Abstract
Introduction
The current study aimed to investigate the psychological impact of the Turkey 2023 earthquakes on children with autism spectrum disorder (ASD) and their parents residing in Hatay, Sanlıurfa, and Ankara provinces, encompassing the periods both before and after the Turkey 2023 earthquakes.
Method
This cross-sectional, multicenter study included 103 children and adolescents with ASD aged between 6 and 18. Participants were evaluated based on their residence in Ankara, Hatay, and Sanlıurfa, three cities affected differently by the earthquake. Parent-report questionnaires were utilized to assess the children’s autism symptoms and behavioural problems. The Childhood Autism Rating Scale was used to determine autism severity. The psychiatric problems of mothers were also assessed with self-report scales.
Results
Significantly increased levels of core autism symptoms, irritability, and hyperactivity were found in Hatay and Sanlıurfa participants after the earthquakes compared to before, while no differences were detected in children from the Ankara group. Scale score increases in the Hatay group, which had to take a more extended break from special education, were higher than in the Sanlıurfa group. Participants with late-diagnosed ASD exhibited a more significant increase in their scale scores after the earthquake. Depression, stress and hopelessness scores were the highest, and the life satisfaction levels were the lowest in mothers of the Hatay and Sanlıurfa groups. More pronounced increases were observed in aberrant behaviours among children of mothers with low educational levels following the earthquake.
Discussion
Our findings demonstrate that the exacerbation of core ASD symptoms and behavioural deterioration after the earthquakes are associated with disruptions in specialized education services, exposure to earthquake-related trauma, and the educational level of mothers.
Keywords: autism spectrum disorder, children, earthquake, trauma
Introduction
A disaster is a sudden event that causes loss of life and property, disrupts the normal flow of life, and cannot be controlled by people once it has started (Espejo 2014). An earthquake is an example of a naturally occurring event that falls under the definition above. On February 6, 2023, two consecutive earthquakes measuring 7.7 and 7.6 in magnitude struck the Turkish province of Kahramanmaras, significantly impacting 11 adjoining regions with an estimated population of around 14 million. Millions of people are estimated to have become homeless as more than half a million buildings were damaged due to the earthquakes (Republic of Turkey Presidency and Strategy and Budget Presidency 2023). It is widely recognized that natural disasters disproportionately impact different segments of society, with children and individuals with disabilities being considered the most vulnerable due to their dependence on caregivers (Blanc and van Balkom 2019). For instance, evidence shows that the Haiti earthquake in 2010 could have devastated children’s mental health and psychological development (Blanc and van Balkom 2019).
When the literature was examined, it was determined that a wide variety of studies investigated the effects of natural disasters on children and adolescents. The most comprehensive studies conducted after disasters for these age groups seem to mainly focus on psychological reactions such as post-traumatic stress disorder (PTSD), depression, and anxiety. In addition to the child’s personal and developmental characteristics such as age, gender, educational status, medical history, and previous disaster experience, the degree of damage caused by natural disasters, the loss of family members, friends, and loved ones after disasters, the social support mechanisms provided to victims after natural disasters are among the factors that determine the effects of disasters on children and adolescents (Karabulut and Bekler 2019).
People with autism and their families are a group at high risk for adverse psychological effects after a major natural disaster such as an earthquake (Valenti et al. 2016). The adaptive behaviours of individuals with autism were shown to be significantly reduced in all dimensions examined (communication, daily life, socialization, and motor skills) in the first months after an earthquake (Valenti et al. 2016). Most research investigating the impact of natural disasters tends to focus primarily, if not exclusively, on the immediate aftermath of these events. As a result, the long-term effects of such disasters are often neglected (Blanc et al. 2020). Our study aimed to investigate the extent to which the symptoms of autism in children and adolescents with autism spectrum disorder (ASD) were affected six months after the devastating earthquakes in Turkey, according to the level of earthquakes’ impact on different regions. For this purpose, children and adolescents with ASD from three different cities in Turkey were evaluated. One of the cities where the patients were recruited was Hatay province, where 90 per cent of the destruction was caused by earthquakes, and shelter was provided in containers even while the study was being carried out. In Sanlıurfa, another province where the participants were evaluated, although the earthquake’s impact was intense, the shelter was generally provided in houses when the study was carried out. The last province where patients were evaluated was Ankara; the seismic activity registered within the province was relatively mild, with no resulting destruction. Our research hypotheses are as follows: 1) There is a significant difference in the increase of autism symptom severity and maladaptive behaviours after the earthquake in children and adolescents with ASD living in Hatay, Ankara and Sanlıurfa provinces. 2) There is a significant correlation between autism symptom severity and maladaptive behaviours and parents’ depression, anxiety, stress and hopelessness and life satisfaction levels.
Method
Our study is a comparative, cross-sectional, multicenter study. The study data was collected from children and adolescents diagnosed with ASD who applied to child psychiatry outpatient clinics in the Hatay, Sanlıurfa, and Ankara provinces between 20.07.2023 and 20.08.2023. The data was collected after obtaining Ethics Committee permission from the Niğde Ömer Halisdemir University Ethics Committee (05/07/2023, Decision no: 2023/09-11) and relevant institutional permissions from all three provinces. These three provinces were preferred due to their different levels of being affected by the earthquake. In Hatay province, 90% of the houses were destroyed or heavily damaged. The people remaining in the Hatay city were sheltered in containers. However, in Sanlıurfa province, there were collapsed buildings, the earthquake’s impact was not at a level that would prevent life from continuing for a long time, and people mostly continued to live in their homes. The impact was minimal in Ankara, and no significant destruction was observed there (Republic of Turkey Presidency and Strategy and Budget Presidency 2023). The children residing in Hatay province were compelled to suspend their special education temporarily until the time of the study. In contrast, the children living in Sanlıurfa had to be absent from their special education for a few initial months following the earthquakes. In contrast, the children in Ankara continuously received special education without any interruptions.
Participants
After the 2023 Kahramanmaras earthquakes, 103 children with ASD living in Hatay, Sanlıurfa, and Ankara were included in the study. Criteria for inclusion in the study were being diagnosed with ASD and having at least one parent reading and understanding Turkish. Exclusion criteria were having a cerebral palsy diagnosis and a severe physical disability. Upon obtaining written consent from the parents, sociodemographic and scale forms were administered. Parents were asked to complete the Aberrant Behavior Checklist and Autism Behavior Checklist scales twice, considering the symptoms before and after the earthquake.
