Him ORIGINAL CONTRIBUTION Symptoms of Posttraumatic Stress Disorder and Depression Among Children in Tsunami-Affected Areas in Southern Thailand Warunee Thie Barbara Lopes MLA. Somehai Chakkraband, MD ‘uparat Ekassawin, MD Benjaporn Panyayong, MD x ME Jordan W. Tappero, MD, MPH MD Ph Tor the Thailand Posi-Tsanami alee Vara hhreibe Mental Health Study Croup N DECEMBER 26, 2004, 4 massive undersea earth- quake northwest of Su matra, Indonesia, with a Richter-scale magnitude of 9.3, caused a giant ocean shockwave, or tsunami, that devastated the shorelines of Indo- nesia, Sri Lanka, India, Thailand, and several other countries.’ More than 200000 people are estimated to have died from the tsunami, making it one ‘of the deadliest natural disasters in his- tory.! In Thailand, Phang Nga prov- ince was most severely affected, fol- lowed by Krabi and Phuket In Phang Nga alone, more than 4200 people died, and another estimated 4250 people ‘were displaced alter their houses were See also pp 537 and 576 and Patientt Page. (©2006 American Medical Assoc Context On December 26, 2004, an undersea earthquake occurred off the north- west coast of Sumata,Indnesa, The tsunami that flowed severely impacted all 6 southwestern provinces of Thaland, where approximately 20000 children were di- rectly affected, Objective To assess trauma experiences and the prevalence of symptoms of post- traumatic stress disorder (PTSD) and depression among children in tsunami-affected provinces in southern Thailand, Design, setting, and Participants, Population-based mental health surveys were conducted among children aged 7 to 14 years in Phang Nga, Phuket, and Krabi prov- inces from February 15-22, 2005 (2 months posttsunami), and September 7-12, 2005, (@ months posttsunami) Main Outcome Measures Trauma experiences and symptoms of PTSD and de- pression as measured by a tsunami-modified version of the PsySTART Rapid Triage System, the UCLA PTSD Reaction Index, and the Birleson Depression Self- Rating Scale. Results A total of 371 children (167 displaced and living in camps, 99 not displaced from vilages affected by the tsunami, and 105 not displaced from unaffected vil- lages) participated in the frst survey. The prevalence rates of PTSD symptoms were 113% among children living in camps, 11% among children from affected vilages, and 66% among children from unaffected villages (camps vs unaffected villages, P= 25); for depression symptoms, the prevalence rates were 11%, 5%, and 8%, respectively (P=.38). in multivariate analysis ofthe fist assessment, having had a delayed evacu- ation, having felt one’s own or a family members life to have been in danger, and having fet extreme panic or fear were significantly associated with PTSD symptoms. (Older age and having felt that their own ora family member's life had been in danger were significantly associated with depression symptoms. Inthe follow-up survey, 72% (151/210) of children from Phang Nga participated. Prevalence rates of symptoms of PTSD and depression among these children did not decrease significantly over time. Conclusions This assessment documents the prevalence of mental health problems among children in tsunami-affected provincesin southern Thailand at 2and 9 months posttsunami, Traumatic events experienced during the tsunami were significantly as- sociated with symptoms of PTSD and depression. These data may be useful to target ‘mental health services for children and may inform the design of these interventions. JAMA, 2006296599-559 ww jamacom | Author Afflitions: Thailand Ministry of Puble shoo ot Medne a he Usivesty of Califia tos Heats Centr for Disease Control and Preven- _Argoks (Dr shee, Dr Seveber wae Cen ten Colaberston Nonthabur, Thatand (er nen- terfr Puc Heath ag DiasterSthoal of Publ snus and Varngat MY Guaéamuz, end Drs Tapper Heath, Univers of Calfora, Los Anges, Sevan terse USCenesforiese Corba and Member othe TalandPstTsuar Mental Heath Prevention Alara, GDrstepes Carden, Tapper, Study Group aeltd al the endo hs aie. van Grins Department Metal Mire Conesponding Author Bafta Lopes Cardozo, WO, ity of Pubic Heath, Nonthabur, Thaland (Ore MPH Centers for Desc Cont aa Prevention, Na Chalaraband, Pengunt,Tanopstanet Eas Sonal Cente for Environmental Heath 10 Cron ‘awn andPanyajengand MSarstan:andNes- Read NE. Malstop E97, Alara, GA 30333 (hc ropsyciatne ste and Hostal David Geffen ede go. tion. Al rights reserved. (Reprinted) JAMA, August 2, 2006-296, No.5 549PTSD AND DEPRESSION AMONG CHILDREN IN TSUNAMI Figure 1. Samping Stages for Dsplaced CChideen in Phang Nga Province Cc “Hsehols were sed the pinay sampling unit and were defied as any foup of persons (some {ies mute ames) shang same Suture and resources such food or bedang destroyed. In Krabi, the death tll mea- sured 721, and in Phuket, 279.’ tise Limated that approximately 20.000 chil dren in southern Thailand were displaced, lost 1 or more family mem- bers, were orphaned or injured, or lost important belongings (material posses- sions with sentimental value to the child). Several studies have reported in- cercased psychological trauma among children after natural disasters."