International Society for Traumatic Stress Studies

Do all children follow the same symptom trajectory after exposure to a disaster?

11/28/2017
by Rayleen M. Lewis, MPH, Michelle S. Livings, Betty S. Lai, Ph.D., Annette M. La Greca, Ph.D., ABPP and Ann-Margaret Esnard, Ph.D.
More than 100 million children worldwide are exposed to disasters each year (UNISDR, 2011), and disasters are increasing in both frequency and intensity (USGCRP, 2016). Following a disaster, posttraumatic stress symptoms (PTSS) are the primary problem presenting in children (Furr, 2010). However, research on PTSS trajectories in children following a disaster is limited. Understanding symptom trajectories is particularly important to ensure that the most appropriate resources are provided to children. Disaster management experts recommend using a stepped care approach to intervention, in which children at highest risk of chronic distress after a disaster receive the most intensive treatment, while children at lower risk receive less intensive and less costly interventions. To efficiently distribute resources to children post-disaster, it is crucial to understand PTSS trajectories and risk factors for more severe PTSS trajectories.

A majority of research to date has focused on adult PTS trajectories. Four trajectories are commonly found: chronic, recovery, resilience, and delayed. Research on children has used a priori categorization to identify how these four adult trajectories apply to children. However, these trajectories have been defined based on adult experiences, and children have distinct experiences compared to adults during and after a disaster. Thus, the literature may provide only limited insight into children’s post-disaster PTSS trajectories. Person-centered approaches to identifying symptom trajectories in children post-disaster have also been used, but there is not a clear consensus on the number or types of PTSS trajectories or risk and protective factors associated with specific PTSS trajectories.

We addressed this substantial knowledge gap in the literature in two ways. Our first aim was to evaluate the typical number and types of child post-disaster PTSS trajectories identified in the literature. Our second aim was to evaluate risk and protective factors that distinguished PTSS trajectories among children post-disaster.
In order to accomplish these aims, we conducted a review of PubMED and EBSCOhost Database to identify studies that quantitatively examined PTSS trajectories in children and adolescents following either a natural or man-made disaster. A total of eight studies were included in the review.

To address our first aim, each study was reviewed to determine the number and types of PTSS trajectories found. All eight studies reviewed included at least 3 trajectories: chronic, recovery, and resilience. Three studies identified a delayed trajectory, and an additional three studies found limited evidence of a delayed trajectory (i.e., less than 5% of the children fell into this trajectory). In seven studies, the most common trajectory was the resilience trajectory. The recovery trajectory was the most common trajectory in the eighth study.

To address our second aim, each study was reviewed for assessment of risk and protective factors associated with following particular PTSS trajectories. Studies reviewed a variety of types of factors including factors related to child characteristics, exposure stressors, recovery stressors, social support, and coping. The chronic trajectory and the resilience trajectory differed with respect to multiple factors, including age, gender, severe posttraumatic stress disorder (PTSD) at the first assessment in the study (Time 1), general anxiety symptoms, numerous exposure and recovery stressors, less social support, less positive coping, and more negative coping. Factors distinguishing the recovery trajectory from the resilience trajectory were similar, but did not include gender or severe PTSD at Time 1. Factors that distinguished the chronic trajectory from the recovery trajectory included severe PTSD at Time 1, general anxiety symptoms, use of blame and anger coping, and multiple exposure and recovery stressors.
We found a variety of risk and protective factors that distinguished between trajectories, many of which showed some degree of inconsistency across studies. Future research is needed to clarify which factors, and under what circumstances, differentiate those who develop chronic PTSS versus those who recover.

Study design features such as timing of assessments, sample diversity, and sample size limit the generalizability of individual studies to all children affected by a disaster. Integrative data analysis (IDA) is a useful analytic technique that integrates data at the participant level from multiple studies. The resulting data source is more powerful and diverse than any of the individual studies included. IDA could be used to address some of the limitations of individual studies and address more difficult research questions, such as determining the most appropriate time point for assessment post-disaster or determining if PTSS trajectory types are consistent across various traumas (e.g., natural disaster, injury, war). In order to conduct IDA, repositories of data created by child trauma researchers are needed for joint examination of children’s responses to trauma. Contributions made to such repositories will require some overlap of items in pooled datasets. Researchers should consider using consistent measures across studies and should participate in the building of data repositories to further advance the literature on children’s responses to trauma.

