Psychological Morbidity in Children 18 months after Kashmir Earthquake of 2005

ORI GIN AL ARTICLE

Psychological Morbidity in Children 18 monthsafter Kashmir Earthquake of 2005

Muhammad Ayub • Ishwari Poongan • Khadija Masood •

Huma Gul • Mahwish Ali • Ammara Farrukh • Aisha Shaheen •

Haroon Rasheed Chaudhry • Farooq Naeem

Published online: 12 November 2011� Springer Science+Business Media, LLC 2011

Abstract A severe earthquake occurred in Kashmir in 2005. The epicentre was close to

Muzzafarabad. We collected data on over 1,100 children 18 months after the earthquake to

look at symptoms of PTSD and behavioural and emotional problems using well established

questionnaires. We found that 64.8% of children had significant symptoms of PTSD. Girls

were more likely to suffer from these symptoms. The proportion of children suffering from

emotional and behaviour difficulties was 34.6%. This percentage was not different from

other studies of children from Pakistan within areas which were not affected by the

earthquake. The rate of emotional symptoms was higher in girls while hyperactivity was

more frequent in boys. This pattern is similar to other studies from across the world.

Keywords Children � PTSD � Pakistan � Developing Country � Earthquake

M. AyubUniversity of Durham, Durham, UK

M. Ayub � I. PoonganTees, Esk and Wear Valleys NHS Foundation Trust, Durham, UK

M. Ayub (&)Sniperley House, Lanchester Road Hospital, Durham, UKe-mail: [email protected]

K. MasoodSheikh Zayed Medical College, Rahim Yar Khan, Pakistan

H. Gul � A. Farrukh � A. ShaheenSir Ganga Ram Hospital, Lahore, Pakistan

M. Ali � F. NaeemLahore Institute of Research and Development, Lahore, Pakistan

H. R. ChaudhryFatima Jinnah Medical College and Sir Ganga Ram Hospital, Lahore, Pakistan

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Child Psychiatry Hum Dev (2012) 43:323–336DOI 10.1007/s10578-011-0267-9

Introduction

Earthquake is a commonly occurring natural disaster. On average in a year 939 earth-

quakes of a magnitude between 5 and 8 on the Richter scale occur around the world.

About 1.8 million people lost their lives in 108 earthquakes during the twentieth century

(http://earthquake.usgs.gov).

Many people affected by an earthquake develop Post Traumatic Stress Disorder and

other psychological symptoms. Children are no exception to the effect of psychological

trauma [1–4]. A systematic review of Post Traumatic Stress Disorder (PTSD) after

disasters identified 116 studies in the category of natural disasters [5] and only 32 of these

were about children. Fourteen studies were from US, 2 each from Australia, Greece, Sri

Lanka and Turkey, 3 each from India and Armenia and 1 each from Taiwan, Thailand,

South Korea, and Nicaragua. All in all 20 studies were from the developed world and only

12 from the developing world. These figures represent an imbalance in the research focus

as the majority of the world children live in developing world and ninety one of the 108

major earthquakes (with a death toll over 1,000) in the twentieth century occurred in the

developing countries, accounting for 83% of 1.8 million deaths worldwide (http://

earthquake.usgs.gov). These countries are prone to large-scale destruction because of their

geographical location, poor structural quality of buildings, and preparedness for earth-

quakes. More studies are required from the developing world to look at the psychological

effects of natural disaster in children.

There was a wide variation in the prevalence of the PTSD between the studies reported

in the above review ranging from 5.42 to 90% [6, 7].

This variation in the rate could have resulted from a number of factors including time

lag between trauma and assessment, nature and severity of the disaster and method of

assessment.

In literature the factors which influence the development and persistence of symptoms

of PTSD and other psychopathology in children after disasters are grouped into [8];

• individual characteristics of the child; like age and gender,

• Characteristics of the family and social environment; access to social support and

quality of supportive relationships

• Exposure to trauma, threat and disruption to the life

• Child’s coping

Many published studies over last few decades have studied these factors. The symptoms

of PTSD and other psychiatric disorders are higher in girls than boys after disasters [7–18].

Age and developmental levels affect a child’s response to trauma. Some studies

reported a higher rate of PTSD symptoms in younger children [7, 10, 19] while other

studies reported fewer symptoms in younger age group [14, 20].

In terms of psychological and temperamental factors pre-existing anxiety disorder

[21–23], suffering from separation anxiety [6] and trait anxiety [10] predisposed children

to develop PTSD. Children who felt sad, anxious, worried, scared, alone, or angry during

the disaster had higher rate of PTSD afterwards [10, 24]. Coping style of children had a

bearing on the symptoms. Positive coping, blame and anger, and social withdrawal were

associated with PTSD symptoms [8, 16, 17, 25]. In another study avoidant coping was a

predictor of PTSD [22]. Stallard et al. [26] found that cognitive coping predisposed

children to PTSD.

Lack of social support predisposed children to PTSD as did parental psychiatric

symptoms including symptoms of PTSD [8, 15, 25, 27, 28]. Positive mother child

324 Child Psychiatry Hum Dev (2012) 43:323–336

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http://earthquake.usgs.gov



relationship was protective [29]. Previous history of traumatic experiences increased the

risk of PTSD symptoms in children [30, 31].