* Post- traumatic stress disorder (PTSD) and. depression may arise weeks oF months after the traumatic event. The severity of children’s symptoms depends on fac- tors such as level of exposure to the event, personal injury, loss of loved {550 JAMA, Agus 2, 2006 Vol 296, No. 5 Repited) cones, level of parental support, and dis- location.” Life-threatening events dur- ing a disaster have been associated with psychological problems in children." ‘As part of a public health emer gency response, we conducted a rapid assessment of symptoms of mental ill- ness among adults and children 2 months alter the tsunami. A surveil- lance follow-up survey was con- ducted among a subset of those most alfected, 9 months after the disaster. Here we present the prevalence of symptoms of PTSD, depression, and as- sociated risk factors among children aged 7 to 14 years in tsunamiaffected provinces in southern Thailand at 2nd © months postisunami, Symptoms of PTSD, anxiety, and depression among adults after the tsunami in Thailand are reported elsewhere in this issue." To our knowledge, no data have been pub- lished regarding posttsunami mental health problems in children. Anassess- ‘ment of stich problems is essential estimate the need for mental health ser- vices, to identify those at highest risk {for mental health problems, and to de- sigh and implement appropriate men- tal health interventions for them, METHODS: Study Design Two mental health assessments were conducted among children aged 7 to 14 years, 2 and 9 months postisunami. The first survey was conducted between Feb- ruary 15 and 22, 2005, in Phang Nga, Krabi, and Phuket provinces. These provinces were selected because they were the most severely affected by the (sunami, 4 follow-up survey was con- ducted in Phang Nea only, between Sep- tember 7 and 12, 2005, 9 months aller the disaster. We aimed to enroll 200 dis- placed and 150 nondisplaced house- holds from Phang Nga and 200 nondis- placed households from Krabi and Phuket. As explained elsewhere, this sample size was calculated on the basis ofan assumed PTSD prevalence of 15% in displaced and 12.5% in nondis- placed adults, adesign effect 2, anda 95% confidence interval (CI) (45%). For the purpose of this analysis we aimed to cenrolla sample of 350 children: 150 ing in camps for displaced persons, 100 not displaced from from villagesalfected by the tsunami, and 100 nor displaced Irom unaffected villages. These num- bers wouldallow us to estimate preva- lence of mental health problems of 5%, with an accuracy of 05% (44%) and a design effect of 1.5. The first survey included children aged 7 to 14 years, either those living in camps for displaced persons in Phang Nga oF those not displaced from af- fected and unaffected villages in Phang Nga, Krabi, and Phuket. OF 16 camps registered by February 14, 2005, 10 were selected. Six camps were ex- cluded because they had fewer than 50 households, Houscholds were used as the primary sampling unit and were d fined as any group of persons (some- times multiple families) sharing the same structure and resources, such as food of bedding. Household members ‘were not necessarily relatives by blood lor marriage We drew a systematic sample of households living in displacement ‘camps in Phang Nga, as explained else where (Ficure 1).!' In every house- hold, all children aged 7 to 14 years ‘were asked to participate, OF the 133 children inthis age group identified in these houscholds, 91 were located and interviewed, either in the camp or in the village school. If children were not present during initial field-staff visits, stall returned atallater time, fora maxi- two children mum of 2 visits, Forty ‘were absent or could not be located. With the help of village school stall, we identified all eligible 7- to 14-year-old children living in the camps who wer presentat the school at the time of the Field staff visit but who had not been able 1o participate through the hous hold survey. All of the children (n=76) ‘were identified and included to reach the target sample size, bringing the total, number of children from camps to 167. All these children were asked for as- sent and their parents or guardians pro- vided otal informed consent to partic pate. If children were present, refusal lo participate was rare. (©2006 American Medical Association, All rights reserved.To identify nondisplaced children, we drew a multistage cluster sample of 350 households from affected and un- affected villages in Phang Nga (de- fined as the high-impact cluster, 4224 deaths), and Krabi and Phuket (de- lined as the lower-itmpact cluster, 721 and 279 deaths, respectively) as ex- plained elsewhere in this issue!” (FiguRE 2). Inevery household all chil- dren aged 7 to 14 years were asked to participate. OF the 202 eligible chil- dren (87 from affected and 115 from unaffected villages), 108 (47 from af- fected and 61 from unaffected vil lages) were located and interviewe ther at home ot atthe village school U children were not present during ini- lial field-staff visits, stall returned at a later time, for a maximum of 2 visits Ninety-four children were