Prevalence of Violence Exposure and Post Traumatic Stress Disorder (PTSD) Among Adolescents in Udugama, Sri Lanka

Prevalence of Violence Exposure and Post Traumatic Stress Disorder (PTSD) among Adolescents in Udugama, Sri Lanka

Grace E. Lowitzer

Duke Global Health Institute Duke University

Date:______Approved:

______Truls Ostbye, Advisor

______Lawrence P. Park

______Joseph R. Egger

Thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in the Duke Global Health Institute in the Graduate School of Duke University

2021

ABSTRACT

Prevalence of Violence Exposure and Post Traumatic Stress Disorder (PTSD) among Adolescents in Udugama, Sri Lanka

Grace E. Lowitzer

Duke Global Health Institute Duke University

Date:______Approved:

______Truls Ostbye, Advisor

______Lawrence P. Park

______Joseph R. Egger

An abstract of a thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in the Duke Global Health Institute in the Graduate School of Duke University

2021

Abstract

Background: Violence exposure in children can lead to psychological problems and poor health outcomes that can be associated with post-traumatic stress disorders

(PTSD). This study aimed to estimate the prevalence of full or partial PTSD associated with exposure to community and domestic violence in school aged children in Sri

Lanka. The study aimed to (1a) estimate the prevalence of community violence and domestic violence among school aged adolescents in Sri Lanka, (1b) estimate the prevalence of community violence and domestic violence overall and by sex among school aged adolescents in Udugama, Sri Lanka, (2) estimate the prevalence of partial

PTSD and full PTSD among those who experience community and/or domestic violence,

(3) and does it vary by age, sex, socioeconomic status, and length of exposure to do violence with exposure to domestic and community violence.

Methods: This study was a secondary data analysis that utilized a cross-sectional design, using two questionnaires: (1) Child Exposure to Domestic Violence (CEDV) Scale to measure violence exposure, and (2) The UCLA PTSD Reaction Index for DSM IV, a self-report questionnaire to screen for exposure to traumatic events and assess PTSD symptoms in school-age children and adolescents. 346 school children were selected for the study. Children in grade 10 and 11 were selected with a mean age of 14.9 years (SD

= 0.02), with a range of 14 to 16 years old were randomly selected from two secondary schools in Udugama MOH area. The two largest schools were non-randomly selected.

Within the two schools, four classes were selected randomly. All children present at the day of data collection were selected for the study. As more than 90% of the children are schooling in Sri Lanka, we believe a school-based screening will obtain a representative sample of adolescents in the community. Logistic regression models were used to explore the relationship between sex, age, socioeconomic status, and length of exposure with domestic and community violence. Log-risk regression models were used to explore the prevalence of community and domestic violence and the relationship between violence exposure and full or partial PTSD symptoms. Univariable logistic models were used to estimate associations between individual characteristics (such as age, sex, socioeconomic status, and length of exposure to violence) and partial or full

PTSD.

Results: Among the 346 participants, 304 (88%) adolescents reported experiencing some type of violence, whether it was community violence or domestic violence on the CEDV questionnaire. Only those who reported experiencing violence were then asked to take the UCLA PTSD Index. Of these a total of 203 (68%) met criteria

A on the UCLA PTSD index and therefore had experienced at least one traumatic event.

Of these a total of 52(26%) did not have PTSD, 53 (26%) had partial PTSD, and 98 (48%) had full PTSD. The results showed that age and sex were not associated with PTSD severity. Sex was not associated with the outcome of partial PTSD (p > 0.682; CI: -0.136,

0.089) and full PTSD (p > 0.682; CI: -0.089, 0.136). Age was not statistically significantly

associated with the outcome of partial PTSD (p > 0.924; CI: -0.147, 0.162) and full PTSD

(p >0.924; CI: -0.162, 0.147). However, the age range was limited to 14 to 16 years, and further research needs to be done for more definitive conclusions. Duration of violence was the only individual characteristic that was statistically significant in the analysis for two responses 1) two to three years back (OR 5.07 (CI:1.11; 23.21) p = 0.037) and 2) as long as

I can remember (OR 11.03 (CI: 1.22; 99.51) p = 0.032).

Conclusions: The most significant finding of this study is that of those who experience domestic or community violence, 61.9% will develop PTSD. Additionally, domestic violence 189 (90.8%) was reported more often by adolescents than community violence 20 (9.57%). This study was limited due to the small study size and the narrow range of age, which limits it generalizability to the wider population of Sri Lanka or adolescents in general. Therefore, conclusions about the significance of individual characteristics such as age, sex, socioeconomic status, and duration of violence exposure resulting in partial or full PTSD could not be determined. More studies are necessary to test the hypothesis of whether individual characteristics of adolescents in Sri Lanka is associated with partial or full PTSD.

Dedication

I dedicate this thesis to everyone who has believed in me and supported me through my educational journey. To my husband, thank you for your patience and love through the long nights and difficulties. To my family, thank you for always encouraging me to follow my dreams.

Finally, I dedicate this to Dr. Thyaggi Ponnamperuma for all of her hard work and dedication to compile this data and to the adolescents in Udugama, Sri Lanka for courageously accepting to take part in this study.

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Contents

Abstract ...... iv

List of Tables ...... x

1. Introduction ...... 1

1.1 Adolescent Exposure to Community and Domestic Violence ...... 1

1.2 Exposure to Violence and the Psychological Outcomes ...... 2

1.3 Adolescent Exposures to Violence and Trauma in Sri Lanka ...... 4

1.3.1 Background and History ...... 4

2. Methods ...... 10

2.1 Setting ...... 10

2.2 Participants ...... 10

2.3 Procedures ...... 11

2.4 Measures ...... 12

2.4.1 Demographic Survey ...... 12

2.4.2 Child Exposure to Domestic Violence (CEDV) Scale ...... 13

2.4.3 UCLA PTSD Index ...... 14

2.5 Analysis ...... 14

3. Results ...... 17

3.1 Description of Sample ...... 17

3.2 Prevalence of Community and Domestic Violence Among Adolescents in Sri Lanka ...... 18

3.3 Violence exposure and the prevalence of partial and full PTSD ...... 18

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3.3 Associations between characteristics of individuals experiencing violence and PTSD ...... 22

Individual Characteristics, Violence Exposure, and Outcome ...... 24

4. Discussion ...... 26

4.1 Implications for policy and practice ...... 30

4.2 Implications for further research ...... 30

4.3 Study strengths and limitations ...... 31

5. Conclusion ...... 34

Appendix A: Child Violence Exposure to Domestic Violence (CEDV) Questionnaire .... 35

Appendix B: UCLA PTSD Index for DSM IV ...... 47

Appendix C: Scoring Worksheet for UCLA PTSD Index for DSM-IV, Adolescent Version ...... 52