Greater exposure to trauma leading to more and severer symptoms has been replicated

by many studies both for PTSD and psychiatric symptoms [6, 12, 13, 31–35].

Loss of a family member [12, 36], degree of home damage reported [10], being in an

unfamiliar location at the time of disaster [10] and perceived life threat [8, 19, 24–26, 34,

37, 38] had positive association with PTSD.

Having a life threatening experiences during the incident [8, 9, 25], personal losses [30]

dissociation and grief, [30, 39] and physical injury [18, 21, 36] were associated with PTSD

and other psychiatric symptoms.

The impact of disaster can lead to ongoing stressors which continue after the phase of

acute damage. The phases of recovery and reconstruction have their own stresses. From the

literature we found that ongoing adversity after earthquake [13, 34] family separation at

2 months [40] loss of income and resources [10, 27, 40] life events during follow-up

[14, 25, 40], continued displacement [10], loss and disruption after disaster [8, 13, 25] were

all associated with PTSD and psychiatric symptoms.

In addition to PTSD children do develop other psychological and psychiatric symptoms

in the wake of disasters. Frans Norris in a review of literature about effects of trauma

(www.redmh.org) showed that some studies in children and young people looked and

found that they suffered additional problems unique to their age groups, such as behavioral

problems, hyperactivity, and delinquency, but like adults, they were also vulnerable to

PTSD, depression, somatic complaints, and ongoing stress. They recommended that the

breadth of the outcomes observed clearly indicates that we should not focus too narrowly

on any one condition in either research or practice.

South Asia is a densely populated region and the impact of natural disasters can have

significant impact. We specifically looked at studies conducted in this area because of the

social and cultural similarities. In October 1999 a Super-Cyclone hit 12 Districts of Orissa

on the East Coast of India and it continued for 72 h. It was a disaster at a big scale as 15

million people were affected and around 10,000 died. In one of the most severely affected

districts Kar and Bastia interviewed 108 adolescents from two schools using Mini Inter-

national Neuropsychiatric Interview for children and adolescents (MINI-KID). The study

was conducted 14 months after the disaster. They looked at PTSD, Major Depressive

Disorder and Generalized Anxiety Disorder.

The prevalence of PTSD was 26.9%, of Depression it was 17.6% and for Generalised

Anxiety Disorder it was 12.0%. A total of 37.9% suffered from psychiatric disorder and

39.0% among those had multiple diagnoses. In this study there was no difference in rate of

psychopathology across genders [41]. Another study was conducted 1 year after the same

Super-Cyclone which involved children and adolescents. The study was conducted in two

different areas; one with high exposure and other a low exposure area. The selection of

sample was random. The age range was 7–17 and total number of children was 447. The

diagnoses were based on interviews by clinicians. They did not use any structured

instrument for the interview. PTSD was present in 30.6% but additionally 13.06% had sub-

syndromal symptoms. Depression was associated with symptoms of PTSD. Level of

exposure to trauma and lower educational level was associated with PTSD [42]. In

December 2004, a giant tidal wave (tsunami) caused by an underwater earthquake in the

Indian Ocean resulted in an unprecedented natural disaster in Indonesia, Sri Lanka,

Thailand, and India. It caused 30,000 casualties. Neuner et al. conducted a study 4 weeks

after the disaster and selected three areas which were similar in exposure to tsunami but

different in terms of prior exposure to violence because of war. The University of

Child Psychiatry Hum Dev (2012) 43:323–336 325

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http://www.redmh.org

California at Los Angeles (UCLA) PTSD Reaction Index (PTSD-RI) for children was used

as the main instrument for the assessment of PTSD symptoms. The PTSD symptoms were

assessed in 264 children. The prevalence rate of tsunami-related posttraumatic stress

disorder ranged between 14 and 39%. Severity of the trauma exposure and family loss and

previous traumatic events predicted the PTSD [31]. In another study 296 children were

interviewed. The authors looked at multiple traumas (war, disaster and family violence)

and its effects on children. The rate of PTSD was 30.4% and Major Depression was 19.6%.

A clear dose–effect relationship between exposure to various stressful experiences and

PTSD was found in the examined children. The study highlights the importance of

interplay between different types of trauma and their cumulative effect on the rates of

PTSD as well as Depression [43].

On 8th October 2005, a major earthquake measuring 7.6 on the Richter scale hit the

remote and mountainous region of northern Pakistan and Kashmir. The epicentre was just

north of Muzzafarabad the capital city. Altogether 4,000 villages were affected, 73,000

people killed, 79,000 injured and 3.3 million rendered homeless. Over 470,000 houses

were completely destroyed, nearly 65% of the hospitals in the area were destroyed or badly

damaged and an estimated 10,000 school buildings were affected. This caused widespread

devastation in major towns of Balakot, Muzzafarabad, Bagh and Rawalakot (www.

reliefweb.int).

