Risk indicators for post-traumatic stress disorder in adolescents exposed to the 5.12 Wenchuan earthquake in China
Introduction
On 12 May 2008, a devastating earthquake, measuring 8.0 on the Richter scale, struck Wenchuan County in Sichuan province and surrounding areas, China. The affected area is mainly a rural mountainous region; traffic accessibility of some regions is inadequate. Cities in the region were extensively damaged, and experienced many aftershocks. The number of dead and missing exceeded 90,000. More than 400,000 people were injured, and about 10,000,000 displaced after their homes were destroyed. A number of schools collapsed, burying many children, some of whom died. The significant level of aftershock created fear among the population, with many people hesitant to sleep indoors, even those whose houses had sustained minimal or no damage. The present study was undertaken in Mianzhu city. Situated in the northwest Sichuan Basin, Mianzhu is a county-level city in Deyang City, 83 km away from Chengdu, the largest city of Sichuan province. It covers an area of 1245 sq. km., and has a population of 510,000. It is divided into 19 towns and two townships. The city was seriously damaged in the earthquake.
Previous research has shown that children and adolescents exposed to traumatic or life-threatening events may develop symptoms of post-traumatic stress and post-traumatic stress disorder (PTSD) (Schnurr et al., 2002). Children with PTSD may reexperience the traumatic event, avoid trauma-related cues and thoughts, and suffer from emotional numbness and disruptions of arousal. However, not all individuals exposed to trauma develop PTSD. The rates of PTSD vary between 3% and 70%, depending on sex, age, the nature of the event, severity of injury, financial loss, social support, previous metal illness and the population studied (La et al., 1996, Cohen, 1998, Asarnow et al., 1999, Davis and Siegel, 2000). Structured diagnostic interviews are viewed as the gold standard for assessing PTSD (Cohen, 1998), but their use in large-scale traumas can be impractical. An alternative strategy involves using brief, child-friendly, self-report measures to initially screen large numbers of trauma-affected children (Yule and Udwin, 1991, Stallard et al., 1999, Brewin et al., 2000), and to conduct structured diagnostic interviews only with those identified as being at high risk of developing PTSD (Sahin et al., 2007). One of the most commonly used instruments to screen for PTSD symptoms is the Children's Revised Impact of Event Scale (CRIES).
Findings as regards risk indicators of PTSD are inconsistent, and some results are contradictory. Considering the individual differences, recent research has shown the development and sustainment of PTSD to be partly associated with an individual's post-traumatic cognitive structures and beliefs (Resick and Schnicke, 1992, Bennett et al., 2001). Wenninger (Wenninger and Ehlers, 1998) reported the process of traumatisation to be associated with the “shattering of cognitive schemas or core assumptions” in survivors who were unable to adapt. A recent report on the aetiology of PTSD in adolescents implicated problems in emotional regulation and maladaptive cognitive styles, with traumatized adolescents experiencing high levels of dissociation, trauma-related cognitions, and depression (Ehlers et al., 2003). Cognitive models of PTSD in adolescents postulate that emotions and cognitions related to traumatic events are stored together in memory or fear networks (Salmon and Bryant, 2002). Pine et al. (Pine et al., 2005) suggest that individuals with PTSD may have an attentional bias for threatening stimuli, and difficulty managing emotions associated with problematic memories.
Social support is considered an important factor influencing an individual's reaction to stress. Galea et al. (Galea et al., 2005) found social support to have a beneficial effect in PTSD. Low levels of social support after traumatic experiences have been associated with significantly higher rates of PTSD symptomatology (Flannery et al., 1991). Similar results have been reported for Chinese flood victims (Feng et al., 2007). The results of these individual studies are supported by those of meta-analyses (Brewin et al., 2000, Ozer et al., 2003).
Although previous studies suggested a number of predictive factors for PTSD, the optimal method to define multifactor strategies is controversial. As part of a larger epidemiological study on PTSD and related factors in a population affected severely by the 5.12 Wenchuan earthquake in China, the main aims of the present study were: firstly, to evaluate the prevalence of post-traumatic stress symptoms and PTSD by using CRIES as the screening tool in adolescents, who were near the epicentre when the earthquake happened; secondly, to assess cognition and social supports in this population in 6 months after the earthquake by using Post-traumatic Cognitions Inventory (PTCI) and the Social Support Rating Scale (SSRS); finally, to identify variables predictive of or associated with the presence of PTSD, post-traumatic cognition and post-traumatic stress symptoms in adolescents by jointly employing both logistic regression methods and classification and regression tree (CART) analysis. The latter method allows probing of optimal cut-offs and the sequencing of predictive factors.
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Subjects
The study population included 3,645 adolescents, aged 12–18 years, from four counties affected severely by the earthquake in Mianzhu city. All participants are Han Chinese and speak Chinese. Of the 3,645 children, 3,208 children (88%) completed the investigation. The majority of subjects came from three middle schools: 919 from school A, 899 from school B, and 1,004 from school C. There was severe building destruction at all three schools, but no deaths at schools B or C. The rest of the 386
Descriptive information
In the present study, of the 3208 respondents (52.1% of them girls), the mean age was 13.8 ± 1.1 years. Among them, 39 (1.2%) subjects were buried during the earthquake. The duration of being buried was between 30 min and 6 h for most of the buried subjects (32 out of 39), 30 min for four others, between 6 and 12 h for two subjects and between 12 and 24 h for one subject. As many as 115 (3.6%) were wounded, 28 injured seriously, and were treated as inpatients. Surgery was required for 12 subjects, and
Discussion
There is large variability in the prevalence rate of PTSD in children and adolescents, depending on the method of assessment, the origin of samples, and the nature of the event and the length of duration since the trauma event. In the present study, we found that the overall prevalence of PTSD was 2.5% in a sample of 3,208 adolescents. This PTSD prevalence rate is much lower than that previously reported for earthquake children victims (Hsu et al., 2002, Giannopoulou et al., 2006, Sahin et al.,
Acknowledgements
This work was partly funded by the National Nature Science Foundation of China (30530300 and 30125014, TL), the National Basic Research Program of China (973 Program 2007CB512301, TL; 863 Program 2008AA022601 and 2008AA022603), NARSAD Independent Investigator Award (TL) and the Wellcome Trust (International Collaborative award to TL, DAC and XL).
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These two authors made equal contributions to this article.