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Posttraumatic Stress and Depressive Reactions
Among Nicaraguan Adolescents After Hurricane Mitch
Armen K. Goenjian, M.D.
Luis Molina, M.D.
Alan M. Steinberg, Ph.D.
Lynn A. Fairbanks, Ph.D.
Maria Luisa Alvarez, M.D.
Haig A. Goenjian
Robert S. Pynoos, M.D.
Objective: This study determined the
severity of posttraumatic stress and depressive reactions among Nicaraguan adolescents after Hurricane Mitch and the relationship of these reactions to objective
and subjective features of hurricane exposure, death of a family member, forced relocation, and thoughts of revenge.
across cities. Level of impact (city), objective and subjective features, and thoughts
of revenge accounted for 68% of the variance in severity of posttraumatic stress reaction. Severity of posttraumatic stress reaction, death of a family member, and
sex accounted for 59% of the variance in
severity of depression.
Method: Six months after the hurricane,
158 adolescents from three differentially
exposed cities were evaluated by using a
hurricane exposure questionnaire, the
Child Posttraumatic Stress Disorder Reaction Index, and the Depression Self-Rating
Scale.
Conclusions: After a category 5 hurricane, adolescents in heavily affected areas with extreme objective and subjective
hurricane-related traumatic features of
exposure experience severe and chronic
posttraumatic stress and comorbid depressive reactions. The recovery of the severely affected Nicaraguan adolescents is
vital to the social and economic recovery
of a country ravaged by years of political
violence and poverty. These findings
strongly indicate the need to incorporate
public mental health approaches, including systematic screening and trauma/
grief-focused interventions, within a comprehensive disaster recovery program.
Results: Severe levels of posttraumatic
stress and depressive reactions were
found among adolescents in the two
most heavily affected cities. Severity of
posttraumatic stress and depressive reactions and features of objective hurricanerelated experiences followed a “dose-ofexposure” pattern that was congruent
with the rates of death and destruction
(Am J Psychiatry 2001; 158:788–794)
H
urricane Mitch, classified as a category 5 storm on
the Saffir-Simpson scale, was the most deadly hurricane to
strike the Western Hemisphere in the last two centuries. It
struck Central America between October 26 and November
4, 1998, causing massive destruction in Nicaragua and
Honduras. Approximately 10,000 people were killed. Winds
reached up to 200 miles per hour. Torrential rains fell at a
rate of 1–2 feet per day in many of the mountainous regions, resulting in massive floods and mudslides. Food and
cash crops were largely wiped out. Hundreds of thousands
of people were left without work and any means of income.
Damage to basic infrastructure, agriculture production,
and the industrial sector virtually destroyed more than two
decades of progress in these countries.
In Nicaragua, 2 million people were directly affected;
approximately 4,000 died, and 500,000 were left homeless.
Intense rain falling over western Nicaragua left tens of
inches of rain. Crater Lake, on top of the dormant Casita
volcano, filled with water and part of the wall collapsed,
causing mudflows that covered an area 10 miles long and 5
miles wide. Five villages were buried under several feet of
mud. Over 2,000 of the dead were from the area around
the collapsed volcano in and around the city of Posoltega.
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In Chinandega there was massive flooding. Although
property damage was extensive, it was comparatively less
than in Posoltega. Property damage in Leon was considerably less than in the other two cities.
Children and Disasters
The two most studied hurricanes have been Hugo and
Andrew. In 1989 Hurricane Hugo, classified as a category 4
storm, left 60 dead in the wake of its path of destruction
across South Carolina. In 1992 Hurricane Andrew, also
classified as a category 4 storm, killed 40 people in Dade
County, Fla.
Shannon et al. (1), using the Child Posttraumatic Stress
Disorder (PTSD) Reaction Index reported mild reaction
scores (mean=21.7) among children and adolescents 3
months after Hurricane Hugo and estimated that 5% had
posttraumatic stress syndrome. Belter et al. (2) reported
moderate Child PTSD Reaction Index scores (range=26.9–
35.1) among children 5 months after Hugo. Garrison et al.