References ...... 53

List of Tables

Table 1: Sample Demographics and Characteristics ...... 17

Table 2: Exposure to Types of Violence by Sex (n=346) ...... 18

Table 3: UCLA PTSD Index Criteria A (n=304) ...... 20

Table 4: Met UCLA PTSD Index Criteria A by Sex (n=304) ...... 20

Table 5: UCLA PTSD Index Criteria B through D (n=244) ...... 21

Table 6: Outcome of Partial or Full PTSD by Sex (n=244) ...... 22

Table 7: Prevalence of PTSD by Sex (n=244) ...... 22

Table 8: Multivariate Regression Models for Outcome of Partial PTSD Using Characteristics of Individuals Experiencing Violence (n=244) ...... 23

Table 9: Multivariate Regression Models for Outcome of Full PTSD Using Characteristics of Individuals Experiencing Violence (n=244) ...... 24

Table 10: Univariable Regression Model of PTSD by Sex (n=244) ...... 25

Table 11: Univariable Regression Model of PTSD by Socioeconomic Status (n=244) ...... 25

List of Figures

Figure 1: Study Flow Chart ...... 14

Acknowledgements

I would like to thank my supervisor, Dr. Truls Ostbye and Lauren Hart for all of their help and mentorship. Second, I would like to thank Thyagi Ponnamperuma for advising me and for allowing me to use a dataset that she collected in light of the difficulties of my travel during the COVID-19 pandemic. Third, I would like to thank the members of my committee. To Dr. Park for always believing in me and my abilities as a researcher. Finally, I would like to thank Dr. Joseph Egger for his guidance and encouragement in the statistical analysis of the data for this study.

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1. Introduction

1.1 Adolescent Exposure to Community and Domestic Violence

Violence exposures of children are divided into several categories; community violent exposure, school violence exposure and home violence exposure. Community violence is defined as exposure to intentional acts of interpersonal violence committed in public areas by individuals who are not intimately related to the victim. This can be either experiencing violence or witnessing violence. These include sexual assault, burglary, use of weapons, muggings, the sounds of bullet shots, as well as the presence of teen gangs, drugs, and racial divisions (National Center for Children Exposed to

Violence, 2010). Community violence exposure is measured as 19% in United States

(Hart et al., 2007).

Domestic violence exposure is defined as when children see, hear, directly involved in (i.e., attempt to intervene), or experience the aftermath of physical or sexual assaults that occur between their caregivers (Saigh, Yasik, Oberfield, Halamandaris, &

McHugh, 2002). Children in families in which such violence occurs are the invisible victims of the event. Domestic violence includes; physical abuse involving contact intended to cause pain, injury or other physical suffering or bodily harm. These include hitting, slapping, punching, choking, pushing, throwing objects, burning and other types of contact that result in physical injury to the victim. Emotional abuse includes yelling, name calling, blaming & shaming and denigration of the child’s personality.

Scientifically credible estimates of the prevalence of children exposed to home-based violence is minimum, but existing data suggest that large numbers of children are affected. It is estimated to be more than 60% in United States (Finkelhor D, 2009).

1.2 Exposure to Violence and the Psychological Outcomes

Violent exposure within the population is becoming more common around the world, leading to many trauma related psychopathologies. Children and adolescents can be considered one of the most vulnerable groups. Whether the child is a direct victim or a witness of the violent events, childhood exposure to violence can lead to a range of psychopathologies. These post trauma psychopathologies of the young vary from many psychological problems to different psychiatric disorders e.g., Post-Traumatic Stress

Disorder (PTSD), anxiety, phobias, obsessive compulsive disorder and depression. Even though many studies were conducted in the western setting (Salmon & Bryant, 2002), limited number of studies were done in Sri Lanka on this topic and the available evidence reveals a considerably high number of suffering victims (Catani et al., 2008).

Exposures to both domestic and community violence can be considered common in the general population, however only a minority of exposed adolescents will develop PTSD from their experiences (Kessler et al., 1995). Adolescents who do develop PTSD can experience symptoms from a range of only a few months to multiple years. The differences in length of symptoms can be contributed to the time and method that each individual processes the violence experienced according to a cognitive model by Ehlers

and Clark, 2000. More symptoms may arise as the individual processes the violent event and can lead to anxiety (Ehlers & Clark, 2000). There are a number of studies, both prospective and longitudinal which provide evidence for this model, but only have empirical support using adults, not adolescents (Dunmore et al., 2001; Ehring et al.,

2006). Results from these studies show that recalling violent exposures as negative memories lead to persistent PTSD symptoms. Surprisingly, little is known about individual characteristics or features of violent exposures that increase the probability that a violence exposed adolescent will then develop full or partial PTSD. However, demographic characteristics such as sex and age might be relevant. One study of children aged 7-13 years showed that younger children were more likely to develop

PTSD after a violent exposure than older children (Salmon & Bryant, 2002). However another study found in contrast that there were no age differences in a larger sample size of children aged 6-18 years old (Meiser-Stedman et al., 2009). Additionally, there are few studies that show sex as a significant factor as it relates to violence exposure resulting in PTSD. Even though female adolescents show a greater tendency to ruminate in response to stressful events (Trickey et al., 2012), there are not enough studies to demonstrate that this aforementioned tendency in girls results in PTSD. One study reported when sex differences are compared, sex is weakly associated with PTSD

(Stallard & Smith, 2007).

The vast majority of studies in children and adolescents in Sri Lanka have focused on single incident traumas such as vehicle accidents, with fewer studies focusing on longer term exposures such as community and domestic violence

(Ponnamperuma & Nicolson, 2016). Events that affect large groups such as natural disasters and war should be examined differently than those affecting individuals as acts of domestic violence may results in a more negative appraisal and therefore more symptoms of PTSD (Bryant & Guthrie, 2005; Meiser-Stedman et al., 2009;

Ponnamperuma & Nicolson, 2016; Trickey et al., 2012).