In this report we describe a study conducted 18 months after the earthquake in

Muzzafarabad city in children and adolescents. We looked at the prevalence of symptoms

of PTSD as well as emotional and behavioural difficulties because the literature in this area

suggests that in addition to PTSD other psychopathology is common in the children

exposed to trauma [12, 44–46]. The effects of natural disasters are moderated by existing

vulnerability of the community including the buildings, physical infra-structure, and

material, emotional and social resources. Ongoing adversity resulting from long term

effects on earning, living conditions, health and social support networks means that stress

continues long after the disaster. The complex interplay between these factors may have an

effect on emotional and behavioural difficulties and PTSD. We hypothesized that the

pattern of relationship between factors like age, gender, family history of mental illness,

socioeconomic status, family deaths, severity of exposure to trauma and ongoing adversity

after the earthquake and symptoms will be similar to the international literature.

Family’s income, educational level and employment of the head of the family are

measures of socioeconomic status in this community. The degree of damage to the building

where the child was at the time of the earthquake is a measure of severity of exposure to

the trauma [47]. Damage to the child’s family home, disability of the head of the family

and living in a tent are measures of ongoing adversity after the earthquake.

In our previous work we have found that extended family is a source of social support

and protective against psychiatric morbidity in adults [48].

We wanted to explore the differential effect of these measures on symptoms of PTSD and

other psychiatric morbidity. We hypothesised that socioeconomic variables and ongoing

adversity will have more effect on emotional and behavioural difficulties than PTSD.

Methods

The project had ethical approval from Pakistan Psychiatric Research Centre, Lahore and

informed written consents were sought from the parents. Children were given information

about the study and their agreement was also sought.


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http://www.reliefweb.int


Site

Muzaffarabad is the capital city of Azad Kashmir. Its population at the time of 2005

Earthquake was 100,000. The city is spread over 45 km and it is divided into 22 wards. The

ward is the smallest local government administrative unit in Pakistan and Azad Kashmir.

The population of the smallest ward was 583 and the largest ward had 12,450 residents. In

the city 17,111 houses were affected by the earthquake out of which 7,782 were fully

damaged while 5,518 were partially damaged. The damage to schools was very high

(www.reliefweb.int). The children were at school at the time and they died in great numbers.

Sample Selection and Assessment

Data was collected in 2007. Based on time and staff availability we initially planned to

interview 1,100 subjects. A significant proportion of people were living in tents and they

were also interviewed. Some of these tents and temporary residences were within the wards

but there were additional people from tents in some central camps. Only those people who

were from local wards were included. In the tents families were living together and we

only took two children from one family using the randomisation process described above.

We proposed to take a third of our sample from the families residing in the tents.

The study focused on children between ages 7 and 16. The local guides were asked to

accompany the teams and stop in any street in the ward. The team would then knock on the

door closest to the spot and ask the residents if there was a person of age 16 or under living

in the house. If there was a person of relevant age then the team would request them to

participate in the study. If they agreed the team would write names of all the relevant

young people and children and draw the names for assessment from a hat. There were

separate draws for males and females. The team would not recruit more than one male and

one female from a house. If the property was empty or no one with the relevant age resided

there then the team would move to the next door. After a successful recruitment from a

house they would go to the fifth door on the same side of the street.

We designed a form to collect demographic information. The information we collected

was about;

• Demographic and socioeconomic factors; age, gender, family history of mental illness,

family system (nuclear and extended), family’s income, education of head of family,

employment of the head of the family.

• Trauma related factors; loss of family member, degree of damage to the building where

the child was at the time of earthquake. The degree of damage was classed as no

damage, some damage, and total destruction.

• Post trauma factors; damage to the child’s family home, disability of head of family, living

in a tent. The damage to the child’s home was categorized into damage and no damage.

In addition we used two questionnaires.

The Strengths and Difficulties Questionnaire (SDQ) For assessment of psychological

morbidity we used SDQ, which is a simple and effective screening tool and provides

balanced coverage of behavioural, emotional, and social issues. A validated Urdu trans-

lation of the parents’ version with normative data from Karachi was available. SDQ has

four sub-scales which assess emotional, behavioural, hyperkinetic, and peer problems and

yield a total score for mental health difficulties. The additional subscale for strengths

focuses on pro-social behaviour [49, 50].


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There are further questions which assess the impact of a child’s difficulties in terms of

distress and interference with everyday home life, friendship, classroom learning, or leisure

activities. We used the parent’s version of the scale.

Assessment of Post Traumatic Disorder [51, 52] (CRIES-13 items, 4-point scale)

measures the impact of traumatic experiences on children. It has three subscales intrusion,

avoidance and arousal. The prior research indicates that the combined score of 8 items of

intrusion and avoidance is a valid measure of a diagnosis of PTSD. Scores of 17 or more

indicate a level of distress consistent with post-traumatic stress. We translated and back-

translated the instrument and reviewed the quality of translation in a group discussion of

the professional colleagues.

Interviewer Selection and Training

The interviewers were psychology graduates and they had experience of working in mental

health care for at least 2 years. All of them received 1 day training in use of assessments

and data collection techniques. They were supervised daily on site by two experienced

psychiatrists, both with post graduate qualifications.

