60 (23.6)
0 siblings 33 (3.3) 22 (4.2) 19 (3.5) 8 (3.0) 14 (3.0) 14 (5.5)
1 sibling 305 (30.2) 133 (25.6) 121 (22.4) 53 (19.9) 184 (39.1) 80 (31.5)
2 siblings 256 (25.3) 115 (22.1) 137 (25.4) 52 (19.5) 119 (25.3) 63 (24.8)
3 or more 123 (12.2) 86 (16.5) 69 (12.8) 49 (18.4) 54 (11.5) 37 (14.6) siblings
Highest Parental 0.09 <0.0001 0.26
Occupation (ASCO):
Unknown 478 (47.3) 260 (50.0) 377 (69.8) 198 (74.4) 101 (21.4) 62 (24.4)
1: Manager 203 (20.1) 79 (15.2) 78 (14.4) 32 (12.0) 125 (26.5) 47 (18.5)
2: Professional 78 (7.7) 20 (3.8) 11 (2.0) 1 (0.4) 67 (14.2) 19 (7.5)
3: Associate 53 (5.2) 35 (6.7) 11 (2.0) 6 (2.3) 42 (8.9) 29 (11.4)
Professional
4: Tradesperson 69 (6.8) 27 (5.2) 10 (1.9) 6 (2.3) 59 (12.5) 21 (8.3)
5-8: Clerical 53 (5.2) 36 (6.9) 17 (3.1) 7 (2.6) 36 (7.6) 29 (11.4)
9: Labourer 44 (4.4) 34 (6.5) 18 (3.3) 10 (3.8) 26 (5.5) 24 (9.4)
Unemployed or 5 (0.5) 4 (0.8) 3 (0.6) 1 (0.4) 2 (0.4) 3 (1.2) Pension
Home Duties 28 (2.8) 25 (4.8) 15 (2.8) 5 (1.9) 13 (2.8) 20 (7.9)
Miranda Van Hooff 2010 131 Bushfire Control P-value Participant Overall Non- Bushfire Non- Control Non- P-value P-value Inter- Characteristic Responders Responders Responders Responders Responders Responders Response Group action
Parent Rutter:
Total Score 5.6 (2-7) 6.6 (3-9) 5.0 (1-7) 3.9 (1-6) 5.9 (3-8) 7.4 (4-10) 0.32 <0.0001 0.01
Disorder 49 (9.3) 31 (12.4) 15 (9.3) 1 (1.7) 34 (9.3) 30 (15.6) 0.27 0.03 0.03
Teacher Rutter:
Total Score 2.3 (0-3) 3.6 (0-6) 1.4 (0-2) 1.9 (0-3) 2.9 (0-4) 4.6 (0-7) 0.004 <0.0001 0.14
Disorder 14 (1.8) 26 (6.8) 0 (0.0) 4 (2.9) 14 (3.0) 22 (9.0) 0.001 0.03
Exposure to the bushfire:
Total exposure 1.5 (0-2) 0.9 (0-1) 0.003
Any exposure 150 (42.5) 49 (30.4) 0.01
Notes: Values are number (%) of subjects, mean (sd) or median (interquartile range); ASCO, Australian Standard Classification of Occupations; level of exposure to the bushfire is based on sum of property and personal loss items, Rutter scores represent baseline scores.
Miranda Van Hooff 2010 132
6 Impact of childhood exposure to a natural disaster on adult mental health: 20-year longitudinal follow-up study
6.1 Commentary:
The following chapter is a paper that has been recently published in the British Journal of
Psychiatry: (McFarlane, AC and Van Hooff, M. (2009). Impact of childhood exposure to a natural disaster on adult mental health: 20-year longitudinal follow-up study. British Journal of Psychiatry, 195: 142-148). Signed statements regarding each author’s personal contribution to this paper and permission from the co-author of this paper for it to be included in this thesis is provided in Appendix K.
This chapter addresses the combined role of the disaster exposure and the impact of post- disaster behavioural problems on lifetime and current prevalence of DSM-IV anxiety, depressive and eating disorders assessed 20 years after a disaster. The overall aim of this paper is to investigate the adult psychiatric outcomes of childhood exposure to a major
Australian bushfire in the context of other lifetime trauma by utilising an unexposed control sample recruited at the time of the initial disaster.
The relevance of this chapter to the overall thesis lies primarily in the sample composition. In contrast to chapters 7 and 8, which utilise a sub-sample of 677 participants with a complete data set across phases 1, 2, 3 and 4 of the study, chapter 6 presents the findings of the entire sample of 1011 responders (N = 540 bushfire group, N = 471 control group). Most importantly therefore, findings presented in this chapter provide the most accurate report of both demographic findings and prevalence of disorder within this community.
Miranda Van Hooff 2010 133
Secondly, this paper compliments the overall theme of this thesis by comparing the risk of developing PTSD in bushfire participants (in relation to the bushfire) with the risk of developing PTSD in both the bushfire participants and the controls (in relation to a self nominated worst lifetime event). This is important to the subject matter presented in this thesis as it examines the disaster within the context of other lifetime trauma instead of treating the disaster as a discrete event. Consequently, the disaster emerges as a less potent predictor of PTSD in the disaster group compared to other self-nominated traumatic events raising an important issue regarding the methodology employed by previous longitudinal studies following childhood disaster exposure.
Finally this paper provides insight into the relative contribution of each of the PTSD symptom clusters to the development of bushfire related PTSD in the bushfire survivors and worst event PTSD in the bushfire survivors and controls.
This paper has been reformatted to be consistent with the overall presentation of the thesis.
Miranda Van Hooff 2010 134
McFarlane, A.C. and Van Hooff, M. (2009) Impact of childhood exposure to a natural disaster on adult mental health: 20-year longitudinal follow-up study. British Journal of Psychiatry, v. 195 (2), pp. 142-148
NOTE: This publication is included in the print copy of the thesis held in the University of Adelaide Library.
It is also available online to authorised users at:
http://dx.doi.org/10.1192/bjp.bp.108.054270
7 Risk factors for the development of post-disaster psychopathology Part 1: aims, literature and sample description
7.1 Aims
The following two chapters (chapters 7 and 8) provide a detailed examination of the predictors of poor long-term psychological outcomes in children exposed to the Ash
Wednesday Bushfires. This will be undertaken using a conceptual risk factor model originally developed by Korol, Green and colleagues (Green, Korol et al. 1991; Korol, Green et al.
1999) using data obtained in relation to the Buffalo Creek Dam collapse. This framework identifies four factors that have been reported in the wider disaster literature to influence children’s post-disaster reactions: (a) characteristics of the stressor (life threat and level of exposure to the disaster), (b) characteristics of the child (demographics, pre-disaster functioning), (c) characteristics of the post-disaster environment (additional life events, parental reactions to the fire) and (d) the child’s efforts to process and cope with disaster- related distress.
Prior studies utilising this model, have shown that each of these factors, when entered into a regression model, accounted for 39.1% to 62% of the variance in PTSD scores, with the addition of each new factor improving the overall prediction of PTSD. In each of these papers, over half of the variance in PTSD scores was accounted for by the level of exposure to the disaster (in relation to life threat and loss/disruption) alone, suggesting that it is the level of exposure to the disaster that has the strongest influence over children’s posttraumatic stress responses in the short term (La Greca, Silverman et al. 1996; La Greca, Silverman et al.
1998).
Miranda Van Hooff 2010 156 More recently, Pina et al (2008) extended this model to examine predictors of PTSD, anxiety and depression in 46 youth exposed to Hurricane Katrina, modifying the variables slightly to include measures of discrimination as well as familial-, extra-familial-, and professional– support. Extra-familial social support predicted all three disorders, indicating that youth with
PTSD were also those most likely to seek help from friends, co-workers and church members.
Professional support predicted PTSD, whereas avoidant coping style predicted both PTSD and anxiety. Discrimination, familial social support and active coping did not emerge as significant predictors in any of the models. Results of this study however, should be considered in the context of the small sample size employed in this study (Pina, Villalta et al.
2008).
Drawing on this research, the following two chapters (chapters 7 and 8) further extend the work of these authors by including additional lifetime traumatic events and lifetime DSM-IV disorder in order to examine the relative contribution of child characteristics, disaster related factors, and other disorders to the development of PTSD and other psychopathology following the Ash Wednesday Bushfires.
This model will extend this prior research in the following ways:
(1) By examining the strength of this model in predicting the long-term development of
psychopathology over a 20-year period
(2) By extending this model to the prediction of lifetime and current DSM-IV PTSD in
addition to self-reported posttraumatic stress symptoms
(3) By extending this model to the prediction of PTSD associated with the participant’s
worst lifetime event
Miranda Van Hooff 2010 157 (4) By applying this model to the prediction of other lifetime and current DSM-IV anxiety
and depressive disorders
(5) By extending aspects of the immediate post-disaster period to include child emotional
and behavioural problems and parental reactions to the disaster as potential risk factors
for adult psychopathology
(6) By extending aspects of the recovery environment to include family functioning (in
relation to the level of family distress and involvement)
(7) By extending the examination of lifetime stressors to include a lifetime history of
Criterion A1 events occurring both prior and after the Ash Wednesday Bushfires in
1983.
Due to the small number of PTSD cases resulting from the bushfire (N=4) and the limitations this imposes on statistical power in logistic regression, multivariate predictors of PTSD will only be examined for PTSD associated with the participant’s worst event. Information provided on bushfire related PTSD is for descriptive purposes only.
To incorporate the breadth of the information presented in this model, the findings are reported across two chapters. Accordingly, chapter 7 provides a comparison of these risk factors in the bushfire and the control group. Chapter 8 provides details of the how the overall model performs in the sample.
The following chapter is separated into four primary sections. The first section provides a very brief summary of the risk factor literature in relation to childhood disaster exposure. The second section defines the sample and reports on the demographic characteristics of the longitudinal sample used in the analysis. The third section provides a detailed comparison of the bushfire and control group on each of the four factors of the model. The final section
Miranda Van Hooff 2010 158 provides a summary of the findings. A more thorough examination of the findings in relation to the published literature will be undertaken in the final chapter of this thesis (chapter 10) to limit replication.
7.2 Brief review of the background literature
The following section will begin with a brief summary of the key papers examining risk factors that contribute to the development of long-term adult psychopathology following childhood disaster exposure. A more detailed review of the literature relevant to this chapter can be found in section 2.6.
There are a number of risk and protective factors that mediate a child’s short and long-term psychological response to a disaster. Although transient mild stress reactions should be expected following exposure to a disaster, the duration, course and magnitude of these symptoms assist in determining whether these reactions are atypical.
7.2.1 Factor 1: Characteristics of the stressor
The most intensely researched risk factor in the development of psychopathology following childhood disaster exposure is the level of exposure to the disaster and includes the individual’s physical proximity to the trauma (including personal and property loss), loss experienced by a family member or close associate, degree of physical injury to self and secondary adversity and traumatic reminders which occur in the aftermath of the event
(Pfefferbaum 2005). Several studies have supported a “dose of exposure” pattern of psychopathology, such that the number of PTSD symptoms, is congruent with the child’s level of exposure to the disaster (Pynoos, Frederick et al. 1987; Nader, Pynoos et al. 1990;
Pynoos, Goenjian et al. 1993; Goenjian, Pynoos et al. 1995; Pfefferbaum, Nixon et al. 1999;
Miranda Van Hooff 2010 159 Pfefferbaum, Seale et al. 2000; Goenjian, Molina et al. 2001; Groome and Soureti 2004;
Goenjian, Walling et al. 2005; Hoven, Duarte et al. 2005; Vijayakumar, Kannan et al. 2006;
Chemtob, Nomura et al. 2008). This pattern of response however is associated more with the actual level of exposure as opposed to the participant’s perceived level of exposure (Goenjian,
Molina et al. 2001) and is attenuated by other lifetime traumatic events (Chemtob, Nomura et al. 2008). Some studies suggest that exposure to certain aspects of a disaster may have a cumulative effect. PTSD, for example, has reported to be more prevalent in individuals with injuries to both self and family members than in those experiencing only one of these events
(Godeau, Vignes et al. 2005).
Death or injury to a family member or friend (more specifically a parent or sibling), number of known deceased, and the closer the relationship with the victim has been found to magnify symptoms in childhood disaster survivors (Pynoos, Frederick et al. 1987; Milgram, Toubiana et al. 1988; Nader, Pynoos et al. 1990; Pynoos, Goenjian et al. 1993; Green, Grace et al. 1994;
Goenjian, Pynoos et al. 1995; Winje and Ulvik 1998; Pfefferbaum, Nixon et al. 1999; Hsu,
Chong et al. 2002), with the number of family members injured having a direct relationship to the severity of intrusion symptoms.
For a more detailed summary of the types of exposure variables most likely to influence outcome please see section 2.6.2
7.2.2 Factor 2: Characteristics of the child
7.2.2.1 Sex
Consistent with the literature on adult trauma survivors, girls have been reported to have more severe posttraumatic stress reactions and to be at greater risk of developing PTSD following
Miranda Van Hooff 2010 160 exposure to a disaster than boys (Goenjian, Pynoos et al. 1995; Pfefferbaum, Nixon et al.
1999; Pfefferbaum, Doughty et al. 2002; Pfefferbaum, Sconzo et al. 2003; Goenjian, Walling et al. 2005) (Milgram, Toubiana et al. 1988; Green, Korol et al. 1991) (John, Russell et al.
2007) (Garrison, Weinrich et al. 1993) (Shannon, Lonigan et al. 1994) (Vernberg, Silverman et al. 1996), (Weems, Pina et al. 2007) (Pynoos, Goenjian et al. 1993) (Hsu, Chong et al.
2002) (Groome and Soureti 2004; Roussos, Goenjian et al. 2005; Giannopoulou, Strouthos et al. 2006) (Kilic, Ozguven et al. 2003). In general, boys display externalising behaviours that are antisocial, violent (including vengeful thoughts), or aggressive and take longer to recover from these symptoms (Hoven, Duarte et al. 2005; Lengua, Long et al. 2005; Roussos,
Goenjian et al. 2005). Girls, on the other hand, display more internalising behaviours such as anxiety and disturbances of mood and are more likely to express their feelings about the disaster than boys (American Academy of Pediatrics Work Group on Disasters 1995; Pine and Cohen 2002; Hagan 2005). In particular girls with higher intrusion scores are more likely to experience later depression (Winje and Ulvik 1998). Other childhood disaster studies show no relationship between sex and the development of post-disaster psychopathology (Shaw,
Applegate et al. 1995; La Greca, Silverman et al. 1996; La Greca, Silverman et al. 1998;
Kolaitis, Kotsopoulos et al. 2003; Vijayakumar, Kannan et al. 2006).
7.2.2.2 Age
Age related effects have been observed following both natural and manmade disasters with younger children most likely to exhibit symptoms of PTSD and other post-disaster psychopathology (Kar, Mohapatra et al. 2007; Piyavhatkul, Pairojkul et al. 2008). Other studies have reported fewer symptoms in younger children due to an inability to conceptualise the true magnitude of the event, and different post-disaster responses at different developmental ages.
Miranda Van Hooff 2010 161 7.2.2.3 Pre-disaster functioning
Pre-disaster anxiety, inattentiveness and poor academic skills have been reported to increase a child’s risk of developing psychopathology following a disaster (Pynoos, Frederick et al.
1987; Lonigan, Shannon et al. 1994; La Greca, Silverman et al. 1998; Hock, Hart et al. 2004).
These symptoms have been reported to both increase the number of PTSD symptoms as well as impede recovery by slowing the decline in symptoms over time (La Greca, Silverman et al.
1998; Weems, Pina et al. 2007). Furthermore, pre-disaster anxiety has been reported to be a stronger predictor of anxiety and depressive disorders post-disaster than the level of disaster exposure (Asarnow, Glynn et al. 1999).
7.2.3 Factor 3: Characteristics of the post-disaster environment
7.2.3.1 The child’s emotional and behavioural response to the disaster
The child’s immediate emotional response to the disaster is one risk factor that has received considerable attention in the literature to date. Reactions manifested in high levels of separation anxiety (Goenjian, Pynoos et al. 1995; Terr, Bloch et al. 1999), mourning (Tyano,
Iancu et al. 1996) anxiety, depression, fear, guilt and amnesia (Udwin, Boyle et al. 2000), guilt over acts of omission and/or commission (Goenjian, Pynoos et al. 1995), fear of death, level of panic, feelings of fear (Udwin, Boyle et al. 2000) and emotions such as sadness, worry, and loneliness (Lonigan, Shannon et al. 1994) have been reported to influence not only the development of PTSD but also the onset, duration and severity of the disorder.
Interestingly, the child’s perception of the severity of the disaster has also been reported to influence individual outcomes, with more home damage being reported in younger children
(Shannon, Lonigan et al. 1994) , and more severe peri-traumatic reactions being noted in females (Pfefferbaum, North et al. 2003).
Miranda Van Hooff 2010 162 7.2.3.2 Family functioning and home environment
Secondary adversities and dysfunction occurring within the context of the family can serve to trigger and intensify symptoms. McFarlane noted the importance of family cohesiveness in the 2-year follow-up of Ash Wednesday bushfire victims. In this report families who were separated from each other in the first three days following the fires (due to parents sending their children out of the district in order to allow them to concentrate on salvaging the property and disposing of injured stock), reported more enduring family problems in the post- disaster period. McFarlane suggests that this is due to the family being unable to share in their immediate reactions to the disaster (McFarlane 1987).
7.2.3.3 Parent reactions
The way the child’s caregivers respond to the disaster can by a major risk factor for the development of post-disaster psychopathology in children. In the face of trauma, children depend almost entirely on their parents for guidance and support and often mimic their parents reactions to the event (Wooding and Raphael 2004). Parents who appear overanxious, hysterical, distressed, and worrisome following a disaster generally report having children with poorer psychological outcomes. Following the Ash Wednesday Bushfires in 1983, continuing maternal preoccupation with the fires, and changed family functioning better predicted the children’s posttraumatic stress symptoms 26 months after the bushfire than the child’s level of exposure to the fire in relation to personal and property loss (McFarlane,
1987).
Miranda Van Hooff 2010 163 7.2.4 Factor 4: Additional lifetime trauma and psychopathology
Finally, a number of studies have reported elevated rates of other traumatic events in adults with posttraumatic stress disorder (Bremner, Southwick et al. 1993; Zaidi and Foy 1994;
Breslau, Chilcoat et al. 1999), but few have specifically focused on disaster populations, especially children. One study by Chemtob et al (2008) reported elevated rates of anxiety, inattention and depression in children following the World Trade Centre attacks, but only in those with a combination of both high intensity exposure as well as other lifetime trauma
(Chemtob, Nomura et al. 2008). This finding was extended by Mullet-Hume et al, 2008 who surmised that it is the combination of the number of other lifetime traumas and the level of disaster exposure that predicted subsequent psychopathology following a disaster, with those with a medium to high number of other traumas being more affected by these traumas than the level of exposure to the disaster. Despite these studies however, the exact nature of the relationship between additional traumatic events and post-disaster psychopathology remains unclear.
7.3 Methodology
7.3.1 Defining the sample
This chapter utilises a sub-sample of 677 participants (328 bushfire survivors and 349 control participants) with data from Phase 1, 2 and 3 as well as follow up data (Phase 4). To maximise the sample and to avoid the confounding effects of prior assessment, the first assessment scores on the behavioural measures (Rutter parent and teacher questionnaire) were used in the current analysis. This data was extracted from questionnaires administered as part of Phase 1, 2 and 3 of the study. Participants missing either their 1st assessment data or their
20-year follow-up data were excluded from the analysis in order to maintain cell numbers in the longitudinal analyses. The sample will be referred to herein as the longitudinal sample.
Miranda Van Hooff 2010 164 7.3.1.1 Sample representiveness
To determine if the sample used in this analysis (the longitudinal sample) was representative of the entire follow-up sample (N=1011), primary unadjusted analysis chi-square analyses
(for categorical variables) and t-tests or linear regression (for continuous variables) were performed on all demographic data and are presented in Table 7.1. Six hundred and seventy- seven (67%) of the 1011 participants, who completed Phase 4 of the study, had the relevant data from one of the first three phases of the study and hence were included in the longitudinal sample. To account for the possible confounding effects of age and sex (known to be strong predictors of adult psychopathology), as well as the number of months between the fire and the first assessment, adjusted p-values were calculated using generalised estimating equations. The mean number of months between the bushfire and the first assessment data in the bushfire group and the mean number of months between the bushfire and the first assessment data in the control group was not significantly different (15.71months in the bushfire group compared to 15 months in the control group).
Miranda Van Hooff 2010 165 Table 7.1: A comparison of demographic characteristics of participants in the longitudinal sample (N=677) and not in the longitudinal sample (N=334)
Unadjusted Adjusted Not in Sample In Sample P-value P-value
Total sample n=334 n=677
Number of participants n=262 n=576 completing both interview and self-report booklet
Years since fire 20.8 (0.6) 20.8 (0.6) 0.90
Sex 0.17 0.18
Male 132 (50.4) 261 (45.3)
Female 130 (49.6) 315 (54.7)
Age (years) 28.5 (2.5) 28.2 (2.2) 0.10
Marital status
Married 104 (39.7) 235 (40.8) 0.76 0.40
Separated 11 (4.2) 8 (1.4) 0.01 0.02
Divorced 3 (1.1) 11 (1.9) 0.42 0.34
Never married 73 (27.9) 172 (29.9) 0.56 0.80
De facto 71 (27.1) 150 (26.0) 0.75 0.65
Children 110 (42.0) 195 (33.9) 0.02 0.09
Current residential address
Urban (Pop >= 100,000) 78 (29.8) 229 (39.8) 0.01 0.01
Miranda Van Hooff 2010 166 Unadjusted Adjusted Not in Sample In Sample P-value P-value
Rural (Pop=10,000- 166 (63.4) 317 (55.0) 0.02 0.03
99, 999)
Remote (Pop<10,000) 16 (6.1) 20 (3.5) 0.08 0.09
Overseas 1 (0.4) 9 (1.6) 0.14 0.15
Number of times moved 8.9 (5.9) 8.7 (6.1) 0.69 0.84
Education
Completed year 12 164 (62.6) 424 (73.6) 0.001 0.003
Attained tertiary 49 (18.7) 181 (31.4) 0.0001 0.0002 qualifications
Occupation
ASCO: Manager 22 (8.4) 50 (8.7) 0.89 0.69
ASCO: Professional 44 (16.8) 138 (24.0) 0.02 0.03
ASCO: Associate 30 (11.5) 81 (14.1) 0.30 0.33 professional
ASCO: Tradesperson 37 (14.1) 55 (9.5) 0.05 0.05
ASCO: Advanced clerical 15 (5.7) 37 (6.4) 0.70 0.74
ASCO: Intermediate 26 (9.9) 44 (7.6) 0.27 0.24 clerical
ASCO: Intermediate 16 (6.1) 24 (4.2) 0.22 0.24 production
ASCO: Elementary 1 (0.4) 6 (1.0) 0.33 0.35 clerical
ASCO: Labourer 26 ( 9.9) 54 ( 9.4) 0.80 0.79
Miranda Van Hooff 2010 167 Unadjusted Adjusted Not in Sample In Sample P-value P-value
Employment
Currently employed 210 (80.2) 473 (82.1) 0.50 0.57
Home duties 29 (11.1) 57 ( 9.9) 0.60 0.73
Student 3 (1.1) 8 (1.4) 0.77 0.80
Unemployed 6 (2.3) 17 (3.0) 0.59 0.61
Hours worked per week 38.5 (16) 38.6 (16) 0.97 0.96
Annual household income
Income Up to $12,000 4 (1.5) 14 (2.4) 0.40 0.42
Income $12,001-$20,000 8 (3.1) 17 (3.0) 0.94 0.91
Income $20,001-$30,000 23 (8.8) 37 (6.4) 0.22 0.22
Income $30,001-$40,000 31 (11.8) 69 (12.0) 0.95 0.96
Income $40,001-$50,000 32 (12.2) 71 (12.3) 0.96 1.00
Income $50,001-$60,000 29 (11.1) 70 (12.2) 0.65 0.64
Income $60,001-$80,000 52 (19.8) 97 (16.8) 0.29 0.35
Income More than 39 (14.9) 144 (25.0) 0.001 0.001 $80,000
Income don't know 16 (6.1) 19 (3.3) 0.06 0.06
Income private 28 (10.7) 38 (6.6) 0.04 0.04
Income government or disability 21 (8.0) 36 (6.3) 0.35 0.34 assistance
Notes: Values are number (%) of subjects or mean (sd), adjusted for age (except for age section), analyses using demographic data from the self-report booklet use a slightly smaller sample due to a small proportion of study participants not returning their completed booklet.
Miranda Van Hooff 2010 168 Overall there were few relevant differences between the participants in the longitudinal study and those who were not. The sub-sample with complete data (N = 677) were slightly more educated (having completed year 12 χ2 (1) 8.57, p = 0.003 and gone on to gain tertiary qualifications χ2 (1) = 14.05, p = 0.0002), were more likely to be employed in professional occupations χ2 (1) =5.01, p = 0.025, had family incomes greater than $80, 000 per year χ2 (1)
=10.68, p = 0.001 and were more likely to live in urban χ2 (1) =7.29, p = 0.006 as opposed to rural areas.
As a consequence of the control group being recruited after commencement of the 8 month follow-up assessment in the bushfire group there was a significant difference between the mean number of months between the bushfire and completion of the 1st assessment Rutter questionnaires t (327) = -31.7, p < 0.0001. The mean number of months between the bushfire and the 1st assessment in the bushfire group (M = 6.52, SD = 4.84) was significantly less than the number of months between the bushfire and assessment in the controls (M =15, SD = 0).
This will therefore be controlled for in the relevant analyses in this chapter.
The following sections compare the demographic and risk factor characteristics in the bushfire and control group for participants in the longitudinal sample (N=677).
7.3.1.2 Demographics at follow-up
Table 7.2 compares demographic characteristics of the bushfire group and the control group in the longitudinal sample. Overall the bushfire group worked less hours per week, t (1) =
2.10, p = 0.04 and moved residences less t (1) = 2.67, p = 0.001. In contrast, a higher proportion of the control participants were currently employed in associate professional roles
(χ2 (1) = 5.50, p < 0.019).
Miranda Van Hooff 2010 169 Table 7.2: A comparison of adult demographics in the longitudinal bushfire group (N=328) and control group (N=349)
Adjusted P- Bushfire Control value
Total sample n=328 n=349
Number of participants completing both n=280 n=296 interview and self-report booklet
Years since fire 20.7 (0.6) 20.8 (0.6)
Sex 0.98
Male 127 (45.4) 134 (45.3)
Female 153 (54.6) 162 (54.7)
Age (years) 28.5 (2.3) 27.9 (2.1)
Marital Status
Married 121 (43.2) 114 (38.5) 0.81
Separated 3 (1.1) 5 (1.7) 0.55
Divorced 4 (1.4) 7 (2.4) 0.26
Never Married 82 (29.3) 90 (30.4) 0.57
De Facto 70 (25.0) 80 (27.0) 0.70
Children 110 (39.3) 85 (28.7) 0.10
Current residential address
Urban (Pop >= 100,000) 100 (35.7) 129 (43.6) 0.06
Miranda Van Hooff 2010 170 Adjusted P- Bushfire Control value
Rural (Pop = 10,000-99,999) 165 (58.9) 152 (51.4) 0.07
Remote (Pop < 10,000) 10 (3.6) 10 (3.4) 0.93
Overseas 4 (1.4) 5 (1.7) 0.64
Lifetime number of times moved 8.2 (5.2) 9.2 (6.8) 0.01
Education
Completed year 12 196 (70.0) 228 (77.0) 0.17
Attained tertiary qualifications 85 (30.4) 96 (32.4) 0.62
Occupation
ASCO: Manager 23 (8.2) 27 (9.1) 0.43
ASCO: Professional 62 (22.1) 76 (25.7) 0.40
ASCO: Assoc. professional 29 (10.4) 52 (17.6) 0.02
ASCO: Tradesperson 32 (11.4) 23 (7.8) 0.19
ASCO: Advanced clerical 16 (5.7) 21 (7.1) 0.54
ASCO: Intermediate clerical 21 (7.5) 23 (7.8) 0.89
ASCO: Intermediate production 16 (5.7) 8 (2.7) 0.07
ASCO: Elementary clerical 4 (1.4) 2 (0.7) 0.41
ASCO: Labourer 28 (10.0) 26 (8.8) 0.61
Employment
Currently employed 229 (81.8) 244 (82.4) 0.99
Home duties 29 (10.4) 28 (9.5) 1.00
Student 3 (1.1) 5 (1.7) 0.59
Unemployed 9 (3.2) 8 (2.7) 0.57
Miranda Van Hooff 2010 171 Adjusted P- Bushfire Control value
Hours worked per week 37.1 (16) 39.9 (16) 0.04
Annual household income
Income up to $12,000 8 (2.9) 6 (2.0) 0.44
Income $12,001-$20,000 10 (3.6) 7 (2.4) 0.28
Income $20,001-$30,000 14 (5.0) 23 (7.8) 0.19
Income $30,001-$40,000 33 (11.8) 36 (12.2) 0.84
Income $40,001-$50,000 33 (11.8) 38 (12.8) 0.81
Income $50,001-$60,000 38 (13.6) 32 (10.8) 0.31
Income $60,001-$80,000 57 (20.4) 40 (13.5) 0.06
Income more than $80,000 63 (22.5) 81 (27.4) 0.15
Income don't know 9 (3.2) 10 (3.4) 0.98
Income private 15 (5.4) 23 (7.8) 0.33
Recipient of government or disability 21 (7.5) 15 (5.1) 0.20 assistance
Notes: Values are number (%) of subjects or mean (sd), adjusted for age (except for age section), analyses using demographic data from the self-report booklet use a slightly smaller sample due to a small proportion of study participants not returning their completed booklet.
Miranda Van Hooff 2010 172 7.4 Results
7.4.1 Factor 1: Characteristics of the stressor
Data comprising factors 1 to 3 was collected within the first 2 years following the Ash
Wednesday Bushfires in 1983.
7.4.1.1 Level of exposure to the Ash Wednesday bushfires
Table 7.3 outlines the total property and personal loss experienced by children in the bushfire group. In total 42.4% of participants reported some degree of property or personal loss following the fires, 35% experienced property loss and 22% percent had a family member or friend injured or killed in the fires.
Using methodology outlined in McFarlane (1987), personal losses were weighted according to the nature of the relationship of the victim to the child and the severity of the loss (i.e. injury to mother, father or sibling = 3, injury to grandparent or other relative = 2, injury to parent’s or child’s own friend = 1; death of mother, father or sibling = 6, death of grandparent or other relative = 4, death of parent’s or child’s own friend = 2). Weighted scores for all of these losses were then added to produce a measure of total personal loss. The mean weighted score for personal loss in the bushfire group was 0.72 (SD = 1.61, Range 0 to 11).
Property loss items were weighted according to the amounts of practical assistance required to reparate for losses which was devised from a survey conducted on a special team of 20 bushfire relief workers appointed to assist the Ash Wednesday Bushfire victims in 1983
(McFarlane 1987) (i.e. house destroyed = 4, house damaged = 2, property effecting livelihood damaged or destroyed = 3, car damaged or destroyed =1, house threatened = 1, stock injured
Miranda Van Hooff 2010 173 or killed = 1, pets injured or killed = 1). Weighted scores for all of these losses were then added to produce a measure of total property loss. The mean weighted score for property loss in the bushfire group was 1.71 (SD=2.64, Range 0-10). Items in both subscales were then summed to produce a measure of total personal and property loss.
Approximately 30% of the children were on the school bus at the time of the fires and were therefore separated from their parents. Nine percent came close to injury on the day of the fires.
7.4.2 Factor 2: Characteristics of the child at the time of fires
Bushfire children were significantly older at the time of the bushfire (M = 8.33, SD = 2.24) compared to children from the unexposed comparison sample (M = 7.44, SD = 2.01); t (656)
= 5.44, p < 0.0001, with ages ranging from 3.23 years to 13.49 years in the bushfire group and
3.94 to 11.75 in the control group
The entire sample consisted of 331 males (N=163 in the bushfire group and N=168 in the control group) and 346 females (N=165 in the bushfire group, and N=181 in the controls).
There were no significant differences between the number of males and females in the bushfire and control group
7.4.3 Factor 3: Characteristics of the post disaster environment
7.4.3.1 Childhood emotional and behaviour problems
Both parents and teachers of children in the bushfire and control group reported child behaviour problems (on the Rutter) following the bushfires. For the purpose of this chapter
Miranda Van Hooff 2010 174 and to increase the sample size, each participant’s first assessment Rutter scores were used in the analyses.
Table 7.3: Frequency and proportion of participants in the bushfire group reporting specific exposures to the Ash Wednesday bushfires
Type of Loss N (%) Any property loss 111 (35.6%) House destroyed 17 (5.4%) House damaged 18 (5.8%) Family’s plant or farm machinery damaged or destroyed 47 (15.1%) Family car damaged or destroyed 10 (3.2%) Family’s sheds damaged or destroyed 67 (21.5%) Property damaged or destroyed 80 (25.6%) Livestock injured or killed 76 (24.4%) Pets injured or killed 45 (13.7%) House threatened but not damaged 42 (13.5%)
Any personal loss 74 (22.6 %) Parents or siblings injured 11 (3.5%) Parents or siblings killed 1 (0.3%) Grandparents or other relatives injured 19 (6.1%) Grandparents or other relatives killed 8 (2.6%) Friends or parent’s friends injured 14 (4.5%) Friends or parent’s friends killed 47 (15.1%)
Child on school bus during the fire (N=304) 90 (29.6%) Mother was close to being injured (N=306) 50 (16.3%) Father was close to being injured (N=306) 78 (25.5%) Child was close to being injured (N=306) 28 (9.2%)
Miranda Van Hooff 2010 175 Table 7.4 presents the percentage of participants in the bushfire and control group displaying each of the Rutter symptoms. The symptoms most frequently observed and reported by parents in both the bushfire and control groups were headaches (43.6% of bushfire group,
49% of controls), vomiting (35.6% of bushfire group, 46.7% of controls), worry (36.9% of bushfire group, 35.2% of controls) and disobedient behaviour (33.9% of bushfire group,
34.4% of controls). Symptoms most commonly observed and reported by teachers were poor concentration (21.6% of bushfire group, 22.9% of controls), worry (19.5% of bushfire group,
21.5% of controls), squirminess (18.6% of bushfire group, 22.6% of controls) and solitary behaviour (15.2% of bushfire group, 15.8% of controls). Chi square analyses revealed that a higher proportion of bushfire children were reported by their parents to be miserable, to stammer or stutter, to have temper tantrums and to be unable to settle. Children from the control group however were significantly more likely to have stomach pains or vomiting, and to tell lies. Teachers reported more lies, fussiness and over-particular behaviour in the control group than in the children from the bushfire group. Overall however, behaviour patterns in the bushfire and control group were remarkably similar (Figure 6.1).