absent or could not be located. With the help of village school staff in 2 villages (1 af- fected, 1 unaffected), we identified all cligible children who were present at the school at the time of the field stall visit but who had not been able to par- licipate through the household sur vey. All of these children (n=96; 52 Irom allected villages, 44 from wnat fected villages) were identified and in- cluded to reach the target sample size, bringing the total number of children from the villages to 204 (09 from af- fected and 105 from unaffected vil- lages). All children were asked for as- sent, and their parents or guardians provided oral informed consent to par licipate. If children were present, re- Iusal to participate was rare Instruments and Data Collection or both the initial rapid assessment and the surveillance follow-up assess- ment, we used standard instruments 16 assess the prevalence of symptoms of PTSD and depression, Other mea- sures of mental health problems (eg, anxiety) were excluded to limit the number of questions and the duration fof the interview for children. To in- form fieldwork procedures and 1st nami-specific questions, we collected information from adult key infor mants (persons affected by the tsu- (©2006 American Medical Assoc 1, All rights reserved. PISD AND DEPRESSION AMONG CHILDREN IN TSUNAMI rnami, health care workers, and com- munity leaders) about traumatic experiences, culture-specific coping ‘mechanisms, and tsunami-related men- tal health and subsistence issues. That nationality was determined by the in- terviewers (a child with a Thai na- Ldonal identification number was con- sidered That; children who lacked a number but who could speak Thai were offered enrollment); nationality was de- termined to control for the numbers of legal and illegal immigrants from Burma working in the tsunami ares. Religion was assessed by having the interview- crs ask for that information, Symptoms of PTSD were evaluated using the child version of the Univer- sity of California, Los Angeles PTSD Re- action Index. This index has been used to assess traumatized children after major disasters and catastrophic vio- lence." The questionnaire contains 20 yes/no items, with « 4-point seale to measure range of allirmative re- sponses, ranging from I (alitle of the time”) to4 (most ofthe time"). Ano’ answer was given a score of 0. A total PTSD symptom score was obtained by summing across all tems. A child with score higher than 40 was classified as having PTSD symptoms. The Bitleson Depression Self-Rating Scale was used to assesssymptoms of de- pression, This cale is considered avalid tool for the screening of depressive symptoms in children." The que: tionnaire contains 18 items rating the frequency of depressive symploms over the previous week on a 3-point scale (Cmost of the time,” “ never"). A score of 15 or higher was used to classify a child as having as symptoms of depression, A tsunami-modified version of the PsySTART Rapid Triage System! was used to ask children 13 yes/no ques: tions about tsunsami-specifie eauma e periences. These traumatic experi- ences included having seen tsunami waves, having seen anyone dead or in- jured, having heard screams, having had a delayed evacuation, having felt one’s own or a family members life to have been in danger, having felt unable toes cape, having felt extreme panic or fear, hhaving lost a close family member of Iriend, having had a close family mem- ber or friend injured, having lost home for important belongings, and having sustained an injury Allquestions were translated from En- lish to Thai and verified for accuracy by bilingual local mental health e: perts (but were not back-translated). Questionnaires were programmed for use on handheld computers and admis istered by tained interviewers who were psychologists, social workers, and psy chiatric nurses, Completed question- naires were downloaded to laptop com- puter and electronically transported 16 the Bangkok-based data management center using General Packet Radio Ser- vice at the end of each day The protocol of our assessment was reviewed by the US Centers for Dis cease Control and Preventionand by the Department of Mental Health of the Thailand Ministry of Public Health and was determined an emergency public health response, which, consequently, did not require an institutional review board review. Data collection con- sisted of face-to-face interviews car- ried out in a temporary housing struc ture, a home, or a school. The parent ‘or guardian was notin close proximity during interviews; thus, each child responded to all questions without consultation of interference. Parents received 100 Baht (US $2.50) as com- pensation for their children’s partick- pation, Children in need of mental health support were referred to met tal health services available both in ‘camps and in community areas. Data Analysis Prevalence rates of symptoms of PTSD and depression and other characteris- tics were calculated and analyzed using SPSS version 12.0 (SPSS Inc, Chicago, ID. Frequencies and standard devia- tions were calculated fordescriptivedata, ‘tests were