Data Collection

Data collection process was piloted initially for 2 days to provide onsite experience to

interviewers and address any problems in use of assessments. The interviewers were divided

into 7 teams of two and each team was accompanied by a local guide. Every morning there

was a meeting of all the teams and each team was allocated one ward to work in for the day.

Data Analysis

We used SPSS 15 for data analysis. We performed t test to compare ages between male and

female participants. For gender distribution and comparison of nuclear and joint families

we performed Chi-square test. We report the overall caseness status and caseness on the

subscales. To compare genders for caseness we have used Chi-square test.

Univariate regression analysis for age, head of family education in years, family system,

income in rupees, damage to the building where the person was, presence and absence of

family death, family history of psychiatric illness, head of family disability and living in

tent or house were carried out. In this analysis SDQ scores and CRIES scores were the

dependent variables.

For CRIES we computed Chronbach’s alpha for the subscales as well as the total score.

Results

Demographic

We collected data on 1,154 participants and 559 (48.7%) of them were males. The mean

(SD) age for males was 10.82 (2.89) years and for females it was 11.05 (3.00). There was

no statistical difference in the age across genders (p value 0.18 for t test).

Table 1 gives information about the families of the participants as well as the details of

the damage caused by the earthquake. A family with children and parents was classed as


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Table 1 Information aboutfamily and damage caused by theearthquake

Family system

Joint 602 (52.2%)

Nuclear 484 (41.9%)

Missing 68 (5.9%)

Family income rupees (US $)

1,000–5,000 (16.6–83) 431 (40.36%)

6,000–10,000 (99.6–166) 337 (31.55%)

11,000–15,000 (182.6–249) 94 (8.80%)

16,000–20,000 (265.6–332) 146 (13.67%)

21,000–25,000 (348.6–415) 56 (5.24)

Over 250,000 (415) 4 (0.37%)

Missing 86 (7.5%)

Family history of psychiatric disorder

Present 38 (3.3%)

Absent 857 (74.3%)

Missing Miss 259 (22.4%)

Education of head of family

No schooling 223 (19.30%)

5–10 years 412 (35.70%)

12 years 253 (21.90%)

Over 14 years 208 (18.00%)

Missing 58 (5%)

Employment of head of family

Unemployed 102 (8.8%)

Employed 449 (38.9%)

Student 161 (14%)

Housewife 351 (30.4%)

Retired 29 (2.5%)

Disabled 1 (0.1%)

Missing 61 (5.3%)

Damage to the building

No 269 (23.3%)

Some 694 (60.1%)

Total 106 (9.2%)

Missing 85 (7.4%)

Damage to own house

Yes 863 (74.8)

No 207 (17.9%)

Missing 84 (7.3)

Currently living in

Home 669 (58%)

Tent 409 (35.4%)

Missing 76 (6.6%)

Disability of head of family

Present 106 (9.2%)

Absent 985 (85.4%)

Missing 63 (5.5%)


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nuclear while the families who had grandparents or other relatives as their part were

classed as joint. Majority of the children lived in joint families (N 602, 52.2%).

Nearly 70% of the building where the children were at the time of the earthquake

sustained some damage. This was used as a measure of exposure to trauma. Damage to the

houses where children lived before the disaster may be an important ongoing stressor post

disaster. Nearly 75% of these had some damage.

Ninety two percent of the children had a family death.

Thirty four percent children met the criteria for caseness based on total SDQ scores.

Twenty five percent boys and 35% girls had emotional disorder. This difference was

significant (p value 0.000). More boys (16.1%) met caseness criteria for Hyperactivity as

opposed to 10.1% girls. This was a significant difference (p value 0.000).

The p values are for the gender difference based on Chi-square test. Although there was

no gender difference for the overall cases, hyperactivity was more frequent in males and

emotional difficulties were more common in females.

The Impact Score

The second part of SDQ measures the overall distress and social impairment caused by the

problems. The questions in this section focus on the distress to the child and impairment in

areas of relationships, family life and learning. Based on number of the positive responses

and the degree of their severity 0–10 scores can be generated for a child. A score of one is

for borderline abnormality and 2 or above means abnormal. In our sample data for impact

score was available in 1,009 cases. Of these 739 (73.2%) were normal, 34 (3.3%) bor-

derline and 236 (23.3%) abnormal.

Diagnosis of PTSD

For our data the Chronbach’s alpha of the Child Revised Impact of Events Scale (CRIES-

13 items) scale was 0.82. This statistics for Intrusion subscale was 0.67, for avoidance it

was 0.63 and for arousal it was 0.61.

Table 2 gives the diagnoses based on this scale. The rate was significantly higher in

females and overall rate of the disorder was nearly two-third of the sample.

Linear Regression

We performed a regression analysis to look at the association between the various factors

identified in previous studies and morbidity. In separate analyses total scores on SDQ and

CRIES were dependent variables. The independent variables were age, head of family

education in years, family system, income in rupees, did someone in family die, family

Table 1 continuedDeath in the family

Mother 505 (44.40%)

Father 523 (45.32%)

Siblings 14 (1.21%)

Others 12 (1.04%)

None 90 (7.80%)


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history of psychiatric illness, head of family disability and living in tent or house. Age was

a significant predictor for both SDQ and CRIES scores. Younger children were at high risk

of symptoms (Table 3).