Miranda Van Hooff 2010 176 Table 7.4: Proportion of children reporting each symptom type on the parent and teacher
Rutter questionnaire
Parent Rutter Teacher Rutter
P- P-
Bushfire Control Value Bushfire Control Value
% % % %
Neurotic behaviours
Often worriedab 37.0 35.2 0.634 19.5 21.5 0.524
Sleeping difficultya 21.6 17.2 0.143 0 0 NA
Tears at schoolab 4 5.5 0.364 2.7 4.0 0.363
Stomach ache / vomitinga 35.6 46.7 0.004 0 0 NA
Afraid of new thingsab 25.6 28.7 0.374 13.1 16 0.280
Miserableb 23.7 13.4 0.001 10 8.3 0.430
Antisocial behaviours
Steal thingsab 5.8 9.5 0.074 1.5 2.3 0.467
Destroys propertyab 7.9 8.9 0.654 3.3 1.4 0.100
Disobedientab 33.9 34.4 0.882 9.4 12.6 0.191
Often tells liesab 13.7 21.2 0.011 6.1 10.6 0.035
Bullies other childrenab 12.8 10.6 0.372 7.9 8 0.963
Fightsb 24.7 20.3 0.175 11.6 14 0.340
Other behaviours
Wets bed or pants 10.7 10.3 0.880 5.8 7.2 0.470
Loses controls of bowels 2.1 4.3 0.113 5.8 7.2 0.470
Truants from school 2.4 0.9 0.104 0.9 0.6 0.604
Miranda Van Hooff 2010 177 Parent Rutter Teacher Rutter
P- P-
Bushfire Control Value Bushfire Control Value
% % % %
Stammer or stutter 3.4 0.9 0.023 1.5 1.7 0.841
Speech difficulty 5.8 7.2 0.470 5.2 5.2 0.988
Restless 24.1 21.5 0.421 13.5 16.7 0.238
Squirmy 18.3 17.8 0.858 18.6 22.6 0.195
Not much liked 6.4 5.4 0.597 8.2 11.7 0.128
Solitary 20.8 16.6 0.169 15.2 15.8 0.853
Irritable 32.9 28.9 0.262 7.3 8 0.730
Twitches 2.1 2.3 0.889 0.9 2.6 0.101
Sucks thumb 9.5 6 0.094 2.7 1.2 0.130
Bites nails 22.9 26.7 0.255 3.3 4.8 0.322
Fussy or over particular 14.9 20.3 0.066 7.6 14 0.007
Often tells lies 13.7 21.2 0.011 6.1 10.6 0.035
Headaches 43.6 49 0.16 0 0 NA
Asthma wheezing 10.9 14.9 0.129 0 0 NA
Temper tantrums 31.7 24.4 0.033 0 0 NA
Eating difficulty 20.4 22.6 0.485 0 0 NA
Cannot settle 18.2 12 0.023 0 0
Trivial absences school 0 0 NA 4 1.1 0.019
Poor concentration 0 0 NA 21.6 22.9 0.690
Pains or aches 0 0 NA 7.9 7.2 NS a Parent Rutter b Teacher Rutter
Miranda Van Hooff 2010 178 Figure 6.1: Pattern of Rutter symptoms reported by parent and teachers in the 15 months following the bushfire
Miranda Van Hooff 2010 179 Using general estimating equations controlling for sex and the mean number of months between the bushfire and the first assessment, bushfire participants reported significantly higher on the Parent Rutter summary scales compared to controls (Table 7.5) and were significantly more likely to meet the cut-off for a neurotic disorder (Table 7.6). This effect however, was observed for females only with females in the bushfire group 4.42 times more likely to meet criteria for a neurotic disorder than females in the control group (Table 7.7).
Using a cut-off of 9 on the teacher scale, a significant effect of sex on Rutter behaviour problems emerged in the control group only, with males being most likely to meet criteria for an antisocial disorder (Tables 7.8 and 7.9). There was no significant effect of bushfire status on teacher rated Rutter problems.
Table 7.5: A comparison of Rutter summary scores in the bushfire and the control group
Parent Parent Teacher Teacher
Rutter Rutter Adjusted Rutter Rutter Adjusted
Bushfire Control P-value P-value Bushfire Control P-value P-value
Total Sample n=328 n=349 n=328 n=349
Total Score 6.36 (5.82) 6.01 (4.98) 0.393 0.017 2.35 (3.57) 2.75 (3.71) 0.153 0.615
Neurotic Score 1.39 (1.50) 1.42 (1.33) 0.777 0.077 0.51 (1.03) 0.57 (1.05) 0.469 0.920
Antisocial Score 0.83 (1.33) 0.89 (1.33) 0.565 0.913 0.44 (1.17) 0.55 (1.25) 0.234 0.902
Notes: P-values are adjusted of sex and number of months between bushfire and completion of first assessment Rutter questionnaire
Miranda Van Hooff 2010 180 Table 7.6: A comparison of the number of cases on the parent Rutter questionnaire in the
bushfire and the control group at first assessment
P-Value P-Value Main Main Bushfire Control Effect OR Effect OR Males Females Males Females Group Group Sex Sex
Total Sample n=163 n=165 n=168 n=181
Rutter Case 21 (12.88) 26 (15.76) 17 (10.12) 17 (9.39) 0.007 2.36 (1.26-4.42) 0.727 1.09 (0.68-1.74)
Neurotic Case 9 (5.52) 15 (9.09) 7 (4.17) 8 (4.42) 0.002 3.44 (1.58-7.48) 0.367 1.37 (0.69-2.69)
Antisocial Case 10 (6.13) 8 (4.85) 9 (5.36) 4 (2.21) 0.726 1.25 (0.35-4.46) 0.132 0.55 (0.26-1.19)
Notes: P-values are adjusted for number of months between the bushfire and the first assessment, Odds Ratios > 1 means that the Bushfire group has higher odds of caseness; for sex comparisons, an OR > 1 means that females have higher odds of being a Rutter case; based on Rutter parent questionnaire cut-off of 13
Table 7.7: A comparison of the number of cases on the parent Rutter questionnaire in the
bushfire and the control group at first assessment (within group comparisons)
P-Value OR P-Value OR P-Value OR P-Value OR Within Within Within Within Within Within Within Within Males Males: Females Females: Bushfire Bushfire Control Control B vs. C B vs. C B vs. C B vs. C F vs. M F vs. M F vs. M F vs. M
Rutter Case 0.087 2.00 (0.90-4.41) 0.010 2.79 (1.28-6.06) 0.431 1.29 (0.69-2.40) 0.819 0.92 (0.45-1.87)
Neurotic Case 0.075 2.68 (0.91-7.91) 0.003 4.42 (1.67-11.7) 0.206 1.75 (0.73-4.19) 0.907 1.06 (0.38-3.00)
Antisocial Case 0.883 0.90 (0.23-3.49) 0.497 1.74 (0.35-8.65) 0.593 0.77 (0.30-2.01) 0.133 0.40 (0.12-1.32)
Notes: P-values are adjusted for number of months between the bushfire and the first assessment, Odds ratios > 1 means that the Bushfire group has higher odds of being a Rutter case; for sex comparisons, an OR > 1 means that females have higher odds of being a Rutter case; F, Female; M, Males; Bush, bushfire; Con, controls; based on the Rutter parent questionnaire with a cut-off of 13
Miranda Van Hooff 2010 181 Table 7.8: A comparison of the number of cases on the teacher Rutter questionnaire in the bushfire and the control group at first assessment
P- P- Value Value Main Main Bushfire Control Effect OR Effect OR Males Females Males Females Group Group Sex Sex
Total Sample n=163 n=165 n=168 n=181
Rutter Case 12 (7.4%) 7 (4.2%) 17 (10.1%) 8 (4.4%) 0.768 1.14 (0.47-2.78) 0.026 0.48 (0.25-0.92)
Neurotic Case 3 (1.8%) 2 (1.2%) 5 (3.0%) 3 (1.7%) 0.980 0.98 (0.21-4.56) 0.390 0.60 (0.19-1.91)
Antisocial Case 7 (4.3%) 5 (3%) 11 (6.5%) 2 (1.1%) 0.264 1.96 (0.60-6.38) 0.025 0.33 (0.13-0.87)
Notes: P-values are adjusted for number of months between the bushfire and the first assessment; Odds ratios > 1 means that the bushfire group has higher odds of being a Rutter case; for sex comparisons, an OR > 1 means that females have higher odds of being a Rutter case; based on Rutter teacher questionnaire with a cut-off of 9
Table 7.9: A comparison of the number of cases on the teacher Rutter questionnaire in the
bushfire and the control group at first assessment (within group comparisons)
P-Value OR P-Value OR P-Value OR P-Value OR Within Within Within Within Within Within Within Within Males Males: Females Females: Bushfire Bushfire: Control Control: B vs. C B vs. C B vs. C B vs. C F vs. M F vs. M F vs. M F vs. M
Rutter Case 0.963 0.98 (0.36-2.62) 0.636 1.34 (0.40-4.45) 0.239 0.56 (0.22-1.47) 0.045 0.41 (0.17-0.98)
Neurotic Case 0.902 0.89 (0.15-5.25) 0.946 1.07 (0.14-8.48) 0.652 0.66 (0.11-4.01) 0.417 0.55 (0.13-2.34)
Antisocial Case 0.910 0.93 (0.28-3.08) 0.122 4.11 (0.69-24.7) 0.554 0.70 (0.22-2.26) 0.018 0.16 (0.03-0.73)
Notes: P-values are adjusted for number of months between the bushfire and the first assessment, Odds ratios > 1 means that the Bushfire group has higher odds of being a Rutter case; for sex comparisons, an OR > 1 means that females have higher odds of being a Rutter case; F, Female; M, Males; Bush, bushfire; Con, controls; based on the Rutter parent questionnaire with a cut-off of 9
Miranda Van Hooff 2010 182 7.4.3.2 Family functioning following the fires
The way families cope, and interact in the aftermath of traumatic event can impact negatively on long-term adjustment following disasters. For the purpose of this thesis family functioning following the fires will be defined in relation to 4 main constructs reported in the literature to impact on long term psychological outcomes following disaster exposure: (1) overprotective parenting, (2) irritable distress, (3) family involvement, and (4) maternal psychopathology
7.4.3.2.1 Overprotective parenting Overprotective parenting was measured by asking the parents of children in the bushfire two questions, ‘Since the disaster, do you worry more about your children coming to harm?’ and
‘Do you need to know where your children are more than before?’ Each overprotection question was rated on a 3-point scale: 0 (not at all), 1 (sometimes) and 2 (often). Scores for the two questions were added to produce a total score ranging from 0 to 6. In total 308 of the
328 mothers answered each of the overprotection questions. The mean overprotection score in the bushfire group was 2.20 (SD = 1.40 Range = 0 to 4).
7.4.3.2.2 Irritable distress in family Irritable distress in the family was examined using a measure devised by McFarlane
(McFarlane 1987) through observation and consultation with disaster-exposed schools in the area, disaster victims, disaster services, as well as previous literature. Describing a pattern of family interaction characterised by irritability, fighting, emotional withdrawal, and loss of pleasure from shared activities this scale is comprised of six questions each rated on a 3-point scale from 0 (does not apply) to 2 (certainly applies) with a total score ranging from 0 to 12.
Results of an independent sample t-test indicated that families affected by the bushfire
Miranda Van Hooff 2010 183 reported significantly more irritable distress than families from the control group t (369) =
3.70, p <0.001 (Table 7.10).
Table 7.10: A comparison of levels of irritable distress and family involvement in the bushfire group and the control group at first assessment
Bushfire Control P-Value
M (SD) M (SD)
N=224 N=302
Irritable distress 1.18 (2.13) 0.57 (1.44) 0.000
Family involvement 2.42 (2.14) 2.54 (2.28) 0.514
7.4.3.2.3 Family involvement Derived from the same measure used to assess irritable distress, involvement characterises families who had a better sense of their goals, were closer than before, talked over problems and were concerned about putting strain on each other. This scale is comprised of 5 questions each rated on a 3-point scale from 0 (does not apply) to 2 (certainly applies) with a total score ranging from 0 to 10. Unlike the irritable distress measure, which captures dysfunctional adaptation processes within the family, family involvement examines the positive elements of the post-disaster family environment. No significant differences emerged between the bushfire group and the comparison group in the level of family involvement 15 months following the bushfire (Table 7.10).
7.4.3.2.4 Maternal psychopathology Maternal wellbeing and intrusive phenomenology were assessed following the fires using two questions; (1) how have you been feeling in the last month? (Scored on a three-point scale ranging from 1–more able to cope than usual to 3-less able to cope) and (2) do you still find Miranda Van Hooff 2010 184 unwanted thoughts and feelings about the fires pop into you mind? (scored on a three-point scale ranging from 0–not at all to 3-often). In response to these questions, 7.1% (N = 22) of mothers said they felt they were more able to cope than usual, 82.5% (N = 254) said they were much the same and 10.4% (N = 32) said they were less able to cope than usual at first assessment. In relation to whether they had had unwanted fire thoughts and feeling abut the fires pop into their minds, 13.3% (N = 41) of mothers said not at all, 20.7% (N = 64) said rarely, 50.5% (N = 156) said sometimes and 15.5% (N = 48) said often.
7.4.3.3 Post-traumatic symptoms following the fires
Posttraumatic phenomena in the in children exposed to the bushfire were examined using four questions. Scoring followed the same pattern as the Rutter (0 = doesn’t apply, 1= applies somewhat, 2 = certainly applies) with the last two responses indicating a positive response.
Questions included in the parent questionnaire examined four types of symptoms: 1. Has dreams or nightmares about the fire, 2. At times plays games about the fire and paints pictures about it, 3. Is upset or worried by reminders of the fire (e.g., sirens, strong winds, etc.), 4.
Spontaneously talks about the fire. Scoring was based on both the sum of the responses to each of the PTSD questions (range 0 to 8) as well as the proportion of children exhibiting at least one post-trauma symptom. Teachers were asked to answer all but one of these questions
(at times plays games about the fire and paints pictures about it). Items were chosen based on available research reports at the time and the investigator’s clinical experience (McFarlane,
1987).
Almost half of the parents of children in the bushfire group reported that their children talked about the fire (44%) and 37% reported their children to be upset or worried by reminders of the fire. Both parents and teachers reported talking about the fire to be the most common symptom in the children (Table 7.11).
Miranda Van Hooff 2010 185 Table 7.11: Posttraumatic phenomena in children in the bushfire group following the bushfires
Items on measure assessing posttraumatic N (%)
phenomena
Parent Measure
Has dreams or nightmares about the fire 45 (14.4%)
At times plays games about the fire and 43 (13.7%)
paints pictures about it
Is upset or worried by reminders of the fire 116 (37.1%)
Child talks about the fire 138 (44.1%)
Teacher Measure
Has dreams or nightmares about the fire 11 (3.4%)
Is upset or worried by reminders of the fire 14 (4.4%)
(i.e fire sirens)
Child talks about fire 24 (7.5%)
Miranda Van Hooff 2010 186 7.4.4 Factor 4: Lifetime trauma and psychopathology
All data included in factor 4 was obtained using a telephone interview conducted by research psychologists over a three year period from 2002 to 2005.
7.4.4.1 Lifetime trauma exposure
Lifetime exposure to traumatic events was examined by asking each participant whether they had experienced any event from the standard list of 10 Criterion-A events from the Composite
International Diagnostic Interview (CIDI)(World Health Organisation 1997; World Health
Organization Collaborating Centre for Mental Health and Substance Abuse 1997). These were direct combat, life-threatening accident, fire, flood or natural disaster, witnessed someone being badly injured or killed, rape, sexual molestation, serious physical attack or assault, threatened with a weapon or held captive or kidnapped, tortured or the victim of terrorists, and any other stressful event. In addition, each participant was asked about seven other event types (domestic violence, witnessed domestic violence, threatened or harassed without a weapon, finding a dead body, witnessing someone suicide or attempt suicide, child physical abuse, child emotional abuse). These events were based on a systematic recoding of the
“other” trauma category in a random community sample (Goldney, Wilson et al. 2000).
Participants were asked whether they had experienced any of these events and whether they had ever experienced a great shock due to any of these events happening to someone close to them (“Learning about an event happening to another”). The total number of times each event occurred was also documented.
Estimates of the lifetime prevalence of trauma exposure in the bushfire survivors and controls in the follow-up sample are presented in Table 7.12. The traumatic event experienced by the largest proportion of people in both the bushfire group and the control group was the
Miranda Van Hooff 2010 187 composite group of vicarious traumas grouped together under the heading “Learning about event happening to another” (41.8% in the bushfire group and 38.4% in the control group).
This group of traumas covers any trauma arising from an event occurring to someone close to the participant.
In the bushfire group, following a natural disaster (93.9%), the most frequently reported traumatic events were witnessing someone being badly injured or killed (27.4%), being threatened or harassed without a weapon (25.6%) and life threatening accidents (21.6%)
(Table 7.12). In the control group, the most frequently reported events were witnessing someone being badly injured or killed (22.3%) and life threatening accidents (21.5% of controls). A significantly higher proportion of the bushfire survivors compared to the controls
2 had witnessed domestic violence (χ 1= 4.16, p < 0.05) and had been threatened or harassed
2 without a weapon (χ 1= 5.68, p < 0.05) (Table 7.12).
Of particular interest is the finding that only 93.9% of the bushfire survivors responded “Yes” when directly asked, “Have you ever been involved in a fire, flood or natural disaster?” This is despite that fact that all 36 of these individuals who answered no to this question were identified as attending schools in the fire-affected region on the day of the fires.
Interestingly, in both groups the events most likely to be nominated as the worst (namely
“other event” and learning about event happening to another) were not the events that most frequently resulted in PTSD (Table 7.12). In the bushfire group, rape and childhood emotional abuse were the two events most likely to result in PTSD, with 50% of participants nominating this event as their worst event subsequently developing PTSD. In the control group, a similar pattern of results emerged, with rape and childhood physical abuse most likely to result in
PTSD (50% of survivors developing PTSD in both instances).
Miranda Van Hooff 2010 188 Table 7.12: Lifetime trauma exposure, PTSD and the proportion of participants nominating each event as their worst lifetime event
Bushfire (N = 328) Control (N = 349)
% % PTSD % % PTSD Exposed Worst Among Exposed Worst Among Among Worst Among Worst Exposed (N=25) Exposed N(%) N(%) N(%) N(%) N(%) N(%) No lifetime events 7 (2.1) - - 88 (25.2) - -
Event happening to self Direct combat 3 (0.9) 1 (33.3) 0 (0.0) 0 (0.0) - - Life-threatening accident 71 (21.6) 20 (28.2) 0 (0.0) 75 (21.5) 37 (49.3) 4 (10.8) Fire, flood, or natural disaster 308 (93.9) 112 (36.4) 3 (2.7) 50 (14.3) 2 (4.0) 0 (0.0) Rape 14 (4.3) 6 (42.9) 3 (50.0) 11 (3.2) 4 (36.4) 2 (50.0) Sexual molestation 28 (8.5) 10 (35.7) 3 (30.0) 22 (6.3) 9 (40.9) 1 (11.1) Serious physical attack/assault 25 (7.6) 6 (24.0) 1 (16.7) 25 (7.2) 7 (28.0) 0 (0.0) Threatened with a weapon/ 33 (10.1) 3 (9.1) 1 (33.3) 36 (10.3) 10 (27.8) 1 (10.0) held captive/kidnapped Tortured or victim of 0 (0.0) - - 1 (0.3) 1 (100.0) 0 (0.0) terrorists Domestic violence 18 (5.5) 4 (22.2) 0 (0.0) 22 (6.3) 9 (40.9) 2 (22.2) Threatened/harassed without a 84 (25.6) 18 (21.4) 2 (11.1) 63 (18.1) 11 (17.5) 0 (0.0) weapon Finding dead body 33 (10.1) 6 (18.2) 0 (0.0) 31 (8.9) 9 (29.0) 1 (11.1) Child abuse – physical 9 (2.7) 1 (11.1) 0 (0.0) 11 (3.2) 2 (18.2) 1 (50.0) Child abuse – emotional 19 (5.8) 4 (21.1) 2 (50.0) 17 (4.9) 5 (29.4) 0 (0.0)
Witnessing an event that happened to another Witness someone badly 90 (27.4) 33 (36.7) 2 (6.1) 78 (22.3) 30 (38.5) 1 (3.3) injured or killed Witnessed domestic violence 61 (18.6) 7 (11.5) 2 (28.6) 45 (12.9) 6 (13.3) 0 (0.0) Witness someone 20 (6.1) 5 (25.0) 0 (0.0) 21 (6.0) 9 (42.9) 0 (0.0) suicide/attempt suicide Other event 46 (14.0) 22 (47.8) 6 (27.3) 64 (18.3) 47 (73.4) 4 (8.5) Learning about an event 137 (41.8) 63 (46.0) 0 (0.0) 134 (38.4) 63 (47.0) 4 (6.3) happening to another
Miranda Van Hooff 2010 189 Table 7.13 reports the number of different traumas experienced by the bushfire and control group. Excluding the bushfire from the total number of traumas, there were no significant group differences in the total number of lifetime traumatic events t (675)=1.45, p=0.148 experienced by the bushfire group and the controls. However, when included, bushfire survivors report significantly more lifetime traumas than the control group t (675) = 6.62, p<0.001. This result is expected given the nature of the sample collection and the purpose of the study.
Table 7.13: Number of lifetime traumatic events in the bushfire and control group
Number of Event Types Bushfire Group Control group
N(%) N(%)
0 66 (20.1) 86 (24.6)
1 80 (24.4) 84 (24.1)
2 69 (21.0) 65 (18.6)
3 40 (12.2) 48 (13.8)
4 28 (8.5) 30 (8.6)
5 16 (4.9) 15 (4.3)
6 10 (3.0) 8 (2.3)
7 10 (3.0) 7 (2.0)
8 5 (1.5) 2 (0.6)
9 2 (0.6) 1 (0.3)
10 2 (0.6) 2 (0.6)
11 1 (0.3)
Notes: Cell numbers exclude the Ash Wednesday Bushfires
Miranda Van Hooff 2010 190 7.4.4.2 Posttraumatic Stress Disorder
7.4.4.2.1 PTSD from the worst lifetime event
Current and lifetime DSM-IV PTSD was examined in all participants in relation to the event rated subjectively by the participant to be their “worst lifetime traumatic event”. This methodology is in contrast to previous longitudinal studies on disaster-affected populations, which predominantly examine PTSD in relation to the disaster in the exposed population and
PTSD in relation to the worst lifetime traumatic event in the controls. The purpose of assessing PTSD in this way in this study was to determine how the disaster was subjectively rated in terms of severity and life impact compared to other traumatic life events and whether experiencing other events in addition to the bushfire impacts on the prevalence of PTSD in relation to the bushfire.
In total 7.6% (N = 25) of the bushfire-exposed participants and 6.1% (N = 21) of the controls met criteria for PTSD in relation to their self-nominated worst lifetime event with 2.4% (N =
8) of the bushfire group and 2.6% (N = 9) of controls still meeting criteria some time in the month prior to assessment (Table 7.14). Using the standard CIDI method of nominating the worst lifetime event, there were no significant differences in the prevalence rates of lifetime or 1 month prevalence of PTSD between the bushfire group and the controls.
Miranda Van Hooff 2010 191 Table 7.14: Lifetime and 1 month prevalence of posttraumatic stress disorder in relation to the bushfire and a self-nominated worst lifetime event
Lifetime Current
Bushfire Control RR (95% CI) p-value Bushfire Control RR (95% CI) p-value
N=328 N=349
PTSD: Worst Event 25 (7.6) 21 (6.1) 1.38 (0.78-2.44) 0.26 8 (2.4) 9 (2.6) 1.02 (0.39-2.64) 0.97
N=237 N=237
PTSD Bushfire 4 (1.7) 2 (0.8)
Notes: P-values are adjusted for current age at T4 and sex, Total N for bushfire related PTSD is 237 as this is number of participants who nominated the bushfire as one of their three worst events.
7.4.4.2.2 Lifetime and current prevalence of bushfire related PTSD: In addition to the assessment of PTSD in relation to the participant’s worst lifetime event
(using the standard CIDI method of assessment), a more detailed examination of the prevalence of lifetime and current DSM-IV PTSD in relation to the bushfire was also performed in the bushfire group using the CIDI. Bushfire participants were asked about PTSD symptoms in relation to the bushfire if the participant, as one of their three worst lifetime events, nominated the Ash Wednesday bushfires. In total, 72.3% (N = 237) of the bushfire group nominated the bushfire as one of their three worst lifetime events, 46% (N = 109) as their worst event, 32% (N = 77) as their second worst event and 21.5% (N = 51) as their third worst lifetime event.
Of these 237 participants, 4 (1.7%) met DSM-IV criteria for lifetime PTSD from the bushfire, with two (0.8%) of these participants still meeting criteria for PTSD 20 years on (Table 25).
Interestingly these rates are much lower than the prevalence of lifetime PTSD from the worst lifetime event both in the bushfire group (7.6%) and in the controls (6.1%).
Miranda Van Hooff 2010 192 For the majority of the children in the bushfire group (85.1%), the Ash Wednesday bushfires represented the child’s first exposure to a traumatic event. Only 14.9% of children in the bushfire group had experienced a prior trauma and only 1 person (0.3%) met DSM-IV criteria for PTSD prior to the bushfire when assessed retrospectively using the CIDI at the 20-year follow-up assessment (Table 7.15). Seventy eight percent of children experiencing the bushfire went on to experience another trauma following the bushfires with 6.4% of these participants developing PTSD.
Table 7.15: Traumatic events and PTSD occurring prior to and after the Ash Wednesday
Bushfires in the bushfire group (N=328)
YES NO
N% N%
Prior Trauma 49 (14.9) 279 (85.1)
Prior Trauma with PTSD 1 (0.3) 327 (99.7)
Post Bushfire Trauma 258 (78.7) 70 (21.3)
Post Bushfire Trauma with PTSD 21 (6.4) 307 (93.6)
Notes: Rates of PTSD presented in this table do not include PTSD cases associated with Ash Wednesday bushfires.
7.4.4.2.3 Current self–reported levels of PTSD related Distress: Current distress associated with PTSD symptoms was examined at the 20 year follow-up assessment using the self-report Impact of Events Scale - Revised (Weiss and Marmar 1997).
Symptom questions were anchored to the bushfire in the survivor group and a self-nominated life event in the controls. Analyses were limited to participants who completed the self-report questionnaire component of the study (N = 280 in the bushfire group and N = 271 in the control group), therefore samples sizes are slightly lower than those used in prior analyses of
PTSD and trauma. Individual symptom scores were added to produce an overall total score
Miranda Van Hooff 2010 193 and three symptom clusters, intrusion, avoidance and hyper-arousal (Table 7.16). Twenty seven percent of the bushfire-exposed group reported no current bushfire related distress
(IES-R total score = 0) at the follow-up assessment. In general, total scores on the IES-R were low, with 80% of the bushfire-exposed participants scoring 10 or below. Intrusion symptoms were most common and were experienced by 67.1% of the bushfire-exposed population.
Hyper-arousal symptoms were the least prevalent symptom cluster affecting only 26.8% of the sample. Forty-nine percent of the sample met criteria for Avoidance. Of those who reported at least one symptom of distress, the three most commonly endorsed symptoms were reminders brought back feelings (55.4%), pictures popped into my mind (47.9%) and things made me think about it (31.8%).
IES-R total scores were significantly lower in the bushfire group (in relation to the bushfire) than in the control group (in relation to their self-nominated “most stressful and upsetting event life”), supporting earlier findings from the interview data. In the control sample, death of a family member or friend was the event most commonly reported in the unexposed population to be their most stressful life event (14.6%), followed by relationship breakup or divorce (7.8%). Only 8.1% of the unexposed population reported never having experienced a stressful life event.
Miranda Van Hooff 2010 194
Table 7.16: Current PTSD distress relating to the Bushfire in the bushfire group (N=280) and other events in the control group (N=271)
Bushfire Control Mean (SD) Mean (SD) t-value p-value IES-R Avoidance Score 0.31(0.52) 0.64 (0.80) -5.63 0.000
IES-R Hyperarousal Score 0.19 (0.50) 0.34 (0.62) -3.20 0.002
IES-R Intrusion Score 0.42 (0.60) 0.57 (0.73) -2.69 0.007
IES-R Total Score 6.98 (10.86) 11.73 (14.29) -4.39 0.000
7.4.4.3 Other psychopathology
Lifetime and 1-month point prevalence rates of DSM-IV (American Psychiatric Association
1994) disorder were assessed using a computerised version of the fully structured, standardised and comprehensive Composite International Diagnostic Interview (World Health
Organisation 1997). DSM-IV Disorders were sub-grouped as follows: any depressive disorder
(major depression- single episode, major depression-recurrent, depressive disorder NOS and dysthymia), any anxiety disorder (panic disorder, panic with agoraphobia, agoraphobia, specific phobia-animal, specific phobia-environmental, specific phobia-blood, specific phobia-situational, specific phobia-other, social phobia, obsessive compulsive disorder, generalised anxiety disorder, anxiety NOS and PTSD-based on worst event) and any eating disorder (anorexia nervosa, bulimia nervosa and eating disorder NOS.
In total, 33.0% of the bushfire group and 30.0% of the controls met criteria for any DSM-IV psychiatric disorder during their lifetime and 15% of bushfire group and 9.2% of controls met criteria for a disorder in the past month. Only lifetime rates of ‘any anxiety, excluding PTSD’
Miranda Van Hooff 2010 195 were significantly more prevalent in the bushfire exposed than in the controls (Table 7.17). A higher proportion of bushfire exposed compared to controls met criteria for ‘any disorder’ in the past month. When the individual DSM-IV diagnoses were examined, the only disorder that was more prevalent in the disaster-exposed group was a lifetime history of specific phobia (animal type).
Miranda Van Hooff 2010 196 Table 7.17: Lifetime and point (1-month) prevalence of DSM-IV anxiety, depressive and eating disorders in a longitudinal sample of bushfire survivors and controls
Lifetime DSM-IV Disorder Current DSM-IV Disorder
Bushfire Control RR (95% CI) p-value Bushfire Control RR (95% CI) p-value
n=328 n=349
Any Disorder 108 (33.0) 104 (30.0) 1.11 (0.89-1.38) 0.36 49 (15.0) 32 (9.2) 1.76 (1.15-2.68) 0.01
Any Disorder 103 (31.4) 101 (28.9) 1.08 (0.86-1.36) 0.49 45 (13.7) 28 (8.0) 1.86 (1.19-2.92) 0.01
(excl PTSD)
Any Depression 66 (20.1) 72 (20.6) 0.99 (0.74-1.34) 0.96 13 (4.0) 8 (2.3) 1.76 (0.73-4.26) 0.21
Major Depression 34 (10.4) 39 (11.2) 1.01 (0.96-1.07) 0.67 6 (1.8) 8 (2.3) 0.84 (0.29-2.44) 0.76
Single Episode
Major Depression 30 (9.2) 31 (8.9) 1.09 (0.67-1.76) 0.73 7 (2.1) 4 (1.1) 1.95 (0.56-6.73) 0.29
Recurrent Episode
Depression NOS 1 (0.3) 0 (0.0)
Dysthymia 8 (2.4) 7 (2.0) 1.23 (0.44-3.41) 0.69 1 (0.3) 0 (0.0)
Any Anxiety 70 (21.3) 52 (14.9) 1.47 (1.06-2.04) 0.02 30 (9.1) 21 (6.0) 1.64 (0.95-2.82) 0.07
Panic Disorder 7 (2.1) 6 (1.7) 1.44 (0.48-4.28) 0.51 3 (0.9) 4 (1.1) 0.93 (0.21-4.18) 0.92
Panic with 9 (2.8) 5 (1.4) 1.89 (0.63-5.67) 0.26 2 (0.6) 0 (0.0)
Agoraphobia
Agoraphobia 3 (0.9) 3 (0.9) 1.13 (0.22-5.67) 0.89 0 (0.0) 0 (0.0)
Specific Phobia 36 (11.0) 27 (7.7) 1.45 (0.89-2.34) 0.13 8 (2.4) 5 (1.4) 1.75 (0.57-5.40) 0.33
Phobia Animal 20 (6.1) 11 (3.2) 2.15 (1.04-4.45) 0.04 6 (1.8) 3 (0.9) 3.02 (0.75-12.22) 0.12
Phobia 21 (6.4) 13 (3.7) 1.83 (0.92-3.64) 0.08 3 (0.9) 2 (0.6) 2.10 (0.35-12.79) 0.42
Environmental
Phobia Blood 17 (5.2) 17 (4.9) 1.12 (0.58-2.17) 0.74 1 (0.3) 3 (0.9) 0.40 (0.04-3.99) 0.44
Phobia Situational 11 (3.4) 5 (1.4) 2.38 (0.82-6.86) 0.11 1 (0.3) 0 (0.0)
Phobia Other 1 (0.3) 0 (0.0) 0 (0.0) 0 (0.0)
Social Phobia 22 (6.7) 13 (3.7) 1.87 (0.95-3.68) 0.07 12 (3.7) 8 (2.3) 1.73 (0.71-4.24) 0.23
Miranda Van Hooff 2010 197 Lifetime DSM-IV Disorder Current DSM-IV Disorder
Bushfire Control RR (95% CI) p-value Bushfire Control RR (95% CI) p-value
OCD 9 (2.8) 5 (1.4) 1.71 (0.57-5.14) 0.34 8 (2.4) 3 (0.9) 2.40 (0.63-9.18) 0.20
GAD 3 (0.9) 6 (1.7) 0.45 (0.11-1.82) 0.26 0 (0.0) 1 (0.3)
Anxiety NOS 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Any Eating Disorder 4 (1.2) 4 (1.1) 1.25 (0.31-5.05) 0.75 1 (0.3) 0 (0.0)
Anorexia 0 (0.0) 1 (0.3) 0 (0.0) 0 (0.0)
Bulimia 4 (1.2) 3 (0.9) 1.52 (0.34-6.91) 0.59 1 (0.3) 0 (0.0)
Eating Disorder 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
NOS
Any Bipolar 6 (1.8) 5 (1.4) 1.39 (0.42-4.59) 0.59 4 (1.2) 3 (0.9) 1.40 (0.31-6.36) 0.66
Diagnosis
Mood Disorder NOS 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Notes: All p-values are adjusted for current age at Phase 4 and sex, OCD, Obsessive Compulsive Disorder, GAD, Generalized Anxiety Disorder
Miranda Van Hooff 2010 198 7.5 Summary of findings
7.5.1 Immediate post-disaster period
This chapter draws on a conceptual model originally developed Korol, Green and colleagues
(Green, Korol et al. 1991; Korol, Green et al. 1999) describing a pattern of risk factors associated with poor long-term outcomes following childhood disaster exposure. Four risk factors were examined: (a) characteristics of the stressor (b) characteristics of the child (c) characteristics of the post-disaster environment (additional life events, parental reactions to the fire) and (d) additional lifetime trauma and lifetime DSM-IV disorder.
