A multidimensional anxiety assessment of adolescents after Typhoon Morakot-associated mudslides

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Abstract

The aims of this study were to examine the factor structure, reliability and validity of the Taiwanese version of the Multidimensional Anxiety Scale for Children (MASC-T) in a group of adolescents in mountainous regions worst affected by Typhoon Morakot-associated mudslides. In total, 271 adolescents in grades 7–9 completed the MASC-T and the Chinese version of the Impact of Events Scale-Revised (C-IES-R). They also received a diagnostic interview to determine whether they had post-traumatic stress disorder (PTSD). We examined adequacy of the original four-factor structure of the MASC-T using confirmatory factor analysis, as well as its internal reliability, discriminant and predictive validities for PTSD, and convergent validity with the C-IES-R. Results support adequacy of the four-factor structure and internal reliability of the MASC-T in adolescents affected by Typhoon Morakot. Scores for the total MASC-T and subscales significantly discriminated adolescents with PTSD from those without PTSD. However, levels of predictive values for PTSD and the convergent validity with the C-IES-R differed among the MASC-T subscales and the total scale. The physical symptoms and harm avoidance subscales had the highest and lowest predictive accuracies for presence of PTSD, respectively. The MASC-T combined with diagnostic interviews for PTSD and self-report measures for assessing PTSD-specific symptoms can be used to evaluate a broad range of anxiety symptoms.

Research highlights

▶ This study confirmed the adequacy of the four-factor structure and internal reliability of the Taiwanese version of the Multidimensional Anxiety Scale for Children (MASC-T) in adolescents affected by Typhoon Morakot. ▶ Scores for the total MASC-T and subscales significantly discriminated adolescents with PTSD from those without PTSD. ▶ The levels of predictive values for PTSD and the convergent validity with the C-IES-R differed among the MASC-T subscales and the total scale.

Introduction

Post-traumatic stress disorder (PTSD) is a prevalent type of psychological distress among young people who are exposed to life-threatening stressors (McKnight, Compton, & March, 2004). Previous studies revealed that PTSD among children/adolescents experiencing natural disasters was common but the reported prevalence of PTSD-related syndromes varied substantially. For example, reported prevalence rates one year following natural disasters ranged from no one with a full syndrome after severe flooding in rural Missouri (Earls, Smith, Reich, & Jung, 1988), 3.8–6.2% with PTSD after Hurricane Hugo (Garrison, Weinrich, Hardin, Weinrich, & Wang, 1993), and 28.6% with mild to moderate PTSD following the Northridge earthquake (Asarnow et al., 1999) to 30.6% with PTSD following a super-cyclone in India (Kar et al., 2007). PTSD often has a chronic course for many young victims (Bolton, O’Ryan, Udwin, Boyle, & Yule, 2000). Given that PTSD often results in severe impairment to individuals and enormous societal costs (Kessler, 2000), early identification and active treatment of people with PTSD are necessary. As in all psychiatric disorders, the first step in setting up a program of treatment for PTSD is scrupulous assessment (March, 1999). In addition to a standardized interview to ascertain a diagnosis of PTSD, self-report measures for assessing PTSD-specific and multidimensional anxiety symptoms are frequently used. PTSD-specific measures, e.g., the Pynoos-Nader version of the Post-traumatic Stress Reaction Index (Pynoos et al., 1987), the Child and Adolescent Trauma Survey (March, 1999), and the Impact of Events Scale-Revised (IES-R) (Weiss & Marmar, 1997), assess PTSD symptoms and may provide cut-off points to identify potential PTSD candidates for further diagnosis and treatment. Multidimensional measures can also provide information regarding different aspects of anxiety across a broad range of dimensions (Chorpita, 2007) and provide information for possible internalizing comorbidities (McKnight et al., 2004). Information on comorbid anxiety symptoms is necessary because a high proportion of subjects with PTSD have preexisting (Breslau, Davis, Andreski, Peterson, & Schultz, 1997) and concurrent or subsequent anxiety disorders (Giaconia et al., 1995). For example, PTSD is associated with a significantly increased risk of social anxiety (33%) and specific phobia (29%) among adolescents (Giaconia et al., 1995). Clinicians are interested in the ability of the scores of multidimensional measures to predict specific DSM-IV anxiety disorders (van Gastel & Ferdinand, 2008).

The Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997) is one of the self-report multidimensional measures which identify anxiety problems among children and adolescents. A 2005 review concluded that the MASC was the best instrument for both screening for anxiety disorders in youth and discriminating between youth with anxiety disorders and those with other psychiatric disorders (Silverman & Ollendick, 2005). The MASC has several unique characteristics. First, it was developed through a “bottom-up” approach by adopting the final 39 items from a 104-item pool. Second, it assesses broad dimensions of anxiety and includes more anxiety problems (e.g., harm avoidance) than are listed in the DSM-IV diagnosis classification (March, 1997). A factor-analytic study revealed four factors (i.e., physical symptoms, harm avoidance, social anxiety, and separation/panic) that represent the core symptoms of DSM-IV anxiety disorders (March et al., 1997).