Data collection tools
The Depression, Anxiety and Stress Scale-21 (DASS-21)
DASS-21 contains seven questions each to measure depression, stress, and anxiety dimensions. The scale is a 4-point Likert Type Scale, and 0 is ‘Did not apply to me at all’, 1 is ‘Applied to me to some degree, or some of the time’, 2 is ‘Applied to me to a considerable degree or a good part of the time’, and three is ‘Applied to me very much or most of the time’. The Depression, Anxiety, and Stress Scale, consisting of 42 items, was created by Lovibond in 1995. Subsequently, a 21-item short form of the scale was created (Brown et al. 1997). There are seven questions each to measure depression, anxiety, and stress dimensions. A minimum of 0 and a maximum of 21 points can be obtained in each dimension. Increasing scores on the scale indicate increasing symptoms. The scale’s Turkish validity and reliability study was conducted (Yılmaz et al. 2017). The Turkish version of DASS-21 had Cronbach’s alphas ranging from 0.87 to 0.90 and intra-correlations ranging from 0.82 to 0.93.
Childhood Autism Rating Scale (CARS)
It is a scale based on observation of the child’s behaviour and the history taken, in which the presence and severity of autism diagnosis are evaluated by giving points between 1 and 4 for each of the 15 items. Those who score between fifteen and 29 constitute the group with no autism symptoms, and those who score between 30 and 38 constitute the group with mild-moderate autism symptoms. Those who score between 38 and 60 constitute the group with severe autism symptoms. An adaptation study of the CARS to Turkish was initially conducted by (Sucuoglu et al.1996), followed by another study conducted by Gassaloğlu, Baykara et al. which expanded the validity and reliability analysis and reported the cut-off score for autism diagnosis as 29.5 (Incekas Gassaloglu et al. 2016). The Cronbach’s alpha value of the total scale score was determined to be 0.95. Test-retest reliability (r = 0.98, p < 0.01) and inter-rater reliability (r = 0.98, p < 0.01) were also determined for the total score of the scale.
Autism Behavior Checklist (ABC)
It is primarily used to determine the frequency and severity of autism symptoms. The instrument consists of a list of 57 questions divided into five categories: sensory (9), relating (12), body and object use (12), language (13), and social and self-help (11). The lowest score that can be obtained from the scale is 0, and the highest score is 159. The caregiver completes the scale or a teacher within a timeframe of approximately 15 min (Krug et al. 1980). It was adapted into Turkish and found to be a valid and reliable tool for Turkish society (Irmak et al. 2007). The Turkish adaptation study of the ABC was conducted in children and adolescents with ASD, intellectual disability, and without any psychiatric disorders. Cronbach’s alpha value was detected as 0.92, and inter-rater reliability was 0.86.
Aberrant Behavior Checklist (AbBC)
It is a scale to determine the behaviour problems in children with ASD. The scale consists of 5 subscales as ‘Hyperactivity’, ‘Lethargy/Social Withdrawal’, ‘Stereotype Behaviors’, ‘Self-injury’ and ‘Other Behaviors’ and is completed by parents. Evaluation is made according to the scores of the subscales. The validity and reliability study of the Turkish version was carried out by (Sucuoglu 2003) among Turkish children and adolescents. Cronbach’s alpha value ranged between 0.89 and 96 for subscales and 0.96 for the total score.
The Satisfaction with Life Scale (SWLS)
The scale, which reflects the individual’s subjective life evaluation, measures perceived general life satisfaction (Diener et al. 1985). Increasing scale scores indicate an increase in the perceived general life satisfaction. In the scale scoring, ‘I Strongly Disagree’ is evaluated as 1 point; ‘I slightly agree’ 2 points; ‘I Moderately Agree’ 3 points; ‘I largely agree’ 4 points; and ‘I Totally Agree’ is evaluated as 5 points. The Turkish validity and reliability study of the scale was conducted, and it was determined that the scale is a valid and reliable tool for Turkish society (Daglı and Baysal 2016). The Cronbach Alpha coefficient for internal consistency was detected as 0.88, and test-retest reliability as 0.97.
The Beck Hopelessness Scale (BHS)
The scale aims to determine the individual’s level of pessimism about the future (Beck et al. 1974). Turkish validity and reliability study was conducted (Seber et al. 1993). The hopelessness scale consists of 20 items that can be answered as ‘Yes’ or ‘No’. The scores that can be obtained from the scale vary between 0 and 20. The items on the scale consist of 11 positive and nine negative statements. ‘Yes’ answers to positive items and ‘No’ answers to negative items are coded as 1 point, and answers in the opposite direction are given 0 points. As the scores obtained from the scale increase, the hopelessness levels of the individual also increase. Cronbach’s alpha value was determined as 0.86, and the correlation coefficient for point invariance was reported as r = 0.73.
Statistical analyzes
In the analysis, loss of a parent, injury of a parent, loss of a sibling, injury of a sibling, loss of an acquaintance, injury of an acquaintance, being buried under the rubble after the earthquake, being injured, sustaining permanent physical damage after the earthquake, receiving outpatient or inpatient treatment after the earthquake, seeing people being trapped under the rubble were defined together as ‘earthquake trauma’. If the parents were married, it was coded as ‘family unity present’; if they were not, it was coded as ‘family unity absent’. ABC and AbBC scale score differences were created by subtracting the pre-earthquake score from the post-earthquake score. An increase in the participants’ scores in at least one of the AbBC subscales was defined as an ‘AbBC score increase.’
In statistical analysis, the compatibility of continuous variables with normal distribution was evaluated with the Shapiro-Wilk test and Kolmogorov-Smirnov test. The continuous variables were shown as mean ± standard deviation. Categorical data were shown as frequency (n) and percentage (%). Wilcoxon Signed Ranks Test was used to compare scale scores before and after the earthquake. Mann Whitney U and Kruskal Wallis tests were used to compare the ABC and AbBC subscale score differences between groups. The Chi-square test was used to compare the groups. Spearman correlation test was used to compare two continuous variables. Correlation coefficient: 0–0.29 was accepted as a weak correlation, 0.30–0.64 as a medium correlation, 0.65–0.84 as a strong correlation, and 0.85–1 as a very strong correlation. The statistical significance level was accepted as p < 0.05.
In our study, post-hoc power analysis was performed using the G-power application. Considering the approximate effect size calculated using the mean and standard deviation values of AbBC score increase in the groups as 0.3, alpha error as 0.05 and sample size as 103, the power of the study was calculated as 91%.