The sample used in this chapter comprised 677 participants with both follow-up and first assessment data (data collected within the first 15 months following the bushfires), which were selected in order to maximise the sample while maintaining consistency in sample numbers. With the exception of being slightly more educated, urban dwellers employed in professional occupations, no significant differences emerged between the sub-sample and the entire follow-up sample (N = 1011). Overall, findings from this study characterise a sample of adults aged between 23 and 35 with a moderate level of exposure to a bushfire in childhood and a sample of adults from a neighbouring community not directly affected by the fires (age range 23 to 32 years). Ten percent of children from the bushfire-affected region reported damage or destruction to their family home, over one third of participants reported some degree of property loss and 22% had a family member or friend injured or killed in the fires.
The reports from the initial phases of this study, conducted between 1983 and 1985, demonstrated an emerging pattern of a general increase in symptoms in the fire-exposed children in contrast to the unexposed controls. Twenty-six months after the disaster there were
21.4% scoring as cases on the Rutter parent questionnaire compared to the 10.5% of the
Miranda Van Hooff 2010 199 control sample (McFarlane 1987). This chapter further extends these findings by highlighting the role of sex in the relationship between bushfire exposure and Rutter symptoms. Despite the similarities in the prevalence of individual Rutter symptoms in bushfire survivors and controls, female bushfire survivors showed a particularly strong vulnerability to the short term effects of the fires being 4.42 times more likely to meet criteria for a neurotic disorder than females from the control group within 15 months following the fires. In contrast, in those not affected by the bushfire as has been reported in community samples, males were most likely to meet criteria for an antisocial disorder.
A higher proportion of bushfire children were reported by their parents to be miserable, to stammer or stutter, to have temper tantrums and to have difficult settling. Children from the control group however were significantly more likely to tell lies which was consistently reported by both their parents and their teachers. The fact the lie telling was more prevalent in the control population in this instance may indicate a sense of independence and stability in the control population rather than reflecting a type of antisocial behaviour. Accordingly, rather than lie telling increasing in prevalence following the fires in the control group, this significant effect may have emerged due to a decrease in lie telling in the bushfire affected group due to children from the bushfire group becoming more socially compliant because of their sense of social fragility.
Consistent with findings from the original study the overall prevalence of Rutter disorder in this sample of childhood bushfire survivors was lower than expected, with more parents than teachers rating the children as cases on the Rutter at first assessment (1st assessment parent cases in the bushfire group14%, 1st assessment teacher cases in the bushfire group 5.8%; 1st assessment parent cases in the control group 9.7%, 1st assessment teacher cases in the control group 7.2%). There was also a larger discrepancy between parent rated cases in the bushfire
Miranda Van Hooff 2010 200 and control group than teacher rated cases in the bushfire and control group. One explanation for the low teacher rates is that a number of teachers had only known the students for 10-11 weeks. Other possible explanations include the tendency of children to comply while in the school environment, the teachers’ tendency to deny the continuing effects of the disaster or an indication of the parents’ intolerance of the child’s normal behaviour patterns hence inflating their assessments of poor behaviour in their children.
Results in this chapter indicate a pattern of family interaction in the bushfire-affected families characterised by irritability, fighting, emotional withdrawal, and loss of pleasure from shared activities. Families affected by the bushfire scoring significantly higher on irritable distress than families from the control group. This replicates earlier findings of McFarlane 1987 that reported significantly more irritable distress at eight months and 26 months in the bushfire group than the control group. In specific relation to maternal psychopathology, most mothers reported that they were coping much the same as they normally would, with a small proportion (10.4%) reporting they were less able to cope then usual 15 months following the fires. Despite these low reports of problems coping, intrusive thoughts about the fire were common in mothers with 70% reporting having regular unwanted thoughts and feelings about the fire.
7.5.2 20-year follow-up data
In relation to the data that was collected at the 20-year follow-up assessment, this chapter demonstrated few differences between the bushfire and the control group in the prevalence of lifetime psychopathology. For example, attending school in the bushfire-affected region did not significantly increase the rates of adult psychopathology other than specific phobia
(animal type) nor was it associated with feelings of distress (using the IES-R) except for in a
Miranda Van Hooff 2010 201 small proportion of individuals. This lack of effect may be attributable to the largely skewed distribution of scores on all bushfire exposure measures within the fire-affected group, which may have diluted the impact of the bushfire on the overall sample. Although the fire posed a significant physical threat to all children attending school in the fire affected region, with the fire encroaching on the grounds of several of the schools, only 35% of children were from families who suffered property loss and 22% percent had a family member or friend injured or killed in the fires. Approximately 60% of children in the bushfire group were evacuated safely on the day of the fires and experienced no ongoing difficulties associated with the death or injury to a family member or friend or property loss. Accordingly only a very small proportion of the overall bushfire group were highly exposed to the fires. Low weighted personal and property loss mean scores further demonstrate this effect. In relation to the weighted scores for property loss, only 12.2% scored 5 or above (total range 0-10). In relation to the weighted scores for personal loss, only 1.6% of bushfire survivors scored 5 or above
(total range 0-11).
Point (1 month) prevalence rates of DSM-IV disorder in survivors and controls, likewise revealed few differences. Overall, 15% of the bushfire survivors and 9.2% of the comparison sample currently met criteria for a DSM-IV disorder (adjusted odds ratio [OR], 1.76; 95% CI,
1.15-2.68). 3.9% of the bushfire group and 3.4% of the control group met current diagnostic criteria for major depression, and 9.1% of bushfire survivors compared to 6.0% of the control subjects met criteria for ‘any’ anxiety disorder (NS). Importantly, the prevalence rates for individual disorders reported in this paper are within one or two percentage points of the
Australian national rates (Andrews, Henderson et al. 2001).
An important strength of this chapter lies in the methodology employed to investigate the prevalence of PTSD in this population. In contrast to other longitudinal studies of childhood
Miranda Van Hooff 2010 202 disaster survivors which limit the assessment of PTSD symptoms to the disaster in the disaster-affected group and the worst lifetime event in the controls, PTSD was examined in this study in relation to both the participant’s self nominated worst lifetime event as well as the Ash Wednesday Bushfires. The purpose of assessing PTSD in this way was to determine how the disaster was subjectively rated in relation to other traumatic life events. Also to determine whether the experience of other events impacts on the prevalence of PTSD in relation to the bushfire. It also allows an examination into the relationship between bushfire related PTSD and PTSD following other types of events which will be discussed further in the following chapter.
When PTSD was examined in this way, only 4 (1.7%) developed lifetime PTSD from the bushfire, with two of these participants still meeting DSM-IV criteria for PTSD 20 years on.
This rate of PTSD represents less than 1% of all bushfire-exposed participants in this sample.
These rates are in stark contrast to rates of PTSD following rape or sexual molestation, whereby 42.9% and 35.7% of those exposed nominated the rape and sexual molestation as their worst event, with 50% and 30% respectively going on to develop PTSD from that event.
Although rape and sexual molestation were not a common experience in this sample, the rates of PTSD following these events were much higher, at least one in five of those raped and one in ten of those sexually molested compared to approximately one in one hundred of those exposed to a bushfire in childhood.
Consistent with the prevalence of PTSD in Australian community settings, 7.6% of the bushfire-exposed participants and 6.1% of the controls met criteria for PTSD in relation to their self-nominated worst lifetime event. 2.4% of bushfire survivors and 2.6% of controls met criteria some time in the month prior to assessment. There were no significant differences in the prevalence of lifetime or 1-month PTSD between the bushfire group and the controls.
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Remarkably, 6.8% of the fire-exposed children when asked if they had ever been involved in a fire, flood or natural disaster said “No”. Several factors may be apparent here. It is possible that the threshold for self-report is higher than that determined at the time of the original study. One school exposed to the fire was not fully burned although it was threatened by the disaster. Furthermore, a number of the children at this school had their own homes and farming properties destroyed. Also, there is a small group who significantly underreported their exposures. This is similar to the observation of Williams in her study of sexually victimised women (Williams 1994) and may have in fact contributed to these diminished rates.
Contrary to expectation, the events most likely to be nominated as the worst lifetime events
(namely ‘other event’ and ‘learning about event an happening to another person’) were not the events that most frequently resulted in PTSD. Typically these events were not conventional
Criterion A1 events. They were events which were offered by the participant in response to one of the following two questions: “Have you ever experienced any other extremely stressful or upsetting event” (other event), and after having being read the entire list of possible traumas “Have you ever suffered a great shock because one of these events happened to someone close to you?” (learning about event happening to another). This finding clearly demonstrates one of the most controversial aspects of the stressor A1 criteria for PTSD– the potential over-application of the construct of trauma to regular everyday events. It also highlights the need to more clearly define the role of the stressor in the nomenclature of PTSD in order to avoid large margins of error in relation to PTSD and trauma prevalence rates. The relationship between stressor type and the impact this has on the development of PTSD will be discussed in detail in chapter 10 of this thesis.
Miranda Van Hooff 2010 204 Finally, a significantly higher proportion of the bushfire survivors compared to the controls had witnessed domestic violence and had been threatened or harassed without a weapon.
These findings are consistent with the high levels of irritable distress reported by the bushfire- affected families 15 months following the fires. A review of the disaster literature has indicated that children may become targets of the aggressive behaviours from parents in the aftermath of a disaster brought about by both the feelings of frustration, stress and powerlessness with events over which they have no control and disruption to normal social connections, which guide appropriate and inappropriate interpersonal interactions (Kotch,
Browne et al. 1995). This may explain the elevated rates of these experiences in the bushfire- affected sample.
This chapter, while providing a summary of the overall characteristics of this sample, introduces the complexity that is inherent in the interrelationship between childhood disaster exposure and adult psychopathology. One of the weaknesses of many epidemiological samples of psychiatric disorders following disasters is that they fail to take account of the background spectrum of psychopathology within that community and the mediating effects of lifetime trauma exposures. The following chapter attempts to unravel some of these complexities, by examining a risk factor model for adult psychopathology that incorporates four main facets of disaster exposure: characteristics of the stressor, characteristics of the child, characteristics of the post-disaster environment and additional lifetime trauma and psychopathology. A summary of the combined findings of Chapter 7 and 8 will be presented at the end of Chapter 8.
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8 Risk factors for the development of post-disaster psychopathology Part 2: results of univariate and multivariate analyses
8.1 Introduction
Directly following on from Chapter 7, this chapter reports on the results of the univariate and multivariate logistic regressions that examine risk factors associated with lifetime DSM-IV disorder following exposure to the Ash Wednesday bushfires during childhood.
As previously noted in chapter 7, the overall chapter is guided by a well-recognised conceptual model developed and refined by several prominent researchers in the field of
PTSD and the long-term effects of disasters (Green, Korol et al. 1991; Korol, Green et al.
1999). This model postulates that there are four main factors that contribute to the development of post-disaster reactions in children (a) characteristics of the stressor (life threat and level of exposure to the disaster), (b) characteristics of the child (demographics, pre- disaster functioning), (c) characteristics of the post-disaster environment (additional life events, parental reactions to the fire) and (d) the child’s efforts to process and cope with disaster-related distress. This model has since been extended to include major life events occurring in the year following the disaster that were not necessarily related to the disaster
(i.e. death or hospitalisation of a family member or friend), measures of discrimination as well as familial-, extra-familial-, and professional–support (La Greca, Silverman et al. 1996; Pina,
Villalta et al. 2008).
The current chapter further extends this model by both broadening the major life events factor proposed by LaGreca et al (1996) to include all lifetime traumatic events occurring prior to the 20-year follow-up assessment and by examining the utility of this overall model in Miranda Van Hooff 2010 206 predicting both DSM-IV depressive and anxiety disorder. Due to the retrospective nature of data collection at the 20-year follow-up and the absence of prospective data pertaining to the child’s coping efforts and skills in the immediate post-disaster environment, Factor D (the child’s efforts to process and cope with disaster-related distress) will be excluded from the model.
The findings of this chapter are organised into eight sections. Section one provides a brief outline of each of the predictor variables and outcome variables that will be used in the risk factor model. Section two provides a summary of the statistics used. Section three examines the predictors of bushfire-related PTSD in bushfire participants with both first assessment
(approximately 15 months post-disaster) and follow-up data. Section four examines predictors of PTSD arising from the participant’s self nominated worst lifetime event. Section five describes the pattern of predictors associated with any lifetime DSM-IV disorder (excluding
PTSD). Section six examines predictors of lifetime DSM-IV depressive disorder and Section seven examines predictors of lifetime DSM-IV anxiety disorder (excluding PTSD). The final section provides a detailed summary of overall findings presented in chapters 7 and 8.
8.2 Description of variables
8.2.1 Predictor variables
There are twenty-eight predictor variables included in this chapter all of which relate in a very specific way to the four factors outlined in the conceptual model. For a thorough description of these variables please refer to section 7.4 of this thesis.
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8.2.1.1 Factor 1: Characteristics of the stressor
(1) ‘Any property loss’ (participants are scored as a case if they experienced damage or
destruction to any of the following: house, plant or farm machinery, car, sheds, family
property, threat to house, as well as injury or death to livestock, or pets)
(2) ‘Any personal loss’ (participants are scored as a case if they experienced injury or
death of parent, siblings, grandparent, friend(s) or parent’s friend(s))
(3) ‘Both property and personal loss’ (participant is regarded as a case if they experienced
both property and personal loss as described above).
(4) ‘High weighted property loss’ (participant is a case if they scored above the 80th
percentile on the weighted property loss summary score. See section 7.4.1.1 for a
detailed description of the weighting process).
(5) ‘High weighted personal loss’ (participant is a case if they scored above the 80th
percentile on the weighted personal loss summary score. See section 7.4.1.1 for a
detailed description of the weighting process).
(6) ‘High weighted property loss and personal loss’ (participant is a case if they scored
above the 80th percentile on the combined weighted personal and property loss
summary score. See section 7.4.1.1 for a detailed description of the weighting
process).
8.2.1.2 Factor 2: Characteristics of the child at the time of the disaster
(7) ‘Age at the time of the bushfire’
(8) ‘Sex’ (female versus male)
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8.2.1.3 Factor 3: Characteristics of the post-disaster environment
8.2.1.3.1 Behaviour and emotional problems in the child
(9) ‘Parent rated Rutter case’ (participant is regarded as a case if their total score is ≥13 on
the parent rated Rutter)
(10) ‘Parent rated Rutter neurotic case’ (participant is regarded as a case if their total score
on the parent rated Rutter is ≥ 13 and their score on the neurotic subscale is greater
than their score on the antisocial subscale)
(11) ‘Parent rated Rutter antisocial case’ (participant is regarded as a case if their total score
on the parent rated rutter is ≥ 13 and their score on the antisocial subscale is greater
than their score on the neurotic subscale)
(12) ‘Teacher rated Rutter case’ (participant is regarded as a case if their total score is ≥9 on
the teacher rated Rutter)
(13) ‘Teacher rated Rutter neurotic case’ (participant is regarded as a case if their total score
on the teacher rated Rutter is ≥ 9 and their score on the neurotic subscale is greater than
their score on the antisocial subscale)
(14) ‘Teacher rated Rutter antisocial case’ (participant is regarded as a case if their total
score on the teacher rated Rutter is ≥ 9 and their score on the antisocial subscale is
greater than their score on the neurotic subscale)
8.2.1.3.2 Family functioning and home environment
(15) ‘Overprotective parenting’ (sum of two questions assessing overprotective parenting
following the bushfire range 0 to 6)
(16) ‘Irritable distress’ in the family (sum of six questions completed by the parent
following the fire with score ranging from 0 to 12)
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(17) ‘Family involvement’ (sum of five questions completed by the parents following the
fire with score ranging from 1to 10).
(18) ‘Maternal psychopathology’ (two separate questions assessing maternal wellbeing
“How have you been feeling in the last month”? and intrusive phenomena “Do you
still find unwanted thoughts and feelings about the fires pop into you mind” with
scores on each question ranging from 1 to 3).
(19) ‘Posttraumatic phenomena in the bushfire sample’ (a sum of four questions examining
post-trauma symptoms with scores ranging from 0 to 8 on the parent scale and 0 to 6
on the teacher scale).
8.2.1.4 Factor 4: Lifetime trauma and other psychopathology
(20) ‘Current bushfire related distress’ (based on the total score on the IES-R in relation to
the bushfire in the bushfire survivors).
(21) ‘Any traumatic event occurring prior to the bushfire’ (participant is a case if they
report having experienced any trauma on the CIDI trauma list prior to the bushfire).
(22) ‘Any traumatic event occurring after the bushfire’ (participant is a case if they report
having experienced any trauma on the CIDI trauma list subsequent to the bushfire).
(23) ‘Number of traumatic life events’ (based on number of yes responses to the CIDI
trauma questions outlined in section 7.4.4.1 of this thesis).
(24) ‘PTSD as a result of trauma other than the bushfire’ (participant is a case if they met
DSM-IV diagnostic criteria for PTSD to their worst lifetime event (excludes the
bushfire).
(25) ‘Any other lifetime DSM-IV disorder’ (participant is a case if they met criteria for any
DSM-IV depressive or any DSM-IV anxiety disorder on the CIDI, excluding PTSD).
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(26) ‘Any other lifetime DSM-IV anxiety disorder’ (participant is a case if they met criteria
for any DSM-IV anxiety disorder on the CIDI, excluding PTSD).
(27) ‘Any other lifetime depressive disorder’ (participant is a case if they meet criteria for
any DSM-IV depressive disorder on the CIDI).
(28) ‘Number of other disorders’ (total number of lifetime CIDI DSM-IV disorders).
8.2.2 Outcome Variables
Lifetime DSM-IV disorders were measured using a computerised version of the fully structured, standardised and comprehensive Composite International Diagnostic Interview
(CIDI, World Health Organisation 1997). In this chapter, the relationship between a selection of the twenty-eight predictor variables and the following five disorders will be examined. A more thorough description of these variables is presented in section 7.4.4 of this thesis.
(1) Bushfire related PTSD
(2) PTSD arising from the participant’s worst lifetime event
(3) Any lifetime DSM-IV disorder
(4) Any lifetime DSM-IV depressive disorder
(5) Any lifetime DSM-IV anxiety disorder (excluding PTSD)
Eating disorders were not modelled in this chapter due to an insufficient number of positive cases in this sample.
Due to the small number of PTSD cases resulting from the bushfire (N=4) and the limitations this imposes on statistical power in logistic regression, multivariate predictors of PTSD is
Miranda Van Hooff 2010 211 limited to PTSD associated with the participant’s worst event. Univariate data provided on bushfire related PTSD is for descriptive purposes only.
8.3 Statistics
Univariate associations between the five outcome variables (PTSD from the Bushfire, PTSD from the worst lifetime event, any lifetime DSM-IV disorder, any lifetime DSM-IV depressive disorder, and lifetime DSM-IV anxiety disorder) and the twenty-eight predictor variables that compose the four factors of the model were analysed using chi-square or
Fisher’s exact tests. Odds Ratios and 95% confidence intervals for each disorder with each of these predictor variables were estimated using a series of logistic regressions. Both main effect p-values (for the whole longitudinal sample, and within the bushfire group and the controls) and interaction p-values (variable*group) are reported for each outcome variable/disorder type.
Multivariate logistic regressions were used to estimate adjusted relative risks for each disorder type. To take into account the intercorrelations among variables examined in each analysis, two sets of multivariate logistic regressions were performed for each outcome variable
(disorder type). The first set examined the main effects of each predictor variable, controlling for the effects of all other variables in the model, on each outcome variable in the entire longitudinal sample (bushfire and control group combined). The second set of analyses examined both the main effects and interaction effects (variable*group) of each predictor variable on each disorder type and presents the results for the entire longitudinal sample as well as the bushfire and control group separately. Results are presented as adjusted Odds
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Ratios. The equations include independent variables identified as potential risk factors in previous studies on disaster-affected populations.
8.4 Prediction of lifetime bushfire-related DSM-IV PTSD
Table 8.1 outlines the total property and personal loss experienced by the four children in the bushfire group who developed lifetime PTSD as a consequence of the bushfires. Of these four children three (75%) experienced some degree of property loss (including two (50%) who had their houses destroyed) and two (50%) had a family member or friend injured or killed in the fires. These proportions, although only drawn from a sample of 4 cases, are much higher than exposure rates in the bushfire population as a whole in which 35% of all bushfire survivors experienced property loss and 22% had a family member or friend injured or killed in the fires. Interestingly three of these four children (75%) also reported that their mother had been close to injury on the day of the fires, this compares to 16.3% of children in the entire bushfire affected sample.
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Table 8.1: Frequency and proportion of bushfire participants with PTSD (N = 4) reporting specific exposures to the Ash Wednesday bushfires
TYPE OF LOSS N (%) Any property loss 3 (75%)
House destroyed 2 (50%) House damaged but not destroyed 0 (0%) Family’s plant or farm machinery damaged or destroyed 2 (50%) Family car damaged or destroyed 2 (50%) Family’s sheds damaged or destroyed 2 (50%) Property damaged or destroyed 3 (75%) Livestock injured or killed 3 (75%) Pets injured or killed 2 (50%) House threatened but not damaged 1 (25%)
Any personal loss 2 (50%) Parents or siblings injured 0 (0%) Parents or siblings killed 0 (0%) Grandparents or other relatives injured 0 (0%) Grandparents or other relatives killed 1 (25%) Friends or parent’s friends injured 2 (50%) Friends or parent’s friends killed 1 (25%)
Child on school bus during the fire (N=4) 1 (25%) Mother was close to being injured (N=4) 3 (75%) Father was close to being injured (N=4) 3 (75%) Child was close to being injured (N=4) 1 (25%)
Univariate estimates of relative risk for bushfire related PTSD are presented in Table 8.2. In relation to the exposure variables, children from families exposed to a high degree of property loss were at an increased risk of developing PTSD from the bushfire whereas personal loss in relation to the number of family and friends injured or killed in the fires had no effect.
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Characteristics of the child at the time of the fires such as sex and age did not predict bushfire-related PTSD. Children who at first assessment were rated by their parents as antisocial or by their teachers as neurotic on the Rutter questionnaire were at an elevated risk of developing PTSD from the bushfires later in life.
Maternal post-trauma psychopathology in terms of intrusive thoughts about the fire and problems coping emerged as a univariate predictor of bushfire related PTSD. This result replicates findings from the earlier phases of this study whereby continuing maternal preoccupation with the fires predicted the children’s PTS symptoms 26 months after the bushfire over and above than the child’s level of exposure to the fire or degree of property loss (McFarlane, 1987). Parent rated post-trauma symptoms in the child also predicted PTSD, however overprotective parenting, family involvement and irritable distress did not.
Interestingly, additional lifetime trauma had no impact on the development of PTSD from the bushfire whereas current bushfire related distress and number of lifetime DSM-IV disorders did.
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Table 8.2: Univariate (max N = 328) predictors of bushfire related PTSD in the bushfire group (where number of PTSD cases = 4 (1.23%)
Univariate
Predictor N OR (95% CI) p-value
Demographics
Current age 325 1.248 (0.786-1.981) 0.35
Factor 1: Characteristics of the stressor
Weighted property loss 309 1.642 (1.134-2.378) 0.009
Weighted personal loss 309 1.294 (0.922-1.818) 0.137
Weighted property & personal loss 308 1.276 (1.065-1.529) 0.008
Factor 2: Characteristics of the child
Age at the time of the bushfire 325 1.458 (0.859-2.475) 0.16
Sex (female) 325 0.981 (0.136-7.061) 0.98
Factor 3: Characteristics of the post-disaster environment
Behaviour & emotional problems in the child
Parent rated Rutter total score* 325 1.142 (1.010-1.291) 0.034
Parent rated Rutter neurotic score* 325 1.492 (0.866-2.571) 0.150
Parent rated Rutter antisocial score* 325 1.493 (0.997-2.235) 0.052
Teacher rated Rutter total score* 325 1.202 (1.032-1.399) 0.018
Teacher rated Rutter neurotic score* 325 2.152 (1.307-3.544) 0.003
Teacher rated Rutter antisocial score* 325 1.178 (0.644-2.154) 0.594
Family functioning
Overprotection score* 305 2.683 (0.823-8.748) 0.102
Family involvement score* 222 1.055 (0.628-1.770) 0.841
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Univariate
Predictor N OR (95% CI) p-value
Irritable distress score* 222 1.188 (0.813-1.736) 0.373
How mother feeling in past month* 305 5.980 (1.137-31.46) 0.035
Mother unwanted thoughts feelings pop into mind* 306 11.15 (1.270-97.86) 0.030
Post-disaster symptoms in the child
Parent rated post disaster symptom total score* 310 1.507 (0.992-2.288) 0.054
Teacher rated post disaster symptom total score* 318 1.931 (0.856-4.355) 0.113
Factor 4: Lifetime trauma exposure and psychopathology
Current bushfire related PTSD distress 277 1.165 (1.048-1.295) 0.005
Traumatic events prior to the fire 325 1.896 (0.193-18.61) 0.583
Number of additional lifetime traumas (excl. 325 1.153 (0.774-1.719) 0.483
Bushfire)
Other lifetime disorder (excl. PTSD) 325 n/a # n/a
Number of other disorders (excl. PTSD) 325 2.207 (1.404-3.469) 0.001
Notes: #No univariate estimates were possible, but there are relationships,* Adjusted for months since the bushfire
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8.5 Prediction of lifetime DSM-IV PTSD from worst lifetime event
8.5.1 Univariate Model
Univariate estimates of risk for PTSD associated with the participant’s worst lifetime event in the whole sample (main effects) within the bushfire and the control group are presented in
Table 8.3.
Females, children who were rated above the cut-off on the parent rated antisocial sub-scale of the Rutter, and children with overprotective parents following the fires were at an elevated risk of developing lifetime PTSD following a traumatic event. The bushfire group, however, mostly accounted for these effects. Additionally, participants who were older at the time of their first traumatic event, who had been exposed to a greater number of lifetime traumatic events, who had a lifetime history of anxiety or depression and who had experienced a greater number of DSM-IV disorders were also at an elevated risk. Characteristics of the stressor, namely the degree of property or personal loss as well as maternal post-trauma psychopathology and problems coping were unrelated to the development of PTSD from the participant’s self-nominated worst lifetime event as it was in the development of bushfire- related PTSD. Despite the significant main effects that emerged within the bushfire and the control group, no significant variable*group interaction effects were reported.
8.5.2 Multivariate Model
The multivariate predictors of PTSD from the worst lifetime event in the model examining main effects only (Table 8.4) were slightly different from the multivariate predictors of PTSD in the model that included the interaction effects of variable*group (Table 8.5). In fact, only two variables consistently emerged as significant predictors in both models: current age Miranda Van Hooff 2010 218
(participants who were younger at the 20-year follow-up were more likely to report PTSD from their worst lifetime event) and number of lifetime traumas (participants with a greater number of lifetime traumatic events more likely to report PTSD from their self-nominated worst lifetime traumatic event). Number of lifetime traumas emerged as a significant predictor in both the bushfire group and the control group when analysed separately, whereas current age was a significant predictor in the control group only. Additionally, in the model examining the main effects only in the entire longitudinal sample (Table 8.4), female sex (in whole sample only) and scores above the cut-off for parent rated antisocial disorder on the
Rutter (whole sample and bushfire group only) emerged as significant predictors of worst event PTSD. The participant’s age at the time of their first traumatic event approached statistical significance. The strongest predictor across these two models was caseness on the parent rated antisocial scale of the Rutter with an odds ratio of 5.013 (CI: 1.223-20.55). No significant group*variable interaction effects were reported.
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Table 8.3: Univariate predictors of PTSD from the worst lifetime event in the whole sample
(main effect) (N = 677), within the bushfire group (N = 328) and within the controls (N =349)
Main Inter- Effect action Main Effect Within Bushfire Within Control Risk Factor N p-value p-value OR (95% CI) OR (95% CI) OR (95% CI) Demographics
Current age 674 0.205 0.760 0.914 (0.795-1.051) 0.894 (0.745-1.073) 0.934 (0.756-1.154)
Bushfire group 674 0.413 1.285 (0.705-2.344)
Factor 1: Characteristics of the stressor High weighted property loss^ 658 0.942 1.039 (0.372-2.900) (Above 80th percentile) High weighted personal loss^ 658 0.526 1.370 (0.517-3.627) (Above 80th percentile) High weighted personal and 657 0.494 1.382 (0.546-3.498) property poss^ (Above 80th percentile)
Factor 2: Characteristics of the child at the time of the disaster Sex (Female) 674 0.025 0.817 2.078 (1.098-3.933) 2.241 (0.939-5.349) 1.928 (0.758-4.900)
Factor 3: Characteristics of the post-disaster environment Behaviour and emotional problems in the child Parent rated Rutter case* 674 0.102 0.087 2.070 (0.866-4.944) 4.429 (1.833-10.70) 0.967 (0.215-4.343)
Parent rated Rutter neurotic 674 0.714 0.845 1.260 (0.366-4.343) 1.426 (0.372-5.457) 1.114 (0.139-8.906) Case* Parent rated Rutter antisocial 674 0.023 0.069 3.897 (1.202-12.64) 11.61 (3.933-34.27) 1.308 (0.162-10.57) case* Teacher rated Rutter case* 674 0.241 0.657 1.827 (0.668-4.998) 2.295 (0.613-8.588) 1.455 (0.318-6.650)
Teacher rated Rutter neurotic 674 0.230 2.569 (0.550-12.00) case*^ Teacher rated antisocial 674 0.822 0.804 1.186 (0.268-5.256) 0.983 (0.119-8.139) 1.432 (0.176-11.65) case*
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Main Inter- Effect action Main Effect Within Bushfire Within Control Risk Factor N p-value p-value OR (95% CI) OR (95% CI) OR (95% CI)
Family Functioning
Overprotection score*# 307 0.046 1.410 (1.007-1.975)
Family involvement* 524 0.894 0.321 1.011 (0.864-1.182) 1.094 (0.874-1.370) 0.934 (0.750-1.162)
Irritable distress* 526 0.804 0.455 0.967 (0.744-1.258) 1.069 (0.863-1.324) 0.875 (0.542-1.414)
How mother feeling in past 307 0.671 1.241 (0.459-3.356) month*# Mother unwanted thoughts 308 0.193 1.413 (0.840-2.377) feelings pop into mind*#
Factor 4: Lifetime trauma exposure and psychopathology Age at first trauma 587 0.001 0.404 0.855 (0.780-0.938) 0.822 (0.696-0.971) 0.889 (0.821-0.963)
Number of lifetime traumatic 674 <0.0001 0.381 1.571 (1.385-1.783) 1.485 (1.259-1.752) 1.662 (1.374-2.012) events (excluding bushfire) Additional DSM-IV disorder:
Any other lifetime disorder 674 <0.0001 0.534 13.62 (6.099-30.40) 10.55 (3.836-29.04) 17.57 (5.046-61.15) (excl. PTSD) Any other lifetime anxiety 674 <0.0001 0.142 7.462 (3.975-14.01) 4.656 (2.019-10.74) 11.96 (4.661-30.68) disorder (excl. PTSD) Any lifetime depressive 674 <0.0001 0.682 10.28 (5.320-19.87) 8.960 (3.749-21.41) 11.80 (4.389-31.72) disorder PTSD from Bushfire 674 N/A N/A
Number of other disorders 674 <0.0001 0.162 1.913 (1.607-2.277) 1.690 (1.368-2.087) 2.166 (1.642-2.857) (excl. PTSD)
Notes: * Adjusted for months since the bushfire; # Risk factors were measured in the bushfire group only, so the sample is halved, and a group effect and a group*variable interaction could not be included in the model; ^ Only a main effect could be included in the model, due to low or no variability in one of the groups
Miranda Van Hooff 2010 221
Table 8.4: Multivariate predictors of ‘PTSD from worst lifetime event’ in the whole sample
(N = 430) (main effects only)
Predictor OR (95% CI) p-value Demographics Group (bushfire) 0.681 (0.261-1.776) 0.4321 Current age 0.774 (0.638-0.939) 0.0095
Factor 1: Characteristics of the stressor High weighted personal and property loss 1.417 (0.352-5.710) 0.6241 (Above 80th percentile)
Factor 2: Characteristics of the child at the time of the bushfire Sex (female) 2.288 (0.985-5.316) 0.0543
Factor 3: Characteristics of the post-disaster environment Behavioural and emotional problems in the child: Parent rated Rutter neurotic case 1.564 (0.300-8.147) 0.5953 Parent rated Rutter antisocial case 5.013 (1.223-20.55) 0.0251 Teacher rated Rutter neurotic case 3.760 (0.411-34.43) 0.2411 Teacher rated Rutter antisocial case 0.349 (0.032-3.768) 0.3859
Family functioning Family involvement 0.997 (0.829-1.200) 0.9777 Irritable distress 0.891 (0.680-1.166) 0.4001
Factor 4: Lifetime trauma and psychopathology Age at first trauma 0.912 (0.828-1.004) 0.0599 Number of lifetime traumas (excluding bushfire) 1.498 (1.257-1.784) < 0.0001
Miranda Van Hooff 2010 222
Table 8.5: Multivariate predictors of ‘PTSD from worst lifetime event’ in the whole sample (N = 430) and within the bushfire group and within the controls
Group Inter- Main Effect p- action Within Bushfire Within Control p- Predictor OR (95% CI) value p OR (95% CI) p-value OR (95% CI) value
Demographics
Current Age 0.755 (0.61-0.94) 0.010 0.982 0.753 (0.54-1.04) 0.089 0.757 (0.57-1.00) 0.050
Factor 1: Characteristics of the Stressor
High Weighted Personal and 1.355 (0.30-6.17) 0.694 Property Loss (Above 80th percentile)
Factor 2: Characteristics of the Child at the Time of the Disaster
Sex (Female) 2.316 (0.96-5.59) 0.062 0.798 2.597 (0.68-9.98) 0.164 2.065 (0.66-6.43) 0.211
Factor 3: Characteristics of the Post-Disaster Environment
Behavioural and Emotional Problems in the Child (Rutter)
Parent Rated Neurotic Case 1.586 (0.29-8.65) 0.594 0.677 2.274 (0.24-21.18) 0.471 1.107 (0.09-14.23) 0.938
Parent Rated Antisocial Case 2.643 (0.28-24.76) 0.394 0.250 9.744 (1.80-52.76) 0.008 0.717 (0.01-44.44) 0.874
Teacher Rated Neurotic Case 4.404 (0.44-44.40) 0.209
Teacher Rated Antisocial 0.333 (0.03-3.94) 0.383 Case
Family Functioning
Family Involvement 1.041 (0.85-1.27) 0.691 0.519 1.111 (0.86-1.50) 0.487 0.975 (0.75-1.27) 0.852
Irritable Distress 0.858 (0.59-1.26) 0.431 0.699 0.925 (0.68-1.27) 0.627 0.796 (0.40-1.59) 0.520
Factor 4: Lifetime Trauma and Psychopathology
Age at First Trauma 0.935 (0.81-1.07) 0.343 0.669 0.964 (0.75-1.24) 0.777 0.907 (0.81-1.01) 0.084
Number of lifetime Traumas 1.497 (1.25-1.79) <.0001 0.943 1.506 (1.18-1.93) 0.001 1.487 (1.16-1.91) 0.002 (excl. Bushfire)
Miranda Van Hooff 2010 223
8.6 Prediction of any lifetime DSM-IV disorder
8.6.1 Univariate model
Univariate estimates of relative risk for any lifetime DSM-IV disorder (main effects) in the whole longitudinal sample and within the bushfire and the control group are presented in
Table 8.6. Both main effect p-values and interaction p-values (variable*group) are reported.