Research found that the scores of the total MASC or its subscales significantly differentiated those with an anxiety disorder from those without (Grills-Taquechel et al., 2008, March, 1997) and from those with depressive disorders (Rynn et al., 2006). Dierker et al. (2001) found that with the use of receiver operator characteristic (ROC) curves, the MASC total scale was moderately successful in predicting a DSM-IV diagnosis of a generalized anxiety disorder in female adolescents. van Gastel and Ferdinand (2008) found that using ROC curves with the separation anxiety and physical symptoms subscales of the MASC predicted panic disorder and agoraphobia fairly accurately in youths 8–18 years old. However, there is a paucity of research examining use of the MASC in adolescents with PTSD.

The Taiwanese version of the MASC (MASC-T) (Yen, Yang, Wu, Hsu, & Cheng, 2010) was translated from the original MASC (March, 1997) and evaluates the level of anxiety symptoms in children and adolescents. It has 39 items answered on a 4-point Likert scale ranging from 0 indicating “never true about me”, 1 indicating “rarely true about me”, and 2 indicating “sometimes true about me”, to 3 indicating “often true about me”. The MASC-T is composed of four subscales, including physical symptoms (12 items, for example, item 1: “I feel tense or uptight”), harm avoidance (9 items, for example, item 2: “I usually ask permission”), social anxiety (9 items, for example, item 3: “I worry about other people laughing at me”), and separation/panic (9 items, for example, item 4: “I get scared when my parents go away”). The MASC-T also includes an “anxiety disorder index” (10 items) that can discriminate between youths with and without anxiety disorders. A previous study confirmed suitability of the four-factor structure of the MASC-T, the internal consistency reliability among children and adolescents in the community, and the discriminant validity for anxiety disorders in clinical units (Yen et al., 2010). However, its factor structure, reliability and validity in adolescents who have experienced the major nature disasters have never been examined.

On August 7, 2009, Typhoon Morakot made landfall in Taiwan, and the next day, the storm emerged over the waters of the Taiwan Strait. Most areas of southern Taiwan recorded heavy rainfall peaking at 2777 mm (109.3 in). The extreme amounts of rain caused severe flooding throughout southern Taiwan and triggered enormous mudslides in mountainous areas, causing the deadliest typhoon-related disaster in Taiwan for the past 50 years. The storm caused catastrophic havoc, leaving 650 people dead and roughly US$3.3 billion in damages. Because of mudslides, nearly all inhabitants of steep mountainous areas experienced direct threats to their lives, and the majority of their homes were buried by several meters of mud. We felt that people who experienced Typhoon Morakot and associated mudslides might have sustained severe psychological impacts, and their mental health conditions needed to be carefully evaluated. Because typhoon-associated mudslides have an exceptionally threatening nature which is like to cause pervasive distress, adolescents experiencing Typhoon Morakot needed evaluation for PTSD.

The Center for Disaster Medicine at Kaohsiung Medical University, with support from the National Science Council, organized a team to provide medical services for people who experienced Typhoon Morakot, as well as survey the physical and psychological health of the people and the ecological changes in the disaster areas. The present study was part of an attempt to assess the mental health of displaced adolescents 3 months after the Typhoon Morakot-induced mudslide disaster in Taiwan. We attempted to examine the factor structure, reliability and validity of the MASC-T in a group of adolescents living in mountainous regions of southern Taiwan who experienced Typhoon Morakot. We investigated (1) the adequacy of the original four-factor structure of the MASC-T; (2) the discriminant and predictive validities of the MASC-T for PTSD; (3) the convergent validity of the MASC-T using the correlation between the MASC-T and the Chinese version of the IES-R (C-IES-R); and (4) the internal reliability of the MASC-T. We hypothesized that (1) the original four-factor model is fitted; (2) the MASC-T significantly discriminates adolescents with PTSD from those without; (3) the MASC-T can predict occurrence of PTSD; (4) the MASC-T has good convergent validity with the C-IES-R; and (5) the MASC-T has good internal reliability for Taiwanese adolescents who experienced Typhoon Morakot.

Section snippets

Setting and subjects

This survey was conducted with 277 adolescents in three junior high schools in mountainous regions of southern Taiwan which were worst-affected by Typhoon Morakot. These mountainous regions are inhabited Taiwanese aborigines who farm the mountainous terrain. Because the school buildings were ruined, adolescents who were in grades 7–9 (N = 277) were allocated to board in three areas on the plains where they could continue to receive a formal education in a group setting. These adolescents were set

Results

In total, 271 students (97.8%) completed all questionnaires and the interview. Those who were absent from class (n = 6, 4 boys and 2 girls) were excluded. According to school records, there was no difference in the gender ratio (χ2 = 1.033, p > 0.05) between the groups who did and did not participate in this study. However, those who did not participate were older than those who participated in this study (Z of the Mann–Whitney U-test = −2.645, p < 0.01). Among the 271 students who successfully completed

Discussion

Results of CFA supported the four-factor structure of the MASC-T in Taiwanese adolescents who experienced Typhoon Morakot. They indicated that the four-factor structure was invariant among Taiwanese adolescents who are in the community (Yen et al., 2010) and who experience a natural disaster such as typhoon-induced mudslides. This study also found that the scores of the total MASC-T and its subscales can discriminate adolescents with PTSD from those without; the MASC-T also had acceptable to

Conflicts of interests

The authors report no competing conflicts of interest.

Acknowledgements

This study was supported by grants (NSC98-2321-B-037-063 and NSC98-2410-H-037-005-MY3) from the National Science Council, Taiwan (ROC).

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