Discussion

In this study the rate of PTSD was almost twice the rate of psychiatric morbidity on SDQ.

In a study of adults from the same area at around the same time the rate of PTSD was

55.2% in women and 33.4% in men [47]. The gender difference in rates of PTSD is less

marked in children. Many studies from the region reported a rate of PTSD lower than our

study. These included studies from war stricken Afghanistan and disaster stricken Sri

Lanka and India. Two studies from India after Cyclone reported a rate of 26.9 and 30.6%

[41, 42]. In a study from Sri Lanka where children were exposed to tsunami, war and

family violence the rate of PTSD was 30.4% [43]. In a study from Kabul 14.1% of girls and

26.1% of the boys suffered from PTSD [53]. In another study from 3 centers across

Afghanistan 23.9% suffered from PTSD [54]. This study used CRIES to assess symptoms

of PTSD. In addition to the difference in method of assessment of PTSD the severity of

exposure to trauma may be a reason of high rate of PTSD symptoms in our sample.

Other studies from Pakistan using SDQ have reported a rate of problems similar in

range to our sample. In a study from mainstream schools the rate of behavior problems was

34.4% [55]. This study however used cut off scores from the English version of SDQ

Table 2 Rate of PTSD based on CRIES scores

Diagnosis Male Female Total p Value

PTSD 323 (61.9%) 376 (67.6%) 699 (64.8%) 0.05

Non 199 (38.1%) 180 (32.4%) 379 (35.2%)

Total 522 (48.4%) 556 (51.6%) 1,078

Missing 76 (6.6%)

Table 3 Results of linear regression

Independent SDQ CRIES

Beta p Beta p

Age -0.134 000 -0.11 000

Head education 0.004 0.89 0.011 0.73

Family sys 0.02 0.50 0.049 0.117

Income -0.001 0.96 -0.011 0.71

Damage to building -0.009 0.78 -0.05 0.10

Death in family -0.019 0.55 -0.026 0.38

Own property 0.06 0.06 -0.022 0.49

F H psych 0.03 0.43 -0.004 0.89

Head disability 0.007 0.83 -0.037 0.23

Living in tent -0.048 0.14 -0.71 0.024

Bold indicates statistically significant associations


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which are lower than the Urdu version. If we used those criteria for our data then the rate of

behavior problems would be 41.53%. In another study of children living in orphanages the

rate was 33% [56].

In our sample trauma had less pronounced effects on the broad psychopathology than on

PTSD. It raises the possibility that trauma specifically affects symptoms of PTSD and not

emotional and behavioral symptoms as assessed by SDQ. The evidence from disaster

related as well as other trauma is significant that broader psychopathology is influenced by

the exposure to trauma. There may be some aspect of resilience in this community which

has a differential effect on general psychopathology in children. Community cohesion and

systems of emotional support is one such candidate. We did not study it but it can be the

focus of future research.

As hypothesised, PTSD and emotional problems were more common in females, while

hyperactivity was more frequent in males in our study. Crijnen et al. [57] studied

behavioural and emotional symptoms in 13,697 children and adolescents, ages 6 through

17 years from across 12 cultures. As shown in earlier studies, younger children in our

sample were at high risk of developing PTSD and achieving high SDQ scores, as well.

Education of the head of the family and family income did not predict symptoms. Some

earlier studies in this culture have shown that extended family is a source of social support

and protective against psychopathology. In this study it had no influence on the symptoms.

In our previous work we have found that income does not predict the symptoms of PTSD

or broader psychiatric symptoms in adult population both in context of trauma caused by

disasters or domestic violence [47, 48]. Our speculation is that some aspects of social

support system like extended family provide protection against the disadvantage caused by

the lack of monitory resources. This however is an area which needs to be explored further.

Education and extended family as apposed to nuclear family were protective against the

symptoms in adults in those studies. In this study we looked at the education of head of

family. As an indirect measure it may not be reflective of the resources of the family. The

protective effect of the extended family is not relevant for children. We noticed although

anecdotally that broader network of the relatives who were not living in the same

household were more forthcoming in providing support to care for the children’s needs and

that is a possible mechanism which neutralised the disadvantage of living in a nuclear

household. It would be interesting to look at it in future research.

At the time of earthquake nearly a quarter of the children were in the buildings which

were not damaged. Complete lack of association between the damage to the building and

PTSD symptoms raises questions about the dose response relationship between trauma

exposure and PTSD symptoms. Just the information about the building may have been two

narrow a measure of exposure. Future research needs to focus on more detailed assessment

of trauma exposure including children subjective account. Only about 8% children escaped

a death in the family. There was no association of PTSD symptoms with deaths in the

family. However the proportion of children with no deaths in the family was so small that it

would not have enough power to pick the difference. The trauma appears to be so over-

whelming that probably only children who were extremely resilient did not have the

disorder.