(3) also reported moderate scores (range=26–35) on the
Child PTSD Reaction Index 1 year after Hugo and estiAm J Psychiatry 158:5, May 2001
GOENJIAN, MOLINA, STEINBERG, ET AL.
mated that 5% of the adolescents met DSM-III-R criteria
for PTSD.
Vernberg et al. (4) found moderate (mean=29.6) Child
PTSD Reaction Index scores in children 3 months after
Hurricane Andrew. Garrison et al. (5), using the Diagnostic
Interview Schedule in a population-based study 6 months
after Hurricane Andrew, reported that 7.3% of a mixed-exposure group of adolescents met the criteria for PTSD.
Shaw et al. (6), using the Child PTSD Reaction Index 32
weeks after Andrew, reported that 51% of the children in
the high-impact area had moderate levels of PTSD; 38%
had severe to very severe levels. Mean scores were not
reported. La Greca et al. (7) reported mild to moderate
scores (mean=24.4) on the Child PTSD Reaction Index 7
months after Andrew; 23% experienced moderate levels,
and 18% experienced severe to very severe levels of symptoms. Shaw et al. (8) reported that 70% of the children in
high-impact areas continued to score in the moderate to
severe range 21 months after Andrew. With the exception
of the study by Belter et al. (2), the aforementioned studies
did not report on comorbid depression. Belter et al. (2)
found no differences in depression scores between the different exposure groups and those reported for nonpatient
standardization samples. Studies in Armenia, using the
Child PTSD Reaction Index 1.5 and 3 years after the 1988
Spitak earthquake, have indicated that extreme disasterrelated traumatic experiences have been associated with
severe and prolonged posttraumatic stress and depressive
reactions among adolescents (9, 10).
Trauma researchers have begun to employ more specific evaluations of trauma exposure in studying the impact of traumatic events on children and adolescents.
Vernberg et al. (4) made a notable contribution toward refining the evaluation of exposure, with detailed exploration of objective features of hurricane-related experiences. However, their exposure questionnaire included
only one item related to subjective aspects of hurricane
experiences. In 1994 DSM-IV included numerous objective and subjective features of exposure. The present study
incorporated these features into a hurricane exposure
measure. Clinical observations after the earthquake in Armenia revealed a high prevalence of vengeful thoughts
among adolescents that appeared to interfere with their
recovery. Consequently, in the present study, we evaluated
current thoughts of revenge.
Given the enormity of destruction, morbidity, and mortality associated with Hurricane Mitch, we considered it
important to assess the severity of distress among the
exposed adolescents. This study employed a “dose-of-exposure” design, using level of impact (city) as a major
grouping variable. We investigated whether objective and
subjective exposure, death of a family member, forced relocation after the hurricane, and current thoughts of revenge made an additional contribution toward predicting
the severity of posttraumatic stress and depressive reacAm J Psychiatry 158:5, May 2001
tions beyond that made by level of impact. This study was
conducted 6 months after the hurricane in three differentially affected cities in Nicaragua: 1) Posoltega, in the most
devastated region, 2) Chinandega, and 3) Leon, the least
devastated city.
Method
Subjects
Subjects for this study came from three public schools, one located in each of three cities in the hurricane-affected areas of Nicaragua: Posoltega (N=52), 27 boys, 25 girls, mean age=13 years,
SD=0.4; Chinandega (N=55), 29 boys, 26 girls, mean age=13 years,
SD=0.3; Leon (N=51), 25 boys, 26 girls, mean age=13 years, SD=
0.2. Students from public schools were chosen because they were
more representative of the population than students from private
schools. In Posoltega and Chinandega, both seventh- and eighthgraders were evaluated. In Leon, where class size was larger, only
seventh-graders were evaluated. All students present in the classrooms on the day of the evaluations completed the survey questionnaire; structured directions were given by members of our
team (L.M. and M.L.A.) about how to compete the symptom
scales. Four students from Posoltega, three students from Chinandega, and none from Leon were absent that day. The interview procedures were explained to the parents; the parents gave
written permission for their children to participate. All of the students gave their assent after having the interview procedures explained. No parent refused to give permission for his or her child’s
participation, and no student refused to be interviewed.