used to compare mean val- ues, and y¢ tests were used for categori- cal data, Pearson correlation was used to assess the relationships among the independent and dependent variables. (Repited) JAMA, August 2, 2006 296, No.5 384PTSD AND DEPRESSION AMONG CHILDREN IN TSUNAMI Figure 2. Samping stages for Noncepincea crloren m Phang New Phuket tna Krab Provinces pom pameee em (a “ os \ es / \es / cs / =e / | | sa ne oe [coms > Sones EBT) ae i ef \ oe aa | I I ] ] 1 | q q — oe ee a “Fight duster was used to deserve th ge amber tarred detn the Phang Nga Province G4 death Kab and Phuket weve caaceraed ‘lower-npat cers (721 and 279 eae respecte, “Housel were sed the primary samping unt and wee defined say group of persons (sometimes mui failis) sharing th same uctre and resources, ‘eh as food or bedding 552 JAMA, gus 2, 2006 Vo 290, No. § Reprinted) (©2006 American Medical Association. All rights reserved. jamanetvrork.com/ by a Monash University Library User om 02/20/2020Backward stepwise selection multivar- iate logistic regression analysisadjusted for confounding variables was used 10 identify independent risk factors for symptoms of PTSD and depression. All variables that were theoretically rel- cevant (eg, displacement status) or that hhad P values of 03 or lower in bivariate analysis were entered into multivariate models. Risk factors examined for PTSD included displacement status, having, seen tsunami waves, having seen any- cone dead or injured, having heard screams, having had a delayed evacua- tion, having felt one’s own or a family member’ life w have been in danger, having felt unable to escape, having felt ‘extreme panic or fear, having lost aclose family member or friend, having lost home or important belongings, and hav- ing sustained an injury. Risk factors ‘examined for depression included dis- placement status, age, having seen ts rami waves, having seen anyone dead. or injured, having feltone'sown or afam- ily member’ life to have been in dan- ager, having felt unable to escape, hav- ing feluextreme panicor fear, and having hhad a close family member or friend injured. RESULTS Demographic Characteristics (01371 children participating in the frst survey, 167 (45%) were living in dis- placement camps, 99 (27%) were non- displaced from alfected villages, and 105 (28%) were nondisplaced from unaf- fected villages. Religion differed sig- nificantly between camps, affected vi lages, and unaffected villages (P<.001) Among children from camps, 49% we boys, 95% were Buddhist (3% Mus- lim, 49% Christian), and 99% were Thal, ‘with a mean age of 10.1 years; among children from affected villages, 53% were boys, 47% were Buddhist (52% Muslim, 2% Christian), and 99% were Thal, with a mean age of 10.1 years; among children from unaffected vil- lages, 39% were boys, 62% were Bud- ddhist (37% Muslim, 1% Christian), and (90% were Thai, with a mean age of 10.6 years. Seventy-two percent (151/210) fof children from the first survey in (©2006 American Medical Assoc 1, All rights reserved. PISD AND DEPRESSION AMONG CHILDREN IN TSUNAMI Phang Nga participated in the fol- low-up survey. Inall eases (n=59), re- location was determined to be the rea son for loss to follow-up, Prevalence of PTSD and Depression at 8 Weeks and 9 Months Inthe first survey, prevalences of PTSD symptoms among children from dis- placement camps, affected villages, and unaffected villages were 13%, 11%, and 6%, respectively (camps vs unaffected villages, P=.25). Prevalences of depres- sion symptoms among children Irom camps, affected villages, and unaf- fected villages were 11%, 5%, and 8%, respectively (P=.39). The prevalence of PTSD was higher among children from camps than among those [rom unal- fected villages (P=-049); other differ- ences were not statistically significant (Taste 1), Nine months postisunami in Phang. Nga, prevalence of PTSD symptoms among children in camps had de- creased from 13% (22/167) to 10% (12/ 119), but this decline was not signi cant (P=-43). Prevalence of depression among children in camps stayed ap- proximately similar, with 119 (18/ 167) in the first survey and 12% (14/ 119) in the second (P=.79). The numbers of children participants from affected and unalfected villages in Phang Nga was too small for meaning- ful statistical analysis. ‘Tsunami Experiences, First Survey Children living in displacement camps were significantly more likely (75% [125/167]) to have had direet tsunami experiences (le, to have seen the tsu- nami waves) than children not dis- placed from affected villages (55% [54/ 99]) and unaffected villages (28% [29/ 105]) (P=.001 for all comparisons) (Table 1) Children living in camps more fre- quently reported experiences of fear, loss, and personal injuries during the sunami than nondisplaced children from other areas. Most children living {in camps reported having felt their own, or a family member's life to have been In danger (75%; 95% C1, 67.6%- 81.2%), having felt unable to escape (64%; 05% Cl, 55.7%-70.8%), having felt extreme panic or fear (81%; 05% Cl, 74.7%-87.0%), and having lost close faunily member or friend (83%; 05% Cl, 76.0%-88.1%) (P<001 