Females, participants who were younger at the time of their first traumatic event, and those who had been exposed to a greater number of lifetime traumatic events were at an elevated risk of developing a lifetime DSM-IV disorder regardless of whether they had experienced the bushfire or not (as illustrated by the significant main effect of these variables on the lifetime
DSM-IV disorder in the whole sample as well as within the bushfire and control sample).
Additionally bushfire exposed children with overprotective parents following the fires were also at an increased risk. Characteristics of the stressor, specifically the degree of property loss as well as the high family involvement approached significance, with high levels of family involvement predicting lifetime DSM-IV disorder in the participants from the bushfire group when analysed separately
Furthermore there was a significant interaction effect of parent rated Rutter case, specifically parent rated Rutter antisocial case and group (bushfire or control) on the development of any lifetime DSM-IV disorder, with bushfire-exposed participants who also met criteria for an antisocial disorder being more likely to develop a lifetime DSM-IV disorder than control participants who met criteria for an antisocial disorder being less likely to develop a lifetime
DSM-IV disorder. There was also a significant main effect of the parent rated Rutter antisocial caseness in the bushfire group (OR = 4.461, CI: 1.625-12.25) but not the controls.
Miranda Van Hooff 2010 224
Noteworthy is the interaction relationship between the level of irritable distress in the family
(in the 15 month period following the fires) and group on the development of any lifetime
DSM-IV disorder. Although not quite reaching statistical significance this finding together with the significant main effect of irritable distress on the development of lifetime DSM-IV disorder in the control group, supports an association between high levels of irritable distress in the control population following the fires and the development of any lifetime DSM-IV disorder and low levels of irritable distress in the bushfire group and the development of a disorder.
8.6.2 Multivariate Model
As indicated in Tables 8.7 and 8.8, the multivariate logistic regressions identified 3 significant predictors of any lifetime DSM-IV disorder in the whole sample: sex (females being at higher risk) neurotic behaviour in the children (as identified by the teacher Rutter following the fires) and number of lifetime traumatic events. Of these three predictors, the teacher rated Rutter neurotic case was the strongest predictor with an odds ratio of 5.283 (CI: 1.24-22.44). The only significant multivariate predictor to emerge in the bushfire group and control group separately was the number of lifetime traumas with the greater number of traumas increasing the risk for any lifetime disorder.
The interaction effects of each predictor variable and group on any lifetime DSM-IV disorder as well as the main effect of each predictor variable on any lifetime DSM-IV disorder in the
Bushfire group and the control group separately are presented in Table 8.8. A significant interaction effect emerged for both parent neurotic case and irritable distress. Bushfire participants, who were rated above the cut-off for neurotic disorder by their parents on the
Rutter, were more likely to report a lifetime history of any DSM-IV disorder, whereas control
Miranda Van Hooff 2010 225 participants scoring above the cut-off were less likely to report a lifetime history of any DSM-
IV disorder. The opposite pattern was observed with irritable distress. Bushfire participants whose parents reported high levels of irritable distress following the fires were less likely to report a lifetime history of any DSM-IV disorder whereas control participants with high levels of irritable distress in their families following the fires were more likely to report a lifetime
DSM-IV disorder.
.
Miranda Van Hooff 2010 226
Table 8.6: Univariate predictors of ‘any lifetime disorder’ in the whole sample (main effect) (N = 677), within the bushfire group (N = 328) and within the controls (N = 349)
Main Inter- Effect action Main Effect Within Bushfire Within Control Risk Factors N p-value p-value OR (95% CI) OR (95% CI) OR (95% CI)
Demographics
Current age 674 0.611 0.943 0.981 (0.910-1.057) 0.978 (0.883-1.083) 0.984 (0.882-1.097)
Bushfire group 674 0.393 1.152 (0.832-1.595)
Factor 1: Characteristics of the stressor
High weighted property loss^ 658 0.056 0.539 (0.286-1.017)
(Above 80th percentile)
High weighted personal loss^ 658 0.780 0.920 (0.514-1.649)
(Above 80th percentile)
High weighted personal and 657 0.187 0.682 (0.386-1.205)
property loss^
(Above 80th percentile)
Factor 2: Characteristics of the child at the time of the disaster
Sex (female) 674 <0.0001 0.282 2.336 (1.665-3.277) 1.940 (1.213-3.103) 2.812 (1.728-4.578)
Factor 3: Characteristics of the post-disaster environment
Behavioural and emotional
problems in the child (Rutter)
Parent rated case* 674 0.167 0.006 1.445 (0.858-2.434) 3.001 (1.592-5.659) 0.696 (0.304-1.592)
Parent rated neurotic case* 674 0.414 0.201 1.352 (0.656-2.785) 2.166 (0.925-5.074) 0.844 (0.262-2.713)
Parent rated antisocial case* 674 0.182 0.027 1.757 (0.768-4.019) 4.461 (1.625-12.25) 0.692 (0.187-2.568)
Miranda Van Hooff 2010 227
Main Inter- Effect action Main Effect Within Bushfire Within Control Risk Factors N p-value p-value OR (95% CI) OR (95% CI) OR (95% CI)
Teacher rated case* 674 0.584 0.502 1.201 (0.623-2.314) 1.503 (0.585-3.860) 0.959 (0.385-2.388)
Teacher rated neurotic case*^ 674 0.248 1.917 (0.635-5.786)
Teacher rated antisocial case* 674 0.783 0.775 0.881 (0.357-2.174) 1.005 (0.295-3.421) 0.772 (0.205-2.912)
Family functioning:
Overprotection score*# 307 0.009 1.266 (1.060-1.512)
Family involvement* 524 0.086 0.136 1.077 (0.990-1.173) 1.150 (1.009-1.310) 1.010 (0.906-1.126)
Irritable distress* 526 0.155 0.059 1.084 (0.970-1.210) 0.974 (0.851-1.116) 1.205 (1.012-1.435)
How mother feeling in past 307 0.842 0.945 (0.540-1.654)
month*#
Mother unwanted thoughts 308 0.230 1.182 (0.900-1.552)
feelings pop into mind*#
Factor 4: Lifetime trauma exposure
Age at first trauma 587 0.0003 0.647 0.926 (0.888-0.965) 0.917 (0.852-0.987) 0.935 (0.898-0.973)
Number of lifetime traumas 674 <0.0001 0.468 1.476 (1.347-1.616) 1.427 (1.262-1.613) 1.526 (1.333-1.747)
(excl. bushfire)
Notes: * Adjusted for months since bushfire; ^ Only a main effect could be included in the model, due to low or no variability in one of the groups; # Risk factors were measured in the bushfire group only, so the sample is halved, and a group effect and a group*variable interaction could not be included in the model; + the variables ‘any lifetime anxiety disorder’, ‘any lifetime depressive disorder’, and ‘PTSD from bushfire’ and ‘number of other disorders’ were excluded from the analysis as all participants scoring ‘0’ for ‘any lifetime disorder’ would also have a ‘0’ for these variables preventing the model from running.
Miranda Van Hooff 2010 228
Table 8.7: Multivariate predictors of ‘any lifetime DSM-IV disorder’ in the whole sample (N = 430) (main effects only)
Variable OR (95% CI) p-value
Demographics:
Group (bushfire) 1.263 (0.716-2.228) 0.4208
Current age 0.902 (0.810-1.004) 0.0580
Factor 1: Characteristics of the stressor:
High weighted personal and property loss 0.627 (0.284-1.385) 0.2480 (Above 80th percentile)
Factor 2: Characteristics of the child at the time of the disaster:
Sex (female) 3.134 (1.966-4.994) <.0001
Factor 3: Characteristics of the post-disaster environment:
Behavioural and emotional problems in the child:
Parent rated Rutter neurotic case 0.972 (0.367-2.575) 0.9546
Parent rated Rutter antisocial case 2.030 (0.726-5.676) 0.1773
Teacher rated Rutter neurotic case 5.283 (1.244-22.44) 0.0241
Teacher rated Rutter antisocial case 0.482 (0.112-2.069) 0.3264
Family Functioning:
Family involvement 1.067 (0.964-1.180) 0.2132
Irritable distress 1.005 (0.890-1.135) 0.9342
Factor 4:Lifetime trauma and psychopathology
Age at first trauma 0.988 (0.944-1.033) 0.5889
Number of lifetime traumas (excl. bushfire) 1.496 (1.308-1.710) <.0001
Notes: + The variables ‘Any Lifetime Anxiety Disorder’, ‘Any Lifetime Depressive Disorder’, and ‘PTSD From Bushfire’ and ‘Number of Other Disorders’ were excluded from the analysis as all participants scoring ‘0’ for ‘Any Lifetime Disorder’ would also have a ‘0’ for these variables preventing the model from running.
Miranda Van Hooff 2010 229
Table 8.8: Multivariate predictors of ‘any lifetime DSM-IV disorder’ in the whole sample (N = 430) and within the bushfire group and within the controls
Grp Inter- action Within Within Main Effect p- p- Bushfire p- Control p- Variable OR (95% CI) value value OR (95% CI) value OR (95% CI) value
Current age 0.91 (0.81-1.03) 0.123 0.859 0.92 (0.77-1.10) 0.371 0.90 (0.77-1.05) 0.183
Factor 1: Characteristics of the stressor
High weighted personal 0.73 (0.32-1.68) 0.461 & property loss (Above 80th percentile)
Factor 2: Characteristics of the child at the time of the disaster
Sex (female) 3.05 (1.89-4.93) <.001 0.075 1.97 (0.99-3.91) 0.052 4.72 (2.40-9.25) <.001
Factor 3: Characteristics of the post-disaster environment
Behaviour and emotional problems in the child (Rutter)
Parent neurotic case 0.98 (0.34-2.81) 0.969 0.049 2.83 (0.68-11.77) 0.153 0.34 (0.07-1.61) 0.173
Parent antisocial case 1.34 (0.40-4.46) 0.638 0.089 3.81 (0.99-14.71) 0.052 0.47 (0.06-3.48) 0.459
Teacher neurotic case 4.59 (1.01-20.79) 0.049 0.729 3.51 (0.37-32.85) 0.272 5.98 (0.78-45.89) 0.085
Teacher antisocial case 0.53 (0.11-2.51) 0.420 0.687 0.38 (0.03-4.53) 0.445 0.73 (0.11-4.92) 0.742
Family functioning:
Family involvement 1.06 (0.96-1.18) 0.275 0.196 1.14 (0.98-1.33) 0.105 0.99 (0.86-1.14) 0.882
Irritable distress 1.04 (0.90-1.20) 0.592 0.021 0.88 (0.74-1.05) 0.158 1.23 (0.99-1.54) 0.068
Factor 4:Lifetime trauma & psychopathology:
Age at first trauma 0.98 (0.92-1.04) 0.470 0.608 0.96 (0.88-1.08) 0.494 0.99 (0.94-1.05) 0.808
Number of lifetime 1.51 (1.32-1.74) <.001 0.589 1.46 (1.22-1.74) <.001 1.57 (1.27-1.94) <.001 traumas (excluding bushfire)
Miranda Van Hooff 2010 230
8.7 Prediction of any lifetime DSM-IV depressive disorder
8.7.1 Univariate model
Univariate estimates of relative risk for any lifetime DSM-IV depressive disorder (main effects) in the whole longitudinal sample and within the bushfire and the control group are presented in Table 8.9. Both main effect p-values and interaction p-values (variable*group) are reported.
Females, participants who were younger at the time of their first traumatic event, participants who had been exposed to a greater number of lifetime traumatic events, participants with a lifetime history of an anxiety disorder and PTSD, and participants with a greater number of lifetime disorders were at an elevated risk of developing a lifetime DSM-IV depressive disorder. These predictors also emerged in the bushfire group and control group separately with the exception of age of first trauma, which was significant in the control group only.
Additionally bushfire exposed children with overprotective parents following the fires were also at an increased risk. No significant variable*group interaction effects were reported.
Miranda Van Hooff 2010 231
8.7.2 Multivariate Model
It can be seen in Tables 8.10 and 8.11 that there were only two multivariate predictors of any lifetime DSM-IV depressive disorder: sex (females being at high risk) and number of lifetime traumas (participants with a greater number of lifetime traumas being at a greater risk). These variables emerged as significant predictors in the whole sample and the both the bushfire and control group separately. No significant group*variable interactions were reported
Miranda Van Hooff 2010 232
Table 8.9: Univariate predictors of ‘any lifetime depressive disorder’ in the whole sample
(main effect) (N = 677), within the bushfire group (N = 328) and within the controls (N =349)
Main Inter-
Effect action Main Effect Within Bushfire Within Control
Variable N p-value p-value OR (95% CI) OR (95% CI) OR (95% CI)
Demographics:
Group (bushfire) 677 0.870 0.97 (0.67-1.41)
Current age 677 0.560 0.615 0.98 (0.90-1.06) 0.997 (0.88-1.12) 0.95 (0.84-1.08)
Factor 1: Characteristics of the stressor
High weighted property loss^ 661 0.174 0.59 (0.27-1.27)
(Above 80th percentile)
High weighted personal loss^ 661 0.516 1.24 (0.64-2.40)
(Above 80th percentile)
High weighted personal and 660 0.897 0.96 (0.50-1.83)
property loss^ (Above 80th
percentile)
Factor 2: Characteristics of the child at the time of the disaster
Sex (female) 677 <0.0001 0.415 2.33 (1.57-3.46) 1.98 (1.13-3.45) 2.75 (1.57-4.81)
Factor 3: Characteristics of the post-disaster environment:
Behaviour and emotional problems in the child (Rutter):
Parent rated case* 677 0.804 0.088 1.08 (0.59-1.98) 1.83 (0.91-3.67) 0.69 (0.24-1.71)
Parent rated neurotic case* 677 0.408 0.354 1.40 (0.63-3.08) 2.03 (0.81-5.07) 0.96 (0.26-3.50)
Parent rated antisocial case* 677 0.820 0.596 0.90 (0.34-2.33) 1.16 (0.39-3.65) 0.69 (0.15-3.19) Miranda Van Hooff 2010 233
Main Inter-
Effect action Main Effect Within Bushfire Within Control
Variable N p-value p-value OR (95% CI) OR (95% CI) OR (95% CI)
Teacher rated case* 677 0.715 0.648 0.86 (0.39-1.91) 1.04 (0.33-3.24) 0.72 (0.24-2.16)
Teacher rated neurotic case*^ 677 0.270 0.32 (0.04-2.45)
Teacher rated antisocial case* 677 0.917 0.542 0.95 (0.34-2.62) 1.30 (0.34-4.96) 0.69 (0.15-3.19)
Family functioning:
Overprotection score*# 308 0.001 1.45 (1.16-1.80)
Family involvement* 524 0.574 0.117 1.03 (0.93-1.13) 1.11 (0.96-1.29) 0.95 (0.84-1.08)
Irritable distress* 526 0.393 0.222 1.052 (0.94-1.18) 0.98 (0.83-1.15) 1.13 (0.96-1.34)
How mother feeling in past 308 0.838 1.071 (0.56-2.06)
month*#
Mother unwanted thoughts 309 0.168 1.26 (0.91-1.74)
feelings pop into mind*#
Factor 4: Lifetime trauma exposure and psychopathology
Age at first trauma 589 0.022 0.917 0.95 (0.90-0.99) 0.94 (0.87-1.03) 0.95 (0.91-0.99)
Number of lifetime traumatic 677 <0.0001 0.781 1.47 (1.34-1.61) 1.45 (1.27-1.65) 1.49 (1.30-1.71)
events (excl. bushfire)
Any lifetime anxiety disorder 677 <0.0001 0.650 6.03 (3.91-9.31) 6.67 (3.67-12.12) 5.46(2.91-10.22)
(excl. PTSD)
PTSD from Bushfire 670 <0.0001 0.998 12.89 (7.28-22.85) 12.88 (5.88-28.25) 12.91 (5.615-29.67)
PTSD from worst event (excl. 674 <0.0001 0.682 10.28 (5.32-19.87) 8.960 (3.75-21.41) 11.80 (4.39-31.72)
bushfire)
Number of other disorders 677 <0.0001 0.259 3.43 (2.74-4.28) 3.02 (2.28-3.98) 3.89 (2.75-5.50)
(excl. PTSD)
Notes: * Adjusted for months since bushfire; ^ Only a main effect could be included in the model, due to low or no variability in one of the groups; # Risk factors were measured in the bushfire group only, so the sample is halved, and a group effect and a group*variable interaction could not be included in the model; + the variables ‘any lifetime anxiety disorder’, ‘any lifetime depressive disorder’, and ‘number of other disorders’ were excluded from the analysis as all participants scoring ‘0’ for ‘any lifetime disorder’ would also have a ‘0’ for these variables preventing the model from running
Miranda Van Hooff 2010 234
Table 8.10: Multivariate predictors of ‘any lifetime DSM-IV depressive disorder’ in the whole sample (N=430) (main effects only)
Variable OR (95% CI) p-value Demographics: Group (bushfire) 0.857 (0.457-1.605) 0.6293 Current age 0.964 (0.855-1.087) 0.5507
Factor 1: Characteristics of the stressor: High weighted personal and property loss (above 1.017 (0.406-2.548) 0.9717 80th percentile)
Factor 2: Characteristics of the child at the time of the fire Sex (female) 3.184 (1.871-5.417) <.0001
Factor 3: Characteristics of the post-disaster environment Behaviour & emotional problems in the child (Rutter) Parent neurotic case 1.264 (0.448-3.565) 0.6573 Parent antisocial case 0.739 (0.222-2.464) 0.6225 Teacher neurotic case 0.221 (0.016-2.989) 0.2560 Teacher antisocial case 0.526 (0.099-2.800) 0.4517
Family functioning: Family involvement 0.998 (0.891-1.118) 0.9751 Irritable distress 0.992 (0.864-1.139) 0.9075
Factor 4:Lifetime trauma and psychopathology: Age at first trauma 1.011 (0.961-1.063) 0.6765 Number of lifetime traumas (excluding Bushfire) 1.553 (1.351-1.784) <.0001
Miranda Van Hooff 2010 235
Table 8.11: Multivariate predictors of ‘any lifetime DSM-IV depressive disorder’ in the whole sample (N=430) and within the Bushfire group and within the controls
Inter- action Within Main Effect p- p- Bushfire p- Within Control p- Variable OR (95% CI) value value OR (95% CI) value OR (95% CI) value
Current age 0.97 (0.86-1.11) 0.689 0.776 0.99 (0.81-1.22) 0.941 0.96 (0.81-1.13) 0.586
Factor 1: Characteristics of the stressor:
High weighted 1.14 (0.44-2.97) 0.785 personal and property loss (Above 80th percentile)
Factor 2: Characteristics of the child at the time of the disaster:
Sex (female) 3.11 (1.80-5.37) <.001 0.218 2.20 (0.99-4.90) 0.051 4.39(2.08-9.24) 0.000
Factor 3: Characteristics of the post-disaster environment:
Behaviour and emotional problems in the child (Rutter):
Parent neurotic case 1.30 (0.45-3.79) 0.629 0.246 2.45 (0.56-10.81) 0.236 0.69 (0.15-3.22) 0.638
Parent antisocial case 0.60 (0.15-2.36) 0.461 0.564 0.89(0.20-3.87) 0.871 0.40 (0.04-3.98) 0.434
Teacher neurotic case 0.22 (0.02-3.00) 0.255
Teacher antisocial case 0.55 (0.10-2.99) 0.484
Family functioning:
Family involvement 1.00 (0.89-1.12) 0.981 0.149 1.09 (0.91-1.30) 0.342 0.92 (0.78-1.07) 0.270
Irritable distress 1.00 (0.86-1.16) 0.977 0.087 0.88 (0.71-1.08) 0.224 1.14 (0.92-1.40) 0.229
Factor 4:Lifetime trauma and psychopathology:
Age at first trauma 1.00 (0.93-1.07) 0.915 0.528 0.97 (0.85-1.11) 0.689 1.02 (0.96-1.08) 0.517
Number of lifetime 1.57 (1.36-1.81) .0001 0.443 1.48 (1.23-1.78) .0001 1.66 (1.33-2.07) .0001 traumas (excl. bushfire)
Miranda Van Hooff 2010 236
8.8 Prediction of any lifetime DSM-IV anxiety disorder (excl. PTSD)
8.8.1 Univariate model
Univariate estimates of relative risk for any lifetime DSM-IV anxiety disorder (main effects) in the whole longitudinal sample and within the bushfire and the control group are presented in Table 8.12. Both main effect p-values and interaction p-values (variable*group) are reported.
Nine significant univariate predictors of lifetime DSM-IV anxiety disorder emerged in this analysis: group (bushfire), sex (female), parent rated Rutter caseness, overprotective parenting following the fires, greater level of family involvement following the fires, younger age at first trauma, greater number of lifetime traumas, any lifetime depressive disorder and PTSD either from the bushfire or from the participant’s worst lifetime event.
Characteristics of the post disaster environment were significant predictors in the bushfire group but not in the control group. These variables included parent rated Rutter case, parent rated Rutter neurotic case, parent rated Rutter antisocial case and family involvement.
Younger age at first trauma was a significant predictor in the control group only, whereas sex, greater number of lifetime traumas, any lifetime depressive disorder and PTSD either from the bushfire or from the participants worst lifetime event were predictors in both the bushfire and the control group. High weighted property loss, high weighted property and personal loss and teacher rated Rutter neurotic caseness approached but did not quite reach statistical significance. No significant group*variable interaction effects were reported.
Miranda Van Hooff 2010 237
8.8.2 Multivariate model
As indicated in Tables 8.13 and 8.14, the multivariate logistic regressions identified 5 significant predictors of any lifetime DSM-IV anxiety disorder in the whole sample: current age (with participants who were younger at follow-up more likely to report having a lifetime disorder), sex (females being at higher risk) neurotic behaviour in the children (as identified by the teacher Rutter following the fires) family involvement (high scorers being at an increased risk) and number of lifetime traumatic events (participants with a greater number of events being at an increased risk). Of these five predictors, the teacher rated Rutter neurotic case was the strongest predictor with an OR of 8.338 (1.915- 36.30). The only significant multivariate predictors to emerge in both the bushfire group and control group were the number of lifetime traumas and sex. Teacher rated Rutter neurotic caseness was a significant predictor of lifetime anxiety disorder in the control group but not the bushfire group with cases being nine times more likely to develop a DSM-IV anxiety disorder than non cases. No significant group*variable interactions were identified.
Miranda Van Hooff 2010 238
Table 8.12: Univariate predictors of ‘any lifetime anxiety disorder (excl. PTSD)’ in the whole sample (main effect) (N = 677), within the bushfire group (N = 328) and within the controls (N = 349)
Main Inter- Main Within
Effect action Effect Bushfire Within Control
Variable N p-value p-value OR (95% CI) OR (95% CI) OR (95% CI)
Demographics:
Group (bushfire) 677 0.030 1.550 (1.043-2.302)
Current age 677 0.565 0.830 0.974 (0.889-1.066) 0.964 (0.858-1.084) 0.983 (0.855-1.131)
Factor 1: Characteristics of the stressor:
High weighted property loss^ 661 0.098 0.525 (0.245-1.126)
(Above 80th percentile)
High weighted personal loss^ 661 0.955 0.981 (0.505-1.906)
(Above 80th percentile)
High weighted personal and 660 0.076 0.528 (0.261-1.070)
property poss^
(Above 80th percentile)
Factor 2: Characteristics of the child at the time of the disaster:
Sex (female) 677 <0.0001 0.857 2.521 (1.649-3.853) 2.424 (1.391-4.226) 2.621 (1.380-4.979)
Factor 3: Characteristics of the post disaster environment:
Behaviour and emotional problems in the child (Rutter):
Parent rated case* 677 0.036 0.186 1.846 (1.040-3.278) 2.721 (1.399-5.292) 1.253 (0.492-3.194)
Parent rated neurotic case* 677 0.072 0.387 2.056 (0.938-4.506) 2.906 (1.208-6.992) 1.454 (0.396-5.341)
Parent rated antisocial case* 677 0.191 0.222 1.833 (0.739-4.548) 3.230 (1.223-8.533) 1.040 (0.224-4.833) Miranda Van Hooff 2010 239
Main Inter- Main Within
Effect action Effect Bushfire Within Control
Variable N p-value p-value OR (95% CI) OR (95% CI) OR (95% CI)
Teacher rated case* 677 0.198 0.817 1.604 (0.781-3.294) 1.746 (0.637-4.783) 1.473 (0.527-4.117)
Teacher rated neurotic case* 677 0.054 0.390 3.311 (0.980-11.19) 5.650 (0.924-34.55) 1.940 (0.381-9.884)
Teacher rated antisocial case* 677 0.820 0.879 1.126 (0.407-3.116) 1.218 (0.320-4.639) 1.040 (0.224-4.833)
Family functioning:
Overprotection score*# 308 0.010 1.317 (1.067-1.625)
Family involvement* 524 0.008 0.586 1.147 (1.036-1.270) 1.180 (1.017-1.370) 1.115 (0.971-1.282)
Irritable distress* 526 0.488 0.771 1.044 (0.924-1.181) 1.026 (0.882-1.192) 1.064 (0.876-1.292)
How mother feeling in past 308 0.409 0.756 (0.389-1.469)
month*#
Mother unwanted thoughts 309 0.206 1.231 (0.892-1.698)
feelings pop into mind*#
Factor 4: Lifetime trauma exposure and psychopathology
Age at first trauma 589 0.009 0.725 0.937 (0.892-0.984) 0.929 (0.853-1.011) 0.945 (0.900-0.992)
Number of lifetime traumas 677 <0.0001 0.930 1.339 (1.222-1.466) 1.333 (1.181-1.505) 1.344 (1.174-1.538)
(excl. bushfire)
Any lifetime depressive 677 <0.0001 0.650 6.033 (3.911-9.305) 6.670 (3.671-12.12) 5.457 (2.912-10.22)
disorder
PTSD from bushfire 670 <0.0001 0.434 9.172 (5.319-15.81) 7.378 (3.510-15.51) 11.40 (5.138-25.31)
PTSD from worst event 674 <0.0001 0.142 7.462 (3.975-14.01) 4.656 (2.019-10.74) 11.96 (4.661-30.68)
Number of other disorders 677 N/A N/A
(excl. PTSD)
Notes: * Adjusted for months since bushfire, ^ Only a main effect could be included in the model, due to low or no variability in one of the groups, # Risk factors were measured in the bushfire group only, so the sample is halved, and a group effect and a group*variable interaction could not be included in the model
Miranda Van Hooff 2010 240
Table 8.13: Multivariate predictors of ‘any lifetime DSM-IV anxiety disorder (excl. PTSD)’ in the whole sample (N=430) (main effects only)
Variable OR (95% CI) p-value Demographics: Current age 0.879 (0.777-0.994) 0.0405 Group (bushfire) 1.873 (0.978-3.587) 0.0585
Factor 1: Characteristics of the Stressor: High weighted personal and property loss (Above 0.502 (0.197-1.279) 0.1485 80th percentile)
Factor 2: Characteristics of the child at the time of the fires Sex (female) 2.889 (1.653-5.049) 0.0002
Factor 3: Characteristics of the post-disaster environment: 1.341 (0.472-3.810) 0.5814 Behaviour & emotional problems in the child (Rutter): Parent rated neurotic case 1.341 (0.472-3.810) 0.5814 Parent rated antisocial case 2.080 (0.715-6.045) 0.1787 Teacher rated neurotic case 8.338 (1.915-36.30) 0.0047 Teacher rated antisocial case 0.887 (0.184-4.283) 0.8813
Family functioning: Family involvement 1.150 (1.023-1.293) 0.0190 Irritable distress 0.977 (0.842-1.134) 0.7575
Factor 4: Lifetime trauma and psychopathology Age at first trauma 0.988 (0.936-1.044) 0.6668 Number of lifetime traumas (excl. bushfire) 1.298 (1.139-1.478) <.0001
Miranda Van Hooff 2010 241
Table 8.14: Multivariate predictors of ‘any lifetime DSM-IV anxiety disorder’ in the whole sample (N=430) and within the bushfire group and within the controls
Group Inter- Within Within Main Effect p- action Bushfire p- Control p- Variable OR (95% CI) value p-value OR (95% CI) value OR (95% CI) value
Demographics:
Current age 0.88 (0.77-1.01) 0.075 0.522 0.92 (0.76-1.12) 0.429 0.85 (0.70-1.02) 0.080
Factor 1: Characteristics of the stressor
High weighted personal 0.48 (0.18-1.28) 0.143 and property loss (Above 80th percentile)
Factor 2: Characteristics of the child at the time of the disaster:
Sex 2.82 (1.60-4.96) 0.000 0.785 2.60 (1.18-5.75) 0.018 3.05 (1.36-6.85) 0.007
Factor 3: Characteristics of the post-disaster environment:
Behaviour and emotional problems in the child (Rutter):
Parent rated neurotic case 1.28 (0.43-3.84) 0.660 0.438 1.98 (0.47-8.40) 0.356 0.83 (0.16-4.34) 0.823
Parent rated antisocial case 1.82 (0.54-6.07) 0.333 0.560 2.60 (0.70-9.73) 0.156 1.27 (0.17-9.58) 0.819
Teacher rated neurotic case 8.93 (1.92-41.57) 0.005 0.974 8.71 (0.86-87.97) 0.067 9.16 (1.21-69.54) 0.032
Teacher rated antisocial case 0.97 (0.19-5.04) 0.968 0.758 1.25 (0.12-13.25) 0.851 0.75 (0.07-7.55) 0.803
Family functioning:
Family involvement 1.15 (1.02-1.30) 0.021 0.797 1.17 (0.98-1.40) 0.077 1.13 (0.96-1.33) 0.137
Irritable distress 0.98 (0.84-1.15) 0.814 0.997 0.98 (0.81-1.190) 0.846 0.98 (0.77-1.25) 0.884
Factor 4: Lifetime trauma and psychopathology
Age at first trauma 0.98 (0.91-1.06) 0.633 0.761 0.97 (0.86-1.10) 0.660 0.99 (0.93-1.06) 0.850
Number of lifetime 1.30 (1.14-1.49) <.000 0.713 1.27 (1.07-1.51) 0.006 1.34 (1.09-1.64) 0.005 traumas (excl. bushfire)
Miranda Van Hooff 2010 242
8.9 Summary of findings
This aim of this chapter was to examine risk factors for the development of DSM-IV disorder using a well-established conceptual model originally developed by Korol (1990) and Green et al (1991). Five disorder types were examined: PTSD from the Bushfire, PTSD from the worst lifetime event, any lifetime DSM-IV disorder, any lifetime DSM-IV depressive disorder and any lifetime DSM-IV anxiety disorder. Each disorder type was examined in relation to four distinct predictive factors: (1) characteristics of the stressor (2) characteristics of the child at the time of the disaster (3) characteristics of the post-disaster environment and (4) lifetime trauma and psychopathology.
The principle findings of this chapter were that: (1) characteristics of the disaster (in particular property loss) emerged as a risk factor for bushfire related PTSD only, (2) females were at a significantly greater risk of developing PTSD (but not in relation to the bushfire), lifetime anxiety and lifetime depression compared to males, (3) children reported by teachers to have a neurotic disorder following the fires were at an increased risk of developing a lifetime anxiety disorder, (4) children who were rated by a parent as meeting criteria for an antisocial disorder following the fires were at an increased risk of developing PTSD, (5) overprotective parenting in the aftermath of the bushfire was a risk factor for the development of all types of disorder
(PTSD, depression and anxiety), but not PTSD in relation to the bushfire, (6) greater family involvement following the fires was a risk factor for the development of a lifetime anxiety disorder, (7) participants whose mothers reported having more intrusive thoughts about the fires and who had more problems coping were at an increased risk of developing PTSD in relation to the bushfire, (8) participants experiencing a greater number of traumatic events in their lifetime were at an increased risk of developing all types of disorder with the exception of bushfire related PTSD, (9) the experience of other lifetime psychopathology lead to an
Miranda Van Hooff 2010 243 increased risk of developing all types of disorder except bushfire related PTSD, (10) bushfire group measured dichotomously, is a risk factor for lifetime anxiety disorder only, (11) high levels of bushfire related distress at follow-up (measured using the IES-R) was a risk factor for bushfire-related PTSD and finally (12) participants who were younger at the follow-up assessment were more likely to report a lifetime history of PTSD (from their worst lifetime event) as well as a lifetime anxiety disorder.
One of the most unexpected findings to emerge from this study is the modest effect of bushfire exposure on lifetime psychopathology overall. Most previous studies have reported a strong relationship between the development of psychopathology following childhood disaster exposure and the individual’s physical proximity to the trauma (including personal and property loss), loss experienced by a family member or close associate, degree of physical injury to self and secondary adversity and traumatic reminders which occur in the aftermath of the event (Pfefferbaum 2005). In the present study, characteristics of the stressor (in particular property loss) emerged as a risk factor for bushfire-related PTSD but not any of the other disorder types. Additionally, personal loss, defined as death or injury to family members and friends, showed no effect on the development of long-term disorder. This suggests a degree of specificity in the relationship between property loss and bushfire related PTSD that was not generalised to other disorder types in this study.