1.3 Adolescent Exposures to Violence and Trauma in Sri Lanka

1.3.1 Background and History

The Northeastern provinces of Sri Lanka has experienced much suffering and devastations over the last two decades. Thousands of people have been killed and many more displaced due to the conflict and violence in the country. The Liberation Tigers of

Tamil Elam (LTTE) have been fighting for political autonomy which has resulted in ongoing conflict. Civilians have been caught up in the violence and have seen casualties from landmines, unexploded ordnance, the destruction of hospitals and schools, as well as a struggling economy. Although a cease fire agreement was called in December of

2001, tragedy struck once again as a tsunami ripped through Sri Lanka in December of

2004. The tsunami caused more than 30,000 casualties in Sri Lanka and even more were forced to relocated to provisional camps. The added stress and tension from disaster

resulted in a civil war, costing the lives of 3,000 people in one year alone (Anbarasan,

2006). In 2008, the armed conflicts characterized by high levels of deliberate and systematic violence against the civil population affected Sri Lankan society on multiple levels to include individual, family, and community (Elbert et al., 2009). A survey of

Tamil school children exposed to war in the North Eastern provinces of Sri Lanka showed that 19-20% of the sample showed symptoms of PTSD after the war, but before the tsunami (7). However, it can be challenging to predict if PTSD is caused by one particular event or that of sustained events such as we see in most instances of community and domestic violence. Unfortunately, there are not many studies of children in Sri Lanka or in other countries that examine the impact of other ongoing stressors within an ongoing emergent conflict such as war or natural disasters. Hart and colleagues used a variety of qualitative methods with children in a heavily war-affected region of Sri Lanka, where children identified aspects of armed conflict as well as other threats to their well-being (Hart et al., 2007). Another study of adults in Afghanistan found that daily stressors, such as domestic violence, community violence, poverty, and unemployment predicted psychological and psychosocial distress better than previous exposure to war related violence and loss; where daily stressors and war exposure accounted for almost equal variance in levels of PTSD symptoms (Miller et al., 2009). In yet another study they found that family violence was more strongly related to the

children’s mental health than the degree of exposure to political violence (Al-Krenawi et al., 2007).

In Sri Lanka, only a few studies were conducted; Neuner and colleagues found that 17% - 24% of children have witness domestic violence and 11%-27% have personally experienced physical abuse at home (Neuner et al., 2006). Catani and colleagues revealed a very high value of 97% in child exposure to family violence in the northern province of the country (Catani et al., 2008). A recent study revealed that 7.5% of the children experience community violence and 22.2% witness community violence, while

20% experience domestic and 22.7% witness domestic violence in southern Sri Lanka

(Ponnamperuma & Nicolson, 2016). Recent community based surveys have reported that 24-34% of women in various regions of Sri Lanka experience domestic violence in the form of intimate personal violence (Guruge et al., 2015).

Many risk factors associated with child exposure to violence were identified: parent or caregiver factors; alcoholism, marital conflict, single parenthood, unemployment and financial stress, child factors; child’s physical, mental, emotional impairments, unwanted child etc. and environmental factors like community characteristics. Combination of all these factors makes a child vulnerable for violence exposure (Finkelhor D, 2009).

Effects of child exposure to domestic violence are deleterious and children do not have to be directly affected in order to suffer the effects of violence. They have shown to

have emotional and behavioral problems, difficulty in learning and limited social skills.

Further, they may exhibit violent and risky behavior, suffer from PTSD, depression or severe anxiety. If their problems are not identified and helped, they can multiply, intensify and diversify over time and make the children at increased risk for academic failure and social isolation, which can then lead to school avoidance, alcoholism, drug abuse, and lifetime antisocial behavior adolescent delinquency and even to adulthood psychiatric disorders (Heather M. Baltodano, 2003). Many adulthood disorders have their roots in their young ages. One longitudinal study has shown that psychopathologies in adulthood can be traced back to adolescent emotional and disruptive disorders (Roza, Hofstra, van der Ende, & Verhulst, 2003). Therefore, there is an unmet need to identify these children in the population to help them.

Children exposed to domestic violence are not uncommon in Sri Lanka and the gravity of it cannot be underestimated. The literature says violence exposure is common in the Sri Lankan society but research in the field is lacking. Children who grow up in a violent environment are more likely to be victims and liable to suffer from a range of different problems. Sri Lanka has no proper system to identify the children with these problems to help them. Funding and “political will” for mental health are low and are near the bottom of the priority list (Siva, 2010). Sri Lanka does not have established sustainable proper counseling services or student support services functioning at all schools in the country. “Basic Needs”, a humanitarian organization that works with

people with mental health problems estimates that there is only one psychiatrist for every 5000,000 people in Sri Lanka and are concentrated in urban areas (Siva, 2010). The existing School Medical Inspection program screens children up to 14 years old, but screening has mainly focused on early detection of physical illnesses and less attention was given to mental health or psychological problems. Furthermore, public health services of the country have established a family supportive service called ‘Mithuru

Piyasa’ to help the women exposed to the sex-based violence, however, these services are not offered to the children leaving a significant gap in care (Guruge et al., 2015;

Mithuru Piyasa – CSHW, n.d.). Also, these services have not yet reached to all areas of the country. Moreover, these available services are not linked with each other and no proper channel of referral system is established (Wijegunasekara & Wijesinghe, 2020).

In summary, children who are exposed to violence are neglected and not identified. Children who are exposed to violence trust adults and their teachers to help them cope with their problems, but there are no services or support systems already in place. In order to protect these children, services and interventions are necessary to help them cope with violence. Hopefully, more attention will be paid by society towards the severity of the problem by collecting reliable data on this mental health and neglected issues of children in Sri Lanka. Therefore, the purpose of this study is to (1a) estimate the prevalence of community violence and domestic violence among school aged adolescents in Sri Lanka, (1b) estimate the prevalence of community violence and

domestic violence overall and by sex among school aged adolescents in Udugama, Sri

Lanka, (2) estimate the prevalence of partial PTSD and full PTSD among those who experience community and/or domestic violence, (3) and does it vary by age, sex, socioeconomic status, and length of exposure to community and/or domestic violence.

2. Methods

The sample for the study included 346 school aged children in the grades of 10 and 11 with a mean age of 14.9 years (SD = 0.02), with a range of 14 to 16 years old were non-randomly selected from two different secondary schools in Udugama, Sri Lanka.

The two schools selected were the largest schools in the district. The study used a two stage cluster prevalence survey with purposive sampling at level 1 (schools), and random sampling at level two (classes). Data were collected from four classes that were selected at random from each of the eight schools and all children that were present that day were included in the data collection for the study. There was no follow-up day for any students who missed class that day. More than 90% of the children in Sri Lanka attend school, therefore it is reasonable to assume that school-based screening obtained a representative sample of adolescents in the community.

2.1 Setting

This study was conducted in Udugama, Sri Lanka. The two largest schools in the area were selected. Within each school, four classes, for a total of eight classes, were selected from each school to participate in the study.

2.2 Participants

Participants for this study comprised of 346 school aged children (n=346; girls =

155; boys = 143; miss = 48). Student grades ranged from 10 and 11. The mean age of the adolescents is 14.9 years (SD = 0.02), with a range of 14 to 16 years. Only children in

grades 10 and 11 were selected from two different secondary schools in Udugama, Sri

Lanka. Inclusion criteria included that they must be student in grades 10 or 11 and be present on the day of data collection. Exclusion criteria included any student who was not in one of the two schools selected or within one of the four classes selected or any student who was not present for the day of data collection.