Results
A total of 103 children, 35 (34%) from Hatay, 33 (32%) from Sanlıurfa, and 35 (34%) from Ankara, who were previously diagnosed with ASD, were included in our study. 81.6% (84) of all participants were male, and the average age was 10.10 ± 3.78 (min: 4, max: 18). The three provinces showed a similar distribution regarding age and gender variables (p > 0.05). The education levels of the mothers (p < 0.001) and fathers (p = 0.001) of the participants in Ankara were higher than in Hatay and Sanlıurfa provinces. Additionally, children in Ankara were diagnosed with ASD at an earlier age (p = 0.010). While all the children in Ankara and Sanlıurfa were residing at homes, all Hatay children stayed in containers (p < 0.001). The sociodemographic characteristics of the participants by province are presented in detail in Table 1.
Table 1.
Participants’ sociodemographic characteristics by province.
| Hatay | Sanlıurfa | Ankara | p value* | ||
|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | |||
| Sex | Male | 31 (88.6) | 26 (78.8) | 27 (77.1) | 0.413 |
| Female | 4 (11.4) | 7 (21.2) | 8 (22.9) | ||
| Age | 9.64 ± 3.71 | 10.10 ± 3.87 | 10.57 ± 3.82 | 0.529 | |
| Maternal education level | Illiterate | 1 (2.9) | 4 (12.1) | 0 (0.0) | <0.001 |
| Primary school | 13 (37.1) | 10 (30.3) | 6 (17.1) | ||
| Secondary school | 17 (48.6) | 17 (51.5) | 5 (14.3) | ||
| High school | 2 (5.7) | 1 (3.0) | 12 (34.3) | ||
| Junior college | 1 (2.9) | 1 (3.0) | 5 (14.3) | ||
| University and higher education | 1 (2.9) | 0 (0.0) | 7 (20.0) | ||
| Paternal education level | Illiterate | 0 (0.0) | 3 (9.1) | 0 (0.0) | 0.001 |
| Primary school | 12 (34.3) | 5 (15.2) | 3 (8.6) | ||
| Secondary school | 10 (28.6) | 13 (39.4) | 4 (11.4) | ||
| High school | 7 (20.0) | 7 (21.2) | 11 (31.4) | ||
| Junior college | 3 (8.6) | 3 (9.1) | 7 (20.0) | ||
| University and higher education | 3 (8.6) | 2 (6.1) | 10 (28.6) | ||
| Parents’ relationship status | Married | 27 (77.1) | 28 (84.8) | 31 (88.6) | 0.490 |
| Divorced | 4 (11.4) | 3 (9.1) | 3 (8.6) | ||
| Father deceased | 4 (11.4) | 1 (3.0) | 1 (2.9) | ||
| Mother deceased | 0 (0.0) | 1 (3.0) | 0 (0.0) | ||
| Shelter conditions | Container | 35 (100.0) | 0 (0.0) | 0 (0.0) | <0.001 |
| Tent | 0 (0.0) | 0 (0.0) | 0 (0.0) | ||
| House | 0 (0.0) | 33 (100.0) | 35 (100.0) | ||
| Presence of neurological disease | Present | 2 (5.7) | 10 (30.3) | 11 (31.4) | 0.015 |
| Absent | 33 (94.3) | 23 (69.7) | 24 (68.6) | ||
| Age at the time of ASD diagnosis | 3.7 ± 1.5 | 3.6 ± 1.0 | 3.0 ± 1.3 | 0.010 | |
Chi-square test, ASD: Autism Spectrum Disorder.
Bold values denote statistical significance at the p < 0.05 level.
When the participants’ earthquake-related traumas and changes in their routines by province were examined, it was determined that the frequency of experiencing traumatic events was highest in Hatay (62.9%). In contrast, children in Ankara did not experience any situation posing a trauma risk during and after the earthquakes (p < 0.001). Following the occurrence of earthquakes, it was detected that all participants in Sanlıurfa and Hatay provinces suspended special education, whereas in Ankara, all children continued their special education uninterruptedly. The difference in receiving special education services between the two provinces and Ankara was statistically significant (p < 0.001). The distribution of the traumatic events experienced by the participants related to the earthquakes by province is presented in Table 2.
Table 2.
Earthquake-related trauma situations and changes in routines of participants by province.
| Hatay | Sanlıurfa | Ankara | p value** | |
|---|---|---|---|---|
| n (%)* | n (%)* | n (%)* | ||
| Loss of a parent | 1 (2.9) | 1 (3.0) | 0 (0.0) | 0.591 |
| Injury of a parent | 6 (17.1) | 5 (15.2) | 0 (0.0) | 0.041 |
| Loss of a sibling | 0 (0.0) | 2 (6.1) | 0 (0.0) | 0.115 |
| Injury of a sibling | 1 (2.9) | 5 (15.2) | 0 (0.0) | 0.019 |
| Loss of a friend | 19 (54.3) | 3 (9.1) | 0 (0.0) | <0.001 |
| Injury of a friend | 10 (28.6) | 4 (12.1) | 0 (0.0) | 0.002 |
| Being trapped under rubble | 0 (0.0) | 6 (18.2) | 0 (0.0) | 0.001 |
| Being injured | 1 (2.9) | 5 (15.2) | 0 (0.0) | 0.019 |
| Permanent bodily damage | 0 (0.0) | 0 (0.0) | 0 (0.0) | - |
| Receiving outpatient treatment | 0 (0.0) | 5 (15.2) | 0 (0.0) | 0.004 |
| Receiving inpatient treatment | 0 (0.0) | 0 (0.0) | 0 (0.0) | - |
| Seeing people pulled out from the rubble | 6 (17.1) | 9 (27.3) | 0 (0.0) | 0.005 |
| Having experienced any trauma related to earthquakes | 22 (62.9) | 13 (39.4) | 0 (0.0) | <0.001 |
| Suspension of special education | 35 (100.0) | 33 (100.0) | 0 (0.0) | <0.001 |
For Yes/No questions, only positive answers are shown.
Chi-square test.
Bold values denote statistical significance at the p < 0.05 level.
CARS score was found to be highest in Sanlıurfa (p < 0.001) (mean ± sd →Ankara: 38.51 ± 6.37, Sanlıurfa: 42.09 ± 4.29, Hatay: 34.86 ± 7.78). It was detected that the DASS depression (p < 0.001) and DASS stress (p < 0.001) scores of the parent scales were highest in the participants in Hatay province. There was no statistically significant difference between the three provinces in terms of DASS anxiety scores (p = 106). It has been shown that in Sanlıurfa, the BHS-total (p < 0.001) score is higher than in the other two provinces, and the SWLS-total score (p < 0.001) is lower.
No difference was observed in Ankara when evaluating the changes in AbBC and ABC subscale scores of participants before and after the earthquake by province (p > 0.05). All AbBC subscales and ABC sensory, relating, body and object use, and total scores increased in Hatay and Sanlıurfa provinces after the earthquake. Changes in scale scores according to provinces are presented in detail in Table 3.