In general, exposure was much higher in bushfire survivors with PTSD compared to bushfire group as a whole with 2 people (50%) losing their homes and 2 of them (50%) losing their cars. This compares with only 5.4% of the whole bushfire group who had their homes destroyed and 3.2% who had their cars damaged or destroyed. In interpreting these findings it is important to keep in mind that exposure to the bushfire in this study was limited to an assessment of objective experiences of loss as reported by the parents and did not include an Miranda Van Hooff 2010 244 assessment of perceived life threat to the child at any time point. In addition, very little loss of life was reported in this sample as a result of this disaster especially in first-degree relatives despite the ferocity and speed of the fire. Overall the findings of this chapter further confirm the role of exposure in the development of Bushfire related PTSD but raises questions as to the applicability of this risk factor to other disorders.
In comparison to exposure, the role of child demographic characteristics (specifically sex) in predicting the development of lifetime disorder was consistent across all disorder types
(except bushfire related PTSD) with female sex emerging as a significant risk factor for lifetime PTSD, any lifetime disorder, lifetime depressive disorder and lifetime anxiety disorder. The role of female sex in mediating long term outcomes of childhood disaster exposure has been reported in previous studies with females generally reporting more severe posttraumatic stress reactions and to be at greater risk of developing PTSD following exposure to a disaster than males (Goenjian, Pynoos et al. 1995; Pfefferbaum, Nixon et al.
1999; Pfefferbaum, Doughty et al. 2002; Pfefferbaum, Sconzo et al. 2003; Goenjian, Walling et al. 2005) (Milgram, Toubiana et al. 1988; Green, Korol et al. 1991) (John, Russell et al.
2007) (Garrison, Weinrich et al. 1993) (Shannon, Lonigan et al. 1994) (Vernberg, Silverman et al. 1996), (Weems, Pina et al. 2007) (Pynoos, Goenjian et al. 1993) (Hsu, Chong et al.
2002) (Groome and Soureti 2004; Roussos, Goenjian et al. 2005; Giannopoulou, Strouthos et al. 2006) (Kilic, Ozguven et al. 2003). Age of the child at the time of the bushfire in contrast showed no effect on the development of bushfire related PTSD in the current study.
The finding of an increased risk of lifetime anxiety disorder in children meeting criteria for a neurotic disorder following the fires supports a previously established link between post- disaster responses of sadness, worry anxiety and loneliness in childhood disaster victims and the onset duration and severity of post-disaster psychopathology (Lonigan, Shannon et al. Miranda Van Hooff 2010 245
1994) (Udwin, Boyle et al. 2000). It also indicates stability in anxiety-related symptoms over time with children exhibiting neurotic style behaviour in childhood more inclined to develop a diagnosable anxiety disorder in adulthood. In the current study, teacher rated neurotic disorder emerged as a significant predictor of lifetime anxiety disorder, whereas parent rated neurotic disorder did not. This discrepancy between parent and teacher reports of behavioural problems is well established in the literature (Achenbach, McConaughy et al. 1987). In the study of childhood survivors of the Aberfan disaster for example, there was a large proportion of children who showed behavioural disturbances at home but not at school, and consequently missed out on being treated by a child psychologist. In light of these findings it is possible that the children displaying neurotic behaviours at home in the present study were also the children who the parents sought treatment for, explaining why only the teacher neurotic scores emerged as a significant predictor of long-term psychopathology. Alternatively, the children displaying neurotic behaviours at school may have represented those with more severe psychopathology making them more vulnerable to anxiety disorder in adulthood.
Parent-rated antisocial disorder assessed using the Rutter Behaviour Questionnaire emerged as a significant predictor of worst event PTSD. This finding once again calls attention to the role of the immediate post-disaster response in the emergence and maintenance of post- trauma symptoms over time. The role of antisocial behaviour in the development of PTSD has also been reported in a recent longitudinal study by Koenen et al (2006), which found that childhood antisocial behaviour increased one’s risk for both trauma exposure and PTSD in a
New Zealand Community Birth Cohort.
Parents own reactions to the bushfire disaster were observed in the current study to have strong implications for how well the children adjusted over time. Of particular interest is the finding that overprotective parenting significantly increased one’s risk of developing all types Miranda Van Hooff 2010 246 of disorder (with the exception of bushfire related PTSD). In the original phase of this study,
McFarlane observed that parental over-protectiveness constituted a risk factor for the development of PTSD symptoms in children, attributing this parental attitude to fears about the family's safety and the need to protect their children should such a tragedy recur
(McFarlane 1987). The current study further supports this relationship extending these findings to the long-term development of adult anxiety and depressive disorder.
In addition to overprotection, families characterised by high levels of involvement
(manifested in a better sense of their goals, being closer than before, talking over problems and being concerned about putting strain on each other) were at an increased risk of developing a lifetime anxiety disorder. In the original study, McFarlane (1987) reported that maternal post-traumatic imagery and the level of direct exposure to danger in parents predicted family involvement. In line with these findings, family involvement in the current study may represent a form of overprotective parenting, which developed in the families in response to intrusive phenomena experienced by the mother and the level of threat associated with the bushfires.
With regards to impact of maternal wellbeing and psychopathology on the development of disorder in the children, this study revealed a significant long-term role of post-disaster maternal functioning on the development of bushfire related PTSD only. Previous research by
Green, Korol et al (1991) identified parental functioning as one of the most influential factors contributing to number of PTSD symptoms in both very young children and adolescents following the Buffalo Creek Dam collapse (Green, Korol et al. 1991). Swensen et al (1996) identified maternal hurricane related distress to be the only significant predictor of Hurricane related behavioural problems in children exposed to Hurricane Hugo (Swenson, Saylor et al.
1996). Finally, Hock et al (2004) found that maternal worry after September 11 predicted the Miranda Van Hooff 2010 247 level of child’s fear, whereas early anxiety about being separated from the child was not predictive (Hock, Hart et al. 2004). The current study adds to this literature by supporting the link between maternal psychopathology and coping and the development of lifetime disaster related PTSD in a sample of childhood bushfire survivors over time.
Current distress associated with bushfire related PTSD symptoms emerged as a risk factor for lifetime bushfire related PTSD supporting a relationship between current self-reported PTSD symptoms and DSM-IV diagnosis. It is noteworthy that the IES-R was completed by participants around the 20-year anniversary of the Ash Wednesday Bushfire when the media was saturated with images of the 1983 fires. Such images may have increased intrusive thoughts about the fires consequently inflating self-reported levels of distress associated with the fires in those already at risk of having bushfire related PTSD.
One of the most compelling findings to emerge from this study is role of additional lifetime trauma in the development of lifetime anxiety and depressive disorders. To date only a small number of studies have examined disaster related psychopathology in the context of additional trauma and PTSD, with most of these studies focussing on prior trauma. Mullet-
Hume et al (2008) for example, examined PTSD symptoms in childhood survivors of the
World Trade Centre attacks and found that the number of prior traumas rather than the level of exposure to the 9/11 World Trade Centre attacks best predicted the severity of PTSD symptoms. Chemtob et al (2008) examined the combined effects of being exposed to the
World Trade Centre attacks and other lifetime traumatic events (excluding physical abuse, sexual abuse and domestic violence) on the behaviour of 116 pre-school children from
Manhattan. Compared with children who had no other trauma or who were considered to have low intensity exposure to the World Trade Centre attacks, children who had experienced high intensity exposure in combination with other trauma were over 21 times more likely to be Miranda Van Hooff 2010 248 emotionally reactive and anxious or depressed and 16 times more likely to have attention problems. Pfefferbaum et al (2003) studied children (aged 9 to17) eight to 14 months following the 1998 bombing of the American Embassy in Nairobi Kenya. Number of prior lifetime traumatic events as well as PTSD symptoms arising from these events significantly predicted PTSD symptoms arising from the bombing itself (Pfefferbaum, North et al. 2003).
Finally Garrison et al (1993) followed up a community sample of 1264 adolescents (11 to 17 years old), one year following Hurricane Hugo in 1990. Using a multivariate model individuals who had experienced other traumatic events in the year prior to their assessment were more than twice as likely to develop PTSD.
Findings from the current study together with the results of these previous studies demonstrate the complexity of the relationship between childhood trauma exposure and adult psychopathology. One of the weaknesses of many epidemiological studies of disaster related psychopathology is their failure to acknowledge the background spectrum of psychopathology within that community and the lifetime history of trauma exposures. The 33-year follow-up study of children from the Aberfan for example, reported significantly higher rates of PTSD in the exposed population compared to a matched control sample (Morgan, Scourfield et al.
2003) but failed to ask the participants about the existence and impact of any subsequent trauma limiting assessment of PTSD symptoms to the disaster alone. There is a distinction between this condition emerging solely from the disaster compared to the disaster having modified their reaction or having led to greater trauma exposures in their lifetime which in turn increases one’s risk for disorder. Future studies should incorporate as a minimum, a basic assessment of additional trauma to ensure a more precise understanding of the true nature of the relationship between disaster and the resulting psychopathology. Findings from the current study show that of itself, the bushfire disaster had a significant but not major long- term impact on the health outcomes of this population. Combine this level of exposure with Miranda Van Hooff 2010 249 other additional lifetime traumas however and an increased risk of developing a broad spectrum of both depressive and anxiety disorders emerges.
Despite the important contributions of the present study, there are several limitations to this study that must be acknowledged. Firstly, prevalence of bushfire related PTSD in this population was low (N = 4) raising concerns about the legitimacy of the risk factors to emerge in this model. Secondly, additional trauma was included in each model in the form of the total number of additional lifetime traumatic events. A more meaningful way of investigating the mediating role of additional trauma would have been to incorporate both pre-bushfire trauma and post-bushfire traumatic events into the predictive model together with any resultant
PTSD. Statistically however, such an analysis could not be performed in this study due to low or no variability between groups. Thirdly, although the Rutter was completed by parents and teachers approximately 15 months following the fires, the absence of pre-disaster measures makes it difficult to ascertain whether or not these behaviours were evident in the children prior to or subsequent to the disaster. Fourthly, in the present study both lifetime disorder and exposure to traumatic events was assessed retrospectively introducing potential recall bias.
In conclusion, this study makes an important contribution to research on childhood disaster victims by highlighting the complexity involved in undertaking a longitudinal study against the background of a broad spectrum of other lifetime traumatic events. A more detailed discussion of the findings of Chapter 7 and 8 in the context of the broader findings of this thesis will be discussed in Chapter 10.
Miranda Van Hooff 2010 250 9 The stressor Criterion-A1 and PTSD: A matter of opinion?
9.1 Commentary
The following chapter presents findings from a research paper recently published in the
Journal of Anxiety Disorders (Van Hooff, M., McFarlane AC., Baur J., Abraham, M., Barnes
DJ. (2009). The stressor Criterion-A1 and PTSD: a matter of opinion? Journal of Anxiety
Disorders, 23(1): 77-86. Signed statements regarding each author’s personal contribution to this paper are included in Appendix L of this thesis.
This paper highlights the subtle complexities inherent in posttraumatic stress disorder’s stressor Criterion (A1), demonstrated through a detailed examination of the impact that event categorisation has on the prevalence of trauma and PTSD. Although a substantial number of papers have now been published examining differences between Criterion A1 and non- traumatic stressors in relation to posttraumatic stress disorder prevalence and symptom severity, few studies have acknowledged the underlying process involved in initially categorising such events. This study together with the results of two other recently published papers suggest an inverse relationship between level of agreement and the number of raters, emphasizing the level of subjectivity involved in interpreting DSM-IV Criterion-A1.
In terms of the overall theme and content of this thesis, this paper is particularly pertinent as it highlights a potential confound inherent in most disaster literature published to date: reliance on a single word (“disaster”) to determine group classification (exposed/not exposed). This process has the potential for misclassifying an event as satisfying Criterion A1 based on a few descriptor words, such as “natural disaster” or “man-made disaster” in contrast to a detailed
Miranda Van Hooff 2010 251 history or inventory of the disaster (McFarlane 1987; McFarlane 1988). This misclassification process can lead to artificially inflated rates of both trauma and PTSD.
In the present study for instance, of the 173 participants who initially answered, “yes” to the question “Have you ever been involved in a fire, flood or natural disaster”? (Question extracted directly from CIDI version 2.1 which is based on DSM-IV criteria), only 136
(78.6%) were unanimously classified by our raters as meeting Criterion A1 based on the participant’s narrative about this event. A further 21 (12.1%) were unanimously coded as non- traumatic and 16 (9.2%) were coded as both traumatic and non-traumatic by at least 1 of the raters. One reason for such discrepancy in ratings in this particular study was the prior experience and knowledge of the senior author on this paper (Rater 3) which made it possible for him to interpret, clarify and elaborate on the often-insufficient explanations provided by the participants.
The findings from the present study support the need for a re-formulation of Criterion-A1 to include a more detailed definition of the type of events considered to satisfy the stressor criteria for each trauma type. Until that time, methodology such as that employed in the present study will be constrained by preceding studies otherwise direct comparison of prevalence of disorder cannot be made.
9.2 Introduction
Post Traumatic Stress Disorder (PTSD) is unusual in psychiatric nomenclature because the aetiological agent, namely the traumatic stressor, is defined within the diagnostic criteria implying a direct casual link between a definable external factor and consecutive symptoms
(Maier 2006) . Since definition of stress disorder in DSM-III (American Psychiatric
Miranda Van Hooff 2010 252 Association 1980), the effects of traumatic stress have been widely researched. However, the definition of the boundaries of the stressor “A1” criterion has emerged as one of the most controversial aspects of the diagnostic criteria (Breslau and Davis 1987; Solomon and Canino
1990; March 1993; Spitzer, First et al. 2007). For example, according to DSM-IV (American
Psychiatric Association 1994) to qualify as a traumatic event such an event should involve
“actual or threatened death or serious injury, or threat to the physical integrity of self or others” (p. 427). In contrast, ICD-10 (World Health Organization 1992) defines a traumatic event as being an event “of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone” (p. 147). The lack of clarity and vagueness of the Criterion-A1 language has consequently lead to an over-application of the construct of
‘trauma’ resulting in what McNally has termed a “conceptual bracket creep” (McNally 2003;
Spitzer, First et al. 2007), resulting in the abuse of this diagnosis in real life settings (Rosen and Taylor 2007).
Considerable debate exists about whether or not events that typically do not meet Criterion-
A1 (referred to as life events, non-traumatic events or low magnitude events) can result in the development of PTSD (Avina and O'Donohue 2002; McNally 2003; Gold, Marx et al. 2005).
It is implied in DSM-IV that an extremely traumatic event has a unique etiological effect in comparison to less dramatic life events and that there is a quantitatively and qualitatively different relationship between these two types of events and consequent psychopathology
(Lindy, Green et al. 1987). If this is the case, then while a person who has experienced a “life event” may describe this event as “traumatic,” a diagnosis of PTSD generally cannot be given if that event does not meet DSM-IV PTSD Criterion-A1. In the absence of sufficient evidence to support a diagnosis of PTSD, adjustment disorder would become the relevant diagnosis, as this disorder requires an identifiable stressor of any severity. The real conundrum, therefore, is how do we define a stressor as “traumatic” without relying on our own subjective
Miranda Van Hooff 2010 253 interpretation of the definition of Criterion-A1 and, if PTSD symptoms occur in response to life events, should Criterion-A1 be widened to incorporate such stressors (Avina and
O'Donohue 2002; Gold, Marx et al. 2005)?
A number of cases have been reported whereby PTSD symptoms have been experienced as a result of traditionally defined “non-traumatic” or “life events.” For example, in response to miscarriage, spousal affair (Helzer, Robins et al. 1987), marital disruption and collapse of adoption arrangements (Burstein 1985), non-serious nor life-threatening physical assault
(Seidler and Wagner 2006), work-related stressors, caring for a chronically ill loved one
(Scott and Stradling 1994), and loss of cattle due to foot and mouth disease (Olff, Koeter et al.
2005).
Inconsistent findings, however, have been reported in studies comparing PTSD prevalence rates following Criterion-A1 and other non-traumatic life events. Kilpatrick et al (1998) examined prevalence of PTSD in a sample who had experienced no event, a “low magnitude event” (non-traumatic life event) or a “high magnitude event” (Criterion-A1 event) and found only a minimal increase in overall PTSD prevalence when broadening the A1 criterion to include low magnitude events such as the non-violent death of a loved one, serious illness and sudden divorce. In a similar study, Hovens and Van der Ploeg (1993) found no significant differences between the non-traumatic life event and no event groups on self-reported PTSD scores using both the MMPI-PTSD and the Mississippi PTSD scale for civilians (Keane,
Malloy et al. 1984; Keane, Caddell et al. 1988), but significantly higher PTSD scores in those classified as experiencing a Criterion-A1 event.
In contrast, most other studies have reported similar or greater mean PTSD scores and/or
PTSD prevalence in individuals reporting non-traumatic life events compared to those who
Miranda Van Hooff 2010 254 report Criterion-A1 events (Solomon and Canino 1990; Spitzer, Abraham et al. 2000; Gold,
Marx et al. 2005; Mol, Arntz et al. 2005; Bodkin, Pope et al. 2007).
In general, studies examining the prevalence of Criterion-A1 events and PTSD utilize one of three methods of categorization; (1) a single rater determines whether an event meets
Criterion-A1 according to his/her interpretation of the definition specified in ICD-10 or DSM-
IV (Roemer, Orsillo et al. 1998); (2) multiple raters independently rate the event with majority agreement being required before an event is categorized as meeting Criterion-A1 according to the definition specified in ICD-10 or DSM-IV (Hovens and Van der Ploeg
1993); (3) multiple raters independently rate events with unanimous agreement being required before an event is categorized as meeting Criterion-A1 according to the definition specified in
ICD-10 or DSM-IV (Bodkin, Pope et al. 2007). Other studies appear to use multiple raters, who discuss and reach a consensus as a group as to which events meet Criterion-A1 according to the definition specified in ICD-10 or DSM-IV (Goodman, Corcoran et al. 1998; Gold,
Marx et al. 2005).
One problem inherent in both the single and multiple rater categorization systems is the level of subjectively required on behalf of the raters to interpret Criterion-A1. The use of multiple raters (rather than a single rater) is an attempt to reduce such subjectivity. However, further discrepancies then arise according to which method of agreement is employed – majority or unanimous. This dilemma is illustrated in a study of 27 psychiatric inpatients conducted by
Hovens and Van der Ploeg (1993). Using a majority method of scoring, 5 raters categorized
15 events as meeting DSM-IV Criterion-A1. In contrast however, only 1 event was unanimously agreed upon by all 5 raters as meeting DSM-IV Criterion-A1. Such discrepancy in prevalence of Criterion-A1 events between the unanimous and majority coding methods highlights the need to consolidate the methods of event categorization across studies.
Miranda Van Hooff 2010 255 Although the unanimous method of classification in this instance may reduce categorization discrepancies, it also has the potential to lower PTSD prevalence rates due to the lower overall prevalence of Criterion-A1 events. The impact of categorization differences is somewhat overlooked in research into PTSD resulting from Criterion-A1 and non-traumatic life events, but could account for some of the discrepancies that have emerged in the literature.
The current study is the first to provide a detailed examination of the impact of event categorisation on the prevalence rates of trauma and PTSD. There are three primary aims of this study. First, to explore in detail the types of events that lead to the most disagreement among raters. Second, to provide a descriptive account of whether the prevalence of
Criterion-A1 events and non-traumatic life events differs according to the categorisation method employed (single rater, multiple raters - majority method, multiple raters - unanimous method). Third, to statistically examine the subsequent differences in lifetime PTSD prevalence resulting from Criterion-A1 events and non-traumatic life events, and to determine whether PTSD prevalence also differs according to the type of categorisation method used.
9.3 Method
9.3.1 Participants
Participants were part of a larger longitudinal study examining the psychiatric outcomes of childhood exposure to a natural disaster. The original cohort, recruited from 1983 to 1985, comprised 806 children aged between 5 and 12 years who were attending primary school in a rural region of South Australia, vastly devastated by the 1983 Ash Wednesday Bushfires
(McFarlane 1987; McFarlane, Policansky et al. 1987). A control group of 725 unexposed
Miranda Van Hooff 2010 256 primary school children from a socio-demographically matched neighbouring rural community were recruited 16 months following the fires.
There were 1011 bushfire survivors and controls that were followed-up in adulthood, approximately 20 years later. The remaining participants from the original sample were either deceased (N = 20), withdrew (N = 111), refused to participate (N = 148), could not be contacted (N = 193) or were excluded for other reasons (N = 48). Of the 1011 that were followed-up and agreed to participate, 20 had incomplete data (i.e. did not complete the interview component of the study, the lifetime traumatic events measure or the entire PTSD assessment measures) and were excluded from the analyses. A further 129 participants were excluded because they either had not experienced a traumatic event, or had experienced a lifetime traumatic event but specifically stated that the event had no adverse impact on them and therefore requested not to complete the PTSD symptom questions for that event. Finally,
2 were excluded because they were unable to nominate which single event out of all their lifetime traumatic events was their “worst.” The final sample therefore comprised 860 participants, including 433 (50.3%) females and 427 (49.7%) males, ranging in age between
23 and 34 years (M = 28.3, SD = 2.30). Two thirds of the sample was either married (40.8%) or living in a de facto relationship (26.6%), 4% of participants were currently separated or divorced and 28.7% had never been married. Sixty-nine percent of participants had completed year 12 and 68.6% had completed post-school qualifications such as a trade, certificate, diploma or degree. Sixty-five percent of participants were employed fulltime, 16.3% were employed part time, 2.2% were unemployed and 15.8% were not currently in the labor force.
Miranda Van Hooff 2010 257 9.3.2 Measures
9.3.2.1 Demographics
Demographic characteristics were assessed using questions drawn from the National Survey of Mental Health and Wellbeing (Australian Bureau of Statistics 1998; Australian Bureau of
Statistics 1999).
9.3.2.2 Lifetime exposure to traumatic events
Lifetime exposure to trauma was assessed using the standard set of 10 Criterion-A events from the Composite International Diagnostic Interview (CIDI) (World Health Organization
1997). These were direct combat, life-threatening accident, fire, flood or natural disaster, witnessed someone badly injured or killed, rape, sexual molestation, serious physical attack or assault, threatened with a weapon/held captive/kidnapped, tortured or victim of terrorists, and other stressful event. In addition, the researchers included seven other event types (domestic violence, witnessed domestic violence, threatened/harassed without a weapon, finding a dead body, witnessing someone suicide or attempt suicide, child physical abuse, child emotional abuse). These events were chosen based on the authors’ clinical and research experience with traumatized populations. Participants were asked whether they had experienced any of these events and whether they experienced a great shock due to any of these events happening to someone close to them. They were then asked to nominate which of these events was their worst lifetime event and to provide a brief description of that event. PTSD was assessed in reference to this self-nominated worst lifetime event.
To enable a detailed examination of event types, events that were reported by participants in response to ‘any other stressful event’ were examined and further categorised. If three or more participants reported a similar event it was assigned its own category, leading to a
Miranda Van Hooff 2010 258 further eight event categories (death of a loved one, loved one attempted/committed suicide, miscarriage, still birth, relationship problems/separation, parent divorce/leaving, job stressors, medical illness/complication experienced by a loved one). An ‘other’ category remained for the events that were reported by one or two participants, such as death of a pet and abortion.
Events were also divided into three broad categories: events that happened to self, witnessing an event that happened to another, and learning about an event happening to another.
9.3.2.3 Lifetime PTSD
PTSD was assessed using a computerized version of the Composite International Diagnostic
Interview. The CIDI is a structured, standardised and comprehensive interview used to assess current and lifetime prevalence of mental disorders in adults, based on the Diagnostic and
Statistical Manual for Mental Disorders – 4th edition (DSM-IV; American Psychiatric
Association 1994).The CIDI was chosen in this study for three main reasons; it is designed to be administered by lay interviewers, it is a widely used instrument in epidemiological surveys, and has previously been validated in a Australian Population as part of the 1997
Australian National Mental Health and Wellbeing Survey (Andrews and Peters 1998).
A diagnosis of PTSD was scored according to the standard CIDI scoring criteria of 0
(‘indeterminate diagnosis’), 1 (‘criteria not met’), 3 (‘positive criteria met but exclusion not met’) and 5 (‘all diagnostic criteria met’). The participants were diagnosed with lifetime
PTSD if they scored 3 or 5.
Studies have found that the CIDI has excellent inter-rater reliability, and satisfactory test- retest reliability and validity in Australia and a variety of other settings worldwide (Wittchen,
Robins et al. 1991; Andrews and Peters 1998). To ensure reliability and validity in the current
Miranda Van Hooff 2010 259 study, research psychologists who had extensive experience and training in telephone recruitment, interviewing and psychiatric assessment conducted the interviews. A panel consisting of a psychiatrist and three research psychologists reviewed the scoring of structured interviews on a weekly basis.
9.3.3 Procedure
Original participants were traced to their current addresses through archived school admission records, the State Department of Births, Deaths and Marriages, the Australian Electoral
Commission, and advertisements in local newspapers. A National Death Registry was used to identify the deceased. Initial contact with the participants was by letter, followed by a telephone call from a research psychologist inviting them to participate. Informed consent was obtained from participants after the nature of the procedures had been fully explained.
Consenting participants were asked to participate in a 1-hour telephone interview and complete and return a self-report booklet. Participants did not receive compensation for their participation. The University of Adelaide Human Research Ethics Committee and the
Australian Institute of Health and Welfare research committee approved the study protocol, and the investigation was carried out in accordance with the latest version of the Declaration of Helsinki.
In order to achieve the aims of this study, three raters, blind to each other’s ratings, independently coded each of the worst lifetime events using the participant’s narratives of the event. They were coded as either a Criterion-A1 event or non-traumatic life event in strict accordance with DSM-IV Criterion-A1. The three raters comprised a psychiatrist and two research psychologists, all with extensive experience in PTSD.
Miranda Van Hooff 2010 260 Analyses were then conducted using the following categorisation methods: (1) the scoring of each single rater, (2) the majority scoring method, whereby the stressor was coded as a
Criterion-A1 or non-traumatic life event according to the category nominated by at least two of the three raters, and (3) the unanimous scoring method, whereby an event was coded as a
Criterion-A1 or non-traumatic life event only if all raters unanimously agreed so, and equivocal if there was any disagreement.
9.3.4 Statistics
Descriptive statistics allowed for the exploration of the level of disagreement between raters for each event type and the proportion of events that were coded as Criterion-A1 and non- traumatic life events using the five different categorisation methods (rater 1, rater 2, rater 3, majority, unanimous). Kappa was calculated to determine the level of agreement between the three individual raters.
Chi-square analyses examined if there was a significant difference between the proportions of participants that met lifetime PTSD criteria for non-traumatic life events compared to
Criterion-A1 events. This was conducted separately for the different categorisation methods.
Relative risks were also calculated. Descriptive statistics were used to examine the prevalence of PTSD for different event types.
The Statistical Package for the Social Sciences (SPSS) Version 11 was used to conduct the statistical analyses. A p < .05 significance level was chosen.
Miranda Van Hooff 2010 261 9.4 Results
9.4.1 Categorisation of traumatic and non-traumatic events
Overall, unanimous agreement occurred for 683 (79.4%) events. The greatest level of agreement between raters occurred for events that were witnessed (88.7%), followed by events that happened to self (84.9%), and then events that were learnt about (63.1%). Specific event types associated with the highest level of disagreement included: being threatened/harassed without a weapon (unanimous agreement on only 34.2% of occasions), child physical abuse (66.7%), and events that were learnt about but not experienced directly
(Table 9.1). There was unanimous agreement on all cases of direct combat, rape, being tortured, and having a stillbirth baby, with these events consistently classified by all raters as meeting Criterion-A1 for PTSD. In relation to non-traumatic life events, unanimous agreement was reached for the following events: relationship problems, parental divorce/separation, and job stressors, with all three raters rating these events as a non-
Criterion-A1 event.
In general, rater 1 and 2 (both research psychologists) had the highest level of agreement
(Kappa = .680). Rater 3, the psychiatrist, had the lowest level of agreement with rater 1
(Kappa = .538), followed by rater 2 (Kappa = .593). All Kappa statistics were significant at p
< .001.
Miranda Van Hooff 2010 262 Table 9.1: Levels of agreement among ratings of non-traumatic life events and Criterion-A1 events based on the unanimous categorisation method
Disagree Agree Total N (%) N (%) N Non- Criterion-A1 traumatic Event happened to self total 72 (15.1) 74 (15.5) 332 (69.5) 478 Direct combat - - 2 (100.0) 2 Life-threatening accident 8 (9.4) 2 (2.4) 75 (88.2) 85 Fire, flood, or natural disaster 16 (9.2) 21 (12.1) 136 (78.6) 173 Rape - - 18 (100.0) 18 Sexual molestation 2 (7.4) - 25 (92.6) 27 Serious physical attack/assault 3 (14.3) - 18 (85.7) 21 Threatened with a weapon/held 2 (10.5) - 17 (89.5) 19 captive/kidnapped Tortured or victim of terrorists - - 2 (100.0) 2 Domestic violence 5 (20.8) 3 (12.5) 16 (66.7) 24 Threatened/harassed without a weapon 25 (65.8) 8 (21.1) 5 (13.2) 38 Finding dead body 4 (26.7) - 11 (73.3) 15 Child abuse – physical 2 (33.3) - 4 (66.7) 6 Child abuse – emotional 2 (10.5) 17 (89.5) - 19 Miscarriage 1 (25.0) 3 (75.0) - 4 Still-birth - - 3 (100.0) 3 Relationship problems/separation - 8 (100.0) - 8 Parents divorced/parent left - 4 (100.0) - 4 Job loss/stressors - 3 (100.0) - 3 Other event that happened to self 2 (28.6) 5 (71.4) - 7
Witnessing an event that happened to 16 (11.3) 3 (2.1) 122 (86.5) 141 another total Witness someone badly injured or killed 6 (5.7) - 99 (94.3) 105 Witnessed domestic violence 6 (28.6) 2 (9.5) 13 (61.9) 21 Witness someone suicide/attempt suicide 4 (28.6) - 10 (71.4) 14 Other witnessed event - 1 (100.0) - 1
Learning about an event happening to 89 (36.9) 32 (13.3) 120 (49.8) 241 another total Direct combat - 1 (100.0) - 1 Life-threatening accident 22 (20.8) - 84 (79.2) 106
Miranda Van Hooff 2010 263 Disagree Agree Total N (%) N (%) N Non- Criterion-A1 traumatic Fire, flood, or natural disaster 3 (60.0) 1 (20.0) 1 (20.0) 5 Witness someone badly injured or killed 2 (40.0) 2 (40.0) 1 (20.0) 5 Rape 6 (75.0) - 2 (25.0) 8 Sexual molestation 7 (87.5) 1 (12.5) 8 Serious physical attack/assault 3 (30.0) 1 (10.0) 6 (60.0) 10 Threatened with a weapon/held - - 1 (100.0) 1 captive/kidnapped Tortured or victim of terrorists 1 (100.0) - - 1 Domestic violence 1 (16.7) - 5 (83.3) 6 Witnessed domestic violence - 1 (100.0) - 1 Threatened/harassed without a weapon 2 (100.0) - - 2 Finding dead body - 2 (100.0) - 2 Witness someone suicide/attempt suicide 2 (40.0) 3 (60.0) - 5 Child abuse – physical - 1 (100.0) - 1 Death of a loved one 11 (40.7) 6 (22.2) 10 (37.0) 27 Attempted/committed suicide 21 (70.0) 1 (3.3) 8 (26.7) 30 Medical illness/complications 5 (45.5) 4 (36.4) 2 (18.2) 11 Other learned about event 3 (27.3) 8 (72.7) - 11
9.4.2 Prevalence of non-traumatic life, Criterion-A1 and equivocal events using the
different methods of categorisation
As can be seen in Table 9.2, the proportion of lifetime Criterion-A1 traumatic events varied according to the categorisation method employed. As expected, the majority method resulted in a highest prevalence of Criterion-A1 traumatic events (79.8%) in this population in comparison to the unanimous method of categorisation (66.7%).
Miranda Van Hooff 2010 264 Table 9.2: Numbers (proportions) of events classified as non-traumatic life, Criterion-A1 and equivocal using the different methods of categorisation
Non-traumatic Criterion-A1 Equivocal
N (%) N (%) N (%)
Rater 1 170 (19.8) 690 (80.2)
Rater 2 179 (20.8) 681 (79.2)
Rater 3 220 (25.6) 640 (74.4)
Majority 174 (20.2) 686 (79.8)
Unanimous 109 (12.7) 574 (66.7) 177 (20.6)
9.4.3 Prevalence of PTSD for non-traumatic life events, Criterion-A1 events and
equivocal events using the different methods of categorisation
In total, 68 (7.91%) of the 860 participants that reported a “worst” event met lifetime DSM-
IV criteria for PTSD.
Table 9.3 reports relative risks of having PTSD following a non-traumatic life event compared to Criterion-A1 event (and an equivocal event) using the different categorisation methods. In all the categorisation methods, non-traumatic life events were associated with significantly higher lifetime PTSD prevalence rates than Criterion-A1 events (single rater categorisation: rater 1: N = 860, X2(1) = 5.752, p = .016; rater 2: N = 860, X2(1) = 5.965, p =
.015; rater 3: N = 860, X2(1) = 4.851, p = .028; majority categorisation: N = 860, X2(1) =
3.855, p = .05; unanimous categorisation: N = 683, X2(1) = 14.805, p = .001). The unanimous categorisation method also led to significantly higher PTSD prevalence in the non-traumatic life events compared to equivocal events group (N = 286, X2(1) = 14.607, p < .001).
However, there was no statistically significant difference between the rates of lifetime PTSD Miranda Van Hooff 2010 265 resulting from Criterion-A1 and equivocal events (N = 751, X2(1) = 1.356, p = .294). The highest risk of PTSD for the non-traumatic life event group relative to the Criterion-A1 event group occurred when the unanimous method was used. Participants reporting non-traumatic life events were 2.63 (CI = 1.60-4.32) times more likely than those reporting Criterion-A1 events to meet PTSD criteria using this method.
Interestingly, all the PTSD positive cases in the equivocal group using the unanimous categorisation method moved to the Criterion-A1 group when the majority method was used.
That is, 2 out of 3 raters agreed that that all of the PTSD positive equivocal events were
Criterion-A1 events.
Table 9.3: Lifetime PTSD prevalence for non-traumatic life events (NT), Criterion-A1 events
(Crit-A1) and equivocal events (E) using the different methods of categorisation
Non-traumatic Criterion-A1 Equivocal RR (95% CI) p
N (%) N (%) N (%)
Rater 1 21 (12.4) 47 (6.8) 1.81 (1.12-2.95) .016
Rater 2 22 (12.3) 46 (6.8) 1.82 (1.13-2.94) .015
Rater 3 25 (11.4) 43 (6.7) 1.69 (1.06-2.70) .028
Majority 20 (11.5) 48 (7.0) 1.64 (1.00-2.69) .050
Unanimous 20 (18.3) 40 (7.0) 8 (4.5)
NT vs. Crit-A1 20 (18.3) 40 (7.0) 2.63 (1.60-4.32) .001
NT vs. E 20 (18.3) 8 (4.5) 4.06 (1.85-8.90) < .001
Crit-A1 vs. E 40 (7.0) 8 (4.5) 1.54 (0.74-3.23) .294
Miranda Van Hooff 2010 266 Figure 9.1: Prevalence of lifetime PTSD for specific event types using the unanimous categorisation method
Figure 9.1 shows the specific event types that led to the highest PTSD prevalence using the unanimous method. Criterion-A1 event types that were associated with the highest rates of
PTSD included rape (N = 8, 44.4% of rape victims), and sexual molestation (N = 7, 25.9%).