for all com- parisons). Nearly all children from camps (90%; 95% C1, 84.0%-04.4%) r ported having lost important belong- ings (P<.001) (Table 1) ‘Analysis of PTSD and Depression ‘Symptoms, First Survey The correlation coelficients presented in TABLE 2 indicate there were no sig- nificant correlations between indeper dent variables; however, the depen- dent variables PTSD and depression ‘were significantly correlated at P=.01, In bivariate analysis, demographic characteristics, including living in adis- placement camp, were not signi cantly associated with PTSD symp- toms (TABLE 3). A significantly higher prevalence of PTSD symptoms were found among children who reported Ihaving seen tsunami waves, having seen anyone dead or injured, having heard sereams, having had a delayed evacu- ation, having fel their own ora family member's life to have been in dang thaving felt unable to escape, having felt extreme panic or fear, having lost close family member or friend, having lost ‘home or important belongings, or hav- ing sustained an injury (Table 3). In muluivariate analysis, having had ad layed evacuation, having felt one’s own ora family member's life to have been danger, and having felt extreme panic co fear were significantly and indeper dently associated with PTSD symp- toms (Table 3) In bivariate analysis, older age, hav- ingseen the tsunami waves, having seen, anyone dead or injured, having felt ‘one’s own or a fatnily member’ life to hhave been in danger, having felt un- able to escape, having felt extreme panic fo fear, and having had a close family member or friend injured asa result of the tsunami were significantly associ- ated with symptoms of depression (Taste 4). In multivariate analysis, (Repinted) JAMA, August 2, 2006 Val 296, No.5 383PTSD AND DEPRESSION AMONG CHILDREN IN TSUNAMI colder age and having felt one’s own or family member's life to have been in danger were significantly and indepen- dently associated with symptoms of de- pression (Table 4) COMMENT (Our assessment showed that a signif cantly higher percentage of children dis- placed in southern Thailand as a re reported symptoms of PTSD com- sult of the December 2004 tsunami x 88; P- pared with those who had not been dis placed from unaffected villages in the same area (13% vs 6%, respectively; 049), However, no such ‘Table 1. Demographic Cheraclrses, Traumatic Experiences ara Mental Heath Outcomes Among Charen Enrolled Fm Dispacerent Camps, Tsunam-Affected Villages, and Unaected Vilages— Southern Thailand, 2005 No. (5% CTD Displacement Camps fected Vilages Unatected vilages | Pp Characteristic in r=99) (n= 105) Value Demogapnis Age group. y fio 96 (675 |406-05.1) 57 57.6 472.67. 471448195064.) 7 oo id 7125 R49S0A) AD W.A SSD Sa5 262060) | a, Boye 811485 407-504) 52,525 1422-62.) 4 690 (207-40.1) 9 us we 36575 MErS0S) ar aT ST SST. Baeroea7Oa | “ Fatgjon Bedhist 196(084(886-96.7) 46 405 964.508) SSGLOEITAT — gy ter T66RS105) 33 (5855 432-63 aoa pasa.) J Tans rated Vaumate mparencast ‘Sa une waves ‘Ye seqagperesia) 54545 402-60 2ap76[193272)7 ogy ie 21 [leewA) ASS [S.ASS, Toraa(625-0.7) | Say anyone dead a ee ‘Ye! SIT e62y 4545.5 (964.585: 99,07. 279-47.10 7 on i ZA ROGS22) bf (545 442-64 ween aeza-72.1) | rar sora Yee 2155509) 35/8544 260-45 28 26:7 (185.26.2) 7 we i GOT WOOGLS) 64640 |SAA-TA Trrsseseers) J Fins daayed eacaaton ‘Yee. 50/209 201-975) 25 26.17.1-95 10/95 (87-168) 9 coe i TT O.T STE) 7a 74 OSO-82I Basa ea | Fat ones oan ora amy members We \ohave been hn danger Yes 126749 (67.6812) 59/596 493-00. 4441912235197 ogy ie WZ e5AEeA) AO |aOA VOTO. eres ae er7) | Fat abe to aecape Yes 106,685 (557-708) 98 3e4\a8.47 26248(169241) 7 ogy ie G1 G65 O24) OTLB TST 7a (rez (659-2.1) | Fal gareme pac or Toa Yes! s96e14 747-870) 65 66.7)65.4-74 48157 (26055.)7 ogy ie Bi ie6 20263) at aes Ta eraser) | ‘oat clos ary mariber or rand ‘Yee 19862676088.) 45 465 /964.55.7) 4341.0 /815.51.0) 7 oor ic ZO|ITa|V. 8-280) 54 (SE5 GAZ eaeao (aoe) | ‘Gig ty mone o ena ree ‘Ye 107 601662713) 37 (87-4\79-47-7) BCU 7 — gy i BGS9 BIA T) 02 /0DG AST. Ta es6 pss rr3) J eat heme orimportant batngingst ‘Yes. 151904 [e49944) 46405 904-508) 21 200/128-2897 gy ie TOS BEET S555 METS exenoir1e72) | Sisaned ry ‘Yes! s2e2e 166209) 14 (141180220) SUSf16-408) 7 coop Ne Tear 2 e184) es SO TTA Too 52 502-06. | ‘Tanapeath oncom PSD. 22 182 24-10.) 11411.15.8-1900 616.7 21-120) 18 Depresson TE 108 65-165) BATA aro RSeS) 2B 1554 JAMA, Agus 2, 2006 Vol 296, No. 5 Reprinted) Downloaded From: https:/ (©2006 American Medical Association, AU rights reserved iHjamanetwork.com/ by a Monash University Library User on 02/20/2020PISD AND DEPRESSION AMONG CHILDREN IN TSUNAMI differences were seen between chil- ‘The timing of our surveys to assess depression among students aged 9 to 18, dren whowere displacedand those who PTSD and depression was ritical,since years were 5% and 14%, respectively." had not been displaced from alfected it isbelieved that by 8 weeks postdisas- In our assessment, having had a de villages (119%) (P=.62). Of children re-_ter,acute manifestationsof mental health layed evacuation, having felt one's own. siding