Table 3.
Change in participants’ AbBC and ABC subscale scores after the earthquakes according to province.
| Hatay |
Sanlıurfa |
Ankara |
|||||||
|---|---|---|---|---|---|---|---|---|---|
| Before Earthquake | After Earthquake | p value* | Before Earthquake | After Earthquake | p value* | Before Earthquake | After Earthquake | p value* | |
| mean ± sd | mean ± sd | mean ± sd | mean ± sd | mean ± sd | mean ± sd | ||||
| AbBC-hyperactivity | 12.83 ± 7.23 | 18.51 ± 10.33 | <0.001 | 13.97 ± 6.98 | 15.55 ± 7.19 | 0.002 | 21.26 ± 10.48 | 21.26 ± 10.48 | 1.000 |
| AbBC-social withdrawal | 16.37 ± 6.68 | 20.57 ± 8.38 | <0.001 | 15.88 ± 4.04 | 18.36 ± 4.87 | <0.001 | 26.97 ± 8.19 | 26.97 ± 8.19 | 1.000 |
| AbBC – stereotype behaviors | 5.71 ± 3.20 | 8.11 ± 4.43 | <0.001 | 2.82 ± 3.06 | 3.27 ± 3.57 | 0.006 | 7.03 ± 4.80 | 7.03 ± 4.80 | 1.000 |
| AbBC – self injury | 1.49 ± 1.92 | 2.60 ± 3.35 | 0.004 | 1.03 ± 1.90 | 1.42 ± 2.11 | 0.016 | 1.86 ± 2.58 | 1.86 ± 2.58 | 1.000 |
| AbBC – other behaviors | 4.54 ± 1.85 | 6.29 ± 2.57 | <0.001 | 3.97 ± 1.67 | 4.76 ± 1.82 | <0.001 | 7.43 ± 2.02 | 7.43 ± 2.02 | 1.000 |
| ABC – sensory | 7.14 ± 5.08 | 7.91 ± 5.45 | 0.017 | 8.52 ± 6.01 | 9.18 ± 6.14 | 0.039 | 13.40 ± 6.10 | 13.40 ± 6.10 | 1.000 |
| ABC – relating | 14.29 ± 8.38 | 15.11 ± 7.89 | 0.041 | 17.76 ± 7.74 | 18.39 ± 7.18 | 0.039 | 21.46 ± 6.93 | 21.46 ± 6.93 | 1.000 |
| ABC – body and object use | 15.57 ± 7.90 | 17.09 ± 8.43 | 0.010 | 11.67 ± 13.15 | 13.24 ± 13.76 | 0.002 | 15.14 ± 9.41 | 15.14 ± 9.41 | 1.000 |
| ABC – language | 11.66 ± 5.84 | 12.37 ± 6.03 | 0.066 | 10.48 ± 4.82 | 10.64 ± 4.77 | 0.180 | 15.66 ± 4.14 | 15.66 ± 4.14 | 1.000 |
| ABC – social and self help | 13.20 ± 5.09 | 15.00 ± 5.04 | 0.003 | 11.76 ± 4.23 | 12.55 ± 4.27 | 0.062 | 14.57 ± 4.01 | 14.60 ± 3.98 | 0.317 |
| ABC – total | 61.86 ± 23.96 | 67.60 ± 23.04 | <0.001 | 57.88 ± 26.70 | 61.27 ± 26.79 | 0.002 | 80.23 ± 21.16 | 80.23 ± 21.16 | 1.000 |
Wilcoxon Signed Ranks Test.
Bold values denote statistical significance at the p < 0.05 level.
The difference in children’s AbBC-hyperactivity scores had a positive moderate correlation with DASS-depression (r = 0.371, p < 0.001) and DASS-stress scores (r = 0.350, p < 0.001) and a negative moderate correlation with SWLS-total score (r = −0.355, p < 0.001). AbBC-social withdrawal score difference had a positive and moderate correlation with the DASS-depression (r = 0.330, p = 0.001), DASS-stress (r = 0.349, p < 0.001), and BHS-total (r = 0.331, p = 0.001) scores. Additionally, the AbBC-other behaviours score difference was found to be moderately and positively correlated with the DASS-stress (r = 0.339, p < 0.001) and BHS-total (r = 0.332, p = 0.001) scores (Table 4). ABC-total score difference and SWLS-total score had a moderate and negative correlation (r= −0.304, p = 0.002). The Correlation Between the Difference in Participants’ AbBC Subscale Scores and ABC Subscale Scores, and DASS, BHS, and SWLS Scores is detailed in Table 4.
Table 4.
Correlation between the difference in participants’ pre-earthquake and post-earthquake AbBC and ABC subscale scores and DASS, BHS and SWLS scores.
| Score difference before and after the earthquake (n = 103) | DASS Depression |
DASS Anxiety |
DASS Stress |
BHS | SWLS | |
|---|---|---|---|---|---|---|
| AbBC-hyperactivity | r* | 0.371 | 0.158 | 0.350 | 0.276 | −0.355 |
| p * | 0.000 | 0.110 | 0.000 | 0.005 | 0.000 | |
| AbBC-social withdrawal | r* | 0.330 | 0.206 | 0.349 | 0.331 | −0.266 |
| p * | 0.001 | 0.037 | 0.000 | 0.001 | 0.007 | |
| AbBC – stereotype behaviors | r* | 0.242 | 0.140 | 0.242 | 0.132 | −0.185 |
| p * | 0.014 | 0.158 | 0.014 | 0.185 | 0.061 | |
| AbBC – self injury | r* | 0.228 | 0.183 | 0.217 | 0.117 | 0.037 |
| p * | 0.020 | 0.064 | 0.028 | 0.237 | 0.713 | |
| AbBC – other behaviors | r* | 0.287 | 0.269 | 0.339 | 0.332 | −0.295 |
| p * | 0.003 | 0.006 | 0.000 | 0.001 | 0.002 | |
| ABC – sensory | r* | 0.184 | 0.037 | 0.046 | 0.195 | −0.140 |
| p * | 0.063 | 0.712 | 0.647 | 0.048 | 0.159 | |
| ABC – relating | r* | 0.103 | 0.150 | 0.094 | 0.209 | −0.228 |
| p * | 0.300 | 0.131 | 0.344 | 0.034 | 0.021 | |
| ABC – body and object use | r* | 0.121 | 0.145 | 0.156 | 0.199 | −0.279 |
| p * | 0.222 | 0.144 | 0.117 | 0.044 | 0.004 | |
| ABC – language | r* | 0.229 | 0.236 | 0.274 | 0.232 | −0.281 |
| p * | 0.020 | 0.016 | 0.005 | 0.018 | 0.004 | |
| ABC – social and self help | r* | 0.146 | 0.206 | 0.189 | 0.139 | −0.154 |
| p * | 0.142 | 0.037 | 0.056 | 0.160 | 0.121 | |
| ABC – total | r* | 0.226 | 0.230 | 0.243 | 0.275 | −0.304 |
| p * | 0.022 | 0.020 | 0.014 | 0.005 | 0.002 |
Spearman correlation test.