Non-traumatic life event types that had high levels of PTSD prevalence included miscarriage
(N = 3, 75%), relationship problems (N = 4, 50%), child emotional abuse (N = 6, 31.6%), and job stressors (N = 1, 33.3%). Of the participants that reported PTSD in response to child emotional abuse, 5 of 7 (6 non-traumatic life events and 1 equivocal using the unanimous method) described school bullying. In total, 10 participants reported school bullying (either under the arm of emotional abuse or in the other event section), resulting a lifetime PTSD prevalence of 50%.
Miranda Van Hooff 2010 267 9.5 Discussion
This study is the first published report detailing the impact of event categorisation on the prevalence rates of trauma and PTSD. The first aim of the study was to explore the types of events that lead to the highest level of disagreement among raters. Overall, complete agreement between the three raters was attained for 79.4% of the events. This is slightly lower than the level of agreement (87%: 90 out of 103) between two raters reported in a study by
Bodkin et al. (2007) but higher than the 41% (11 out of 27) agreement between five raters in
Hovens and Van der Ploeg’s (1993) study. The three studies together suggest an inverse relationship between level of agreement and the number of raters, emphasizing the degree of subjectivity that is required to interpret DSM-IV Criterion-A1. The current study is the largest study of its kind published to date.
Several events were unanimously agreed upon as traumatic (meeting Criterion-A1 for PTSD).
These were direct combat, rape, being tortured, and giving birth to a stillborn baby. Non- traumatic life events that were unanimously agreed upon were relationship problems, parental divorce/separation, and job stressors. In general, the Criterion-A1 events that yielded the greatest level of consensus were those involving direct interpersonal violence, except for the category of being “threatened without a weapon”. This suggests that events of lesser intensity are likely to be the events to cause more disagreement between raters. The unanimous consensus between raters for rape supports earlier work by Hovens and Van der Ploeg (1993).
The question of whether this finding is a true and accurate finding or merely an artifact of one’s existing knowledge about the link between rape and PTSD remains to be answered.
Further to this, there were a number of event types that led to high levels of disagreement between raters. These events included being threatened without a weapon and events occurring to a close friend or relative. DSM-IV (American Psychiatric Association 1994) Miranda Van Hooff 2010 268 Criterion-A1 states that the person has been exposed to a traumatic event in which “the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others” (p. 427).
In examples where the participant was threatened without a weapon, disagreement between raters was generally focused on the interpretation and definition of the phrase “threatened death or serious injury.” Is it possible, for instance, for a verbal threat of death or serious injury over the telephone to satisfy this description therefore constituting a Criterion-A1 event, or does the threat need to be more direct, for example, in person? Such a distinction is not made in DSM-IV and requires some degree of subjective interpretation on behalf of the raters to make an accurate judgment.
In relation to events occurring to another, contention arose in the interpretation of the phrase
“threat of death or injury experienced by a family member or other close associate” which appears in the accompanying text in DSM-IV (American Psychiatric Association 1994, p.
424). How does one define the term “family member” or “close associate”? The subjective interpretation of the term “family member” can vary anywhere from a member of one’s immediate family to a distant cousin, depending on the participant and rater’s concept of family. Such variation in individual assessments becomes further compounded in a large sample.
Other traumas that led to confusion and contention between raters were “learning about serious medical illness of family member or other close associate” and “learning about the death of a loved one.” DSM-IV specifies the death of a family member or other close associate as a Criterion-A1 event if that death is unexpected or violent. However, given that death is commonly unexpected, to include such experiences in the definition of Criterion-A1 could potentially inflate the PTSD prevalence rate. These events are likely to happen to the
Miranda Van Hooff 2010 269 majority of people over the course of a lifetime and, hence, have little meaning as per the notion of traumatic stressors.
One way of resolving this issue is to ensure that all participants provide sufficient details in their narratives to allow independent raters to make an informed decision about the nature of the event and the relationship between the participant and the victim. This, however, is not always a possibility, especially in large-scale epidemiological surveys using multiple instruments, where raters are often time limited in their assessments.
The fact that events that were witnessed had lower inter-rater reliability than those that were directly experienced suggests that the perceived distress is more subjective in the witnessed events than events where there is direct impact of a threat. Even greater confusion exists within the learned event category, in part due to that lack of clarity in the descriptors in the text of DSM-IV. On the basis of this observation, a more precise definition of these constructs should be developed in the DSM-V text.
The second aim of the study was to ascertain whether or not the categorisation method employed (single rater, multiple raters-majority, multiple raters-unanimous) sufficiently altered the prevalence of Criterion-A1 events in our study population. Results derived from a descriptive comparison of prevalence rates suggested that it did. Of those who experienced an event, the proportion that were categorised as traumatic varied from 66.7% using the unanimous method to 80.2% using rater 1’s interpretation and classification of events.
In previous studies, the proportion of events that has been classified as Criterion-A1 has ranged from 36% to 85% using various methods and samples (Hovens and Van der Ploeg
1993; Roemer, Orsillo et al. 1998; Spitzer, Abraham et al. 2000; Gold, Marx et al. 2005; Mol,
Miranda Van Hooff 2010 270 Arntz et al. 2005). It is likely that the current study was at the higher end of this spectrum as it employed a sample that had been disproportionately exposed to a natural disaster, a trauma typically classified as a Criterion-A1 event in the scientific literature.
Ratings of the disaster cases were additionally confounded in this study by the problem of a single word defining a category of exposure. The senior author (rater 3) had studied the disaster and traveled extensively in the affected region at the time. This prior knowledge made it possible for him to interpret, clarify and elaborate on the often-insufficient explanations provided by the participants, which gave him a more thorough understanding of the nature of the bushfire experience. Often descriptions provided by the participants were subjectively not distressing, whereas factually they involved significant risk, which may or may not have been perceived by the subjects who were children at the time. This difference further highlights the potential for the misclassification of the stressor criterion from a few descriptor words, such as “natural disaster” or “man-made disaster” as against a detailed history or inventory of the disaster (McFarlane 1987; McFarlane 1988). Again, researchers are required to use judgments about the margins of disasters, for example, has an individual been exposed to hurricane or was it just a storm? If this is the case, one can argue for a reformulation of Criterion-A1 to include a more detailed definition of the type of events to be included under each type of trauma.
The highest level of disagreement overall was between rater 3 (the rater with the most extensive knowledge and practical experience in the field of PTSD) and raters 1 and 2 (both research psychologists trained, educated and experienced in psychological assessment rather than treatment). This provides further support for the argument that past knowledge and experience is strongly likely to influence the coding and definition of Criterion-A1 events. As
Weathers and Keane (2007) pointed out “…there are no crisp boundaries demarcating
Miranda Van Hooff 2010 271 ordinary stressors from traumatic stressors. Further, perception of an event as stressful depends on subjective appraisal, making it difficult to define stressors objectively, and independent of personal meaning making” (p. 108). In general, rater 3, who has considerable clinical and forensic experience, had a higher threshold of categorisation.
The main intention of this paper was not to determine whether there was a significant difference in the proportion of cases classified as traumatic or non-traumatic using the majority or unanimous method, but more so to focus on the effect that classification methods can have on PTSD prevalence. For this reason differences between the proportions of cases defined as traumatic using the various rating methods was derived using descriptive comparisons only. Future studies should aim to extend the findings to incorporate a statistical examination of such differences.
The final aim was to examine the differences in lifetime PTSD prevalence resulting from
Criterion-A1 events and non-traumatic life events, and to determine whether PTSD prevalence differed according to the type of categorisation method used. In this study sample, the total PTSD prevalence for those who experienced a traumatic Criterion-A1 event was
7.91% (68 cases). In line with previous research, events coded as non-traumatic were associated with higher lifetime PTSD prevalence (11.4 - 18.3%) than Criterion-A1 events
(6.7% - 7.0%), independent of the coding method employed (single rater, multiple raters- majority, multiple raters-unanimous) (Solomon and Canino 1990; Gold, Marx et al. 2005;
Mol, Arntz et al. 2005).
This observation may have emerged as a consequence of the category of other events (those events not included in the standard 9 events in the Composite International Diagnostic
Interview and those volunteered by the participant), a number of which were coded as non-
Miranda Van Hooff 2010 272 traumatic. This bias is a consequence of volunteered reporting rather than systematic enquiry of specific event types. The theory behind this argument is that participants generally do not spontaneously report on the occurrence of an event if that event has not caused them significant distress. A miscarriage, for example would not be volunteered under the category
“any other stressful life event” unless that person found that miscarriage traumatic. Recent studies have reported an incidence rate of miscarriage in a representative sample of Australian women aged 16-59 years of 33.4% (Smith, Rissel et al. 2003). In the current study, however, only 4 (0.9%) women reported having a miscarriage as their worst event, with all of these women meeting lifetime diagnostic criteria for PTSD. These results indicate an underestimate of the true incidence of miscarriage in this sample and an inflated prevalence of miscarriage related PTSD. This selected reporting of traumatic events due to a difference in criterion wording and the impact this can have on PTSD prevalence rates has been acknowledged in previous studies (Helzer, Robins et al. 1987; Kessler, Sonnega et al. 1995).
Alternatively, the finding of a higher prevalence of PTSD following non-traumatic events in other studies, such as Bodkin et al. (2007), may also reflect another methodological problem that has not been adequately articulated previously, namely the impact of current mood on recall. Specifically, in this study of depressed patients the associated negative affect may be likely to prompt painful recollections of distressing events, the recall of which is state dependent. This raises the problem that the spontaneous recall and nomination of potential distressing events is vulnerable to the individual mood state. The threshold for recall is likely to be lowered in distressed people, increasing the number of events that will be reported. A further issue is that the A2 criterion of subjective distress, namely fear, horror and helplessness expressed in response to the event, may also be influenced by the current appraisal of the experience rather than recalling the actual response at the time of exposure.
Miranda Van Hooff 2010 273 Again, an individual’s current state may contribute to this criterion being met, a further potential source of error.
The relative risk of satisfying DSM-IV PTSD diagnostic criteria for those in the non- traumatic life events group relative to the Criterion-A1 event group varied depending on the categorisation method. The unanimous method led to the highest relative risk, with non- traumatic events 2.63 times more likely to result in PTSD than Criterion-A1 events, the majority method led to the lowest relative risk (RR: 1.64), and the three single raters fell in the middle (RR: 1.69 – 1.82). Additionally, in the unanimous method, non-traumatic life events led to a greater relative risk of PTSD compared to the equivocal events, however, the equivocal and Criterion-A1 events were not significantly different. These findings contradicted recent work by Bodkin et al. (2007) who employed the unanimous method and reported no differences in PTSD prevalence between non-traumatic life events and Criterion-
A1 events. They, however, included participants who had experienced no event in their non- traumatic group, which may in part explain this discrepancy.
Hovens and Van der Ploeg (1993) employed the majority method and are one of few studies that reported greater PTSD severity in response to Criterion-A events compared to non- traumatic life events. Other studies reported discrepancies in PTSD prevalence but did not provide an adequate explanation of how they arrived at their findings. Gold et al. (2005), for example, noted that they categorized their events according to consensus between 2 raters.
They excluded events that did not provide enough information for accurate classification.
Without further information, it could be assumed that the events were discussed in collaboration (rather than blind) and a final decision was made together as a group. Mol et al.
(2005) failed to adequately explain their classification system except to say that the events were classified based on examples given in DSM-IV. Given the discrepancies in trauma and
Miranda Van Hooff 2010 274 PTSD prevalence evident in this study, research should aim to consolidate their categorisation methods so that more accurate comparisons can be made between studies. The findings of the current study are of specific interest to any research study reporting PTSD prevalence rates as it highlights the potential to limit the comparability between studies and to lead to inflated or understated PTSD prevalence rates following the same type of trauma across studies.
This study is unable to comment on which categorisation method is the most reliable in predicting PTSD prevalence. However, it could be argued that the unanimous method would lead to the most accurate categorisation of events as all raters (regardless of their previous experience, knowledge and expertise) must be in complete agreement before an event is included or excluded from the Criterion-A1 category, diluting the subjective bias. This method of unanimous classification, however, must be differentiated from the method whereby two or more raters discuss the event and together reach a consensus regarding how the event is to be classified. This method of classification is vulnerable to persuasion by those who are more knowledgeable, or more forthright in their opinions, which then becomes a replication of the single rater method.
While the sample that met PTSD criteria in the current study was small, certain events showed a strong relationship with PTSD. Criterion-A1 events that were associated with the highest rates of PTSD included rape and sexual molestation. The non-traumatic life event types included miscarriage, bullying, and relationship problems. The finding that sexual traumas led to high levels of PTSD is common and well-accepted in the literature
(Boudreaux, Kilpatrick et al. 1998; Breslau, Kessler et al. 1998; Cuffe, Addy et al. 1998;
Creamer, Burgess et al. 2001; Kilpatrick, Ruggiero et al. 2003; Hapke, Schumann et al. 2006).
Non-traumatic life events, however, and their association with PTSD are more controversial.
Miranda Van Hooff 2010 275 There is a small body of literature focusing on PTSD as a result of miscarriage and bullying, with PTSD rates following bullying ranging from 65% to 92% (Leymann and Gustafsson
1996; Matthiesen and Einarsen 2004; Tehrani 2004). These samples, however, were recruited from bullying victim groups. Engelhard, van den Hout, and Arntz (2001) argue for miscarriage to be included as a Criterion-A1 event rather than a non-traumatic life event.
Prevalence of PTSD after pregnancy loss has been reported to range from 26% (miscarriage and still-birth) to 39% (miscarriage alone) (Engelhard, van den Hout et al. 2001; Bowles,
Bernard et al. 2006). However, 4 months after the miscarriage, Engelhard et al. (2001) found this prevalence dropped from 26% to 7%, mainly due to participant attrition.
Relationship problems have been reported to be a strong predictor of PTSD symptoms. Gold et al. (2005), for example, found that 80% (eight out of ten) of those that reported relationship problems met PTSD criteria. Second to the expected death/serious illness of close person, relationship problems had the largest number of participants meeting PTSD criteria.
Similarly, Kilpatrick et al. (1998) found that out of eight PTSD positive cases in their non- traumatic life events group, six were the result of deaths or serious illnesses in the past year, and the other two were a result of divorce and being fired. Mol et al. (2005) found that relational problems had the highest mean PTSD scores of the non-traumatic life events, whereas, death of a loved one (sudden or non-sudden) had two of the lowest. All of these studies, however, utilized small samples. Interestingly, death of a loved one (whether sudden or not) was not associated with especially high levels of PTSD in the current study.
It should be noted that the current study did not control for the confounding effects of as sex
(in certain trauma types and populations), prior trauma and psychiatric and family psychiatric history, dissociation, treatment experience or substance abuse on PTSD prevalence rates or the reporting of traumatic events. (Brewin, Andrews et al. 2000; Ozer, Best et al. 2003;
Miranda Van Hooff 2010 276 Ouimette, Read et al. 2005). Furthermore, the aim of this study was not to determine whether
Criterion-A1 or non-traumatic life events result in the highest PTSD prevalence, but rather to examine if the difference between the groups in PTSD prevalence varies according to the categorisation method employed.
Presence of intrusive and distressing recollections of events, other than those considered to be traumatic is another issue that needs to be considered at length by the field. Perhaps the question should not be simplified as to whether Criterion-A1 is a valid stressor or not, but whether or not the event in question is the primary etiological factor in the individual’s disorder, or secondary to other individual risk factors, such as past psychiatric disorder. The role of the event is more likely to be central in high intensity stressors than in low intensity stressors where individual vulnerability has a greater probability of playing a primary role.
Unfortunately, discussions about PTSD are often polarized because of the role this diagnosis plays in determining causation, and hence negligence, in many litigation settings (Maier
2006). This role of the disorder in attributing causation in compensation creates understandable controversy around the diagnosis. The associated polarization of argument in legal settings undermines careful analysis of the margins of the disorder and favors broad and sweeping polemical arguments about the validity of PTSD as a psychiatric disorder, which contribute little to rationale scientific discourse.
In conclusion, large margins of error in relation to PTSD and trauma prevalence rates will continue to prevail until the level of subjectivity involved in interpreting and categorizing traumatic events is eliminated. Traditionally, Criterion-A1 was intended to refer to the objective element of the trauma, with Criterion-A2 relating to the subjective elements of the experience (Creamer, McFarlane et al. 2005; Weathers and Keane 2007), As this study and others have shown however, interpreting Criterion-A1 is a highly subjective process
Miranda Van Hooff 2010 277 influenced not only by the personal experience of the victim but also the experiences and mindset of those who rate them. Significant attention should be given to the language used to define Criterion-A1 in the next revision of DSM-V in order to ensure further compatibility between studies.
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10 Discussion and conclusions
This chapter is divided into four primary sections. Section one discusses the strengths of the overall study design and methodology; Section 2 outlines the methodological issues and limitations of the study; Section 3 provides a detailed summary of the most important conclusions and findings of the study in light of previous research as well as implications for future research and Section 4 provides a series of concluding remarks.
10.1 Strengths of the study
The current study has several strengths over existing studies investigating the long-term outcomes of childhood disaster exposure. First and foremost, it is the first longitudinal study to follow-up a large cohort of primary school children exposed to a natural disaster, using a control sample recruited as children at the time of the original study. Although there are a number of published studies examining the longitudinal psychological outcomes of experiencing a disaster in childhood only three longitudinal studies have been published to date that have followed disaster-affected samples from childhood into adulthood and that have included a control sample (Milne 1977; Terr 1983; Dollinger 1985; Pynoos, Frederick et al.
1987; Earls, Smith et al. 1988; Nader, Pynoos et al. 1990; Honig, Grace et al. 1993; Green,
Grace et al. 1994; Goenjian, Pynoos et al. 1995; Shaw, Applegate et al. 1996; Tyano, Iancu et al. 1996; La Greca, Silverman et al. 1998; Winje and Ukik 1998; Pfefferbaum, Nixon et al.
1999; Pfefferbaum, Nixon et al. 1999; Sack, Him et al. 1999; Bolton, O'Ryan et al. 2000;
Udwin, Boyle et al. 2000; Yule, Bolton et al. 2000; Goenjian, Molina et al. 2001; Brener,
Simon et al. 2002; Dyregrov, Gjestad et al. 2002; Hsu, Choong et al. 2002; Morgan,
Scourfield et al. 2003; Goenjian, Walling et al. 2005).
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Green and colleagues in 1994 conducted a 17-year follow-up of 99 adult survivors of the
Buffalo Creek dam collapse of 1972 (Green, Grace et al. 1994). At the time of the disaster, all subjects were between the ages of 2 and 15 and were recruited from families seeking compensation in relation to the disaster. Overall the follow-up sample represented 48% of the original sample of 207 children recruited in 1974. Yule et al (Yule, Bolton et al. 2000) and
Bolton et al (Bolton, O'Ryan et al. 2000) reported on the results of a 5 to 8 year follow-up of
216 survivors of the sinking of the cruise ship ‘Jupiter’ in Greek Waters in 1988. All subjects were between the ages of 11 and 18 at the time of the disaster and were recruited from a pool of approximately 400 potential survivors. Finally and most recently, Morgan et al (Morgan,
Scourfield et al. 2003) conducted a 33-year follow-up of 41 survivors of the ‘Aberfan’ disaster in 1966 in which a coal slagheap collapsed on to a primary school in South Wales killing 116 children. In this study, only 28% of the original 145 survivors were assessed as adults.
A major limitation of all three of these studies is that they compare the survivors with a comparison group collected at the time of follow-up rather than at the time of the disaster and therefore major issues exist about their comparability. The comparability of the Buffalo Creek controls is particularly questionable as the control group comprised neighbour controls, community volunteers and friends. The authors of this study acknowledge that the comparison subjects were a sample of convenience, raising doubts about the strength of the conclusions of differences in this study. In the Jupiter study, the controls were nominated friends and acquaintances of the survivors, again introducing potential for bias as these individuals had attended the same school. These controls may have been indirectly exposed to the disaster through the experiences of their exposed friends. In the Aberfan disaster, the sample was more appropriate, having attended the same secondary school as the victims, but this did not take account of the survivors who had moved away from the district. These
Miranda Van Hooff 2010 280 controls also had the potential to have been indirectly exposed to the disaster. The research reported here overcomes these methodological weaknesses by using a control group that compared well socio-demographically to the bushfire survivor group and importantly was recruited at the time of the initial study.
The sample size and follow-up rates in the present study were a considerable strength of the study. Previously, the Aberfan study included only 41 survivors and 72 matched controls and only 28% of the survivors were interviewed. The Buffalo Creek study compared 50 survivors with 46 controls. The sample in the Jupiter study was more adequate and comprised 217 survivors and 87 controls with full participation occurring in 54%. Of the 806 potential bushfire participants in the present study, 714 (88.6%) were re-contacted around the 20-year anniversary of the fires and 440 (54.6%) completed the entire study protocol. Six hundred and twenty-two (86%) participants in the comparison sample were also re-contacted of which 382 completed the entire protocol. Thus the risk of response bias issues was minimized in the current study due to the successful tracing and contact that was made with more 80% of the original sample. These follow-up rates mark the present study as the largest longitudinal study conducted in the field to date.
A further strength of the current study relates to the assessment of other trauma exposures and associated PTSD, which are potential confounders, given the significant rates of life time trauma exposures found in general population studies (Kessler, Sonnega et al. 1995; Creamer,
Burgess et al. 2001; Morgan, Scourfield et al. 2003). Previous studies have not examined the prevalence or impact of non-disaster trauma exposure in both the exposed and control groups but have limited the assessment of PTSD in relation to the disaster in the survivor group and the worst lifetime event in the controls.
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Finally, the present study is the longest study to date to examine general psychopathology other than PTSD using a standardised diagnostic interview in a sample of childhood disaster survivors. Previously, the longest and largest study to examine anxiety and depressive disorders was the Jupiter study which followed up 216 survivors and 87 control participants
(Bolton, O'Ryan et al. 2000). The Jupiter study however was limited to the follow-up of adolescents between the ages of 11-17, and a mean period of follow-up since the disaster of
6.7 years. The present study in contrast utilises a slightly younger population of children
(aged between 5 and 12 years at the time of the disaster) with a mean period of follow-up since the disaster of 20.7 years.
10.2 Limitations and methodological issues.
Despite the strengths of this study there are several methodological limitations and weaknesses that must be acknowledged.
Whilst a satisfactory rate of follow-up was obtained in this study, particularly given the difficulties of following-up a sample 20 years since last contact, some differences did occur between the responders and non-responders. Responders in the fire-exposed group reported a higher level of exposure and more behavioural problems in the two-years following the fire than non-responders, whereas, responders in the control group reported less problems compared to non-responders. This suggests that either those who were more adversely affected by the fires had an increased interest and participation in the study or those with a low level of exposure were not motivated to participate, both of which have the potential to increase any apparent differences between the disaster-exposed and the control population.
Hence, all results should be viewed in light of this response bias.
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Another caveat in this study relates to the decision not to operationalise the DSM-IV CIDI exclusion criteria relating to co-morbid disorder. This may have attributed to slightly inflated rates of some disorders in this study. Examination of this confounder, however, revealed that this effect was mainly in the anxiety constellation and did not change overall rates of disorder.
Therefore, for the purpose of retaining co morbidity, this is not perceived to significantly limit the findings.
The statistically significant one-year difference in the age of the bushfire and control sample at follow-up raises some questions about the initial recruitment of the controls. This apparent difference emerged because the control sample was recruited one year after the commencement of the two-month follow-up of the bushfire–affected children. Hence, the older children in the control sample had passed into high school and a younger class had commenced. At the time of the original study, the older children were not followed-up so that these differences did not emerge then. In order to reduce these confounding effects in the analysis, current age was entered as a co-variate in all investigations of lifetime psychopathology comparing bushfire and controls. In addition both current age and age at the time of the bushfire were entered into the multivariate predictive models for all disorder types to both examine and control for any age-related differences between the two groups.
A further limitation relates to the recruitment of participants for the original study. The third assessment, conducted 26 months following the fires was associated with a significant decline in participant numbers. Two of the primary schools in the bushfire-affected region had a change of headmaster during the interim period between assessment 2 and 3 and no longer wished to participate. In addition, the children from the two highest grades had moved on to high school, making these children more difficult to locate. These two factors in combination reduced the maximum number of potential teacher ratings available at the third assessment to
Miranda Van Hooff 2010 283
365. The 26-month sample of parent reports however was increased to 434 as a result of interviewers individually approaching the parents of children from both of these schools and encouraging them to participate. In order to reduce the amount of missing data at these earlier time points and to increase sample size, each participant’s first assessment Rutter scores were used in the present study regardless of whether they had a complete dataset or not. For participants with an increasing pattern of symptoms over time, using the first assessment measures may have slightly reduced their overall score on the Rutter behaviour measures especially if their first assessment was completed at Time 1 (2months) where parents and teachers rated the children with high exposure as less disturbed on the Rutter behaviour measures (McFarlane, Policansky et al. 1987). However for participants with a decreasing pattern of symptoms over time using their first assessment measures may have slightly inflated their overall score on the Rutter behaviour measures. The decision to use the first assessment Rutter scores was made to reduce the likelihood of the Rutter behaviour scores being influenced by the previous assessment while maintaining sample sizes and ensuring the sample closely represented the entire follow-up group.
The reliance on retrospective recall to determine lifetime trauma and disorder histories is an inherent weakness in all longitudinal studies with large intervals between assessments. In the present study, the last time that the participants were assessed was in 1985, 26 months following the fires. All information pertaining to lifetime trauma exposure and lifetime episodes of DSM-IV depressive and anxiety disorder therefore was collected from the participants at the 20-year follow-up interview. This raises two potential issues.
First, some participants were required tor recall events and symptoms occurring over a 32- year period. The reliability of recall of traumatic experiences in particular has received considerable attention in recent times, with several studies advising caution in uncritically
Miranda Van Hooff 2010 284 accepting recalled events (Greenberg and Wessely 2009). Traumatic memories have been shown to be particularly malleable. A number of studies, for example, have reported a memory amplification effect whereby reports of traumatic events increase over time and are related to the severity and number of PTSD symptoms reported at the time of the follow-up assessment (King, King et al. 2000; Giosan, Malta et al. 2009; Heir, Piatigorsky et al. 2009).
Giosan, Malta et al (2009) for example, found an increase over 1 year in the number of traumatic events reported by 60% of restoration workers deployed to the WTC site during or after the 9/11 attacks. This increase was associated with an increase in PTSD symptoms at follow-up. Another study by Heir and colleagues (Heir, Piatigorsky et al. 2009), assessed 532
Norwegian survivors of the 2004 Tsunami in South East Asia and reported elevated recall of threat intensity from six to 24 months. This amplification of recall threat was associated with lack of improvement in PTSD symptoms.
In relation to the recall of psychiatric symptoms, studies have reported decreased reports of psychopathology using retrospective compared to prospective ascertainment. A recent study comparing the prevalence of disorders reported in two New Zealand longitudinal surveys, for example, has shown that the lifetime prevalence of anxiety, depression, alcohol dependence and cannabis dependence up to age 32 is almost doubled if using prospective methodology
(Moffitt, Caspi et al. 2010).
In the present study, 6.1% of the bushfire survivors responded, “No” when directly asked,
“Have you ever been involved in a fire, flood or natural disaster?” This is despite that fact that all 36 of these individuals were identified as attending schools in the fire-affected region on the day of the fires. This finding, together with the knowledge that only a small proportion of the bushfire group were highly exposed to the fires, suggests that the bushfire may not have served as a “marker” in the autobiographical sense for many of these individuals making it
Miranda Van Hooff 2010 285 difficult for them to recall details of their psychological reactions and functioning both at the time of the disaster and in the years following. A recall bias therefore may exist which implies a need to apply caution in accepting recalled events in particular the individual’s emotional reaction to an event, which is subject to variation according to the current level of distress associated with that event.
Second, retrospectively examining the group prevalence of PTSD does not take into consideration within-individual changes that are embedded in the data (North 2005). Research has shown that PTSD is not uni-directional. Some individuals report an attenuation in symptoms and others an amplification (North 2005). Therefore this thesis is not able to comment on the temporal course of PTSD within the individual survivors of the bushfires.
Finally, this thesis reports on the results of a very large number of statistical tests. Therefore the probability of a true positive result emerging from this data is somewhat reduced. Given the breadth of the data presented and the descriptive nature of many of the results, however, a decision was made not to adjust p-values using bonferonni. All p-values, particularly those which are borderline significant therefore should be interpreted with this caveat in mind.
Justification for multiple testing will be performed upon publication.
The present study arose from the unique opportunity to study the longitudinal effects of childhood exposure to a large-scale disaster on a community sample of primary school children in which a comparison group was collected at the time of initial recruitment. In the author’s opinion, these strengths combined with the high cost involved with conducting successive prospective longitudinal studies from childhood to adulthood (Breslau, Peterson et al. 2008) strongly outweigh the limitations associated with the use of retrospective data collection methods and multiple testing used in the present study. Miranda Van Hooff 2010 286
10.3 Overall conclusions and findings from the study
10.3.1 Demographics
Only a few minor demographic differences emerged between the bushfire group and the control group none of which imply severe socio-economic disadvantage as a consequence of the bushfire. Participants who were exposed to the bushfire in childhood tended to be less socially mobile, to have a greater number of children, to continue to reside in rural areas, and to be employed as production workers. In contrast, control participants were more likely to complete high school and to gain employment in associate professional roles. These differences could not be explained by differences in the advantage/disadvantage (SEIFA
Index) that may have emerged since the disaster between the control and fire affected regions.
A comparison of the Socio-Economic Index for Areas (SEIFA) showed no significant differences (F=2.68, df=2, p=0.08) in social disadvantage between the bushfire affected region and the Naracoorte region. This index developed by the Australian Bureau of Statistics
(Australian Bureau of Statistics 2001) is based on four variables shown in the Australian population to related to social disadvantage and to affect how a community copes with change, low income, low educational attainment, unemployed and unskilled occupations. In the earlier phase of this study, it was noted that the educational performance of the symptomatic group of exposed children significantly declined in the aftermath of the fire
(McFarlane, Policansky et al. 1987). Therefore it is possible that the disadvantage observed in this study is not entirely represented by psychopathological outcomes alone.
The principle goal of this study was to provide an unbiased estimate of the conditional risk of
DSM-IV disorder following exposure to a bushfire disaster in childhood. Accordingly, caution should be exercised in the interpretation and generalisation of these findings to the Miranda Van Hooff 2010 287 greater population. Although over 85% of both the bushfire group and the control group were re-contacted at the 20-year follow-up, just over 50% of participants completed all components of the protocol – nothing is known at all about the adult lives of the 15% of participants that could not be contacted. Also the Ash Wednesday Bushfires on February 16th 1983, affected large parts of both South Australia and Victoria. This study is limited to a small subgroup of survivors living in the South East of South Australia only. Thirdly, at initial recruitment, all study participants resided in rural areas therefore there are potential limitations as to the generalisability of these results to disaster-affected children in urban environments. Finally, the current sample was culturally homogenous with majority of participants being of
European descent. This result emerged however due to the cultural demographic of the area and hence is considered appropriate given the epidemiological nature of the study. All of the following findings must be viewed in light of these study characteristics.
10.3.2 PTSD
The lifetime prevalence of bushfire related PTSD reported in the current study was considerably lower than rates reported in studies of other childhood disasters. In total only 6
(1.7%) of the bushfire survivors met lifetime DSM-IV PTSD criteria in response to the bushfire, compared to 27 (5.8%) of the control population who met PTSD in relation to their worst lifetime event. Only 3 (0.9%) bushfire survivors and 11 (2.4%) controls met DSM-IV criteria for PTSD at the time of assessment. These rates are in stark contrast to previous childhood disaster studies using a matched comparison group, which have reported lifetime
PTSD prevalence rates of 34 – 51% and 1-month prevalence rates of 7% - 29% in adults exposed to the Buffalo Creek Dam collapse, the Aberfan disaster and the sinking of the cruise ship Jupiter. In addition, all of these previous studies have reported significantly higher rates
Miranda Van Hooff 2010 288 of lifetime PTSD in survivors compared to matched controls. The present study showed no such effect.
There are several possible explanations for this finding. The first explanation relates to the low rates of death and injury witnessed by the children as a result of the fires in the present study. Death or injury to a family member or friend, number of known deceased persons, and the closer the relationship with the victim has been found to magnify symptoms in childhood survivors of a range of technological and natural disasters. Unlike the Aberfan and Buffalo
Creek disaster, which claimed the lives of 116 and 125 people respectively, the Ash
Wednesday Bushfires only claimed the lives of 14 people in the district even though 75 died as a result of the fires throughout South Australia and Victoria. This explanation however does not explain the findings from the Jupiter sinking, in which only four people were killed.
In fact, the sinking of the Jupiter and the Ash Wednesday Bushfires are probably the most closely related in terms of severity of exposure. Although children in both disasters were exposed to the threat of death, the breadth of exposure was broad with some children more exposed to danger than others, yet the rates of PTSD and other disorders in these two studies still vary significantly. In the current study, personal loss in relation to injury and death of family and friends did not emerge as a significant predictor of lifetime PTSD in relation to either the bushfire or the participant’s worst lifetime event further supporting the lack of effect of personal loss on PTSD symptoms in this sample.
A second possible explanation concerns the instruments used to diagnose PTSD. In contrast to previous studies that used the Clinician Administered PTSD Scale (CAPS) (Jupiter
Disaster) or the Structured Clinical Interview for DSM-IV (SCID) to assess PTSD (Buffalo
Creek Dam Collapse), the current study used the CIDI. This has the potential to significantly alter prevalence rates across studies.
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Additionally, the Aberfan study used ICD-10 criteria derived from the CIDI to assess lifetime
PTSD which has the potential to increase the rates for PTSD given that the 12-month prevalence rates in an Australian sample were more than double those obtained with DSM IV criteria in National Mental Health and Well Being Survey (Peters, Slade et al. 1999;
Rosenman 2002; Peters, Issakidis et al. 2005). The current study in contrast, established both
12 month and lifetime prevalence rates of anxiety and depressive disorders using DSM-IV diagnostic criteria.