We hypothesised that living in the tents and damage to own property would be sources

of ongoing stress for the families. In our adult data living in a tent was associated with

psychiatric symptoms but not with PTSD while damage to own property was associated

with both. In this study living in tent has a negative association with CRIES scores. The

earthquake occurred when children were in schools. There is a possibility that children

living in the tents have a higher proportion of those children whose own houses were


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damaged but their schools were less damaged and as a result they had less direct exposure

to trauma.

The building damage reported in our study is less than reported through the surveys of

the area by local government. It was reported that 89% housing structures were totally

destroyed whereas 9% got partially damaged and only 2% remained in liveable condition.

It is likely that children who survived were in the buildings which were less damaged.

Limitations of the Study

We used questionnaires instead of psychiatric interviews to assess the PTSD symptoms as

well as behavioral and emotional difficulties. SDQ had a valid Urdu version and it is very

well established instrument for epidemiological studies across the world. CRIES has good

validity data in International studies and our team is experienced in translation of health

related instruments. The Chronbach’s alpha in our sample was similar to the one for the

English version.

We used damage to the building as a measure of exposure to trauma. It is an indirect

measure and rather a crude one. A more direct detailed description from children would

have given a better measure of exposure but it was difficult within our resource constraints.

We have not given enough attention to the resilience in the communities and individuals

which protect against the emotional impact of disasters.

Implications for Further Research and Practice

Study of these communities coping and support system would be an important next step for

research. We were not able to look at the functional impact of symptoms on children and

families which would be an important area to look at.

Access to specialist care would not be possible for majority of these children.

Strengthening the capacity of local primary health care systems and making the policy

makers aware of this hidden disease burden would be important.

Summary

Earthquakes are a common form of natural disasters and a significant source of psychiatric

trauma. They affect the developing world disproportionately because of the inherent

weaknesses of the infrastructure and buildings, general lack of resources to cope with the

acute phase of damage and recovery and reconstruction and lack of preparedness. A bigger

proportion of these countries population comprise of children and adolescents and they

suffer psychological consequences. Little research is done in these countries and psy-

chological well being is low in the priority areas for research.

In this study we attempted to look at the psychological symptoms and their correlates in

children after 2005 earthquake in Kashmir. The study was conducted 18 months after the

disaster. Many families were still living in temporary accommodation. The rate of PTSD

symptoms was very high. The frequency of emotional and behavioral symptoms was not

different from studies of these symptoms conducted in unaffected areas of Pakistan.

The measures of trauma exposure we used did not predict the PTSD symptoms.

Similarly the measures of socioeconomic adversity we studied did not predict emotional

and behavioral symptoms in children. Further study of the support systems in this com-

munity may offer us insight into the reasons for these differences. The future planning and


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research should focus on improving the capacity of the health system to address the

psychological impact of such disasters.

References

1. Dyregrov A, Yule W (2006) A review of PTSD in children. Child Adolesc Ment Health 11:176–1842. Copeland WE, Keeler G, Angold A, Costello EJ (2007) Traumatic events and posttraumatic stress in

childhood. Arch Gen Psychiatry 64:577–5843. Bromet E, Dew MA (1995) Review of psychiatric epidemiologic research on disasters. Epidemiol Rev

17:113–1194. Aptekar L, Boore JA (1990) The emotional effects of disaster on children: a review of the literature. Int

J Ment Health 19:77–905. Neria Y, Nandi A, Galea S (2008) Post-traumatic stress disorder following disasters: a systematic

review. Psychol Med 38:467–4806. Goenjian AK, Pynoos RS, Steinberg AM, Najarian LM, Asarnow JR, Karayan I et al (1995) Psychiatric

co morbidity in children after the 1988 earthquake in Armenia. J Am Acad Child Adolesc Psychiatry34:1174–1184

7. Shannon MP, Lonigan CJ, Finch AJ Jr, Taylor CM (1994) Children exposed to disaster: I. Epidemi-ology of post-traumatic symptoms and symptom profiles. J Am Acad Child Adolesc Psychiatry33:80–93

8. Vernberg EM, Silverman WK, La Greca AM, Prinstein MJ (1996) Prediction of posttraumatic stresssymptoms in children after hurricane Andrew. J Abnorm Psychol 105:237–248

9. Green BL, Korol M, Grace MC, Vary MG, Leonard AC, Gleser GC et al (1991) Children and disaster:age, gender, and parental effects on PTSD symptoms. J Am Acad Child Adolesc Psychiatry 30:945–951

10. Lonigan CJ, Shannon MP, Taylor CM, Finch AJ Jr, Sallee FR (1994) Children exposed to disaster: II.Risk factors for the development of post-traumatic symptomatology. J Am Acad Child Adolesc Psy-chiatry 33:94–105

11. Pynoos RS, Goenjian A, Tashjian M, Karakashian M, Manjikian R, Manoukian G et al (1993) Post-traumatic stress reactions in children after the 1988 Armenian earthquake. Br J Psychiatry 163:239–247

12. Goenjian AK, Walling D, Steinberg AM, Karayan I, Najarian LM, Pynoos R (2006) A prospective studyof posttraumatic stress and depressive reactions among treated and untreated adolescents 5 years after acatastrophic disaster. Am J Psychiatry 162:2302–2308