2.3 Procedures

Data collection was conducted on the last day of school of the school academic term and after the last term test. School principals and teachers were consulted to find a convenient time for the students if after the last exam was not feasible. Each participant was first asked to sign a consent form and then they were given two separate self-report questionnaires via paper copy in their classroom. The first questionnaire administered was the Child Exposure to Domestic Violence (CEDV) questionnaire, which takes approximately 30 minutes to complete. The second questionnaire administered was the

UCLA Posttraumatic Stress Disorder Index (Steinberg et al., 2004), which takes approximately 30 minutes to complete. Once the questionnaire was complete, they were gathered and stored. All responses to questionnaires were added to Stata for statistical analysis (Stata v16, College Station, TX). All study procedures were approved by the ethical review boards at Duke University and the University of Ruhuna.

2.4 Measures

The study used three instruments, one demographic survey, as well as the Child

Exposure to Domestic Violence (CEDV) Scale (Edleson et al., 2008) and the UCLA PTSD

Index (Steinberg et al., 2004). The participants were asked to complete the demographic survey and CEDV questionnaire first. The CEDV questionnaire uses the Likert scale for responses including never (0), sometimes (1), often (2), almost always (3). Participants who answered between sometimes to almost always, were considered as the exposure group, and then asked to complete the UCLA PTSD Index questionnaire. Therefore, participants who answered none for all of the questions on the CEDV questionnaire, were determined to not have experienced violence and were dropped from further questions. On the UCLA PTSD Index questionnaire, those who answered yes to at least one of the questions in “criteria A” (n=203) were then scored on for either full or partial

PTSD using the remaining criteria B through D. Participants who answered no to all the questions in “criteria A" (n=41) of the PTSD Index were not measured on the scale for

PTSD and are considered the “comparison group” for this study. Those with more than

30% of their answers missing and the only answered questions were no were dropped from the study (n=60).

2.4.1 Demographic Survey

The survey included questions about the respondent’s sex, age, religion education, socioeconomic status, family structures, and length of violent exposure. Each

respondent was subsequentially given a serial number. Family structure questions simply asked if mother or father was dead, if they had step parents, if they had sibling(s), if so, how many, and if their grandparents were still alive.

2.4.2 Child Exposure to Domestic Violence (CEDV) Scale

Violence Exposure was measured using the CEDV Scale, which is a validated self-report tool for adolescents that assess exposure to violence at home, exposure to violence in the community, involvement to violence and risk factors, in children aged between 10-16 years. Each question is answered using a four-point Likert-type scale, rated as Never (0), Sometimes (1), Often (2) and Almost Always (3). Scores in each subscale are added together. High scores indicate more and lower scales indicate less violence exposure, involvement and risk factors. Exposure to violence at home subscale

(Questions 1-10) requires the child to choose one or more types of exposure and the numbers of boxes checked are added up. The questionnaire consists of 36 questions adapted to culture, divided into 3 parts (see Appendix A). Questions 1-10 measure home violence exposure, 22-28 measure community violence exposure and 11-17 measure involvement (CEDV SCALE | J-Edleson-Homepage, n.d.).

2.4.3 UCLA PTSD Index

The UCLA PTSD Index (Steinberg et al., 2004) was used to screen for PTSD.

Fourteen items assess the subjective experience at the time of worst event exposure and the experience just after in terms of DSM-IV PTSD criterion A. The other symptom items are keyed to DSM-IV criteria B (re-experiencing), C (avoidance), and D (hyperarousal).

Participants rate the items on 4-point scale rated none of the time to most of the time. A

PTSD severity score will be generated by summing the scores over the three symptom clusters. This is a validated questionnaire for adolescents in Sri Lanka.

Adolescents that took the CEDV questionnaire n=346

Exposed to Violence No Exposure to Violence (Community or Domestic) n=83 n=263

Partial PTSD Full PTSD No PTSD Missing (Exposure Group) (Exposure Group) (Comparison Group) (Dropped from Study) n=35 n=152 n=31 n=45

Figure 1: Study Flow Chart

2.5 Analysis

This study was approved by the Institutional Review Board at Duke University and from the Regional Director of Health Services, Sri Lanka. Similar to a past study

conducting by Fernando et al. (2010), a decision was made to recruit youth through the school system as Sri Lankan parents value education, and ensure that their children attend school regularly. Therefore, school-based samples are representative of the rural population of children in Sri Lanka (Fernando et al., 2010). Fully informed written consent was obtained from parents and assent from children prior to administration of either of the surveys. Of the 346 respondents, 42 (12%) were dropped from further analysis as they responded as having not experienced any type of domestic or community violence. The remaining 304 respondents were then asked to complete the

UCLA PTSD index survey. Cases with missing data of more than 30% of the items were dropped (n=60), leaving 244 participants for analysis using the UCLA PTSD Index. All participants must meet criteria A eligibility on the UCLA PTSD Index in order to be scored within the remaining criteria B, C, and D. Of the 244 participants asked to take the

UCLA PTSD Index, 203 (83%) were eligible in criteria A. After meeting the remaining criteria B through D of the 203 eligible participants 93 (38%) were identified as not having PTSD, 53 (22%) were identified with partial PTSD and 98 (40%) with full PTSD, respectively.

Several analyses were conducted in accordance with the hypothesis and the exploratory examinations mentioned earlier. First, the prevalence of partial and full

PTSD was determined using Stata. Next regression analysis was conducted in the following manner:

Aim 1a. To estimate the odds of community violence and domestic violence among school aged adolescents in Sri Lanka, a logistic regression analysis was done between community violence and domestic violence using the scores on the CEDV questionnaire.

Aim 1b. To estimate the prevalence of community violence and domestic violence overall and by individual characteristics among school aged adolescents in Sri Lanka, a univariable logistic regression analysis was done between community and domestic violence exposure and age, sex, socioeconomic status, and length of exposure.

Aim 2. To find the odds of partial PTSD and full PTSD among those who experience community and/or domestic violence, a logistic regression model was conducted for both partial and full PTSD outcomes.

Aim 3. To describe individual characteristics of those who experience violence as it relates to the outcome of PTSD, multiple univariable regression models were conducted for both partial and full PTSD outcomes.

3. Results

3.1 Description of Sample

Table 1 (below) summarizes the demographic and other characteristics of the participants. Among the 346 participants, 26 (7.51%) (Male n= 5; Female n=21) had experienced only community violence, 54 (15.6%) (Male n=29; Female n=25) experienced only domestic violence. Separately, 304 (87.86%) (Male n= 142; Female n= 162) reported any type of violence which could include domestic violence only, community violence only, or both community and domestic violence (see table 2). Therefore, a total of 304 participants reported experiencing some type of violence and were then asked to participate in the UCLA PTSD Index. The remaining 42 (12%) participants were not asked to take the UCLA PTSD Index.