Understanding how and why children differ in their responses to disasters is critical in order for children to receive the most appropriate interventions post-disaster. Children exhibit multiple responses to disasters. To fully understand these responses, analyses focused on changes in an individual’s response rather than changes in the mean response of a group should be used to study children’s disaster responses, as analyzing children’s responses on average will not capture multiple responses. Using person-centered approaches to identify symptom trajectories of children post-disaster will likely help reach a consensus on the number and types of PTSS trajectories children may follow.

References:

Furr, J. M., Comer, J. S., Edmunds, J. M., & Kendall, P. C. (2010). Disasters and youth: A meta-analytic examination of posttraumatic stress. Journal of Consulting and Clinical Psychology, 78(6), 765-780. doi: 10.1037/a0021482

UNISDR. (2011). UNISDR says the young are the largest group affected by disasters. Retrieved from http://www.unisdr.org/archive/22742

USGCRP. (2016). The impacts of climate change on human health in the United States: A scientific assessment. Washington, D.C.: U.S. Global Change Research Program.

Discussion Questions:

  1. Why is it important to consider varying trajectories of distress symptom responses among children post-disaster?
  2. Why has post-disaster distress symptom trajectory research primarily been conducted with adults to date?
  3. How will the findings of this review influence clinical practice?

Reference Article:

Lai, B. S., Lewis, R., Livings, M. S., La Greca, A. M. and Esnard, A.-M. (2017), Posttraumatic Stress Symptom Trajectories Among Children After Disaster Exposure: A Review. JOURNAL OF TRAUMATIC STRESS. doi:10.1002/jts.22242

Author Biographies:

Rayleen M. Lewis, MPH, is a government contractor with Synergy America, Inc. working as an epidemiologist. Her research interests focus on child and adolescent health, including assessment of reactions post-disaster and human papillomavirus vaccine effectiveness.

Michelle S. Livings is an MPH student at Georgia State University’s School of Public Health and works as an epidemiologist at the Georgia Department of Public Health. Her research interests include children’s psychological reactions following traumatic events, surveillance program development and implementation, and spatial and statistical analysis of health and socioeconomic disparities.

Betty S. Lai, Ph.D., is an assistant professor in the Division of Epidemiology and Biostatistics in the School of Public Health at Georgia State University. Her research focuses on how children and families respond to disasters and other traumatic stressors. Her recent work has been funded by the National Science Foundation and the National Institute of Mental Health, and includes projects examining school functioning in relation to disasters, and an integrative data analysis examining children’s reactions to four of the most costly disasters in U.S. history (e.g., Hurricanes Katrina, Ike, Charley, and Andrew).

Annette M. La Greca, Ph.D., ABPP, is the Director of Clinical Training, a Cooper Fellow and Provost Scholar, and a Distinguished Professor of Psychology and Pediatrics in the Department of Psychology at the University of Miami. Her research interests include children’s and adolescents’ peer relations, friendships, and romantic relationships, as they pertain to psychological and physical health; children’s reactions to trauma, including natural disasters (e.g., hurricanes) and peer victimization; social anxiety in children and adolescents; and preventive interventions.

Ann-Margaret Esnard, Ph.D., is the Interim Associate Dean for Research and Strategic Initiatives and a Distinguished University Professor in the Department of Public Management and Policy at the Andrew Young School of Policy Studies at Georgia State University. Her expertise encompasses urban planning, disaster planning, vulnerability assessment, and GIS/spatial analysis. She has been involved in a number of research initiatives, including NSF funded projects on topics of population displacement from catastrophic disasters, school recovery after disasters, long-term recovery, and community resilience.
 
 

 
 

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