Thirdly, the follow-up period in the current study is distinctly longer than the follow-up period in either the Jupiter and Buffalo Creek studies and hence short-lived cases of PTSD may not have been detected in the current study. Previous studies on adult community samples, for example, have reported a high remission rate in the first year followed by a gradual decline in symptoms in the years following (Kessler, Sonnega et al. 1995; Breslau,
Peterson et al. 2004).
A further source of bias is that the Buffalo Creek and Jupiter samples were recruited in the course of their legal action against the defendants. This factor has a major potential to bias the sample towards those with adverse outcomes (Sayer, Spoont et al. 2004) which may have led to increased rates of symptom reporting in these two studies. In the present study, while some families were involved in compensation claims for property damage, personal injury claims were made for only 3 of the 806 children involved in the study and this was not the basis for recruitment.
Females were slightly over-represented in both the Buffalo Creek disaster (62%) and the
Jupiter disaster (74% females), which may have also inflated rates of PTSD in the survivor groups in these two studies due to females being at a greater risk of developing PTSD than
Miranda Van Hooff 2010 290 males following a range of disasters occurring in childhood (Goenjian, Pynoos et al. 1995;
Goenjian, Walling et al. 2005).
The final explanation, the explanation that is most plausible to the author, relates to the way in which trauma and PTSD were assessed in the present study compared to previous studies.
Previously, most studies following childhood disaster survivors over time have restricted the assessment of PTSD to the disaster in the survivor group. This is standard methodological practice employed for one of three reasons: (1) estimates of the probability of developing
PTSD in disaster studies is most commonly assessed using either the National Institute of
Mental Health –Diagnostic Interview Schedule (NIMH-DIS), the World Health Organization-
Composite International Diagnostic Interview or the Clinician Administered PTSD Scale
(CAPS) with both instruments examining PTSD in relation to a single index event only; (2) time and budget constraints limit further investigation of additional traumas and (3) studies have shown that only a small number of participants who do not meet PTSD criteria for their most stressful or upsetting event are likely to meet criteria for their second, third or fourth most stressful event (Kessler, Sonnega et al. 1995). Consequently, in most longitudinal disaster studies, the disaster survivors have their index event pre-selected for them and are required to answer PTSD symptom questions in relation to that event only, regardless of their lifetime exposure to other traumatic events.
In contrast, control participants are generally assessed for PTSD using similar methodology to epidemiological studies of PTSD prevalence using community samples. This involves the participant selecting the “worst” or “most stressful or upsetting event” from a standard list of
Criterion-A1 events and answering PTSD symptom questions in relation to that event. This is a three step process first requiring the participant to recall which traumas they have experienced in their life; to evaluate the impact that each of these traumas has had on them
Miranda Van Hooff 2010 291 and to finally nominate which event was the most stressful or upsetting. PTSD symptom questions are then asked in relation to the participant’s self-nominated worst lifetime traumatic event.
Previous studies have shown that that the method of choosing an index event can potentially bias PTSD prevalence rates. Breslau et al (2004), for example, using a representative sample of 2181 community residents between the ages of 18 to 45 years, compared PTSD prevalence rates using a random event method versus the “worst” event method and reported that the worst event method yielded a moderately higher conditional probability for PTSD.
Additionally PTSD prevalence following disasters in community samples employing the
“worst” event method are generally very low, ranging from 0.4% to 5.4% for lifetime prevalence and 0.3% for 12 month prevalence in an Australian Community setting whereas prevalence rates in large samples of adult disaster survivors are generally much higher
(Kessler, Sonnega et al. 1995; Breslau, Kessler et al. 1998; Perkonigg, Kessler et al. 2000;
Zlotnick, Johnson et al. 2006). Finally, previous research has suggested that individuals identified as having PTSD following an particular event may actually have had PTSD from a pre-existing event or that this pre-existing event may have exacerbated their response to the index event (Resnick, Kilpatrick et al. 1993). Results of these studies together impress the need to examine PTSD prevalence in disaster survivors and controls in an identical manner in order to establish more accurate prevalence estimates.
The current study attempted to remove such bias by examining current and lifetime DSM-IV
PTSD in all participants (both disaster survivors and controls), in relation to the participants worst three lifetime traumatic events and by extracting bushfire-related PTSD prevalence estimates from those who nominated the bushfire as one of their worst three events. Using this method 352 (67%) of the 529 bushfire survivors nominated the bushfire as one of their
Miranda Van Hooff 2010 292 three worst lifetime events: 30.4% (N=161) as their worst event, 113 (21.4%) as their second worst event and 78 (14.7%) as their third worst lifetime event. To re-iterate, 70% of bushfire survivors when asked to reflect on the traumatic events they had experienced in their life chose an event other than the bushfire as their worst lifetime event. This highlights the low priority given to the bushfire disaster when survivors are given the opportunity to nominate their worst lifetime event. In addition, as reported in chapter 4, bushfire participants who nominated the bushfire as their worst lifetime event were at a lower risk of developing lifetime and current PTSD from the bushfire than bushfire participants who nominated some other event as their worst. These results demonstrate the importance of assessing other lifetime traumatic events in longitudinal studies of childhood disaster survivors in order to avoid the bias present in previous studies and may explain the discrepancy between PTSD prevalence rates in this study compared to others. Future research should attempt to further investigate the role of event pre-selection on PTSD prevalence rates not just in disaster populations but also in any study using a large sample of participants exposed to a specific traumatic event.
In addition to PTSD prevalence, this study also examined current levels of distress associated with the bushfire using the revised version of the Impact of Event Scale (IES-R) (Creamer,
Bell et al. 2003). Once again, findings showed that 20 years following the fires, the bushfire was responsible for little overall impact on the group. In fact, total IES-R scores were significantly lower in the bushfire exposed (in relation to the bushfire) than in the non-disaster exposed controls (in relation to their self-nominated “most stressful and upsetting event life event”), highlighting the significance of other event types in this community as a whole. In line with other studies of childhood and adult disaster survivors which have reported a high prevalence of intrusive symptoms in the immediate aftermath of both disasters and other traumatic events (McFarlane 1988; Shalev 1992; North, Nixon et al. 1999; Michael, Ehlers et
Miranda Van Hooff 2010 293 al. 2005), intrusion symptoms remained the most prevalent symptom type in this study, whereas criterion C (avoidance) and F (functioning) were the least prevalent. This finding supports research on adult disaster victims, which have designated these two criteria to be the gatekeepers of the diagnosis. North (2005) for example showed that adults exposed to the
Oklahoma city bombing who reported three or more group C symptoms had a 94% chance of meeting full PTSD diagnostic criteria. The current study supports this finding in childhood disaster victims.
Sixty six percent of the sample continued to be affected by intrusive symptoms 20 years on.
Of those who reported some distress, the two most commonly endorsed symptoms were, reminders brought back feelings (54.2%) and pictures popped into my mind (46.4%). It is important to note here, that the present study was conducted the same year as the 20–year anniversary of the fires, a time when the Australian media was saturated with images from the
1983 Ash Wednesday bushfire disaster. Previous research has implicated disaster related television exposure as a risk factor for the development of psychopathology in both children and adults (Pfefferbaum, Nixon et al. 1999; Pfefferbaum, Seale et al. 2000; Pfefferbaum,
Nixon et al. 2001; Ahern, Galea et al. 2002; Pfefferbaum, Doughty et al. 2002; Fairbrother,
Stuber et al. 2003; Pfefferbaum, Seale et al. 2003; Ahern, Galea et al. 2004; Lengua, Long et al. 2005; Pfefferbaum 2005), despite the fact that the DSM-IV diagnosis of PTSD appears to preclude exposure via the media alone (Hagan 2005; Pfefferbaum 2005). Further to this, a recent study by Bernstein et al (2007) has shown that exposure to television coverage of a disaster on the anniversary of that disaster can result in new-onset of probable PTSD
(Bernstein, Ahern et al. 2007). Given this association between television coverage and psychopathology and the timing of the present study it is not surprising that the most commonly endorsed symptoms in this population at the follow-up assessment were symptoms that were precipitated by visual images and reminders of the fire.
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One of the most unexpected findings to emerge in this study is the modest effect of bushfire exposure on lifetime psychopathology overall. A strong relationship has been reported between the development of psychopathology following childhood disaster exposure and the individual’s physical proximity to threat (including personal and property loss) (Pynoos,
Frederick et al. 1987; Nader, Pynoos et al. 1990; Pynoos, Goenjian et al. 1993; Goenjian,
Pynoos et al. 1995; Pfefferbaum, Nixon et al. 1999; Pfefferbaum, Seale et al. 2000; Goenjian,
Molina et al. 2001; Groome and Soureti 2004; Goenjian, Walling et al. 2005; Hoven, Duarte et al. 2005; Vijayakumar, Kannan et al. 2006; Chemtob, Nomura et al. 2008). In the present study, characteristics of the stressor (in particular high levels of property loss) emerged as a risk factor for bushfire related PTSD only in the univariate analyses. This result suggests a degree of specificity in the relationship between property loss and bushfire related PTSD that was not generalised to other disorder types in this study. Of the four participants with lifetime bushfire related PTSD, three (75%) scored above the 80th percentile for property loss, further highlighting the risk associated with high-level exposure to threat. Unlike previous studies, the degree of personal loss in relation to the number of known family members deceased or injured had no impact on the development of bushfire-related PTSD. This may be attributed to the small number of deaths following the bushfires compared to other longitudinal studies of childhood disaster survivors and therefore insufficient power to adequately test this effect.
Interestingly unlike in the models for depression, anxiety and worst event PTSD, characteristics of the child at the time of the fires such as gender and age did not predict bushfire-related PTSD, whereas children whose mothers reported more intrusive thoughts and problems coping in the aftermath of the fire were at an increased risk. These results emphasize the pivotal role that parental reactions play in mediating PTSD reactions in the child both in the short term and longitudinally. Previously, only a handful of short–term
Miranda Van Hooff 2010 295 follow-up studies have focused on the effects of parental post-trauma symptoms on children’s psychopathology following disasters (Winje and Ulvik 1998; Kilic, Ozguven et al. 2003).
This is the first study to report on the longitudinal effects of post-disaster parental functioning on the development and maintenance of PTSD symptoms in adults exposed to a disaster in childhood.
Finally, children exhibiting a higher number of post-trauma symptoms in the immediate aftermath of the fires, and who were rated by their parents as antisocial or by their teachers as neurotic on the Rutter Behaviour Questionnaire were at an elevated risk of developing PTSD from the bushfires later in life. This has important implications for mental health prevention and intervention. Not only does this finding emphasize the role of the child’s early behavioral response in the development of long-term psychiatric disorder, but it also suggests the need for early identification and treatment of children displaying changes in their normal patterns of behavior in the aftermath of a disaster. The most commonly reported antisocial behaviours were disobedience (33.9% in the bushfire group, 34.4% in the controls), fights (24.7% in the bushfire group, 20.3% in the controls) and the telling of lies (13.7% in the bushfire group,
21.2% in the controls). The most commonly observed neurotic behaviours were being often worried, somatic symptoms such as stomachaches and vomiting and being afraid of new things.
The lifetime prevalence of DSM-IV PTSD in relation to the participant’s self nominated worst lifetime event (7.8% in the Bushfire group and 5.8% in the controls) was in line with national lifetime DSM-IV prevalence rates reported in the US (Breslau, Davis et al. 1991;
Resnick, Kilpatrick et al. 1993; Kessler, Sonnega et al. 1995) and in the Netherlands (de Vries and Olff 2009) but lower than lifetime Australian national rates of 12.2% using ICD-10 criteria (Wells 2009). This may be related to the younger age of the present sample compared
Miranda Van Hooff 2010 296 to the Australian National Samples. In the Aberfan study, the prevalence of PTSD from the worst lifetime event in the controls was 20%. This rate is much higher than the prevalence of
PTSD reported in the present study, but may have been inflated due to the recruitment of the controls from a nearby village that was also potentially affected by the disaster.
One month prevalence rates of PTSD (current PTSD: 3.2% in the bushfire group and 2.4% in the controls) were again lower than 12 month prevalence rates of 6.4% reported in a National
Australian sample (Wells 2009), possibly due to differences in the ICD-10 and DSM-IV criteria for PTSD. An examination of the criteria shows that a DSM-IV traumatic event requires a reaction of fear to qualify as meeting Criterion A, whereas ICD-10 criteria do not.
Additionally, DSM-IV requires a greater persistence of symptoms than ICD-10 (Wells 2009).
Therefore, PTSD rates using ICD-10 may be slightly inflated compared to DSM-IV. The 1- month prevalence of PTSD in the bushfire survivors was also slightly lower than rates reported in survivors of the Buffalo Creek dam collapse after 17 years (4%). The current study is the first longitudinal study to directly compare the prevalence of worst event PTSD in a disaster exposed group and an unexposed comparison group. The results showed no significant differences between the bushfire group and the controls in lifetime or current
PTSD prevalence rates. It is important to exercise caution in the interpretation of these results, however, due to differences across studies in terms of the types of events accepted as satisfying Criterion A1, as well as the use of DSM-III diagnostic criteria in some studies, making true comparisons difficult (Kessler, Sonnega et al. 1995).
In contrast to bushfire-related PTSD, PTSD arising from the participant’s worst lifetime event in both the bushfire group and the controls was strongly predicted by the number of lifetime traumatic events experienced by the participants. In fact, the number of lifetime traumatic events was the one risk factor that consistently emerged in the multivariate predictive models
Miranda Van Hooff 2010 297 for all types of disorder including both depressive and anxiety disorders over and above the level of disaster exposure. Additional trauma following a traumatic event has been previously reported to increase one’s risk of developing PTSD to that event as well as depression in both adolescent and adult trauma victims (Yehuda, Kahana et al. 1995; Lloyd and Turner 2003;
Suliman, Mkabile et al. 2009). In addition, studies have reported a linear association between the increase in the number of traumas and the number of PTSD and depressive symptoms
(Suliman, Mkabile et al. 2009), with those exposed to multiple traumas more likely to experience severe symptoms of PTSD and depression than individuals exposed to a single event. A recent study, following 204 children from an ethnic minority group two and half years following the 9/11 World Trade Centre attacks, examined the potential impact of other
Criterion A1 lifetime trauma events and violence (excluding sexual or physical abuse) on
PTSD symptoms following the disaster (Mullett-Hume, Anshel et al. 2008). Interestingly, this study reported a significant interaction between additional lifetime traumas and the level of exposure to the disaster such that students who had experienced a high number of other lifetime traumas were less vulnerable to the effect of exposure to the World Trade Centre attacks than those with a low number of additional traumatic events. Our findings that adults who were exposed to a larger number of lifetime traumatic events were at an increased risk of developing DSM-IV PTSD and Depression, but not bushfire related-PTSD are in line with these findings. In addition, the present study is the first longitudinal study to examine the role of cumulative lifetime trauma exposure on lifetime adult psychopathology in a sample of childhood disaster survivors. In agreement with Mullet-Hume et al, 2008, results of this study strongly suggest that a lifetime history of multiple traumatic events is a more potent risk factor for adult psychiatric impairment than the severity of exposure to an index event
(Mullett-Hume, Anshel et al. 2008). The clinical implications of this finding are important for disaster intervention and suggest the need to obtain a complete trauma history of all disaster survivors prior to assessing their degree of risk for psychological impairment. The question of
Miranda Van Hooff 2010 298 whether or not children exposed to traumatic events such as disasters are more vulnerable to experiencing further trauma and PTSD or become sensitised to the effects of subsequent trauma requires further investigation.
The finding of an increased risk for the development of lifetime PTSD in children rated by their parents as antisocial cases on the Rutter Behaviour Questionnaire supports findings from previous longitudinal birth cohort studies conducted both in the US and New Zealand as well as veteran populations (Koenen, Fu et al. 2005; Breslau, Lucia et al. 2006; Koenen, Moffitt et al. 2007; Koenen, Moffitt et al. 2008). Generally, these studies have reported increased rates of traumatic events (specifically those involving assaultive violence) and lifetime PTSD following childhood antisocial behaviour, aggressive behaviour and conduct disorder. In the present study, antisocial disorder following the bushfires emerged as predictor of both worst event PTSD (in the bushfire participants) and bushfire-related PTSD, but did not predict who would develop PTSD to their worst lifetime event in the control population. In addition, parent reports of antisocial behaviour but not teacher reports emerged as a risk factor for
PTSD. This disparity between parent and teacher reports of childhood behaviour is well documented in the literature. Parents and teachers often underestimate the number and magnitude of posttraumatic symptoms in their children (McFarlane, Policansky et al. 1987;
Earls, Smith et al. 1988; Yule, Udwin et al. 1990; Vogel and Vernberg 1993; Lengua, Long et al. 2005). Further, parents report their children to have more symptoms than their teachers
(McFarlane, Policansky et al. 1987; Yule, Udwin et al. 1990). Therefore the lack of association between teacher ratings of antisocial behaviour and PTSD may merely be an artefact of the reduced number of cases reported by teachers compared to parents. The mechanism through which childhood antisocial behaviour impacts on lifetime prevalence of
PTSD in disaster affected populations requires further investigation.
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10.3.3 Other psychopathology
Depressive and anxiety symptoms have been reported with greater prevalence in adults following a number of childhood disasters with this study being no exception. In general, the present study identified lower rates of lifetime (24% of those with a depressive disorder,
25.1% with an anxiety disorder) and current depressive and anxiety disorders (4.5% with a depressive disorder, 12.5% with an anxiety disorder) than other disaster studies. However, the prevalence of depressive disorder was higher than that found in an Australian community sample that utilised ICD-10 criteria (15.9% in Australian sample) but was similar for ‘any’ anxiety disorder (26.3% in an Australian sample). Once again, caution should be exercised in the interpretation of these results due to use of different versions of the CIDI in these two studies and a younger age range of participants in the present study.
Previous, long-term studies (5 years or more and followed into adulthood) that examined the post-disaster prevalence of depressive disorders have reported prevalence ranging from 33% following the Buffalo Creek Dam Collapse to 46% following the Aberfan disaster (Green,
Grace et al. 1994; Bolton, O'Ryan et al. 2000; Morgan, Scourfield et al. 2003) while other studies that sampled adult refugees exposed to war atrocities in Cambodia and Afghanistan reported Major Depression to affect between 29%-45% of survivors (Sack, Clarke et al. 1993;
Hubbard, Realmuto et al. 1995; Mghir, Freed et al. 1995). Prevalence of depressive disorder at the time of assessment have generally been reported within the range of 2.8%-24% following a disaster in childhood (Green, Lindy et al. 1990; Green, Grace et al. 1994; Bolton,
O'Ryan et al. 2000), except for in refugees where prevalence is found to be much higher
(Kinzie, Sack et al. 1989; Sack, Him et al. 1999). Long-term studies (5 years or more and followed into adulthood) of post-disaster rates of anxiety disorder are slightly higher than rates of depressive disorders and range from 41% (excl PTSD) following the sinking of the
Jupiter to 61% following the Aberfan disaster (Bolton, O'Ryan et al. 2000; Morgan, Miranda Van Hooff 2010 300
Scourfield et al. 2003). Only one long-term study, the Jupiter study, has reported the point (1 month) prevalence for ‘any’ anxiety disorder. This makes the present study only the second study to report on this issue.
Bushfire survivors in the present study were at an increased risk of developing a current
DSM-IV disorder (in particular a current DSM-IV anxiety disorder), as well as a lifetime
DSM-IV anxiety disorder compared to the control participants. Overall, the increased rates in the bushfire group of “any lifetime anxiety disorder” and “any current DSM-IV disorder” however were small. This is despite the fact that the bushfire survivors were rated as more symptomatic by their parents following the fires. This supports recent work by Bolton and colleagues who reported higher rates of current and lifetime anxiety disorder in adolescent survivors of a shipping disaster. Two other studies following up survivors of the Buffalo
Creek dam collapse and the Aberfan disaster reported no such difference (Green, Grace et al.
1994; Morgan, Scourfield et al. 2003). Interestingly, in both the present study and the Jupiter study, specific phobias were the most common type of anxiety disorder reported, effecting
23.6% of the survivors of the Jupiter sinking and 11% of the bushfire survivors (Bolton,
O'Ryan et al. 2000). This represents a relative risk of 2.57 in the Jupiter study and 1.45 in the present study. In fact, the association between the development of fears or phobias and the experience of a disaster has now emerged in several studies (Dollinger 1985; Yule, Udwin et al. 1990; Terr, Bloch et al. 1999; Kar, Mohapatra et al. 2007). Although the children in these studies were not likely to become generally more fearful, they were significantly more likely to develop fears of stimuli resembling/relating to the event such as fear of death and dying, separation from parents, noise, fear of the unknown, fears of ships storms, water travel and fear of wind and rain. Following the 1986 Challenger Space Shuttle explosion for example, a number of disaster specific fears emerged in the children such as fear of death or dying, fear of taking risks and fears of explosions, fires, space and airplanes (Terr, Bloch et al. 1999).
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Yule, Udwin et al (1990) suggests that such findings provide support for the conditioning theory of fears, whereby children’s fears develop as result of a learning experience such as traumatic experience. In the present study, the finding of an increased prevalence of environmental type specific phobia in the bushfire survivors is noteworthy. For most participants in our study, the objects and situations that cued the fear and avoidance reaction closely resembled the weather conditions present on the day of the Ash Wednesday Bushfires
(i.e., strong winds, darkness, storms and thunder), yet most participants failed to independently make the association between these fears and the weather conditions on the day of the Ash Wednesday bushfires. This is an important observation in terms of the CI and C2 criteria of cognitive, affective and behavioural avoidance in PTSD (Association 1994).
Individuals may have significant avoidance behaviours and fears, which they do not consciously link to a prior exposure, consequently leading to inflated rates of specific phobia or other types of anxiety disorder and an underestimation of the prevalence of posttraumatic stress disorder.
The fact that individual disorders such as panic disorder were not statistically significant when “any” anxiety was significant arose as a consequence of the sample size. Whilst trends existed for individual disorders, this study was un-powered, despite the fact that 993 participants completed the CIDI component of the study.
Alcohol consumption and problem drinking was no more prevalent in the bushfire survivors than the controls, with approximately 30% of both groups classified as ‘harmful or hazardous drinkers’ and 14.2% of bushfire exposed compared to 10.9% of controls classified as ‘alcohol dependent’. This finding is in line with Morgan et al (2003) who reported no significantly increased risk of developing substance misuse in adolescent survivors of a shipping disaster
33 years post-trauma. Reijneveld et al (2003) reported that compared to adolescents from non-
Miranda Van Hooff 2010 302 affected schools, adolescents from schools affected by the Café Fire in Volendam Holland reported a significant increase in alcohol use 5 months following the disaster with 7.3% reporting excessive drinking prior to the disaster compared to 74.7% at follow-up. This study however employed a much shorter follow-up period than the present study, which may explain the discrepancy in results.
Predictors of anxiety and depressive disorders were examined using the same predictive model used for PTSD. Not surprisingly, there was no relationship between the level of exposure to the bushfire and either depression or anxiety, supporting the specificity of the relationship of this factor to PTSD. Bushfire group (coded dichotomously yes/no) did emerge as a significant predictor of any anxiety disorder in the Univariate analysis however this effect disappeared when all other variables were entered into the multivariate logistic regression.
The fact that bushfire group predicted any anxiety disorder is an interesting finding given that this summary variable excluded PTSD. It is possible that this relationship may be mediated by the high prevalence of environmental type specific phobias in this population as previously discussed. As with the other disorder types, females and participants with a greater number of lifetime traumatic events were at an increased risk of developing both a lifetime anxiety and lifetime depressive disorder.
Overprotective parenting style in the 16-month period following the fires was related to the development of both depressive and anxiety lifetime DSM-IV disorders including worst event
PTSD. There is an established link between parenting style in childhood and an increased risk of developing a depressive disorder later in life (PBI; Parker, Tupling et al. 1979), however most of this research has been conducted using clinical samples. Specifically, depressed adults retrospectively report lower levels of maternal and paternal care, and to a lesser degree, higher levels of maternal and paternal overprotection compared to non-depressed adults.
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(Parker 1981; Parker 1983; Gotlib, Mount et al. 1988; Plantes, Prusoff et al. 1988; Parker,
Hadzi-Pavlovic et al. 1995; Rodgers 1996; Patton, Coffey et al. 2001). Only a few studies to date have examined the direct relationship between overprotective parenting following a disaster and the development of psychopathology over time. McFarlane in his original examination of the bushfire cohort observed that parental over-protectiveness constituted a risk factor for the development of PTSD symptoms in children. He attributed this parental attitude to fears about the family's safety and the need to protect their children from further danger. Henry, Tolan and Gorman-Smith (2004) reported an increase in parental monitoring in the aftermath of the September 11 attacks, which was interpreted as “adaptive for their own adjustment and reassuring to their children” (Bokszczanin 2008). Most recently, Bokszczanin
(2008) examined over-protectiveness as a risk factor for PTSD 28 months following a major flood in Poland in 1997 (Bokszczanin 2008). This study involving 533 school children found that higher levels of parental over-protectiveness predicted PTSD symptoms and that parental over-protectiveness mediated the influence of traumatic exposure on distress 28 month post- disaster. Interestingly although the present study replicated these findings in relation to worst event PTSD, over-protectiveness did not predict bushfire related PTSD. This may have been due to the low number of PTSD cases following the bushfire and may therefore be an artefact of insufficient statistical power. Overall the results of the present study demonstrate the longevity of the relationship between overprotective parenting style and PTSD as well as the importance of parental over-protectiveness in the development of lifetime DSM-IV anxiety and depressive disorders. They also suggest a need to educate parents on the negative impact of authoritative parenting practices in the aftermath of a traumatic event in order to reduce long-term adverse outcomes.
In addition to overprotection, families characterised by high levels of involvement
(manifested in a better sense of their goals, being closer than before, talking over problems
Miranda Van Hooff 2010 304 and being concerned about putting strain on each other) were at an increased risk of developing a lifetime anxiety disorder with this effect mostly evident in the bushfire group. In the original study, McFarlane (1987) reported that family involvement was predicted by maternal post-traumatic imagery, the ability of the mother to cope and the impact of the parents’ and children’s direct exposure to danger suggesting that the reactions of both parents and the children affected the pattern of involvement in these families (McFarlane 1987). More importantly, maternal overprotection in this study was correlated highly with family involvement at both the eight and 26-month follow-up. These results help clarify the relationship between family involvement and the development of lifetime anxiety disorder in the present study. While overprotective parenting practices ensure that children stay close physically, greater levels of family involvement may allow parents to keep their children closer emotionally. By being more aware of their children’s goals, talking to their children about problems and maintaining an awareness of the pressures their children are suffering, parents gain a greater sense of emotional connection with their children, enabling them to more closely monitor any threats that are presented both inside and outside the home.
Unfortunately, however results of this study indicate that similar to overprotective parenting practices, high levels of family involvement can also lead to the child developing an anxiety disorder later in life, even after controlling for the actual occurrence of other lifetime traumatic events. In this sense, family involvement may be more suitably labelled family over-involvement in order to capture the true essence and intention of this type of family interaction.
The finding of an increased risk of developing a DSM-IV disorder (most specifically a DSM-
IV anxiety disorder) in participants meeting criteria for a neurotic disorder following the fires supports a previously established link between post-disaster responses of sadness, worry
Miranda Van Hooff 2010 305 anxiety and loneliness in childhood disaster victims and the onset duration and severity of post-disaster psychopathology (Lonigan, Shannon et al. 1994) (Udwin, Boyle et al. 2000).
More generally it supports a large body of previous literature on “internalising disorders”
(conditions involving disordered mood or emotion) which have documented the predictive role of depressive and anxiety disorders in epidemiologic and clinical samples (Kovacs and
Devlin 1998). It is widely accepted in the literature that children or adolescents who have experienced an anxiety disorder in childhood are more likely to develop a subsequent episode of anxiety later in life, as well as a range of other co-morbid disorders (Kovacs and Devlin
1998) This may be influenced by a number of factors including stability of environmental or social pressures from childhood to adulthood, individual characteristics including a genetic pre-disposition towards emotional dysregulation and temperament as well as the possible effects of sensitisation whereby early episodes of anxiety sensitise the central nervous system and make it more vulnerable to subsequent episodes of anxiety (Kovacs and Devlin 1998).
While this study is able to comment on the stability of anxiety symptoms in a disaster affected population from childhood to adulthood, the question of whether this relationship emerges as a consequence of the bushfire or merely as an artefact of an underlying propensity towards disordered mood or emotion was not addressed. Further analyses should examine the age of onset of these disorders to determine whether they occurred prior to or subsequent to the bushfire in order to clarify the mechanisms or process by which such disorders remain “true to form”.
In the current study, teacher rated neurotic disorder emerged as a significant predictor of lifetime anxiety disorder, whereas parent rated neurotic disorder did not. In the study of childhood survivors of the Aberfan disaster there was a large proportion of children who showed behavioural disturbances at home but not at school, and consequently missed out on being treated by a child psychologist. In light of these findings it is possible that the children
Miranda Van Hooff 2010 306 displaying neurotic behaviours at home in the present study were also the children who the parents sought treatment for, explaining why only the teacher neurotic scores emerged as significant. Alternatively, the children displaying neurotic behaviours at school may have represented those with more severe psychopathology making them more vulnerable to anxiety disorder in adulthood (Kovacs and Devlin 1998).
10.3.4 Lifetime trauma
The lifetime prevalence of exposure to listed traumatic events in both the bushfire and control group varied considerably according to the type of event, with some events occurring in less than 1% of the study population (direct combat) and others affecting up to 25% (witnessing some-one badly injured or killed). Overall estimates of lifetime prevalence of trauma exposure were higher than Australian national rates (Creamer, Burgess et al. 2001) with approximately 75% of the bushfire survivors and controls in the present study reporting at least one traumatic event (excluding the bushfire) compared to 57% of the Australian population.
In line with previous epidemiological studies (Breslau, Kessler et al. 1998; Elklit 2002) and replicating findings from a national Australian sample (Creamer, Burgess et al. 2001) the trauma experienced by the largest proportion of people in both the bushfire group and the control group was the composite group of traumas collectively termed “learning about an event happening to another” (41.8% in the bushfire group and 38.4% in the control group).
These events involve traumatisation as a consequence of an event occurring to someone else and are termed “vicarious” traumatisation. In the present study these events included death of a loved one, suicide or attempted suicide of a loved one and serious medical illness in a loved one. Remarkably, these were also the event types that led to the highest levels of
Miranda Van Hooff 2010 307 disagreement between raters in terms of whether or not the event should satisfy criterion A1 for PTSD (Chapter 9).
According to DSM-IV (American Psychiatric Association 1994) to qualify as a traumatic event such an event must involve “actual or threatened death or serious injury, or threat to the physical integrity of self or others” (p. 427). In specific relation to vicarious traumatisation,
DSM-IV includes a statement in the accompanying text to allow for “threat of death or injury experienced by a family member or other close associate” (American Psychiatric Association
1994, p. 424). The problem lies in the ambiguity of the phrases “family member” and “close associate”. Participants in the present study subjectively interpreted the term “family member”, to incorporate a variety of people ranging from a member of their immediate family
(mother, father sibling, spouse and child) to a distant cousin, depending on the participant’s culture, family dynamic and underlying concept of family. However it is unclear whether
DSM-IV intended this definition to have such a broad scope. As a consequence contention arose between raters as to whether such events should satisfy Criterion A1 for PTSD.
Consequently the prevalence of PTSD following this particular type of trauma in the present study is questionable.
Other traumas within this category of events included “learning about serious medical illness of a family member or other close associate” and “learning about the death of a loved one”.
According to DSM-IV the death of a family member or other close associate satisfies
Criterion-A1 provided that the death is unexpected or violent. Death however is frequently unexpected therefore to include a death event based on this definition alone has the potential to inflate the incidence of PTSD. Serious medical illnesses and deaths among family members and friends effect a large proportion of the population on a regular basis and, hence, have little meaning as per the notion of traumatic stressors.
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This methodological limitation of the DSM-IV definition of the Stressor Criterion A1 is particularly problematic when PTSD prevalence is contingent upon the inclusion of such ambiguous events, and prevalence is compared across different study populations. In the present study, the events that were most frequently nominated as the worst (“other event” and
“learning about an event happening to another”) were not the events that most frequently resulted in PTSD and hence PTSD prevalence in this study are less likely to be artificially inflated by this process. However caution should be exercised when comparing the prevalence of PTSD in this study with that reported in other epidemiological studies of disaster populations especially the incidence of PTSD following these types of events could potentially be much higher.
In both the bushfire group and the control group, rape was the trauma most likely to be associated with PTSD with 50% of participants who nominated this event as their worst event developing PTSD. This supports results of epidemiological studies in both western and developing countries, which have highlighted the predictive role of assaultive violence, specifically rape and sexual molestation, in the development of PTSD. (Kessler, Sonnega et al. 1995; Breslau, Kessler et al. 1998; Creamer, Burgess et al. 2001; Rosenman 2002;
Zlotnick, Johnson et al. 2006). In the present study other events strongly associated with
PTSD were childhood emotional abuse, childhood physical abuse, sexual molestation and being threatened with a weapon, all of which involve personal victimisation. In stark contrast, only 36.4% of participants in the bushfire group nominated the bushfire as their worst lifetime event, with only 2.7% of these participants going on to develop PTSD from the bushfire. This rate of PTSD represents less than 1% of all bushfire-exposed participants and represents the lowest likelihood of lifetime PTSD of all the traumatic events examined.
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Future research on this sample should consider the non-random and temporal distribution of the events experienced by participants in order to get a more detailed understanding of the true impact of the disaster in comparison to other events. Rape may be the event most likely to result in PTSD in this particular sample but it may also be the event that occurred most recently in the lives of these participants. In such a situation, a bushfire occurring in childhood has the potential to appear less significant in comparison. The validity of comparing conditional probabilities of PTSD across event types rests on the assumption of randomness or at least heterogeneity, in occurrence over time. In this respect, the bushfire is not random in that for all participants it occurred 20 years prior. Future studies will need to investigate the interaction between event type and recency of event before true and valid comparative statements about disaster related PTSD can be made.
10.4 Concluding comments
Each year thousands of children are affected by disasters worldwide. Historically in the literature, there has been a paucity of research into the psychosocial impact of disasters on children, mainly due to the minimisation of children’s reactions by parents and teachers as mild and transient. In fact it wasn’t until the 1970s to 1980s that the longitudinal effects of childhood exposure to a disaster was first acknowledged by researchers following up childhood survivors of the Aberfan disaster and the Chowchilla school kidnapping. Today a number of theoretical risk factor models have been developed to better understand and explain the longitudinal course and aetiology of disaster related psychopathology. However there is still little systematic research on the application of these models to the development of symptoms from childhood to adulthood.