Bold values denote statistical significance at the p < 0.05 level.
All AbBC subscale score differences varied by province. The highest score difference belonged to Hatay province (Table 5). The AbBC subscale score differences did not differ according to gender (p > 0.05). The increase in AbBC subscale scores of children with low maternal education levels was statistically higher than that of children with higher maternal education. The paternal educational level had a similar effect on AbBC subscale scores other than AbBC-stereotype behaviours (Table 6). It was found that the increase in AbBC hyperactivity (p = 0.007), stereotype behaviours (p = 0.017), and other behaviours (p = 0.003) subscale scores was lesser in children with neurological diseases. In addition, there was a more significant increase in the AbBC subscale scores of those living in containers than those residing at homes, those who experienced any traumatic event during the earthquake compared to those who did not, and those who took a break from special education compared to those who did not (Table 5).
Table 5.
Change in participants’ AbBC subscale score differences (post-earthquake-pre-earthquake) according to sociodemographic characteristics.
| AbBC hyperactivity |
AbBC social withdrawal |
AbBC stereotype behaviors |
AbBC Self injury |
AbBC other behaviors |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| mean ± sd | p value * | mean ± sd | p value * | mean ± sd | p value * | mean ± sd | p value * | mean ± sd | p value * | ||
| Province | Hatay | 5.69 ± 5.40 | <0.001** | 4.20 ± 4.17 | <0.001** | 2.40 ± 1.99 | <0.001** | 1.11 ± 2.01 | 0.003** | 1.74 ± 1.69 | <0.001** |
| Sanlıurfa | 1.58 ± 2.80 | 2.48 ± 3.12 | 0.45 ± 1.00 | 0.39 ± 0.83 | 0.79 ± 0.96 | ||||||
| Ankara | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | ||||||
| Sex | Male | 2.86 ± 4.53 | 0.158 | 2.39 ± 3.69 | 0.672 | 1.11 ± 1.78 | 0.121 | 0.56 ± 1.44 | 0.721 | 0.94 ± 1.41 | 0.230 |
| Female | 0.58 ± 1.80 | 1.47 ± 2.01 | 0.32 ± 0.67 | 0.26 ± 0.65 | 0.42 ± 0.77 | ||||||
| Maternal Education Level | Secondary school and below | 3.34 ± 4.74 | <0.001 | 3.00 ± 3.76 | <0.001 | 1.21 ± 1.78 | 0.004 | 0.66 ± 1.43 | 0.027 | 1.16 ± 1.44 | <0.001 |
| High school and above | 0.23 ± 0.82 | 0.33 ± 1.27 | 0.37 ± 1.13 | 0.13 ± 1.01 | 0.07 ± 0.37 | ||||||
| Paternal Education Level | Secondary school and below | 3.34 ± 4.29 | 0.002 | 3.28 ± 4.15 | 0.003 | 1.12 ± 1.78 | 0.190 | 0.90 ± 1.64 | 0.002 | 1.04 ± 1.29 | 0.029 |
| High school and above | 1.58 ± 4.07 | 1.23 ± 2.26 | 0.81 ± 1.53 | 0.13 ± 0.81 | 0.66 ± 1.34 | ||||||
| Family Unity | Present | 2.67 ± 4.46 | 0.176 | 2.40 ± 3.66 | 0.473 | 1.05 ± 1.76 | 0.471 | 0.57 ± 1.40 | 0.495 | 0.97 ± 1.40 | 0.056 |
| Absent | 1.24 ± 2.80 | 1.35 ± 1.97 | 0.53 ± 0.94 | 0.18 ± 0.88 | 0.24 ± 0.56 | ||||||
| Neurological Disease | Present | 0.35 ± 2.39 | 0.007 | 1.22 ± 2.50 | 0.077 | 0.26 ± 0.86 | 0.017 | 0.13 ± 0.46 | 0.191 | 0.26 ± 1.01 | 0.003 |
| Absent | 3.04 ± 4.48 | 2.51 ± 3.64 | 1.16 ± 1.77 | 0.61 ± 1.48 | 1.01 ± 1.36 | ||||||
| Shelter Conditions | Container | 5.69 ± 5.40 | <0.001 | 4.20 ± 4.17 | <0.001 | 2.40 ± 1.99 | <0.001 | 1.11 ± 2.01 | 0.006 | 1.74 ± 1.69 | <0.001 |
| House | 0.76 ± 2.09 | 1.21 ± 2.50 | 0.22 ± 0.73 | 0.19 ± 0.60 | 0.38 ± 0.77 | ||||||
| Earthquake trauma | Absent | 1.56 ± 3.46 | <0.001 | 1.41 ± 3.00 | <0.001 | 0.60 ± 1.31 | 0.002 | 0.21 ± 0.70 | 0.006 | 0.54 ± 1.16 | <0.001 |
| Present | 4.14 ± 5.11 | 3.80 ± 3.76 | 1.66 ± 2.03 | 1.09 ± 1.96 | 1.43 ± 1.44 | ||||||
| Suspension of special education | Present | 3.69 ± 4.78 | <0.001 | 3.37 ± 3.77 | <0.001 | 1.46 ± 1.86 | <0.001 | 0.76 ± 1.58 | 0.001 | 1.28 ± 1.45 | <0.001 |
| Absent | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | ||||||
Mann Whitney U test, **Kruskal Wallis test.
Bold values denote statistical significance at the p < 0.05 level.
Table 6.