Table 1: Sample Demographics and Characteristics

Characteristic Total (N=346) Males (N=167) Females (N=179) Age (yrs.) 14 36 (10.4%) 19 (11.38%) 17 (9.5%) 15 304 (87.86%) 145 (86.83%) 159 (88.83%) 16 5 (1.45%) 3 (1.8%) 2 (1.12%) Missing 1 (0.29) 0 1 (0.29%) Parental Status Mother alive 307 (88.73%) 145 (86.83%) 162 (90.5%) Father alive 292 (84.39%) 139 (82.23%) 153 (85.47%) Siblings 0 20 (5.78%) 8 (4.79%) 12 (6/7%) 1 124 (35.84%) 58 (34.73%) 66 (36.87%) 2 143 (41.33%) 79 (47.31%) 64 (35.75%) 3 35 (10.12%) 13 (7.78%) 22 (12.29%) 4 13 (3.76%) 5 (2.99%) 8 (4.47%) >4 7 (0.2%) 0 7(0.40%) Min, Max 0, 8 0, 4 0, 8 Religion Buddhist 331 (95.66%) 159 (95.21%) 172 (96.09%) Christian 5 (1.45%) 2 (1.2%) 3 (1.68%) Hindu 7 (2.02%) 4 (2.4%) 3 (1.68%) Socioeconomic Status

Not enough money for food/basic 40 (11.56%) 21 (12.57%) 19 (10.61%) necessities Only enough to pay for what is needed 236 (68.21%) 112 (67.07%) 124 (69.27%) Enough to buy extra things we do not need 9 (2.6%) 2 (1.20%) 7 (3.91%) Don’t know 55 (15.9%) 26 (15.57%) 29 (16.2%)

3.2 Prevalence of Community and Domestic Violence Among Adolescents in Sri Lanka

The first aim of this study was to estimate the prevalence of community and domestic violence among school aged adolescents in Sri Lanka. Table 2 (below) summarizes the prevalence of community and domestic violence among adolescents by sex. The table includes the entire population of the study at 346 observations. Only participants who reported experiencing any type of violence (n=304) were then asked to take the UCLA PTSD index survey.

Table 2: Exposure to Types of Violence by Sex (n=346)

Total (n=346) Males (n=167) Females (n=179) Violence Exposure Any Exposure to Violence * 304 (87.86%) 142 (85.03%) 162 (90.5%) No Exposure to Violence** 41 (23.9%) 25 (14.97%) 16 (11.85%) Missing** 1 (0.29%) 0 (0%) 1(0.56%) *Any exposure to violence group was then asked to take the UCLA PTSD questionnaire. **The “no exposure to violence group” was dropped from the study and not analyzed for the outcome of partial or full PTSD.

3.3 Violence exposure and the prevalence of partial and full PTSD

Of the 346 participants, a total of 304 (88%) reported experiencing some type of violence and were then asked to participate in the UCLA PTSD Index. The remaining 42

(12%) participants who reported not experiencing any type of violence on the CEDV questionnaire were not asked to take the UCLA PTSD Index and were therefore

dropped from the study. Cases with missing data of more than 30% were dropped

(n=60), leaving 244 participants for analysis using the UCLA PTSD Index. All participants must meet criteria A eligibility on the UCLA PTSD Index in order to be scored within the remaining criteria B, C, and D. Among participants who reported violence exposure through the CEDV questionnaire, 203 (83%) met the initial eligibility criteria A for the UCLA PTSD index. The remaining 41 participants who did not meet criteria A were still asked to complete the remainder of the UCLA PTSD index including criteria B through D, however, because they did not meet criteria A, they are considered to not have PTSD.

Table 5 (below) summarizes criteria A for eligibility to be scored on the remainder of UCLA PTSD Index.

Table 3: UCLA PTSD Index Criteria A (n=304)

Dimension Question Yes No Missing

Scared you would die Q15 16 (7.34%) 197 (90.37%) 5 (2.29%)

Scared you would be hurt Q16 26 (11.93%) 186 (85.32%) 6 (2.75%)

Hurt badly Q17 13 (5.96%) 199 (91.28%) 6 (2.75%)

Scared someone else would die Q18 61 (27.98%) 151 (69.27%) 6 (2.75%)

Scared someone else would be hurt Q19 70 (32.11%) 142 (65.14%) 6 (2.75%)

Someone else was hurt badly Q20 51 (23.39%) 163 (74.77%) 4 (1.83%)

Someone died Q21 36 (16.51%) 174 (79.82%) 8 (3.67%)

Most scary experience ever Q22 83 (38.07%) 131 (60.09%) 4 (1.83%)

Couldn’t stop the violence, needed help Q23 98 (44.95%) 116 (53.21%) 4 (1.83%)

Remembering the violence Q24 86 (39.45%) 128 (58.72%) 4 (1.83%)

Felling angry or mad Q25 31 (14.22%) 180 (82.57%) 7 (3.21%)

Dreams about the violence that Q26 112 (51.38%) 99 (45.41%) 7 (3.21%)

happened

Isolating oneself Q27 69 (31.65%) 143 (65.60%) 6 (2.75%)

Summary total responses 752 2,009 73

Table 4: Met UCLA PTSD Index Criteria A by Sex (n=304)

Criteria A Total (N=304) Males (N=142) Females (N=162) Met Criteria A 203 (66.8%) 94 (66.2%) 109 (67.28%) Did not meet Criteria A 41 (13.49%) 19 (13.38%) 22 (13.49%) Missing* 60 (0.29%) 29 (20.42%) 31 (19.14%)

Criteria B through D scored differently than criteria A. The DSM-IV symptoms measured within each criterion were (1) criteria B reexperiencing, (2) criteria C avoidance, and (3) criteria D increased arousal. The questions were answered on a Likert scale from

Table 5: UCLA PTSD Index Criteria B through D (n=244)

Criteria Dimension Question None Little Some Much Most Missing

Cues: Psychological reactivity Q2 61 (32.62%) 61 (32.62%) 28 (14.97%) 22 (11.75%) 13 (6.95%) 2 (1.07%)

Intrusive recollections Q3 86 (45.99%) 50 (26.74%) 29 (15.51%) 11 (5.88%) 8 (4.28) 3 (1.6%)

Trauma/bad dreams Q5 110 (58.82%) 48 (25.67%) 14 (7.49%) 8 (4.28%) 4 (2.14) 3 (1.60%)

Flashbacks Q6 123 (65.78%) 38 (20.32%) 18 (9.63%) 2 (1.07%) 4 (2.14%) 2 (1.07%) Criteria B B Criteria