13. Garrison CZ, Weinrich MW, Hardin SB, Weinrich S, Wang L (1993) Post-traumatic stress disorder inadolescents after a hurricane. Am J Epidemiol 138:522–530

14. Garrison CZ, Bryant ES, Addy CL, Spurrier PG, Freedy JR, Kilpatrick DG (1995) Posttraumatic stressdisorder in adolescents after hurricane Andrew. J Am Acad Child Adolesc Psychiatry 34:1193–1201

15. Kilic EZ, Ozguven HD, Sayil I (2003) The psychological effects of parental mental health on childrenexperiencing disaster: The experience of Bolu Earthquake in Turkey. Fam Process 42:485–495

16. Russoniello CV, Skalko TK, O’Brien K, McGhee SA, Bingham-Alexander D, Beatley J (2002)Childhood posttraumatic stress disorder and efforts to cope after Hurricane Floyd. Behav Med 28:61–71

17. Lee I, Ha YS, Kim YA, Kwon YH (2004) PTSD symptoms in elementary school children after TyphoonRusa. Taehan Kanho Hakhoe Chi 34:636–645

18. Kumar MS, Murhekar MV, Hutin Y, Subramanian T, Ramachandran V, Gupte MD (2007) Prevalenceof posttraumatic stress disorder in a coastal fishing village in Tamil Nadu, India, after the December2004 tsunami. Am J Public Health 97:99–101

19. McDermott BM, Lee EM, Judd M, Gibbon P (2005) Posttraumatic stress disorder and general psy-chopathology in children and adolescents following a wildfire disaster. Can J Psychiatry 50:137–143

20. Green BL, Korol M, Grace MC, Vary MG, Leonard AC, Gleser GC et al (1991) Children and disaster:age, gender, and parental effects on PTSD symptoms. J Am Acad Child Adolesc Psychiatry30(6):945–951

21. Kolaitis G, Kotsopoulos J, Tsiantis J, Haritaki S, Rigizou F, Zacharaki L et al (2003) Posttraumaticstress reactions among children following the Athens earthquake of September 1999. Eur Child AdolescPsychiatry 12:273–280

22. Asarnow J, Glynn S, Pynoos RS, Nahum J, Guthrie D, Cantwell DP et al (1999) When the earth stopsshaking: earthquake sequelae among children diagnosed for pre-earthquake psychopathology. J AmAcad Child Adolesc Psychiatry 38:1016–1023

23. La Greca AM, Silverman WK, Wasserstein SB (1998) Children’s predisaster functioning as a predictorof posttraumatic stress following Hurricane Andrew. J Consult Clin Psychol 66:883–892


123

24. Thienkrua W, Cardozo BL, Chakkraband MLS, Guadamuz TE, Pengjuntr W, Tantipiwatanaskul P et al(2006) Symptoms of posttraumatic stress disorder and depression among children in tsunami-affectedareas in southern Thailand. JAMA 296:549–559

25. La Greca A, Silverman WK, Vernberg EM, Prinstein MJ (1996) Symptoms of posttraumatic stress inchildren after Hurricane Andrew: a prospective study. J Consult Clin Psychol 64:712–723

26. Stallard P, Velleman R, Langsford J, Baldwin S (2001) Coping and psychological distress in childreninvolved in road traffic accidents. Br J Clin Psychol 40:197–208

27. Jones RT, Ribbe DP, Cunningham PB, Weddle JD, Langley AK (2002) Psychological impact of firedisaster on children and their parents. Behav Modif 26:163–186

28. Ostrowski SA, Christopher NC, Delahanty DL (2007) Brief report: the impact of maternal posttraumaticstress disorder symptoms and child gender on risk for persistent posttraumatic stress disorder symptomsin child trauma victims. J Pediatr Psychol 32:338–342

29. Wickrama KAS, Kaspar V (2007) Family context of mental health risk in Tsunami-exposed adoles-cents: findings from a pilot study in Sri Lanka. Soc Sci Med 64:713–723

30. Laor N, Wolmer L, Kora M, Yucel D, Spirman S, Yazgan Y (2002) Posttraumatic, dissociative and griefsymptoms in Turkish children exposed to the 1999 earthquakes. J Nerv Ment Dis 190:824–832

31. Neuner F, Schauer E, Catani C, Ruf M, Elbert T (2006) Post-tsunami stress: a study of posttraumaticstress disorder in children living in three severely affected regions in Sri Lanka. J Trauma Stress19:339–347

32. Najarian LM, Goenjian AK, Pelcovitz D, Mandel F, Najarian B (1996) Relocation after a disaster:posttraumatic stress disorder in Armenia after the earthquake. J Am Acad Child Adolesc Psychiatry35:374–383

33. Shaw JA, Applegate B, Schorr C (1996) Twenty-one-month follow-up study of school-age childrenexposed to Hurricane Andrew. J Am Acad Child Adolesc Psychiatry 35:359–364

34. Giannopoulou I, Strouthos M, Smith P, Dikaiakou A, Galanopoulou V, Yule W (2006) Post-traumaticstress reactions of children and adolescents exposed to the Athens 1999 earthquake. Eur Psychiatry21:160–166