Post-hoc analysis of AbBC subscale score differences (post-earthquake-pre-earthquake) according to the provinces where the participants are located.
| Scale Score |
P value* |
|||||
|---|---|---|---|---|---|---|
| Mean | Standard Deviation | Hatay Sanlıurfa | Hatay Ankara | Sanlıurfa Ankara |
||
| AbBC-hyperactivity | Hatay | 5.69 | 5.40 | |||
| Sanlıurfa | 1.58 | 2.80 | 0.001 | <0.001 | <0.001 | |
| Ankara | 0.00 | 0.00 | ||||
| AbBC-social withdrawal | Hatay | 4.20 | 4.17 | |||
| Sanlıurfa | 2.48 | 3.12 | 0.119 | <0.001 | <0.001 | |
| Ankara | 0.00 | 0.00 | ||||
| AbBC – stereotype behaviors | Hatay | 2.40 | 1.99 | |||
| Sanlıurfa | 0.45 | 1.00 | <0.001 | <0.001 | 0.001 | |
| Ankara | 0.00 | 0.00 | ||||
| AbBC – self injury | Hatay | 1.11 | 2.01 | |||
| Sanlıurfa | 0.39 | 0.83 | 0.208 | 0.001 | 0.004 | |
| Ankara | 0.00 | 0.00 | ||||
| AbBC – other behaviors | Hatay | 1.74 | 1.69 | |||
| Sanlıurfa | 0.79 | 0.96 | 0.017 | <0.001 | <0.001 | |
| Ankara | 0.00 | 0.00 | ||||
Mann Whitney U test, Bonferroni correction has been made, p < 0.016 values were considered statistically significant.
In the post-hoc analysis conducted to compare which provinces the AbBC score differences resulted from, it was determined that all subscale score differences diverged between Ankara-Hatay and Ankara-Sanlıurfa provinces. There was a significant difference between the provinces of Hatay and Sanlıurfa only in the AbBC hyperactivity and stereotype behaviour subscale scores. However, no significant differences were detected in the remaining three subscales (Table 6). The analyses showed that the post-earthquake score increase in any subscale of AbBC differed statistically according to provinces (p < 0.001). While this rate was 94.3% in Hatay province, it was found to be 78.8% in Sanlıurfa province. In Ankara, it was determined that there was no increase in AbBC subscale scores after the earthquake compared to before.
Children’s ABC sensory (p = 0.027), body and object use (p = 0.001), social and self-help (p = 0.007), and total (p < 0.001) score differences differed by province. It was detected that children whose mothers had a higher education level had lower ABC relating (p = 0.034), body and object use (p = 0.037), social and self-help (p = 0.018), and total (p = 0.003) score differences. It was also found that the differences in body and object use (p < 0.001), social and self-help (p = 0.030), and total (p < 0.001) scores were higher in children who experienced a traumatic event during the earthquake. It was also detected that pausing special education also increased score differences in the ABC sensory (p = 0.009), relating (p = 0.018), body and object use (p < 0.001), social and self-help (p = 0.002), and total (p < 0.001) subscales (Table 7). The relationship between ABC subscale scores and sociodemographic characteristics is presented in Table 7.
Table 7.
Change in ABC subscale score differences according to the sociodemographic characteristics of the participants (after the Earthquake – Before the earthquake).
| ABC sensory |
ABC relating |
ABC body and object use |
ABC language |
ABC social and self-help |
ABC total |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| mean ± sd | p value | mean ± sd | p value | mean ± sd | p value | mean ± sd | p value | mean ± sd | p value | mean ± sd | p value | ||
| Province | Hatay | 0.77 ± 1.72 | 0.027 | 0.83 ± 2.24 | 0.060 | 1.51 ± 3.93 | 0.001 | 0.71 ± 2.19 | 0.120 | 1.80 ± 3.12 | 0.007 | 5.74 ± 10.55 | <0.001 |
| Sanlıurfa | 0.67 ± 1.69 | 0.64 ± 1.71 | 1.58 ± 2.35 | 0.15 ± 0.71 | 0.79 ± 2.52 | 3.39 ± 7.51 | |||||||
| Ankara | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.03 ± 0.17 | 0.00 ± 0.00 | |||||||
| Sex | Male | 0.50 ± 1.48 | 0.837 | 0.52 ± 1.77 | 0.960 | 1.18 ± 2.96 | 0.134 | 0.36 ± 1.50 | 0.233 | 1.10 ± 2.51 | 0.075 | 3.76 ± 7.79 | 0.050 |
| Female | 0.37 ± 1.12 | 0.32 ± 0.95 | 0.32 ± 1.00 | 0.00±.00 | −0.11 ± 1.59 | −0.16 ± 7.08 | |||||||
| Maternal Education Level | Secondary school and below | 0.49 ± 1.31 | 0.379 | 0.68 ± 1.93 | 0.034 | 1.32 ± 3.14 | 0.037 | 0.41 ± 1.61 | 0.108 | 1.21 ± 2.79 | 0.018 | 4.03 ± 8.98 | 0.003 |
| High school and above | 0.43 ± 1.65 | 0.00 ± 0.00 | 0.30 ± 0.92 | 0.00 ± 0.00 | 0.07 ± 0.25 | 0.63 ± 2.09 | |||||||
| Paternal Education Level | Secondary school and below | 0.52 ± 1.37 | 0.515 | 0.30 ± 0.91 | 0.949 | 0.96 ± 2.45 | 0.200 | 0.10 ± 0.58 | 0.416 | 1.10 ± 2.08 | 0.097 | 3.26 ± 4.59 | 0.025 |
| High school and above | 0.43 ± 1.46 | 0.66 ± 2.12 | 1.08 ± 2.98 | 0.47 ± 1.80 | 0.66 ± 2.68 | 2.83 ± 9.94 | |||||||
| Family Unity | Present | 0.47 ± 1.39 | 0.975 | 0.45 ± 1.58 | 0.742 | 1.02 ± 2.88 | 0.683 | 0.35 ± 1.49 | 0.264 | 0.87 ± 2.50 | 0.880 | 3.03 ± 8.19 | 0.800 |
| Absent | 0.53 ± 1.59 | 0.65 ± 2.03 | 1.00 ± 1.80 | 0.00 ± 0.00 | 0.88 ± 1.96 | 3.06 ± 5.46 | |||||||
| Neurological Disease | Present | 0.30 ± 1.46 | 0.250 | 0.48 ± 1.75 | 0.865 | 0.87 ± 1.66 | 0.917 | 0.00 ± 0.00 | 0.178 | 0.30 ± 2.55 | 0.386 | 0.96 ± 7.59 | 0.458 |
| Absent | 0.52 ± 1.41 | 0.49 ± 1.63 | 1.06 ± 2.97 | 0.38 ± 1.54 | 1.04 ± 2.36 | 3.64 ± 7.77 | |||||||
| Shelter Conditions | Container | 0.77 ± 1.72 | 0.067 | 0.83 ± 2.24 | 0.244 | 1.51 ± 3.93 | 0.079 | 0.71 ± 2.19 | 0.074 | 1.80 ± 3.12 | 0.053 | 5.74 ± 10.55 | 0.037 |
| House | 0.32 ± 1.21 | 0.31 ± 1.22 | 0.76 ± 1.80 | 0.07 ± 0.50 | 0.40 ± 1.79 | 1.65 ± 5.46 | |||||||
| Earthquake trauma | Absent | 0.41 ± 1.21 | 0.935 | 0.35 ± 1.40 | 0.249 | 0.60 ± 2.86 | <0.001 | 0.31 ± 1.48 | 0.966 | 0.57 ± 2.05 | 0.030 | 2.13 ± 8.25 | <0.001 |
| Present | 0.60 ± 1.75 | 0.74 ± 2.05 | 1.83 ± 2.27 | 0.26 ± 1.12 | 1.46 ± 2.93 | 4.80 ± 6.52 | |||||||
| Suspension of special education | Present | 0.72 ± 1.69 | 0.009 | 0.74 ± 1.99 | 0.018 | 1.54 ± 3.23 | <0.001 | 0.44 ± 1.66 | 0.072 | 1.31 ± 2.87 | 0.002 | 4.60 ± 9.21 | <0.001 |
| Absent | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.00 ± 0.00 | 0.03 ± 0.17 | 0.00 ± 0.00 | |||||||
Mann Whitney U test, **Kruskal Wallis test.