in displacement eamps, 11% re- problems have either disappeared or or a family member's life to have been. ported symptoms of depression, but this have become more permanent.” In the in danger, and having felt extreme panic percentage was not higher than among second survey, 9 months postisunami, or fear were independent risk factors for nondisplaced children living else- prevalence of PTSD and depression PTSD symptoms, while older age and where in provinces affected by the tsu- among children in Phang Ngs had not having felt one's own or family mem- nami. Many ofthese children had lost declined, and follow-up assessments ber's life to have been in danger wer their homes, 1 or more of their par- must be conducted to assess the long- independent risk factors for depres- cents and siblings, and belongings with sentimental value and had undergone long-term need for mental health ser-_perienced extreme panic o fear had a erm mental health outcomes and the sion symptoms. Children who had ex- close-to-death experiences during the vices, Several studies have shown that 9 times higher risk for PTSD symp- tsunami. With the exception of reli- after disasters, mental health problems toms compared with children without sion, demographic characteristics were _amongchildren are common and ofthe this expe: ence. Moreover, children similar between children in camps and same magnitude as those found in our who had felt their own ora family mem- villages. Children in camps were more assessment. Aller Typhoon Rusa in ber’ life to have been in danger had a likely to be Buddhist than those in the South Korea, for instance, 12% of el- 6 times higher risk for depression symp- villages, since most of them origi ementary school children were classi-_ toms. These results may help to ide nated from Baan Nam Khem, a pre- fied ashaving PTSD’ Afterawildfiredi- tify children with an elevated risk for dominantly Buddhist village from sisterin Australia,9.0%ofstudentsaged either PTSD or depression so that they Phang Nga provine: pletely destroyed by the tsunami earthquake in Greece,ratesof PTSD and _ health interver thal was com- So 18years had PTSD.’ Following an can be targeted for appropriate mental, - Intercorelation Coetclent Matix of Tsunami-Raated Traumatic Experiences ana Mental Health Outcomes—Southern Thaland “Traumatic ve PTSO_Dep Age Sex Rel ‘FH = eo et = 7 Depo Ba OTe Foe gon oor Ona 7 Ea ‘os 006 OTT raga ‘aot 00a7 —on0T BOT Saviwamaes ET) _O18F OOF Ones 00g} OTE 7 Swany oad O18} OVATE OTD] ONT OOF OTT —T ‘ore 2) Faasceans 3 TOT} 00a COTE O0ee —OTeET OOF OTT Foadeayed oamaion OZI0T-0a8 COTS OTS OAD _OTeY ORI ODSAT es, Falcnesom arate ODE OVO OUST ODT OTE OEY OT OST T members etna ben eager 3) Fao to escapere5 OTF OTST OUD] _O0G0_—OTEET CARAT OATOT ODOT OTST OAT Fatearanepanc over OZ21T 108] COS? 0050 —OTZEE OADTY OOTY OSTT Ost OAT OTT = (aa com aay ewer OTE OVO] CORT —OOAEODTEF ODDGY ODT OGY OTST ORY OA OSE rend ‘oseiamy amber OGREF OTATY OURO OSE —OTAD ODGGT ODGET ORTT ORGY ODT ODT OOF OST tT orton re Tate orrgaeant OTF 0005 OUND ORE OAD OAGOY ODEET ORGY ODT ORT OAS OMSIE OAT OST lorghgs E10 Siaapedny E11) O72 IS I (©2006 American Medical Association. All ights reserved. (Reprinted) JAMA, Aug 2, 2006 296, No.5 S85 jamanetvrork.com/ by a Monash University Library User om 02/20/2020PTSD AND DEPRESSION AMONG CHILDREN IN TSUNAMI Disaster-related experiences can be tors, such as separation from parents ing screams for help, and feeling dan- traumatic and can have lasting elfects and how quickly a child is evacuated ger to one’s own life oF that of a loved in children." The impact of a disss- as well as experience of traumatic one.” Events threatening (o one’s ler on children depends on many fac- events such as witnessing death, hear own life oF to that of « loved one dur- ‘Table 3. Svarate and Mullvarte Analjse oF PTSD Symptoms Among Chidren--Southem Thaland, 2005, a mney a mega cos 1 7.03 0.53-2.01 ae Era S SET See a aT 296 ha 4A pn ©2006 mein Mea Asoc Al igh ee iHjamanetwork.com/ by a Monash University Library User on 02/20/2020ing a disaster have consistently been found to be significantly associated with postdisaster mental health problems." PISD AND DEPRESSION AMONG CHILDREN IN TSUNAMI ‘Our study has several limita some of which are inherent to disaster emergency response and rapid assess- ments. For instance, our interviewers ‘were not blinded for participants dis- placement status; hence, itis possible that information bias may have been in troduced into the assessment, How- ‘Table 4, Bivarate and Mutivarate Analyas of Depression Symptoms Aiong Chidren-—Southern Thaland, 2005 Depression, Bivariate OF P ‘Maleate OF F No. (2) (oss on Value (8536 0h. value ear area Verve plement camps 8(108) 147061351) 9 ‘ected wage Des: 2% Nae Thafected ogee 3a ia J Demographics arr iae 116 io 9 1.00 65 ot 2 a3 iia ea Zane PRERE) ae Toys 1200) 144068309 7 gy TED) md Fagan Baie 28.2 © 7 9 er 3e0 camareay | Tan eated vaunate oparencasT ‘Sau tsunan waves Vee i) 2.1 1.06-654) os Nae ie 3a im J Saavanyone dear eT Ye 2119 2. 