COMMENTARY ON: Adams ZW, Sumner JA, Danielson CK, et al. Prevalence and predictors of PTSD and depression among adolescent victims of the Spring 2011 tornado outbreak. J Child Psychol Psychiatry 2014;55:1047–55.
What is already known on this topic
The epidemiology of disaster mental health has been well documented in adult populations. In comparison, relatively little is known about psychiatric disorders following exposure to disasters among youth. Even less is known specifically about psychopathology among youth exposed to tornadoes. Very few disaster mental health studies of youth have utilised structured diagnostic interviews, and samples of youth have not often been systematically selected or representative of general populations.
Methods of the study
This study aimed to estimate prevalence of post-traumatic stress disorder (PTSD) and major depressive episode (MDE) in youths residing in tornado-affected areas and to identify risk factors for these disorders. Systematic address-based recruitment yielded a sample of 2000 youths from residences within 2–5 miles of tornadoes that occurred in the spring of 2011 in Joplin, Missouri and Alabama. A structured telephone interview, the National Survey of Adolescents (http://www.icpsr.umich.edu/icpsrweb/ICPSR/studies/2833), assessed symptom criteria for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnoses of PTSD and MDE an average of 9 months after the tornadoes.
What does this paper add
The main conclusion of the study was that adolescents were generally resilient after the tornadoes, except for 7% of the adolescents who developed PTSD and 8% who had MDE. These prevalence findings are far lower than in a study of teenage survivors of a shipwreck assessed with structured diagnostic interviews (52% with PTSD and 34% with major depression).1 This discrepancy likely reflects lower proportions with qualifying trauma exposures in the current study.
In the adolescents studied, female (OR 0.48, 95% CI 0.30 to 0.77 and OR 0.35, 95% CI 0.23 to 0.54), prior trauma exposure (2.27, 1.86 to 2.77 and 2.46, 2.04 to 2.96) and having an injured family member (5.63, 1.94 to 16.39 and 5.63, 2.11 to 15.92) predicted both PTSD and MDE, respectively, similarly to established associations with postdisaster psychopathology in existing research in adult disaster-affected populations.
Limitations
The diagnostic assessment instrument used in this study did not link the post-traumatic symptoms to trauma experienced in the tornado.2 Instead, it apparently assessed the presence of psychological symptoms since the disaster or in the past 4 weeks (as opposed to the requirement for the symptoms to begin or worsen after the trauma for a DSM-IV diagnosis of PTSD). Trauma exposures were not differentiated from other stressors in the data presented. Because PTSD is a conditional disorder requiring linkage of the symptoms to a traumatic event, the post-traumatic symptom constellation in this study's sample with a substantial proportion lacking qualifying trauma exposure (only 3% were injured, 9% were displaced from homes, and a fraction were within the path of the tornado in this disaster) cannot be assumed to represent PTSD.
In assessing MDE, individual depressive symptoms were simply classified as present or not during specified periods rather than identified as a substantial (present on most days for most of the day) part of a depressive episode lasting for at least 2 weeks. Therefore, a substantial fraction of the study sample, with symptoms constituting distress but not necessarily qualifying for MDE, may have been inadvertently represented among those presented as having MDE.
Because this study did not fully assess diagnostic criteria of PTSD and MDE as described here above, accurate estimation of prevalence of these disorders is not possible, and comparability with findings with other research studies lacks the vital foundation of uniformity of methods.
What next in research
Future studies of mental health consequences of disasters should utilise measures that fully assess diagnostic criteria for psychiatric disorders and carefully assess exposures to the disaster trauma, such as in studies of survivors of the Oklahoma City bombing3 and the 9/11 attacks4 using the fully structured Diagnostic Interview Schedule and assessing qualifying exposures to traumatic events. Determination of qualifying exposures to trauma, as defined by established diagnostic criteria (in DSM-V, eg, direct exposure to trauma, defined as threat to life or limb; directly witnessing trauma; or indirect exposure through close associates directly exposed to trauma) is necessary for identification of cases and estimation of the prevalence of PTSD.
Do these results change your practices and why?
Despite limitations in the assessment measures, the findings from this study suggest that general established principles of intervention for adults exposed to disaster likely also apply to youth. These data support recent clinical practice recommendations for a full clinical evaluation for children exposed to disasters, directing children with psychiatric disorders to formal treatment and children without psychiatric disorders to psychosocial interventions.5 Because I personally endorse these recommendations, the results of this study will not change my practice. The findings from this study, however, should help reinforce the value of these recommendations for disaster responders who do not already follow them.
Footnotes
Competing interests: None.
References
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