Bold values denote statistical significance at the p < 0.05 level.
The correlation between age and age at receiving ASD diagnosis and pre-post earthquake differences in AbBC and ABC scores were examined. No correlation was found between age and AbBC and ABC subscale score differences (p > 0.05). A positive correlation was found between the age at the time of receiving ASD diagnosis and differences in AbBC hyperactivity (r = 0.435, p < 0.001), social withdrawal (r = 0.409, p < 0.001), stereotype behaviours (r = 0.279, p = 0.004), self-injury (r = 0.218, p = 0.027), and other behaviours (r = 0.367, p < 0.001) subscales. Additionally, there was a positive correlation between age at ASD diagnosis and ABC language (r = 0.254, p = 0.010), social and self-help (r = 0.270, p = 0.006), and total (r = 0.279, p = 0.004) score differences. It has been shown that score differences increase as the age at diagnosis increases.
Discussion
The main finding of this study is that the factors associated with post-earthquake clinical deterioration in children with ASD are the interruption of special education and the extent of the trauma experienced. Changes in scale scores were more prominent in the Hatay group, which had longer special education interruptions. In contrast, there were no changes in the scale scores of the Ankara group, which had no special education discontinuities. It was determined that the difference in the scale scores of the Şanlıurfa group, where special education was suspended for one month, was less than the Hatay group and more than the Ankara group. The research findings indicate that children and adolescents with ASD experienced a more significant increase in the severity of autism symptoms, irritability, and hyperactivity in areas heavily impacted by the earthquake, such as Hatay and Sanlıurfa. According to the results, we found a significant increase in all AbBC subscale scores and almost all ABC subscale scores of the Hatay and Sanlıurfa participants after the earthquake compared to before. Compared with the Ankara group, where shaking was felt but there was no destruction due to the earthquake, it was determined that the situations associated with increased scale scores were interruption of special education, experiencing trauma related to the earthquake, and low maternal education.
All 11 provinces affected by the earthquakes centred in Kahramanmaras were not equally impacted. Hatay, Malatya, Adıyaman, and Kahramanmaras provinces were the places where the destruction was most intense; many buildings were destroyed or heavily damaged, and life stopped. Although six months have passed since the earthquake, it cannot be said that life continues in these provinces. In these provinces, where the destruction was intense after the earthquakes, a significant part of the population left the cities, and the routine of daily life in these cities perished (Republic of Turkey Presidency and Strategy and Budget Presidency 2023). Due to the collapse of hospitals, schools, and government buildings, services could not be provided. Field hospitals composed of tents and containers were established to provide prompt medical aid. However, education has stopped completely; no educational activities in schools and special education centres have been able to continue, and they still do not. Even though life was disrupted in the first few months after the earthquake in other provinces (such as Sanlıurfa) that were seriously affected by the earthquake and where there was destruction, although not as intense as the cities mentioned earlier, daily life gradually returned to normal after a while. Although earthquake tremors were felt in some provinces other than the 11 affected ones, life was not disrupted in any way in provinces with no destruction (such as Ankara). Among the disasters our country has encountered throughout history, these earthquakes called the disaster of the century, are the most significant natural disasters ever experienced. However, as we mentioned above, the earthquakes that took place on February 6 did not affect all country provinces at the same level. Therefore, in our current study, evaluating how children and adolescents diagnosed with ASD are affected in three provinces where the extent of earthquake impact is different makes a significant contribution to the literature.
Unsurprisingly, children with ASD, who are particularly sensitive to routines, show maladaptive behaviours after the devastating earthquakes that changed their lives. Among the Hatay and Sanlıurfa groups, whose routines had to change due to the earthquakes, it is expected that the frequency and severity of maladaptive behaviours would be higher in children in Hatay, where the destruction was more significant. Identifying the factors most strongly associated with the frequency and severity of maladaptive behaviours is paramount in devising effective strategies to reduce their occurrence. It is known that behavioural and educational therapies are the cornerstone of effective treatment for Autism Spectrum Disorder (Myers and Johnson 2007, Volkmar et al. 2014). These interventions address communication, social skills, daily living skills, play and leisure skills, academic achievement, and maladaptive behaviours (National Research Council 2001, Myers and Johnson 2007). Disruption of education for any reason will cause these children to be deprived of effective treatment and to regress in the mentioned areas. Our study determined an increase in AbBC and ABC scale scores after the earthquake in Hatay and Sanlıurfa groups, which had to interrupt special education due to the earthquake. However, it was determined that there was no change in the Ankara group, which did not interrupt their special education. It was found that the scale score increases in the Hatay group, which had to take a more extended break from special education, were higher than in the Sanlıurfa group. Recently, it has been shown that there are impairments in the main areas affected by this disorder (behaviour, communication, socialization, and autonomy), as the social restriction implemented during the COVID-19 pandemic period disrupted the daily routines of children and adolescents with ASD and prevented their access to individual special education (Ahmed et al. 2022, Bhat 2021, Mumbardó-Adam et al. 2021). It has been reported that during the pandemic period, there was an increase in repetitive and limited behaviours of children with ASD (Di Renzo et al. 2020) and stereotypic and aggressive behaviours, that children with ASD experienced problems in communication skills (Mutluer et al. 2020), and that the most challenging situation for their families was behavioural problems (Neece et al. 2020). The extent of the negative effect of the time without receiving special education on children diagnosed with ASD was shown by the significantly higher increase in scale scores of the participants in Hatay after the earthquake, who still cannot continue education, compared to the participants in Sanlıurfa who continued special schooling after a brief interruption. All these findings indicate that it is vital to prioritize continuing special education for children with ASD as soon as possible after a significant natural disaster that disrupts life, such as an earthquake.