Instruments
A hurricane-related exposure profile was obtained for each
subject. This part of the questionnaire included 13 items: four
items assessed objective features of hurricane exposure, and nine
items assessed subjective features (Table 1). These items were answered “yes” or “no.” Positive responses to these items were
summed for the analyses. Cronbach’s alphas for internal consistency within the objective and subjective exposure scales were
0.64 and 0.55, respectively. Cities, which constituted a broad measure of level of impact, were rated: 1=Posoltega, 2=Chinandega,
and 3=Leon. In addition, students were asked to describe their
worst hurricane-related experience. Information was also obtained about loss of a family member due to the hurricane, forced
relocation, and thoughts of revenge.
Posttraumatic stress symptoms were evaluated by using the
self-reported Child PTSD Reaction Index (11). Frequency of occurrence of symptoms was rated on a 5-point Likert scale, ranging
from 0=none to 4=most of the time. Prior comparisons of Child
PTSD Reaction Index scores with a diagnosis of PTSD in clinical
populations have suggested the following guidelines: 0–11=
doubtful; 12–24=mild; 25–39=moderate; 40–59=severe; 60–80=
very severe (12). Previous findings have indicated that a score of
40 or above is highly associated with a diagnosis of PTSD (13).
Test-retest reliability for the Child PTSD Reaction Index was assessed by the authors. Twelve adolescents were evaluated initially
and again after 7 days. The intraclass correlation coefficient for
these scores was 0.93 (p<0.001).
Ratings of depressive symptoms were obtained by using the
Depression Self-Rating Scale (14). Psychometric properties of this
instrument have been reported. A score of 17 or above is highly
associated with a diagnosis of major depression, dysthymic disorder, or adjustment disorder with depressed mood (14). A translation of all interview questions and instruments into Spanish followed published guidelines, including the use of independent
back-translation (15).
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ADOLESCENT REACTIONS TO HURRICANE
TABLE 1. Endorsement Frequencies, by City, of Objective and Subjective Features of Hurricane-Related Exposure Among
158 Nicaraguan Adolescents During and After Hurricane Mitch
Posoltega (N=52)
Feature of Hurricane-Related Exposure
During the hurricane
Objective features
Seriously hurt
Someone else seriously hurt
Someone else died
Home severely damaged or destroyed
Subjective features
Very scared
Scared you would die
Scared you would be hurt badly
Scared someone else would die
Scared someone else would be seriously hurt
Felt you couldn’t control what was happening
Acted nervous and confused
Felt what you saw was disgusting or gross
Felt what was happening was unreal
Death of a family member
After the hurricane
Objective feature: forced relocation
Subjective feature: thoughts of revenge
a Data are missing for some categories.
b p=0.057.
*p<0.05.
**p<0.01.
Leon (N=51)
%
Na
%
Na
%
Kendall’s
tau-b
14
40
44
33
27
80
85
63
7
25
27
26
13
45
49
47
2
13
7
10
4
25
14
20
0.25**
0.41**
0.54**
0.33**
50
50
44
51
51
49
46
52
42
16
96
96
86
98
98
94
88
100
81
31
51
45
49
52
51
50
46
51
39
8
93
82
89
94
93
91
84
93
71
15
46
43
45
50
50
47
45
51
32
2
90
84
88
98
98
92
88
100
63
4
0.09
0.14*
0.02
0.00
0.00
0.03
0.00
0.00
0.15*
0.28**
15
28
29
54
12
10
22
20
7
12
14
23
0.14b
0.25**
Statistical Analysis
Kendall’s tau-b was used to assess differences in the frequencies of objective and subjective experiences across cities during
and after the hurricane. Pearson’s product moment correlation
was used to assess the relationships among the independent and
among the dependent variables. Multiple stepwise regression
analyses were used to determine the relative contribution of demographic and hurricane-related variables to posttraumatic
stress and depressive reactions.