(reexperiencing) Cues: Physiological reactivity Q18 130 (69.52%) 31 (16.58%) 7 (3.74%) 6 (3.21%) 8 (4.28%) 5 (2.67%)

Summary 510 228 96 49 37 15

Diminished interest Q7 127 (67.91%) 25 (13.37%) 9 (4.81%) 10 (5.35%) 14 (7.49%) 2 (1.07%)

Detachment/estrangement Q8 145 (77.54%) 17 (9.09%) 7 (3.74%) 5 (2.69%) 9 (4.81%) 4 (2.14%)

Avoiding thoughts/feelings Q9 79 (42.25%) 48 (25.67%) 8 (4.28%) 13 (6.95%) 35 (18.72%) 4 (2.14%)

Affect restricted Q10* 129 (68.98%) 28 (14.97%) 12 (6.42%) 6 (3.21%) 8 (4.28%) 4 (2.14%)

Affect restricted Q11* 110 (58.82%) 28 (14.97%) 15 (8.02%) 19 (10.16%) 12 (6.42%) 3 (1.60%)

Forgetting Q15 116 (62.03%) 38 (20.32%) 10 (5.35%) 5 (2.67%) 7 (3.74%) 11 (5.88%) Criteria C Criteria (Avoidance)

Avoiding activities/people Q17 82 (43.85%) 35 (18.72%) 22 (11.76%) 10 (5.35%) 31 (16.58%) 7 (3.74%)

Foreshort. Future Q19** 165 (88.24%) 10 (5.35%) 4 (2.14%) 0 (o%) 4 (2.14%) 4 (2.14%)

Foreshort. Future Q21** 136 (72.73%) 29 (15.51%) 4 (2.14%) 5 (2.67%) 8 (4.28%) 5 (2.67%)

Summary 1,089 258 91 73 128 44

Hypervigilance Q1 83 (44.39%) 50 (26.74%) 20 (10.70%) 9 (4.81%) 21 (11.23%) 4 (2.14%)

Irritability/anger Q4*** 120 (64.17%) 36 (19.25%) 15 (8.02%) 6 (3.21%) 6 (3.21%) 4 (2.14%)

Exaggerated startle Q12 75 (40.11%) 61 (32.62%) 19 (10.16%) 19 (10.16%) 9 (4.81%) 4 (2.14%)

Sleep problems Q13 155 (82.89%) 19 (10.16%) 8 (4.28%) 0 (0%) 2 (1.07%) 3 (1.6%)

Criteria D Criteria Concentration problems Q16 91 (48.66%) 45 (24.06%) 14 (7.49%) 14 (7.49%) 18 (9.63%) 5 (2.67%) (Increased Arousal) Irritability/anger Q20*** 112 (59.89%) 43 (22.99%) 10 (5.35%) 8 (4.28%) 7 (3.74%) 7 (3.74%)

Summary 636 254 86 56 63 27

*The highest score from either question 10 or 11 are used to measure severity ** The highest score from either question 19 or 21 are used to measure severity *** The highest score from either question 4 or 20 are used to measure severity

none (0) to most (4) and scored based on the number of criteria met in each category. Criteria B was met only if the participant answered little (1) to most (4) on at least one question. Criteria C was met only if the participant answered little (1) to most (4)

on at least three questions. Criteria D was met only if the participant answered little (1) to most (4) on at least two questions.

Table 6: Outcome of Partial or Full PTSD by Sex (n=244)

PTSD Severity Total (N=244) Males (N=113) Females (N=131) No PTSD* 93 (38.11%) 40 (35.4%) 53 (40.46%) Partial PTSD 53 (21.72%) 33 (29.20%) 20 (15.27%) Full PTSD 98 (40.16%) 40 (35.40%) 58 (44.27%)

Of those who experienced any type of violence, 22% were scored as having partial PTSD and 40% were scored as having full PTSD. The majority of those who experience violence and meet criteria A by having a memory of a violent experience are shown to have full PTSD over partial PTSD. Girl were slightly more likely to have the outcome of full PTSD than males, however this does not remain true for partial PTSD, where males are more likely than females for the outcome of partial PTSD.

Additionally, as seen in table 9 (below) The odds of having PTSD is below 1 and is not statistically significant (RR 0.92; CI: 0.56-0.74; p = 0.416).

Table 7: Prevalence of PTSD by Sex (n=244)

Total (N=244) No PTSD (n=93) PTSD (n=151) Risk Ratio (95% CI) p-value Male (n=113) 93 (38.11%) 40 (43.01%) 73 (48.34%) REF Female (n=131) 151 (61.89%) 53 (56.99%) 78 (51.66%) 0.92 (0.56; 0.74) 0.416

3.3 Associations between characteristics of individuals experiencing violence and PTSD

Tables 10 and 11 (below) summarizes the results of multivariate logistic regression on the associations between characteristic of individuals experiencing

violence and PTSD. Most characteristics were not statistically significant to include sex, age, and socioeconomic status. However, duration of violence was statistically significant in only two categories, “2-3 years back” and “as long as I can remember” as it relates to full PTSD. It was not statistically significant when related to partial PTSD.

Table 8: Multivariate Regression Models for Outcome of Partial PTSD Using Characteristics of Individuals Experiencing Violence (n=244)

Multivariate Model Characteristics of Individuals Experiencing Violence N Crude OR (95% CI) p-value Sex Male 17 REF Female 18 0.80 (0.36; 1.76) 0.571 Age 14 4 REF 15 30 0.65 (0.20; 2.17) 0.484 16 1 1 - Duration of Violence Can’t remember 27 REF During this year 3 1.56 (0.39; 6.20) 0.532 2-3 years back 1 0.23 (0.03; 1.88) 0.171 More than 4 years 1 0.55 (0.06; 4.24) 0.53 As long as I can remember 0 - - Socioeconomic Status Not enough money for food/basic necessities 4 REF Only enough to pay for what is needed 26 0.90 (0.27; 2.99) 0.857 Enough to buy extra things we do not need 1 1.49 (0.12; 19.16) 0.758 Don’t know 4 0.67 (0.14; 3.15) 0.27 *Statistically significant at p < 0.05

Table 9: Multivariate Regression Models for Outcome of Full PTSD Using Characteristics of Individuals Experiencing Violence (n=244)