Research in educational intervention provides evidence that earlier diagnosis and early intensive intervention can improve outcomes (National Research Council 2001, Olley 2005). The positive correlation between the age at diagnosis of autism and the increase in scale scores after the earthquake found in our study is consistent with this information. Children with ASD who are diagnosed late may not get timely access to educational interventions and are at greater risk of exhibiting maladaptive behaviours in response to their challenges.
We compared the Hatay and Şanlıurfa groups with each other to understand better the factors that may be related to the increase in AbBC and ABC scores of children in Hatay and Şanlıurfa, who were negatively affected by the earthquake. The significant difference in the score increase in the AbBC-hyperactivity and AbBC-stereotype behaviours subscales between the Hatay and Sanlıurfa groups continued. The parameters that were statistically different between the two groups were ‘shelter conditions’ and ‘earthquake trauma’. While keeping in mind that the negative impact of the interruption of special education cannot be ignored, the type of shelter (container/house) or earthquake trauma may also have an effect on the fact that the children in the Hatay group show more maladaptive behaviour than the Sanlıurfa group. A previous study revealed that certain PTSD symptoms observed in children and adolescents diagnosed with ASD, such as aggressive outbursts, distractibility, and social isolation, could potentially be misinterpreted as an exacerbation of ASD-related symptoms (Mehtar and Mukaddes 2011). As a result, the fact that there was no change in the AbBC and ABC scale scores of children and adolescents with ASD living in Ankara, which was least affected by the earthquake, and that those in Hatay were most affected in this regard can also be interpreted as the emergence of PTSD symptoms in these children as an increase in autism symptom severity and maladaptive behaviours.
The mother’s education level was another factor associated with maladaptive behaviours after the earthquake. It was found that children of mothers with low education levels had a higher AbBC score increase after the earthquake. Research shows that mothers of children with special needs take on almost all of the child’s daily care needs and responsibilities (Marcenko and Meyers 1991). Since the primary person who cared closely for the child during the post-earthquake process is the mother, our study shows again how important the mother’s education and the quality time she spends with the child are.
The increase in maladaptive behaviours or autism symptom severity after the earthquakes was not associated with gender in all three groups. In the evaluation six months after the earthquake, the group with the highest CARS score was detected as Sanlıurfa, and the group with the lowest CARS score was Hatay. They are considering that the highest increase in scale scores after the earthquake was observed in the participants from Hatay, it can be assumed that autism severity does not have a significant relationship with the impairment experienced due to the earthquake. This finding appears to contradict the results of a previous study suggesting that trauma-related psychiatric problems are more pronounced in individuals with more autism symptoms (Roberts et al. 2015). However, it is plausible to attribute the observed significant increase in scale scores among patients in Hatay to the magnitude of the traumatic experiences they have undergone. The best distinction of this situation can be demonstrated in future studies by comparing groups with different autism symptom severities from the same earthquake-affected region.
In our study, we found a correlation between maternal depression and stress levels and an increase in scores across all AbBC subscales of participants following the earthquake. This finding suggests a link between maternal psychopathology and increased maladaptive behaviours in children and adolescents with ASD. AbBC social withdrawal score increase was positively correlated with the mother’s anxiety and hopelessness level and negatively correlated with the mother’s life satisfaction level. The increase in scores on the ABC-language subscale was positively correlated with the mother’s level of depression, anxiety, stress, and hopelessness and negatively correlated with the mother’s level of life satisfaction. Hereby, our study showed that the caregiver’s psychological state is related to the symptom severity and maladaptive behaviours of their child diagnosed with ASD. The body of literature regarding this topic reveals that the psychological resilience of caregivers for children with ASD may be impacted by factors such as the severity of ASD symptoms, the number of problems caregivers face, and the lack of support received (Toonsiri et al. 2011).
Research is scarce on the psychological impact of earthquakes on children and adolescents diagnosed with ASD. Therefore, this study would provide a valuable addition to the existing literature on this topic. In our multi-centre study, comparing three provinces affected by the earthquake to different extents enabled the evaluation of factors related to the adverse psychological effects of the earthquakes on children and adolescents diagnosed with ASD, which is the strongest aspect of the study. Another strength of our study is that the psychological effects of the earthquakes were evaluated in a group with special needs, such as children and adolescents with ASD. The most vital limitation of the study was the pre-earthquake evaluation of children relying on scale scores filled out by parental recollection, which might potentially cause recall bias. However, based on the answers given by the parents in the Ankara group regarding their child’s behavioural evaluation before and after the earthquake, it can be stated that there is no bias, such as remembering the pre-earthquake positively. Another limitation of the study was that our main independent variables, such as shelter conditions, interruption of special education, and experiencing earthquake trauma, were not distributed homogeneously among the participants. This situation limited our ability to evaluate the effect of independent variables on the AbBC and ABC scale score differences using advanced analytical methods. Another limitation of the study is that parental psychopathology was not assessed prior to the earthquake but only afterwards. Additionally, due to the study’s cross-sectional nature, we couldn’t determine the direction of cause-effect relationships. Our findings can inform disaster preparedness programs to protect the mental health of children and adolescents with ASD following an earthquake.
Conclusion
To our knowledge, this is the first study to assess the psychological impact of an earthquake on children with ASD while considering the extent of the earthquake’s impact on their place of residence. Our findings suggest that factors associated with psychological distress after the earthquake include interruption of special education, experiencing earthquake trauma, and maternal education level, and this study contributes to the limited literature. With this study, we would like to emphasize the vital role special education plays in ASD and the importance of early diagnosis once again. A long break from special education and being diagnosed at a later age were shown to be associated with maladaptive behaviours after the earthquakes and an increase in autism symptom severity as a result of our study. We also emphasize that the form of shelter provided, particularly those in the form of containers, can increase the detrimental impact of the earthquake on the psychological condition of children with ASD. Hence, it is crucial to prioritize relocating these children to their homes at the earliest to mitigate the adverse effects of such disasters.
To understand the subject thoroughly, longitudinal studies with larger samples that include patients from diverse sociodemographic and cultural backgrounds are essential. Additionally, follow-up studies are necessary for a more comprehensive analysis. We genuinely hope that this study, as well as further research built upon our findings, can guide the development of comprehensive strategies and mental health policies to address the mental health needs of children and adolescents with ASD affected by earthquakes and other traumatic events.
Disclosure statement
No potential conflict of interest was reported by the authors.
Data availability statement
The data supporting this study’s findings are available on request from the corresponding author. The data are not publicly available due to the privacy of research participants.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting this study’s findings are available on request from the corresponding author. The data are not publicly available due to the privacy of research participants.