Results
Objective and Subjective Features
Table 1 shows the frequencies of endorsement of objective and subjective exposure items by city during and after
the hurricane. Objective features of exposure, both during
and after the hurricane, followed a “dose-of-exposure”
continuum; the highest percentages were endorsed in the
most affected region, Posoltega, followed by Chinandega,
and then Leon. Noteworthy in Posoltega were the rates of
being seriously hurt (27%), death of a family member
(31%), and having one’s home severely damaged or destroyed (63%).
Subjective features during the hurricane did not follow a
dose-of-exposure pattern, with the exception of the features “scared you would die” and “felt what was happening
was unreal.” Both showed significant but small differences. After the hurricane, “thoughts of revenge” were
quite prevalent in Posoltega (54%), as compared to Chinandega (20%) and Leon (23%).
Correlations Among Independent Variables
Table 2 presents intercorrelations among independent
variables. City (level of impact), rated as a continuous variable, was significantly correlated with objective hurri-
790
Chinandega (N=55)
Na
cane-related experiences but not with subjective experiences. City was also significantly correlated with death of a
family member and current thoughts of revenge. There
was a significant correlation between sex and endorsement of subjective experiences but not between sex and
endorsement of objective experiences. Girls had significantly higher scores than boys on the subjective exposure
scale. With the exception of sex, all other variables were
significantly correlated with objective experiences.
Worst Hurricane-Related Experience
Representative examples of responses regarding worst
hurricane-related experiences included the following: “I
felt the mudslide was pulling me down. The mud ruined
my house. I felt we were all going to die, and if we managed
to survive, we were all going to starve to death because
there was no food.” “I felt that the mud was covering us,
and it was going to swallow us up.” “I felt the mud and
rocks would drag us. I felt very afraid that I was going to
drown, or my family was going to drown. The house was
dragged by the wind.” “I was very afraid because the winds
took the roof and the water came into the house.
Posttraumatic Stress and Depressive Reactions
Figure 1 presents the mean Child PTSD Reaction Index
and Depression Self-Rating Scale scores for boys and girls
in the three cities 6 months after Hurricane Mitch. Child
PTSD Reaction Index and Depression Self-Rating Scale
scores followed a dose-of-exposure pattern, with the highest scores endorsed in the most affected region: Posoltega,
followed by Chinandega, and then Leon. The severity of
these reactions across cities was congruent with the rates
of positive responses to the objective hurricane-related
exposure items. Adolescents in Posoltega, who reported
Am J Psychiatry 158:5, May 2001
GOENJIAN, MOLINA, STEINBERG, ET AL.
TABLE 2. Correlations Among Sex and Hurricane-Related Exposure Variables for 158 Nicaraguan Adolescents After Hurricane Mitch
Level of
Impact (city)
Sex
Independent Variable
Sex
Level of impact (city)
Objective exposure scale score
Subjective exposure scale score
Death of family member
Thoughts of revenge
Forced relocation
r
1.00
df
r
0.02
1.00
df
156
Objective
Exposure
Scale
r
0.03
0.59*
1.00
df
156
156
Death of
Family
Member
Subjective
Exposure
Scale
r
0.25*
0.12
0.24*
1.00
df
156
156
156
r
0.02
0.29*
0.34*
0.08
1.00
df
156
156
156
156
Thoughts of
Revenge
r
0.03
0.27*
0.37*
0.23*
0.28*
1.00
df
152
152
152
152
152
Forced
Relocation
r
0.11
0.15
0.28*
0.02
0.14
0.13
1.00
df
155
155
155
155
155
151
*p<0.01.