Multivariate Model Characteristics of Individuals Experiencing Violence N Crude OR (95% CI) p-value Sex Male 68 REF Female 84 1.27 (0.68; 2.39) 0.457 Age 14 15 REF 15 136 1.56 (0.58; 4.21) 0.88 16 1 0.25 (0.01; 9.74) 0.457 Duration of Violence Can’t remember 94 REF During this year 7 0.75 (0.22; 2.53) 0.644 2-3 years back 18 5.07 (1.11; 23.21) 0.037 More than 4 years 9 2.62 (0.53; 13.08) 0.240 As long as I can remember 14 11.03 (1.22; 99.51) 0.032 Socioeconomic Status Not enough money for food/basic necessities 24 REF Only enough to pay for what is needed 99 0.61 (0.21; 1.81) 0.373 Enough to buy extra things we do not need 3 0.30 (0.03; 2.83) 0.296 Don’t know 26 0.44 (0.13; 1.57) 0.207 *Statistically significant at p < 0.05

Individual Characteristics, Violence Exposure, and Outcome

Univariable regression models for PTSD outcomes showed that only 38% (n-93) of the participants who met criteria A of experiencing a memorable traumatic event resulted in no PTSD (see table 8). The remaining participants did have the outcome of

PTSD with 22% (n=53) having the outcome of partial PTSD and 40% (n=98) having the outcome of full PTSD. When looking at sex differences in the outcome of PTSD, girls had the outcome of full PTSD (44% [n=58]) more often than boys (35% [n=40]); however, this does not remain true for the outcome of partial PTSD, where boys (29% [n=33]) have the outcome of partial PTSD more often than girls (15%[n=20]). Although the difference is small, it is interesting that the severity of PTSD and gender might play a role in 24

society. In addition, there was no evidence that the odds of PTSD differed by sex. Sex was not statistically significant for the outcome of PTSD (p=0.416) when using a univariable regression model and grouping partial and full PTSD together. These findings do not support the hypothesis that sex differences in the odds of PTSD would be significant following exposure to violence. Table 13 (below) shows the results of a univariable logistic regression model that was used to estimate the association between self-proclaimed socioeconomic status and the odds of PTSD. The majority of adolescents said they only had enough to pay for what is needed. The most significant finding is that 14% (n=22) of those with PTSD reported that they “don’t have enough money for food and basic necessities as compared to 8% (n=8) of those without PTSD.

However, the finding was not statistically significant.

Table 10: Univariable Regression Model of PTSD by Sex (n=244)

Total (N=244) No PTSD (n=93) PTSD (n=151) Odds Ratio (95% CI) p-value Male (n=113) 93 (38.11%) 40 (43.01%) 73 (48.34%) REF Female (n=131) 151 (61.89%) 53 (56.99%) 78 (51.66%) 0.92 (0.56; 0.74) 0.416

Table 11: Univariable Regression Model of PTSD by Socioeconomic Status (n=244)

Socioeconomic Status Total No PTSD PTSD Odds Ratio p-value (N=244) (n=93) (n=151) (95% CI) Not enough money for food/basic 30 (12.3%) 8 (8.6%) 22 (14.57%) REF necessities Only enough to pay for what is needed 161 (65.98%) 67 (72.04%) 94 (62.25%) 0.80 (0.63; 1.03) 0.080 Enough to buy extra things we do not 5 (2.05%) 1 (1.08%) 4 (2.65%) 1.1 (0.68; 1.79) 0.700 need Don’t know 45 (18.44%) 16 (17.20%) 29 (19.21%) 0.89 (0.66; 1.12) 0.431 Missing 3 (1.23%) 1 (1.08%) 2 (1.32%) - -

4. Discussion

The primary purpose of this study was to investigate the relationship among violence exposure and mental health outcomes, specifically full or partial PTSD. Among the 346 participants, 304 (88%) had experienced violence and were there asked to participate in the UCLA PTSD Index. Of the 304 participants who reported experiencing any type of violence, 203 (67%) met the initial eligibility criteria A for the UCLA PTSD index and were then assessed on the remainder of the PTSD Index for PTSD severity. Of the participants who were eligible for the PTSD questionnaire, 22% scored as experiencing “partial PTSD” and 40% scored on the scale as experiencing “full PTSD”.

The first aim was to estimate the prevalence of community and domestic violence in adolescents in Sri Lanka. Results showed domestic violence was experienced more often than community violence with girls experiencing slightly more violence than boys. The second aim was to estimate the prevalence of partial PTSD and full PTSD among those who experience community and/or domestic violence. Results showed that 88% of adolescents in the study experienced violence in some form and of these 67% met criteria A of having a significant traumatic event. Overall, 22% had the outcome of partial PTSD and 40% had the outcome of full PTSD. Therefore, severity of PTSD in this population is significant with more having the outcome of full PTSD than partial PTSD.

The third aim was to describe individual characteristics of those who experience violence as it relates to the outcome of partial or full PTSD. Results showed that none of

the individual characteristics (such as age, sex, socioeconomic status, number of siblings, and mother or father alive) were statistically significant. However, girls were slightly more likely to have the outcome of full PTSD than boys, and boys were slightly more likely to have the outcome of partial PTSD than girls. Consistent with past research

(Goenjian et al., 2000; Neuner et al., 2006; Ponnamperuma & Nicolson, 2016;

Siriwardhana et al., 2013), results indicated that violence exposures have a direct correlation to mental health outcomes of partial and full PTSD. In addition outcomes of

PTSD differed slightly for boys and girls and is therefore consistent with past research

(Ponnamperuma & Nicolson, 2016). Other studies focused on community violence exposure found rates were higher among boys than girls (Fitzpatrick & Boldizar, 1993;

Martinez & Richters, 1993; Springer & Padgett, 2000). Research showing age as a predictor of full or partial PTSD is inconsistent with some studies showing that age is a predictor (Adams et al., 2014) and others showing that it is not (Ponnamperuma &

Nicolson, 2016).. The only individual characteristic that was statistically significant was the duration of violence. Two of the four responses were statistically significant 1) 2-3 years back (p=0.037) and 2) as long as I can remember (p=0.032). This might be explained due to the age of the participants. Some may not have responded to more than 4 years because they could not remember that far back, and so decided to answer as long as I can remember instead. In a similar note, adolescents may have responded 2-3 years back because they were able to remember than far back.

The results of more participants having full PTSD than partial or no PTSD is unusual. One explanation for this might be the use of the UCLA PTSD index tool.

Although this tools has been used in many different studies, it has only been used in Sri

Lanka one time as of 2020 in the published literature (Ponnamperuma & Nicolson, 2016).