118-60 we Nae ie 7 im — J Fmaareare ‘es sect.) 198/095-4159 gy te md Faaemed easton Yes er o7ei0s1-200 7 gg Ne EN a J Fat ena’ om ora Tam member se \havebecn mn danger ‘es 653 (1.05-2.88) om sta.099 os ie ia J “a Fat rate ooops je 21124 2601125680 o Nae Ne Teo ia J Fe exer pico Toa Yes 26 104 2731102-72 7 gg Nae te EcH mJ oat weary mambo Pane ‘es 24,106) 224098659 7 gg te 7ieah mJ ‘eg amy manera and ned Yes 22124 2eriaesy 7 2.14 094-480) ts Tas mm) mJ 2 oath orimparart bananas? ‘Yes (106) 2149-409 7 gy te 36. im J Sasaned ray Ye 4 J 2 (©2006 American Medical Association. All rights reserved Repited) JAMA, August 2, 2000—Vol 296, No.9. SSP iHjamanetwork.com/ by a Monash University Library User on 02/20/2020PTSD AND DEPRESSION AMONG CHILDREN IN TSUNAMI ‘ever, interviewers had no knowledge of ‘our analysis plan to compare children in camps, alfected villages, and unaf- fected villages. Another limitation was that nota children may have been able to understand of verbalize their fee ings regarding tsunami-related experi- ences; thus, some manifestations of PTSD and depression may be underr ported. Also, our instruments were di veloped and validated in the Western world; therefore, cultural factors may play & role in the underreporting or ‘overreporting of these conditions, Inad- dition, the instruments have been used toscteen forsymploms of PTSD and. pression but do not provide elinician- verified diagnoses. Moreover, some ofthe symptoms of PTSD and depression found among children in camps may have been as- sociated with the camp experience it- self and not with tstnami-specific trauma alone. However, our data sug- gest that such an effect would be small, since displacement status was not sig” nificantly associated with symptoms of PTSD and depression in multivariate analysis, Another concern was the limited number of children aged 7 to 14 years in our sampling areas. As a result, we hhad to obtaina supplemental sample of children present in village schoolsatthe lime of our assessment. The limited number of children also negatively affected our ability to perform sul ‘group analysis (because of small cell sizes), which in turn resulted in wide Cis for many of our results. With regards o generalizability ofour results, some children may have been taken into custody by family members or caretak- cers living outside the sampling areas because they were more severely affected. In addition, we did not re cord specific information on physical injuries or on whether some of these children were orphaned or had lost sib- lings as a result of the tsunami. On the other hand, participating children may also have had aecess to mental health services made available after the tsu- nami orto other conditions more favor- able for a rapid and better recovery. S558 JAMA, Agus 2, 2006 Vol 296, No. 5 Repited) Alter the tsunami, the Department of Mental Health of the Royal Thai Gov cenment immediately responded to the needs of affected children by deploy- ing 6 mobile mental health teams of That mental health professionals to tst- nami-allected provinces. Each team consisted of up to 10 professionals—a psychiatrist, 103 psychologist, 2psy- elhatric nurses, asocial worker, aphar- racist an assistant nurse, anda diver To address long-term needs, & Mental Health Center was established in Phang Nga with a S-member team including psychiatrist a psychologist, a psychi alric nurse, social worker, anda coun sclor* The Mental Health Center pro- vides psychological services for PTSD, depression, and other conditions re- lated othe tsunami also provides ofl site mental health services and pro- Vides assistance to traumatized children Findings in our assessment may pro- vide a better understanding of posts nami mental health problemsand asso- ciated risk factors among children. Therapeutic approaches maybe needed tw help children understand and man- age ther felings of fear, s0 that pos- siblenegativeimpactson their develop- smentare minimized. Family counseling say be necessary to make sure tha par- ents are able to recognize and address mental health problems, and schools may be another important venue for alfected children tobe identified and pro- vided withservies to reduce PTSD and depression." Teachers, in particular, ray play a erucial role in the support and referral of affected children; hence, appropriate sensitivity training for mes tal health-related problems is recom rended for school-based sal. Parallel. our work in children, we assessed mental health problems mong adults inthe same geographic areas." The prevalence rates of PTSD symp- toms assessed in adults and children from Phang Nga were similar" Symnp- toms of depression, however, were al- most 3 times higher among adults than among children. Ii important to note that while the assessment took place in similar settings and during the same lime frame, the instruments to assess PTSD and depression in children and adults were not the same. Overall, the prevalence of depression symptoms in children was lower than in adults, but the risk increased significantly with age. This finding suggests that older chi dren may have been better able to eval- ateand understand the possible nega- live consequences ofthe tsunami, such as the loss of loved ones, friends, and possessions, Among adults, the main Fisk factors for symptoms of PTSD and depression were the loss of livelihood asaresult ofthe tsunami. Thus, the fo- cus of intervention approaches for adults and children may need to bed ferent. Children may benefit from thers peutic interventions, while for adults, contextual interventions aimed at the restoration of livelihood may be more appropriate Finally, regular follow-up of tsunami affected children is recommended, since negative mental health consequences of the isunami may emerge later in ife and may otherwise go unnoticed.”