PTSD, Depressive Disorder,
and Their Co-Occurrence
Empirically derived cutoff scores for both the Child
PTSD Reaction Index and Depression Self-Rating Scale
were used to derive estimates by city of the current frequency of PTSD, depressive disorder, and their co-occurrence 6 months after the hurricane. The estimated rates
were as follows: Posoltega (N=52): PTSD, N=47, 90%; depressive disorder, N=42, 81%; comorbid PTSD and depressive disorder, N=41, 79%; Chinandega (N=55): PTSD, N=
30, 55%; depressive disorder, N=28, 51%; comorbid PTSD
and depressive disorder, N=21, 38%; Leon (N=51): PTSD,
N=7, 14%; depressive disorder, N=15, 29%; comorbid
PTSD and depressive disorder, N=4, 8%. Estimated rates of
PTSD, depressive disorder, and their co-occurrence 6
months after the hurricane were high in the two most severely affected regions, Posoltega and Chinandega. Considerably lower estimated rates were found in Leon, where
exposure was less severe.
PTSD and Depression Scores
For the total group, the correlation between Child PTSD
Reaction Index and Depression Self-Rating Scale scores
was r=0.74 (df=126, p<0.001). Within-city correlations
were also high: Posoltega: r=0.81 (df=50, p<0.001), Chinandega: r=0.56 (df=53, p<0.001), and Leon: r=0.62 (df=51,
p<0.001).
Am J Psychiatry 158:5, May 2001
FIGURE 1. Child Posttraumatic Stress Disorder (PTSD) Reaction Index and Depression Self-Rating Scale Scores by Sex
Among 158 Adolescents in Three Nicaraguan Cities 6
Months After Hurricane Mitch
Mean Score on
Mean Score on
Depression Self-Rating Scale Child PTSD Reaction Index
the highest levels of objective exposure, had the highest
Child PTSD Reaction Index scores (boys: mean=55.7, SD=
15.2; girls: mean=61.6, SD=8.9; total: mean=58.6, SD=
12.8). Adolescents in Chinandega reported the next-highest levels of exposure (boys: mean=37.9, SD=11.2; girls:
mean=45.7, SD=15.6; total: mean=41.6, SD=13.9), followed
by adolescents in Leon (boys: mean=26.9, SD=16.3; girls:
mean=28.8, SD=10.8; total: mean=27.9, SD=13.7). Mean
Depression Self-Rating Scale scores for the three cities
were: Posoltega (boys: mean=19.7, SD=8.3; girls: mean=
25.1, SD=5.9; total: mean=22.3, SD=7.7); Chinandega
(boys: mean=16.9, SD=6.6; girls: mean=17.6, SD=7.1; total:
mean=17.2, SD=6.8); and Leon (boys: mean=10.9, SD=6.0;
girls: mean=16.0, SD=5.6; total: mean=13.5, SD=6.3).
80
Male
Female
70
60
50
40
30
20
10
0
40
35
30
25
20
15
10
5
0
Posoltega
Chinandega
Leon
City
Severity of Posttraumatic Stress Reaction
Table 3 presents a stepwise multiple regression analysis
of the contribution of each of the independent variables
toward predicting severity of posttraumatic stress reaction. It displays the adjusted R2, the change in R2, the standardized regression coefficient (beta), and partial correlations. At step 1, the strongest predictor of posttraumatic
stress reaction severity was level of impact (city), which
accounted for 47% of the total variance. The next variable
contributing significantly was objective hurricane-related
exposure, accounting for another 12% of the variance.
This was followed, at step 3, by subjective hurricane-related experiences, which accounted for another 7% of the
variance. Finally, at step 4, current thoughts of revenge
made a significant contribution, adding another 2% to the
prediction of variance in posttraumatic stress reaction severity. These four variables taken together explained 68%
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ADOLESCENT REACTIONS TO HURRICANE
TABLE 3. Stepwise Multiple Regression Analyses of the Contributions of Hurricane-Related Variables and Sex to Severity of
Posttraumatic Stress Reaction for 158 Nicaraguan Adolescents After Hurricane Mitch
Independent Variable
Level of impact (city)
Objective exposure scale score
Subjective exposure scale score
Thoughts of revenge
Sex
Death of family member
Forced relocation
*p=0.02.