Ponnamperuma and Nicolson found that the majority (70%) of adolescents had multiple traumatic events. However, only 25% percent then met the criteria for partial or full

PTSD. This is significantly lower than that of this study. The UCLA PTSD index has also been used in other countries to measure adolescent’s exposure to violence and the outcome of PTSD. Several studies have been conducted in other parts of Asia with similar results. In japan adolescents in prison were measured on the UCLA PTSD index where 36% of participants reported experiencing violence and had a traumatic events making them eligible for criteria A (Yoshinaga et al., 2004). They found that 21% had the outcome of full PTSD and 21% had partial PTSD. Consistent with the current study, they also found that females were more likely to have the outcome of full PTSD than males. Another study was conducted in Kabul, Afghanistan to measure PTSD in adolescents who had experienced war, family violence, and poverty (Catani et al., 2009)

They found that in this highly vulnerable population during high violence only 26% of boys and 14% of girls had the outcome of PTSD. Another study in Taiwan using the

UCLA PTSD index to measure lifetime exposure to child physical abuse with respect to related PTSD symptoms (Chou et al., 2011). They found that 34% of the participants had

experience child physical abuse, yet only 31% of adolescents scored as having PTSD.

Similar to the present study however, girls reported higher and more severe symptoms of PTSD than boys. This may be a connection between the two studies as the present study showed more instances of domestic violence than community violence. Therefore, child physical abuse in the Chou et al. (2011) study may be similar to domestic violence as defined in the present study. These results call into question the validity of the UCLA

PTSD Index as a measurement tool as results from one population to another seem drastically different and inconsistent. Therefore, more studies need to validate the use of the UCLA PTSD index need to be done. Additionally, the UCLA PTSD Index is not culturally adaptable, therefore, the questions and measurement may not be useful in every population depending on cultural norms and the family dynamic.

This study’s main contribution to the current literature is its examination of community and domestic violence and its relationship to mental health outcomes of partial and full PTSD in a representative sample of adolescents in Sri Lanka. As mentioned previously, the literature surrounding PTSD in adolescents in Sri Lanka is scarce at best, and mostly related to individual events such as the Tsunami and war, and less on domestic and community violence. The results of those who experience any type of violence, they are more often to have the outcome of full PTSD than partial PTSD.

Additionally, although most individual characteristics of the participants were not significant, the duration of violence was significant in two categories. Therefore,

additional research needs to be done concerning how individual characteristics effect the outcomes of partial and full PTSD in adolescents.

4.1 Implications for policy and practice

The results of this study show that there is an overwhelming need for mental health interventions and support in Sri Lanka as over 62% of the children who experienced violence had the outcome of full or partial PTSD. This significant finding shows that both girls and boys who experience violence need to have support systems to cope with their possible outcome of PTSD or prevention of PTSD. Currently, Sri Lanka has programs for mothers who experience violence (Catani et al., 2009). Any intervention or policy will have to combat the stigma that is often attached to mental disorders from a social and cultural perspective in both the Sinhalese and Tamil communities (Siva, 2010). However, effective interventions within the schools has been shown to improve the mental health of adolescents and children in Sri Lanka with less risk to stigma when all children participate in the intervention instead of a few (Berger &

Gelkopf, 2009).

4.2 Implications for further research

Further research is needed to evaluate how characteristics such as age, sex, socioeconomic status, and duration of violent exposure effect the prevalence and severity PTSD among adolescents in Sri Lanka. The Lancet published an article in their

World Report stating that Sri Lanka needs “proper evaluation of the mental health of

both urban and rural populations” and that it “has not yet been done, especially in the post-war scenario”(Siva, 2010). Therefore, larger studies that include randomized clusters of schools throughout Sri Lanka are needed to understand the full breadth of how different types of violence result in full or partial PTSD. For example, students who lived through the recent tsunami in Sri Lanka were not part of this study, and therefore it is not known if this event resulted in greater or lesser prevalence of full or partial

PTSD. A 2009 study of a school-based intervention for the treatment of tsunami-related distress in children showed that a quasi-randomized controlled trail can be done regionally in Sri Lanka using the school system. It is apparent that this study was able to strategically build coalitions of stakeholders within the school system in Sri Lanka in order to implement an intervention to reduce PTSD severity, functional problems, somatic complaints, and depression (Berger & Gelkopf, 2009). The intervention included surveys, in-person interviews, as well as 12 sessions that were 90 minute which included homework, warm-up exercises, and other activities. The study demonstrated that these interventions significantly reduce PTSD severity, functional problems, and depression.

4.3 Study strengths and limitations

The main strength of this study was that the surveys were asked of school aged children in an environment that facilitated good response rate. Mental health studies always have a lingering complication with stigma. However, this study was able to

overcome possible stigma though its design, allowing every student in the class to take the survey so that no one felt singled out. Additionally, the response rate to both surveys was more than sufficient to allow additional analysis on the PTSD criteria.

The main limitation of this study was that those who took the CEDV questionnaire, but did not report experiencing violence, were not asked to take the

UCLA PTSD Index. Only those reporting that they experienced community violence, domestic violence, or both were then asked to take the UCLA PTSD Index. Therefore, this study was not able to show the relationship between not experiencing violence on the CEDV scale and partial or full PTSD. Additionally, due to the limited age range in this study, no connections between age and how it affects the outcome of full or partial

PTSD could be correlated. The power of this study is low as the population who actually took the UCLA PTSD Index was much smaller than the initial group who were asked to take the CEVD questionnaire. Additionally, the students selected for this study were all from the same two high schools in the same region. It would have been better to conduct the study with randomized clusters throughout all of Sri Lanka to evaluate the difference in the prevalence of PTSD resulting from community and domestic violence. Therefore, the generalizability of this study is limited and further studies with largest populations from different regions will need to be done for more insight. Finally, the CEDV questionnaire was an imperfect measurement. All of the questions asking about domestic violence were violence from the father to the mother. It did not include

violence from the mother to the father and did not include step mother or father, or siblings. Therefore, some children may have been experiencing domestic violence, but did not report it as the questions did not ask about any other relationship other than abuse from the father to the mother.

5. Conclusion

These finding show that there is a strong connection between adolescents who experience violence and full PTSD. Out of all those who had violence exposure, a stunning 62% of the them had the outcome of PTSD on the UCLA PTSD Index.

Therefore, it is imperative that programs dedicated to protecting and helping adolescents who experience violence are also targeted at the identification and treatment of PTSD. However, due to the small sample population and low statistical power, additional hypotheses concerning the impact of individual characteristics could not be determined. Individual characteristics such as age, sex, socioeconomic status, and duration of violence exposure were not statistically significant and could not be predictors of the outcomes of full or partial PTSD. As mentioned, the current literature on Sri Lankan adolescents and violence exposure resulting in PTSD is scarce and more studies need to be done to further understand the predictors of PTSD and the significance of community versus domestic violence. Additional research with larger samples sizes and more broad geographic locations of school in Sri Lanka is required to understand further the implications of violent exposures and the outcomes of partial and full PTSD.

Appendix A: Child Violence Exposure to Domestic Violence (CEDV) Questionnaire

Appendix B: UCLA PTSD Index for DSM IV

Appendix C: Scoring Worksheet for UCLA PTSD Index for DSM-IV, Adolescent Version

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