35. Hardin S, Weinrich M, Weinrich S, Hardin T, Garrison C (1994) Psychological distress of adolescentsexposed to Hurricane Hugo. J Trauma Stress 7:427–440

36. Hsu C-C, Chong M-Y, Yang P, Yen C-F (2002) Posttraumatic stress disorder among adolescentearthquake victims in Taiwan. J Am Acad Child Adolesc Psychiatry 41:875–881

37. Udwin O, Boyle S, Yule W, Bolton D, O’Ryan D (2000) Risk factors for long-term psychologicaleffects of a disaster experienced in adolescence: predictors of post traumatic stress disorder. J ChildPsychol Psychiatry 41:969–979

38. Dyregrov A, Gupta L, Gjestad R, Mukanoheli E (2000) Trauma exposure and psychological reactions togenocide among Rwandan children. J Traum Stress 13:3–21

39. Ehlers A, Mayou RA, Bryant B (2003) Cognitive predictors of posttraumatic stress disorder in children:results of a prospective longitudinal study. Behav Res Ther 41:1–10

40. McFarlane AC (1987) The relationship between patterns of family interaction and psychiatric disorderin children. Aust N Z J Psychiatry 21:383–390

41. Kar N, Bastia BK (2006) Post-traumatic stress disorder, depression and generalised anxiety disorder inadolescents after a natural disaster: a study of comorbidity. Clin Pract Epidemiol Ment Health 2:17

42. Kar N, Mohapatra P, Nayak K, Pattanaik P, Swain S, Kar H (2007) Post-traumatic stress disorder inchildren and adolescents one year after a super-cyclone in Orissa, India: exploring cross-culturalvalidity and vulnerability factors. BMC Psychiatry 7:8

43. Catani C, Jacob N, Schauer E, Kohila M, Neuner F (2008) Family violence, war, and natural disasters: astudy of the effect of extreme stress on children’s mental health in Sri Lanka. BMC Psychiatry 8:33

44. Breslau N, Davis GC, Andreski P, Peterson E (1991) Traumatic events and posttraumatic stress disorderin an urban population of young adults. Arch Gen Psychiatry 48:216–222

45. Hubbard J, Realmuto GM, Northwood AK, Masten AS (1995) Comorbidity of psychiatric diagnoseswith posttraumatic stress disorder in survivors of childhood trauma. J Am Acad Child Adolesc Psy-chiatry 34:1167–1173

46. Sack WH, McSharry S, Clarke GN, Kinney R, Seeley J, Lewinsohn P (1994) The Khmer AdolescentProject. I. Epidemiologic findings in two generations of Cambodian refugees. J Nerv Ment Dis 182:387–395

47. Naeem F, Ayub M, Masood K, Gul H, Khalid M, Farrukh A et al (2011) Prevalence and psychosocialrisk factors of PTSD: 18 months after Kashmir earthquake in Pakistan. J Affect Disord 130:268–274

48. Ayub M, Irfan M, Nasr T, Lutufullah M, Kingdon D, Naeem F (2009) Psychiatric morbidity anddomestic violence: a survey of married women in Lahore. Soc Psychiat Epidemiol 44:953–960

49. Vostanis P (2006) Strengths and difficulties questionnaire: research and clinical applications. Curr OpinPsychiatry 19:367–372


123

50. Samad L, Hollis C, Prince M, Goodman R (2005) Child and adolescent psychopathology in a devel-oping country: testing the validity of the strengths and difficulties questionnaire (Urdu version). Int JMethods Psychiatr Res 14:158–166

51. Perrin S, Meiser-Stedman R, Smith P (2005) The children’s revised impact of event scale (CRIES):validity as a screening instrument for PTSD. Behav Cogn Psychother 33:487–498

52. Smith P, Perrin S, Dyregrov A, Yule W (2003) Principal components analysis of the impact of eventscale with children in war. Pers Individ Differ 34:315–322

53. Catani C, Schauer E, Elbert T, Missmahl I, Bette J-P, Neuner F (2009) War trauma, child labor, andfamily violence: life adversities and PTSD in a sample of school children in Kabul. J Trauma Stress22:163–171

54. Panter-Brick C, Eggerman M, Gonzalez V, Safdar S (2009) Violence, suffering, and mental health inAfghanistan: a school-based survey. Lancet 374:807–816

55. Syed EU, Hussein SA, Mahmud S (2007) Screening for emotional and behavioural problems amongst5–11-year-old school children in Karachi, Pakistan. Soc Psychiatry Psychiatr Epidemiol 42:421–427

56. Lassi ZS, Mahmud S, Syed EU, Janjua NZ (2011) Behavioral problems among children living inorphanage facilities of Karachi, Pakistan: comparison of children in an SOS Village with those inconventional orphanages. Soc Psychiatry Psychiatr Epidemiol 46:787–796

57. Crijnen AA, Achenbach TM, Verhulst FC (1999) Problems reported by parents of children in multiplecultures: the child behavior checklist syndrome constructs. Am J Psychiatry 156:569–574


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Psychological Morbidity in Children 18 months after Kashmir Earthquake of 2005