**p<0.01.
Step 0
0.69***
0.69***
0.40***
0.43***
0.12
0.30***
0.17*
Step 1:
Adjusted R2=0.47
Step 2:
Delta R2=0.12
Step 3:
Delta R2=0.07
Step 4:
Delta R2=0.02
Partial
Beta
Correlation
0.69***
0.69***
0.47***
0.45***
0.35***
0.19*
0.14
0.09
Partial
Beta
Correlation
0.43***
0.48***
0.43***
0.47***
0.40***
0.26**
0.22**
0.03
0.04
Partial
Beta
Correlation
0.44***
0.52***
0.36***
0.43***
0.26***
0.40***
0.22**
0.12
0.04
0.01
Partial
Beta
Correlation
0.43***
0.52***
0.32***
0.39***
0.24***
0.37***
0.14**
0.22***
0.14
0.04
0.01
***p<0.001.
TABLE 4. Stepwise Multiple Regression Analysis of the Contributions of Hurricane-Related Variables, Child PTSD Reaction
Index, and Sex to Severity of Depressive Reaction in 158 Nicaraguan Adolescents After Hurricane Mitch
Step 1: Adjusted R2=0.55
Independent Variable
Child PTSD Reaction Index
Death of family member
Sex
Level of impact (city)
Objective exposure scale score
Subjective exposure scale score
Forced relocation
Thoughts of revenge
*p<0.02.
**p<0.01.
Step 0
0.74***
0.36***
0.21**
0.46***
0.55***
0.39***
0.06
0.34***
Beta
0.74***
Beta
0.70***
0.15*
Partial
Correlation
0.72***
0.21*
0.21**
0.13
0.02
0.16
0.12
0.00
Step 3: Delta R2=0.02
Beta
0.68***
0.16**
0.14**
Partial
Correlation
0.71***
0.23**
0.21**
0.11
0.06
0.11
0.09
0.02
***p<0.001.
of the variance in Child PTSD Reaction Index scores. Sex,
death of a family member, and forced relocation made no
significant independent contribution toward predicting
posttraumatic stress reaction severity.
Severity of Depression
Table 4 presents a stepwise multiple regression analysis
of the contribution of each of the independent variables
and Child PTSD Reaction Index score toward predicting
severity of depression. It displays the adjusted R2 , the
change in R 2 , the standardized regression coefficient
(beta), and partial correlations. At step 1, the strongest
predictor of severity of depression was Child PTSD Reaction Index score, which accounted for 55% of the total
variance. The next variable contributing significantly was
death of a family member, which accounted for another
2% of the variance in depression severity. At step 3, sex accounted for an additional 2% of the variance. These three
variables taken together explained 59% of the variance in
depression score. Level of impact (city), objective and subjective features, forced relocation, and current thoughts of
revenge made no significant independent contribution
toward predicting severity of depression.
Discussion
The hurricane exposure scales, based on DSM-IV PTSD
category A criteria, were included in order to investigate
the relationship between objective and subjective hurricane-related experiences and subsequent posttraumatic
stress and depressive reactions. Responses across cities to
792
Partial
Correlation
0.74***
0.21*
0.20*
0.10
0.07
0.14
0.09
0.04
Step 2: Delta R2=0.02
the objective exposure questions, both during and after
the hurricane, followed a dose-of-exposure pattern that
was congruent with the magnitude of death and destruction in the region. The high correlation between level of
impact (city) and the objective exposure scale indicates
that these objective exposure items are useful for measuring gradation of exposure to hurricane-related trauma.
Subjects from Posoltega and Chinandega had higher
rates of objective hurricane-related experiences than the
subjects studied after Hurricanes Hugo and Andrew. For
example, the rate of “getting hurt” in the “high-impact”
group after Hurricane Andrew was 4.8% (6). The rate of
getting hurt “some to a great deal” was 4% after Hurricane
Hugo (3). In contrast, the rate of being seriously injured
was 27% in Posoltega and 13% in Chinandega. The rate of
“seeing someone else getting injured” was 11.3% in the
Andrew group versus 80% in Posoltega. While the total
number of dead in Florida and South Carolina were about
40 and 60 respectively, 16 of 52 adolescents in this study in
Posoltega reported the loss of a family member.