**"*" Depending on the outcomes of these as- sessments, iL may be critical that met tal health services forsuch children and others remain available for many y ‘Author Contrbutions Dr van Geneve ad fll a eet alot the dian the td and fake respon Say forthe ntegry of te dat and the scary ofthe data anayse Study concapt and design: Think, Lopes Car ‘ozo Sever van Gaesven ‘eauabon of dts There, Lopes Caco Chal bana, Penguny, Tantpvatanasul,Saxmsatan, ssa, Fanyayong Vara, Taper, ‘alysis and inepretation of dat: Thienkrua, Coadamu, scree. van Grensven. Dating of the manaseipe Tinka, Cuadamun, Scwveber van Grensven cal resin ofthe maruscrit or inprtant inte Fecal cntnt Lopes Cardozo, Chalaaband Per Ir, Tantpnstarsid Sates uss, a Yajng, Vaal, TapoeroSctveber van Ges, Setsatanasi Thru, Screber van Gresven. Obtained funding: Lopes Cardozo, Teppero, ‘an Goensven, ‘aminisrative, technical, or material support: ‘Tena, Vtengrat, Scheer, van Genser Study superosion:vanGnensten. Financ Disclosures: Nove repartee PostTsunam Mental Health Study Group: Dept ‘ant of Meath Thang Minty of Pubic Heath (atuaratPtsonket, Pung Kasay That land Minty of Public HeaitUS Cefers fr Di ease Cotl an Prevention Calaboraton Tavee ‘Sp Sriprpsn MD, Khan Lmpsuamanarst MD MPH, Pp Mock, MxppSiat Wantcaya Ki- fheaiak, Mes MPA, Samar Karueht May Supa (©2006 American Medical Association, All rights reserved.por Jeeyapunt MSc, Pithay Diprayoon, Wiehuda ‘eakso Rung-Arin Chantawatwone Natengt $ippanont, Andres Li MS) US Centers for Disease Central ard Prevention (Cao Golway, PRD, Mam ‘Sr aD) Finding Suppor Tis assesment was spported by {het Confer tor eee Conte and rewenton and {he Thaland Muay of Publ Heath, Role ofthe Sponsor: Boh the Us Centers fr Dis fas Corral and Prevention andthe Thala Min ley of Pubic Heath sessed nthe cen and con uct he sey asessmerclecon, management ‘als, ndinterpretaon ofthe data and prepara {ion review and aperval of he manus Disclamer: The fnngs and eanclsions in this a fice are thow ofthe autre and donot necersaiy "epost the ewsof he US Cees for Disease Co {roland Preventon, Belnonedgment We thankthe penne of he De Dartment of Metal Hest try of Pub Heath, Fenthabur ofthe Menta Heat Horptal of Song Fond Sua hae of he Poul ard Dist Pub Te Heath Orfes of Phang Nga, Kral and Phuket tnd ofthe Talend inst ofublc Healh-US Cen fer for Oveace Contol and Peventon Colaba Aon fr ther em conducting the study RNS 4. United Nations Chirens Fund (UNICEF. Ta ami press foom. Rts: awe unce og/medla nese 24628 Hn Acesed lune 19, 2006 2 Unted Stats Agency or tenant Development inan Orar—eathquskesanaturaris Ripa Usa. govour-wark/umantaran assistance ‘east sctance! courtesan ocean 2005 ‘sanocen et 8 05.06 2005p Aecesed une 49,2006 3. WHOSEA. Emergency preparedness andre Sons: South-Est Al cathouae ard nar Tha land sunami suaton report hip://v3. hoses org Venfseen3/Secon 1/Seten 835 /Sechoni ‘Secon S610 htm. Acesed lupe 19,2006 {4 Goenian Ak, Mal L, teberg AM. et al Pest tTaumatests and depressive reactors among Nez raguan adolescents after Huricane Mitch AJ yen. 2007188 78.794. 5 faralayal Agaogu,Coskun, tal. The symp. {oms of PISD, depresion and aneaty in adolescent Sliders tree and a hal years after the Marmara (©2006 American Medical Association, All rights reserved. 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Peycatry, 200081503 51 1 Rouse A Conan AK Stenberg AV, Pos ‘Downloaded From: https:/fjamanetwork.com/ by a Monash University Library User on 02/20/2020 traumatic tes and depressive reactions among thlden and sdsesents afte the 1999 earthquake Inano ios, Greece. Am J5ycaby 2005 162330 oy 4B, Benuchesne MA, Keley BR Ptsdauper CA. tl ‘tack on Armen ehlre’s veactons and pret Fesporses J Peca Heath Cae 2002-16213-221 20" Uamio Mi shioyama A Kee etal Themen {tne of school hlren afer the Great Han ‘Anaj earthquake, epderilogal study and aka for for mental dese Sahn Shinktga 2st 2ooorto439-400, 21. Veenema To, chroeder-Bruce K. The ater ‘natn of violence: charen, aster, and postrau Irabestess order J Poca ely Care 2002.16 Bo-24s 22° Lubi RRovneD, Derancsc Let a Impact of SToumacn cen Pyechat Pact 3005912818, 23. Green lore crace MG tal Chien sd sas age, gener, and paren effets on PTSD Smplome m cad Cni dl Paychaty. 191 Ssee51 24. McDermott BM, Palmer . 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Pynaos RS, Coenan A Tashan Me Pos ‘rumaesreseacone cen after 1988 A rmeianeuthquke 8 Pychiaty 195; 163:239-247, (Reprinted) JAMA, Aug 2, 2006 296, No.5 $89