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In the assessment of children following a disaster it is essential to differentiate between the typical expected reaction of a child to a disaster and the behaviour and adjustment reactions that deviate from normality. Transient mild stress reactions should be expected following a disaster, due to disruptions in the child’s life and routines, it is when these symptoms persist for a month or more that long-term problems begin to emerge. Methodologically the inclusion of an unexposed comparison group which is recruited at the time of the disaster can help elucidate the role of the disaster in the development of lifetime psychopathology independent of universal environmental influences.
The present study, while acknowledging the detrimental impact of childhood exposure to a natural disaster on the development of long-term anxiety spectrum disorders, raises some important questions regarding the methodologies employed by previous longitudinal follow- up studies of childhood disaster survivors. The main challenge facing researchers to date is to begin to prioritise the disaster in the context of additional lifetime trauma so as not to overemphasise the contribution of one discrete event to long-term psychosocial maladjustment. Children are inherently resilient. It is the experience of additional traumatic events (both related and unrelated to the disaster), in conjunction with both the child’s specific sensitivities and the pattern of family interaction (specifically overprotective and over-involved parenting style) in the immediate aftermath of a major disaster that appear to be the mediators of poor outcome.
Immediate identification of a child at risk of psychological maladjustment following a disaster can significantly improve both the psychological and economic costs of childhood disaster exposure. A focus on family intervention and reducing the risk of further traumatisation by identifying and addressing risk factors known to relate to poor psychological outcomes is the best means of reducing long-term psychopathology.
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World Health Organization (1994). ICD-10 International Statistical Classification of Diseases and Related Health Problems. Geneva, World Health Organization. World Health Organization Collaborating Centre for Mental Health and Substance Abuse (1997). Composite International Diagnostic Interview: CIDI-Auto 2.1 - Administrator's guide and reference. Sydney, World Health Organization Collaborating Centre for Mental Health and Substance Abuse. Yehuda, R., B. Kahana, et al. (1995). "Impact of cumulative lifetime trauma and recent stress on current posttraumatic stress disorder symptoms in holocaust survivors." Am J Psychiatry 152(12): 1815-8. Yule, W. (1992). "Post-traumatic stress disorder in child survivors of shipping disasters: the sinking of the 'Jupiter'." Psychother Psychosom 57(4): 200-5. Yule, W., D. Bolton, et al. (2000). "The long-term psychological effects of a disaster experienced in adolescence: I: The incidence and course of PTSD." J Child Psychol Psychiatry 41(4): 503-11. Yule, W. and O. Udwin (1991). "Screening child survivors for post-traumatic stress disorders: experiences from the 'Jupiter' sinking." Br J Clin Psychol 30 ( Pt 2): 131-8. Yule, W., O. Udwin, et al. (1990). "The 'Jupiter' sinking: effects on children's fears, depression and anxiety." J Child Psychol Psychiatry 31(7): 1051-61. Zaidi, L. Y. and D. W. Foy (1994). "Childhood abuse experiences and combat-related PTSD." J Trauma Stress 7(1): 33-42. Zimmermann-Tansella, C., S. Minghetti, et al. (1978). "The Children's Behaviour Questionnaire for completion by teachers in an Italian sample: preliminary results." Journal of Child Psychology and Psychiatry 19(167-173). Zlotnick, C., J. Johnson, et al. (2006). "Epidemiology of trauma, post-traumatic stress disorder (PTSD) and co-morbid disorders in Chile." Psychol Med 36(11): 1523-33.
Miranda Van Hooff 2010 327 Appendices
A: DSM-IV Criteria for PTSD
328 309.81 DSM-IV Criteria for Posttraumatic Stress Disorder
A. The person has been exposed to a traumatic event in which both of the following have been present:
(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
(2) the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior.
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma
(3) inability to recall an important aspect of the trauma
329 (4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if: Acute: if duration of symptoms is less than 3 months Chronic: if duration of symptoms is 3 months or more
Specify if: With Delayed Onset: if onset of symptoms is at least 6 months after the stressor
330
B: Letter from the South Australian Births Deaths and Marriages Registration Office
331 Contact Officer: Ms Dona Attard
Telephone: (08) 8204 9600
LETTER TO STUDY SUBJECTS
Date
Name Address
Dear XXXX
I have been approached by the University of Adelaide to assist them in contacting persons who were involved in a study, which was conducted in 1983 following the Ash Wednesday bushfires.
The University of Adelaide is conducting a follow-up study that aims to enhance the understanding of the psychological needs of individuals who experience adverse affects or stress in childhood.
You were involved in the original study conducted in 1983 and the University of Adelaide is interested in talking to you about the follow-up study. Please be aware that you may not realise that you were part of the study as your parents and teachers completed the relevant forms and gave their consent.
The University of Adelaide has been unable to contact you primarily because you have changed your name (either by marriage or a formal change of name process).
Whilst I recognise the importance of the study, I am committed to maintaining the privacy of persons whose details are registered in our office and as a result, I have advised the University of Adelaide that I will not disclose your information to them without your consent. The University of Adelaide has therefore asked me to contact you on their behalf.
I have enclosed an information sheet, which describes the university’s study in more detail. If you are interested in learning more about the study or your level of involvement in the study as a young child, you can call the university direct on (08) 8222 6907 or 0421 616 351.
Alternatively if you have any further questions please feel free to contact Dona Attard, Deputy Registrar on (08) 8204 9600 for more information.
Please be assured that if you do not consent to having your details passed on to the University of Adelaide this office will not release any information to them.
Yours sincerely
V J Edyvean REGISTRAR BIRTHS, DEATHS AND MARRIAGES
332
C: Introduction Letter
333
Date
Faculty of Health Sciences
Alexander McFarlane Name Professor Address 1ST Floor Maternity Wing QUEEN ELZABETH HOSPITAL Address WOODVILLE SA 5011 AUSTRALIA TELEPHONE +61 8 8222 6515 FACSIMILE +61 8 8222 6036 Dear
The National Health and Medical Research Council, has funded a research team headed by Professor Sandy McFarlane from the University of Adelaide to investigate the health and wellbeing of adults attending primary school in the South East of South Australia in the years 1983-1985.
Following the Ash Wednesday Bushfires in 1983, Professor McFarlane, who at the time worked at Flinders University, conducted a large-scale study of 1500 primary school children in the South East of South Australia. You have received this letter because you were a part of that original study. You may not be aware that you were a part of this study as your parents and teachers completed the relevant questionnaires and consented to you participating. Two groups of children were examined: those attending schools in areas exposed to the bushfires, and a comparison group of children from Naracoorte who were not directly exposed to the fires.
This current project is a follow-up study that aims to enhance our understanding of the psychological needs of individuals who have experienced adverse events or stress in childhood. It has now been 20 years since this first investigation and we are interested in making contact with you again. Your involvement would be greatly appreciated because of the valuable information you can personally give us. This will be the first study in the world to follow up children exposed to a natural disaster. It offers a unique opportunity to look at the relationship between an individual’s current health and wellbeing in light of childhood experiences. Results obtained from this type of study are very important. They can help us better understand the needs of children and adults who have had to cope with stress and how these needs can be better addressed. Also, quite apart from the bushfire, this study gives us an opportunity to look at the health and wellbeing of individuals who have grown up in rural Australia. Even if you feel that your life has been, and still is, satisfying and you have no health problems, we are still very keen to hear from you.
A central aspect of the study design is to re-contact the same group of individuals following a designated period of time. The success of this study strongly depends on as many people as possible agreeing to be re-interviewed. We would greatly appreciate it if you would participate, as your involvement could be crucial to our findings. All the information is dealt with in an anonymous way so your privacy is ensured.
334 Thank-you for taking the time to read this letter. A member of our research team will call you over the next week to discuss the study with you in detail. Alternatively if you are interested in participating you can call us on (08) 8222 6907 or 0421 616351.
We look forward to speaking to you soon,
Yours sincerely,
Professor Sandy McFarlane Adelaide University MB BS(Hons)., MD., Dip.Psychother., FRANZCP
335
D: Confirmation Letter
336
ICSAH RESEARCH PROJECT Faculty of Health Sciences
Date MIRANDA VAN HOOFF Research Officer 1ST Floor Maternity Wing QUEEN ELZABETH HOSPITAL WOODVILLE SA 5011 AUSTRALIA Name TELEPHONE +61 8 8222 6907 Address FACSIMILE +61 8 8222 6036
Address
Dear
I am writing in response to our recent telephone conversation regarding our research study entitled “The Impact of Childhood Stress on Adult Health: Long term follow-up of adults who were children in 1983 living in the South East of South Australia”.
Thank-you very much for agreeing to participate in the study. As discussed on the phone, your telephone interview has been arranged for (day, date, time). The person interviewing you will be (name of interviewer) and she will call you on (insert person’s phone number).
Enclosed with this letter is an information package including an information sheet, a consent form to participate in the phone interview and questionnaire booklet component of the study (consent form 1), a consent form to allow us access to your Medicare records (consent form 2), a complaints form and questionnaire booklet. Please read the information sheet and consent forms very carefully.
The information sheet will explain the study to you in more detail. Please read it very carefully so that you know exactly what is involved.
Consent form 1 must be signed before you can commence the study. It tells us that you consent to filling in the questionnaire booklet (Part 1) and to partaking in the phone interview (Part 2).
Consent form 2 must be signed in order for us to gain access to information relating to your health care utilisation over the past five years from Medicare (Part 3).
Consent for all three parts of the study is completely voluntary.
The complaints form is to ensure that any complaints that you may have about the study can be dealt with in the correct manner. Keep this form in a safe place.
The questionnaire booklet should take approximately 30 minutes to complete and can be filled in any time between now and your phone interview. Once the booklet is complete, and
337 you have checked that you have answered all questions, please send it back to us in the reply paid envelope provided with the two signed consent forms.
If you have any questions about the booklet or the study in general, or need to change the date or time of your phone interview please call (08) 8222 6907 or 0421 616 351 and ask to speak to one of the ICSAH research staff.
We greatly appreciate your kind offer to assist us with our research.
Yours sincerely,
Miranda Van Hooff
Research Officer ICSAH Research Project UNIVERSITY OF ADELAIDE
338
E: Information Sheet
339
INFORMATION SHEET
THE IMPACT OF CHILDHOOD STRESS ON ADULT HEALTH (ICSAH): Long-term follow-up of adults who were children in 1983 living in the South East of South Australia
Purpose of the study: A team of Adelaide University researchers is investigating the health and wellbeing of adults who grew up in the South East of South Australia in the 1980’s. One aspect of the study is to examine the long-term effect of the Ash Wednesday Bushfires in 1983. A study was conducted using two groups of children in the fire-affected area from 1983-1985: children who were directly exposed to the bushfires in 1983 and a comparison group of children from Naracoorte. We are contacting you because you were a part of that early study. You may not even remember or indeed be aware that you were involved in that study because information was gained from your parents and teachers. Your parents’ consent was obtained when they completed the questionnaires. You have been given this information sheet so that you will be properly informed about the project before taking part in the follow-up study. Please read the sheet carefully. The sheet remains your property.
Apart from a disaster, a number of other experiences in childhood and later, can have an effect on people’s lives. In both the disaster affected and comparison group from Naracoorte, we are interested in how experiences, above and beyond the fire, have impacted on people’s health and wellbeing. Even if you feel that your life has been, and still is, satisfying and you have no health problems, we are still very keen to hear from you.
The benefits: Surprisingly few studies have detailed systematic records of experiences and health in childhood and then later examined the impact of these experiences on health and wellbeing in adult life. The results of this type of study can assist us greatly in better understanding the needs of children who have had to cope with stress and how these needs can be better addressed. Quite apart from the effect of the bushfire, this study gives us an opportunity to look at the health and wellbeing of children who have grown up in rural Australia.
Although the project may not have any direct benefits for you, it may, in the future, assist researchers to more fully understand the long-term effects of childhood trauma. The results will enhance our understanding of the psychological needs of people, especially children, recovering from accidents and stress and may result in better methods of treating problems. The findings of this study will also have major public health significance in terms of assessing the impact of childhood exposure to traumatic events and will give valuable insight in to the psychological wellbeing of young adults who were brought up in a rural region during a time of significant economic change in Australia.
340 What will the study involve? Taking place over the years 2002 – 2004, the study is divided into three parts. Part 1 is a questionnaire booklet that will be sent to your home address. Part 2 is a 11/2 hour phone interview that will be conducted at a time that is most suitable to you. Part 3 involves obtaining information from Medicare regarding your health care utilisation over the past 5 years.
Part 1- Questionnaire Booklet
The questionnaire booklet will take approximately 1hour to complete and should be returned in the reply-paid envelope provided. We understand that the questionnaire is quite lengthy and may appear repetitive. This is due to the nature of the questionnaires used. It is very important however that all questions are answered, even if you feel you have already answered a similar question before. It may be useful to check over the questionnaire once you have finished to make sure you have not missed any questions.
Some questions may also appear to be quite personal. We assure you that all information you provide will be kept strictly confidential and is securely stored. All questionnaires are coded with an ID number that is used to identify you. You are not required to put your name anywhere on the booklet. If you find any of the questions too distressing and wish to discuss them with one of the researchers please do not hesitate to call one of the people listed at the bottom of this sheet.
Part 2- Interview
Part 2 consists of a 1 to 11/2 hour phone interview with a qualified research officer. This interview will address a series of questions relating to your psychological health and wellbeing. The interview will be conducted at a time that is most suitable to you.
Part 3 – Obtaining Information from Medicare
Part 3 involves obtaining information relating to your health care utilisation over the past 5 years. The purpose of this task is to assess how your life experiences have impacted on your use of the government health care system. No information on single individuals will be scrutinised and all analyses will involve looking at trends in groups. Your individual results will be kept confidential and will not be published. A signed consent form must be returned to us before we can access any of your personal details.
Contact Information: For any questions regarding the study please contact:
Miranda Van Hooff (Research Officer) Rima Al Atrash-Najar (Research Officer) Professor Alexander McFarlane (Professor, Head of Department) Phone: 8222 6907 or 0421 616 351
341
F: Self-Report Measures
342
F.1 Demographics 6. Which of the following best describes the highest qualification Today’s Date is:………………. you have completed?
1. Sex High School or part of 01 02 Nursing Qualification 1 Male 03 Teaching Qualification 2 Female 04 Trade Certificate/ 2. Age …………… Apprenticeship 05 Technician’s certificate/ 3. What is your current marital Advanced certificate status? 06 Certificate other than Above
1 Married 07 Associate Diploma
2 Separated 08 Undergraduate Diploma
3 Divorced 09 Bachelor Degree
4 Never Married 10 Post Graduate Diploma
5 Widowed 11 Masters Degree/Doctorate
6 Not married but living 12 Other (please specify)…… together with a partner …………………………………… …………………………………… 4. At what age did you leave high school?
01 Never Went Under 14 02 14 years 03 04 15 years
05 16 years
06 17 years
18 years 07 08 19 years 09 20 years
10 21 and over
5. Did you complete Year 12?
No 0 Yes 1
343 7. Which of the following best 9. What is your main source of describes your current income? occupational status?
01 Profit or loss from own 01 Work Part Time/Casual business/partnership
02 Work Full Time 02 Profit or loss from rental investment properties 03 Unemployed but looking for work 03 Dividends
04 Unemployed not looking 04 Interest for work 05 Wage/Salary from 05 On Worker’s employer Compensation 06 Wage Salary from own 06 On Disability Pension limited liability company
07 Unpaid Voluntary Work 07 Family Payment
08 Student 08 Any other government pension or allowance 09 Home Duties Child 10 Other…………………….. 09 support/maintenance
10 Superannuation/Annuity 8. What is the approximate annual 11 Worker’s Compensation/ gross income for your household? Sickness benefits That is a sum of the incomes of all Any other regular income people in your house before tax is 12 (Please describe)………. taken out. ……………………………. …………………………….. 01 Up to $7000
02 $7001 to $12 000 10. If you are currently working part-time or full-time what is your 03 $12 001 to $20 000 occupation? $20 001 to $30 000 04 05 $30 001 to $40 000 …………………………………… 06 $40 001 to $50 000 ……………………………………
07 $50 001 to $60 000 …………………………………… $60 001 to $80 000 …………………………………… 08 ………………………………….. 09 More than $80 000 Don’t Know 10 11. On average how many hours 11 Prefer to be kept private per week do you work?
……………hours
344 12. During the last one month, 17. Do you consider yourself an how many days in total were you Aboriginal/Torres Strait Islander? unable to carry out your usual daily activities fully? 0 No
Yes ……………days 1
18. During your lifetime, how many times have you moved 13. During the last one month, residences, even in the same town? how many days in total did you stay in bed all or most of the day because of illness or injury? Number of times:……………….
…………….days 19. Did you have problems learning to read?
14. How many children do you have? 0 No 1 Yes ………….. children 20. Did you have problems 15. Including yourself, how many learning to spell? people live in your household? (Only include those who live with you more than 50% of the time). 0 No
1 Yes ……………people
16. If you do not live alone, please indicate who resides with you (tick all applicable categories).
1 Live with Spouse/Partner
2 Live with Child/Children
3 Live with Other Relative
4 Live with Non-Relative
5 Other: ………………
6 N/A Live Alone
345 F.2. ALCOHOL USE (AUDIT) 3. How often do you have 6 or more standard drinks on one In answering the following occasion? questions, please remember that a standard drink contains 10g of Never pure alcohol. 0 1 Less than monthly Each of these is one standard 2 Monthly drink: 3 Weekly
4 Daily or almost daily 1 Middy/Pot/Schooner of Standard Beer 1 Pint of Light Beer 4. How often during the last year 1 Glass of Table Wine have you found that you were not 1 Glass of Sherry or Port able to stop drinking once you had 1 Nip of Spirits started?
1. How often do you have a drink Never containing alcohol? 0 1 Less than monthly 2 Monthly 0 Never 3 Weekly 1 Monthly or less Once a week or less 4 Daily or almost daily 2 2-4 times a week 3 4 5 or more a week 5. How often during the last year have you failed to do what was 2. How many standard drinks do normally expected from you you have on a typical day when because of your drinking? you are drinking?
0 Never 0 1 1 Less than monthly 1 2 2 Monthly 2 3 or 4 3 Weekly 3 5 or 6 4 Daily or almost daily 4 7 or more
346 6. How often during the last year 9. Have you or someone else been have you needed an alcoholic injured as a result of your drink in the morning to get drinking? yourself going after a heavy drinking session? 0 No
2 Yes, but not in the last year 0 Never 4 Yes, during the last year 1 Less than monthly
2 Monthly 10. Has a friend, doctor or other 3 Weekly health worker been concerned Daily or almost daily 4 about your drinking or suggested
you cut down?
7. How often during the last year have you had a feeling of guilt or 0 No regret after drinking? 2 Yes, but not in the last year
4 Yes, during the last year 0 Never
1 Less than monthly
2 Monthly
3 Weekly
4 Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
0 Never
1 Less than monthly
2 Monthly
3 Weekly
4 Daily or almost daily
347 F.3 IES-R Bushfire Group 4. I felt irritable and angry.
Below is a list of difficulties people 0 Not at all sometimes have after stressful life A little bit events. Please read each item, and 1 then indicate how distressing each 2 Moderately difficulty has been for you 3 Quite a bit
DURING THE PAST 7 DAYS 4 Extremely with respect to the Ash Wednesday Bushfires in 1983. 5. I avoided letting myself get How much were you distressed or upset when I thought about it or bothered by these difficulties. was reminded of it.
1. Any reminder brought back Not at all feelings about it. 0 A little bit 1 2 Moderately 0 Not at all 3 Quite a bit 1 A little bit Extremely Moderately 4 2 3 Quite a bit 6. I thought about it when I didn’t 4 Extremely mean to.
2. I had trouble staying asleep. Not at all 0 1 A little bit 0 Not at all 2 Moderately 1 A little bit 3 Quite a bit 2 Moderately 4 Extremely 3 Quite a bit 4 Extremely 7. I felt as if it hadn’t happened or wasn’t real.
3. Other things kept making me Not at all think about it. 0 A little bit 1 2 Moderately 0 Not at all 3 Quite a bit 1 A little bit Extremely Moderately 4 2 3 Quite a bit 4 Extremely
348 8. I stayed away from reminders 12. I was aware that I still had a about it. lot of feelings about it, but I didn’t deal with them.
0 Not at all Not at all 1 A little bit 0 A little bit 2 Moderately 1 Moderately 3 Quite a bit 2 Quite a bit 4 Extremely 3 4 Extremely 9. Pictures about it popped into my mind. 13. My feelings about it were kind of numb.
0 Not at all Not at all 1 A little bit 0 A little bit 2 Moderately 1 Moderately 3 Quite a bit 2 Quite a bit 4 Extremely 3 4 Extremely 10. I was jumpy and easily startled. 14. I found myself acting or feeling like I was back at that time.
0 Not at all Not at all 1 A little bit 0 A little bit 2 Moderately 1 Moderately 3 Quite a bit 2 Quite a bit 4 Extremely 3 4 Extremely 11.I tried not to think about it. 15. I had trouble falling asleep.
0 Not at all Not at all 1 A little bit 0 A little bit 2 Moderately 1 Moderately 3 Quite a bit 2 Quite a bit 4 Extremely 3 4 Extremely
349 16. I had waves of strong feelings 20. I had dreams about it. about it.
0 Not at all Not at all 0 1 A little bit A little bit 1 2 Moderately Moderately 2 3 Quite a bit Quite a bit 3 4 Extremely 4 Extremely 21. I felt watchful and on-guard. 17. I tried to remove it from my memory. 0 Not at all
1 A little bit 0 Not at all 2 Moderately 1 A little bit 3 Quite a bit 2 Moderately 4 Extremely 3 Quite a bit
4 Extremely 22. I tried not to talk about it.
18. I had trouble concentrating. 0 Not at all
1 A little bit 0 Not at all 2 Moderately 1 A little bit 3 Quite a bit 2 Moderately 4 Extremely 3 Quite a bit
4 Extremely
19. Reminders of it caused me to have physical reactions such as sweating, trouble breathing, nausea, or a pounding heart.
0 Not at all
1 A little bit
2 Moderately
3 Quite a bit
4 Extremely
350 F.4 IES-R Control Group 3. Other things kept making me think about it. Below is a list of difficulties people sometimes have after stressful life 0 Not at all events. Please read each item, and A little bit then indicate how distressing each 1 difficulty has been for you 2 Moderately DURING THE PAST 7 DAYS 3 Quite a bit with respect to the most stressful 4 Extremely life event you have ever experienced in your life. 4. I felt irritable and angry.
My most stressful life event was Not at all (please describe):…….. 0 A little bit …………………………………… 1 …………………………………… 2 Moderately
3 Quite a bit How much were you distressed or 4 Extremely bothered by the following difficulties in the past seven days. 5. I avoided letting myself get upset when I thought about it or 1. Any reminder brought back was reminded of it. feelings about it.
0 Not at all 0 Not at all 1 A little bit 1 A little bit 2 Moderately 2 Moderately 3 Quite a bit 3 Quite a bit 4 Extremely 4 Extremely 6. I thought about it when I didn’t 2. I had trouble staying asleep. mean to.
Not at all 0 0 Not at all A little bit 1 1 A little bit Moderately 2 2 Moderately Quite a bit 3 3 Quite a bit Extremely 4 4 Extremely
351 7. I felt as if it hadn’t happened or 11.I tried not to think about it. wasn’t real.
0 Not at all Not at all 0 1 A little bit A little bit 1 2 Moderately Moderately 2 3 Quite a bit Quite a bit 3 4 Extremely 4 Extremely 12. I was aware that I still had a 8. I stayed away from reminders lot of feelings about it, but I didn’t about it. deal with them.
0 Not at all 0 Not at all
1 A little bit 1 A little bit
2 Moderately 2 Moderately
3 Quite a bit 3 Quite a bit
4 Extremely 4 Extremely
9. Pictures about it popped into 13. My feelings about it were kind my mind. of numb.
0 Not at all 0 Not at all
1 A little bit 1 A little bit
2 Moderately 2 Moderately
3 Quite a bit 3 Quite a bit
4 Extremely 4 Extremely
10. I was jumpy and easily 14. I found myself acting or feeling startled. like I was back at that time.
0 Not at all 0 Not at all
1 A little bit 1 A little bit
2 Moderately 2 Moderately
3 Quite a bit 3 Quite a bit
4 Extremely 4 Extremely
352 15. I had trouble falling asleep. 19. Reminders of it caused me to have physical reactions such as 0 Not at all sweating, trouble breathing, A little bit 1 nausea, or a pounding heart. 2 Moderately 3 Quite a bit 0 Not at all 4 Extremely A little bit 1 Moderately 16. I had waves of strong feelings 2 about it. 3 Quite a bit
4 Extremely
0 Not at all 20. I had dreams about it. A little bit 1 Moderately 2 Not at all Quite a bit 0 3 A little bit Extremely 1 4 Moderately 2 17. I tried to remove it from my 3 Quite a bit memory. 4 Extremely
21. I felt watchful and on-guard. 0 Not at all
1 A little bit 0 Not at all 2 Moderately 1 A little bit 3 Quite a bit 2 Moderately 4 Extremely 3 Quite a bit
18. I had trouble concentrating. 4 Extremely
22. I tried not to talk about it. 0 Not at all
1 A little bit 0 Not at all 2 Moderately 1 A little bit 3 Quite a bit 2 Moderately 4 Extremely 3 Quite a bit
4 Extremely
353
G: Study Consent Form
354
CONSENT FORM 1
1. I, ………………………………………………………………(please print name) consent to take part in the research project entitled: The Impact of Childhood Stress on Adult Health (ICSAH)
2. I acknowledge that I have read the attached Information Sheet entitled: Information sheet for “The Impact of Childhood Stress on Adult Health”
3. I have had the project, so far as it affects me, fully explained to my satisfaction by the research worker. My consent is given freely.
4. Although I understand that the purpose of this research project is to improve the quality of medical care, it has also been explained that my involvement may not be of any benefit to me.
5. I have been given the opportunity to discuss the project with a member of my family or a friend.
6. I have been informed that, while information gained during the study may be published, I will not be identified and my personal results will not be divulged.
7. I understand that I am free to withdraw from the project at any time and that this will not affect medical advice in the management of my health, now or in the future.
8. I am aware that I should retain a copy of the attached Information Sheet. A copy of the signed consent form will be returned to me upon request.
PARTICIPANT'S SIGNATURE
SIGNED ...... DATED ......
WITNESS (OFFICE USE ONLY)
I have described to ………………………………………………(name of subject) the nature of the procedures to be carried out. In my opinion she/he understood the explanation.
STATUS IN PROJECT …………………………………………………….…………… NAME: ……………………………………………………………………………….…. SIGNATURE: ……………………………………………………………………………. DATE:………………………………………………………………………………………
355
H: Consent Form to link with Medicare and Pharmaceutical Benefit Scheme Data
356
CONSENT FORM 2: MEDICARE CONSENT FORM
I ...... (insert name) authorise the Health Insurance Commission to release my Medicare and Pharmaceutical Benefits Scheme data to the University of Adelaide for use in the study entitled: The Impact of Childhood Stress on Adult Health (ICSAH Research Study).
I understand that the ICSAH research team will have access to information about my Medicare and PBS service use which individually identifies me. No information however on single individuals will be scrutinised and all analyses will involve looking at trends in groups.
I understand that the purpose of gaining this information is to determine how an individual’s life experiences impacts on their level of health care utilisation over a five-year period.
I consent to the Health Insurance Commission releasing personally identifying information about the services I accessed in the five-year period prior to the date I filled in my questionnaire booklet to the ICSAH Research Team.
I understand that I can withdraw my consent to participate in the ICSAH Research Project at any time and that should I wish to withdraw from the Study, I can withdraw my consent to the release of my Medicare and PBS information by:
. telephoning the Study on (08) 8222 6907 or 0421 616 351
. telephoning the Health Insurance Commission on 02 612 46891
. completing a form supplied by the Study and sending it to either the Study or to the
Manager, Privacy and FOI, PO Box 1001, Tuggeranong, ACT 2901.
Before signing this document, I have been given the opportunity to ask any questions about the Study, the type of information that is to be collected and how this information is to be used.
I understand that the information about the services used by me may be collected, stored and analysed only for the purpose of use in the ICSAH Research Project.
357 I understand and consent that the results of the Study may be published provided that my name and Medicare number are not released and that I cannot be identified in any way from the materials published.
PERSONAL DETAILS:
FAMILY NAME ......
GIVEN NAME/S ......
DATE OF BIRTH ...... SEX ......
MEDICARE CARD NUMBER ......
PARTICIPANT'S SIGNATURE
SIGNED ......
DATED ......
358
I: Complaints Form
359
CONTACTS FOR INFORMATION ON PROJECT AND INDEPENDENT COMPLAINTS PROCEDURE
The Human Research Ethics Committee is obliged to monitor approved research projects. In conjunction with other forms of monitoring it is necessary to provide an independent and confidential reporting mechanism to assure quality assurance of the institutional ethics committee system. This is done by providing research subjects with an additional avenue for raising concerns regarding the conduct of any research in which they are involved.
The following study has been reviewed and approved by the University of Adelaide Human Research Ethics Committee:
Project title: The Impact of Childhood Stress on Adult Health (ICSAH) (Project Number: H-68-2001)
1. If you have questions or problems associated with the practical aspects of your participation in the project, or wish to raise a concern or complaint about the project, then you should consult the project co-ordinator:
Name: Miranda Van Hooff
Telephone: (08) 8222 6907 or 0421 616 031
2. If you wish to discuss with an independent person matters related to making a complaint, or raising concerns on the conduct of the project, or the University policy on research involving human subjects, or your rights as a participant contact the Human Research Ethics Committee’s Secretary on phone (08) 8303 4014
360
J: Reminder Letter
361
ICSAH RESEARCH PROJECT Faculty of Health Sciences DATE MIRANDA VAN HOOFF Research Officer NAME 1ST Floor Maternity Wing QUEEN ELZABETH HOSPITAL ADDRESS WOODVILLE SA 5011 ADDRESS AUSTRALIA TELEPHONE +61 8 8222 6907 FACSIMILE +61 8 8222 6036
Dear NAME
RE: Research Study: Impact of Childhood Experiences on Adult Health (ICSAH): Long-term follow-up of adults who were children in 1983 living in the South East of South Australia.
This is a letter to remind you that we have not yet received your completed questionnaire booklet and signed consent forms.
We are extremely appreciative of all of the time you have generously given to us so far, and are very interested in learning about your experiences as documented in the booklet.
The study is proving to be very successful based on the enthusiasm and commitment of the participants we have recruited so far. We are looking forward to processing the results, but this can only be done once we have received both your booklet and consent forms. We are unable to process any information that you have already given us until we receive this information.
If you could please send the booklet and consent forms in the post as soon as you receive this letter we would greatly appreciate it. Your contribution to the study is very important to us.
One of our research staff will be contacting you in the next week to ensure that you have returned your booklet and consent forms.
If you have recently forwarded this information to us please disregard this letter. Thank-you once again for all of your assistance.
Kind Regards
Miranda Van Hooff Research Officer ICSAH Research Team
362
K: Declaration for Thesis Chapter 6
363 Declaration for Thesis Chapter 6
McFarlane, AC and Van Hooff, M. (2009). Impact of childhood exposure to a natural disaster on adult mental health: 20-year longitudinal follow-up study. British Journal of Psychiatry, 195: 142-148.
Declaration by candidate In the case of Chapter 6, the nature and extent of my contribution to the work was the following:
Nature of Contribution Extent of contribution (%) I made a major contribution to the research question. I was 75% responsible for the literature review, data collection, data management, statistical analyses, interpreting the results, writing the paper and undertaking any required revisions.
The following co-author contributed to the work.
Name Nature of contribution AC. Major contribution to the research question. Responsible for reviewing and McFarlane approving all aspects of the research methodology and design, interpretation of results and critical review of the written paper.
Candidate’s Date Signature
364 Declaration by co-authors
The undersigned hereby certify that:
a. the above declaration correctly reflects the nature and extent of the candidate’s contribution to this work, and the nature of the contribution of the co-author. b. they meet the criteria for authorship in that they have participated in the conception, execution, or interpretation, of at least that part of the publication in their field of expertise; c. they take public responsibility for their part of the publication, except for the responsible author who accepts overall responsibility for the publication; d. there are no other authors of the publication according to these criteria; e. potential conflicts of interest have been disclosed to (a) granting bodies, (b) the editor or publisher of journals or other publications, and (c) the head of the responsible academic unit; f. they give their consent for the above-named publication to be included in this thesis g. the original data are stored at the following location(s) and will be held for at least five years from the date indicated below:
Location(s) Centre for Military and Veteran’s Health, University of Adelaide
Signature 1 Date
365
L: Declaration for Thesis Chapter 9
366 Declaration for Thesis Chapter 9
Van Hooff, M., McFarlane AC., Baur J., Abraham, M., Barnes DJ. (2009). The stressor
Criterion-A1 and PTSD: a matter of opinion? Journal of Anxiety Disorders, 23(1): 77-86.
Declaration by candidate
In the case of Chapter 9, the nature and extent of my contribution to the work was the following:
Nature of Extent of contribution contribution (%)
I made a major contribution to the research question and study design. 75% I was responsible for the literature review, data collection, data management, statistical consultation, interpreting the results, writing the paper and undertaking any required revisions.
The following co-authors contributed to the work.
Name Nature of contribution
AC. Major contribution to the research question. Responsible for reviewing and McFarlane approving all aspects of the research methodology and design, interpretation of results and critical review of the written paper. J. Baur Major contribution to the research question. Responsible for assisting in the review of the literature, interpretation of results, statistical analysis and critical review of the written paper. M. Abraham Responsible for assisting in the review of the literature, interpretation of results, and critical review of the written paper. DJ. Barnes Responsible for assisting in the review of the literature, interpretation of results, and critical review of the written paper.
Candidate’s Date Signature
367 Declaration by co-authors
The undersigned hereby certify that:
h. the above declaration correctly reflects the nature and extent of the candidate’s contribution to this work, and the nature of the contribution of the co-author. i. they meet the criteria for authorship in that they have participated in the conception, execution, or interpretation, of at least that part of the publication in their field of expertise; j. they take public responsibility for their part of the publication, except for the responsible author who accepts overall responsibility for the publication; k. there are no other authors of the publication according to these criteria; l. potential conflicts of interest have been disclosed to (a) granting bodies, (b) the editor or publisher of journals or other publications, and (c) the head of the responsible academic unit; m. they give their consent for the above-named publication to be included in this thesis n. the original data are stored at the following location(s) and will be held for at least five years from the date indicated below:
Location(s) Centre for Military and Veteran’s Health, University of Adelaide
Signature 1 Date
Signature 2
Signature 3
Signature 4
368