With regard to the subjective exposure scale, most reactions did not follow a dose-of-exposure pattern. There was
no significant correlation between level of impact (city)
and the subjective exposure scale. The lack of specificity of
the subjective scale in detecting hurricane impact may be
due to the fact that the severity of subjective hurricane-related experiences in all three cities produced a ceiling effect with regard to responses to these items. Use of an intensity rating scale rather than a “yes” or “no” response
Am J Psychiatry 158:5, May 2001
GOENJIAN, MOLINA, STEINBERG, ET AL.
format for the subjective scale may render it more capable
of discriminating across exposure groups.
Adolescents from Posoltega had the highest mean score
on the Child PTSD Reaction Index, followed by those from
Chinandega, and then those from Leon. Mean Child PTSD
Reaction Index score and estimated rates of PTSD also followed a dose-of-exposure pattern across cities. These
findings replicate those from other postdisaster studies in
demonstrating a dose-of-exposure relationship between
the severity of PTSD symptoms and the magnitude of disaster impact (6, 13).
The severity of posttraumatic stress reactions in Posoltega and Chinandega far exceeded reported severity
levels after Hurricanes Hugo (1–3) and Andrew (4, 6, 7), in
which the same PTSD instrument was used. These higher
scores reflect the more severe objective hurricane-related
traumatic exposures among adolescents in these cities.
These adolescents experienced being dragged under by
mud, afraid that they and their family members were going to be buried alive. They were afraid that the wind
would carry them and their houses away.
The Child PTSD Reaction Index score in Posoltega
(mean=58.6) 6 months after the hurricane is comparable
to the 1.5-year postearthquake Child PTSD Reaction Index
score of adolescents (mean=54.2) near the epicenter of the
devastating earthquake in Armenia (9). The comparability
of these scores indicates that exposure to catastrophic disaster results in severe levels of PTSD symptoms, irrespective of type of natural disaster.
High levels of depressive symptoms were found in Posoltega and Chinandega. Few studies have assessed depression in children after natural disasters. Belter et al. (2)
noted no significant depression among children 5 months
after Hurricane Hugo, while Goenjian et al. (9) reported
high levels of depression among children and adolescents
near the epicenter 1.5 years after the earthquake in Armenia. Yule and Udwin (16) and Goenjian et al. (10) found an
increase in levels of depression over time among adolescents with chronic PTSD. The latter two studies suggest
that adolescents in Posoltega and Chinandega may be at
risk for a worsening course of depression.
This study examined a conceptual model for the prediction of severity of posttraumatic stress and depressive
reactions. In addition to the anticipated contribution of
objective hurricane-related traumatic experiences, subjective registration of danger, horror, and helplessness also
contribute to predicting posttraumatic stress reactions.
These findings lend empirical support to DSM-IV criterion A.
This study found a small but significant predictive
value of having current thoughts of revenge for severity of
posttraumatic stress reaction. Vengeful thoughts as a consequence of human-perpetrated trauma have been described in the literature (17). In this study, vengeful
thoughts (54%) were prevalent in the most exposed
group, the adolescents from Posoltega. Most adolescents
Am J Psychiatry 158:5, May 2001
expressed vengeful thoughts toward the government for
not warning them in advance or helping them during or
after the hurricane. This finding indicates that vengeful
thoughts may be prevalent after natural disasters as well
as after human-perpetrated violence and points to the
need to evaluate and address them in treatment.
The lack of contribution of forced relocation for predicting severity of posttraumatic stress reaction is consistent
with the results of prior studies among survivors of an
earthquake (18). With regard to the lack of contribution of
death of a family member, prior studies have found higher
levels of PTSD symptoms among those who suffered the
death of a nuclear family member (9, 13). However, these
studies did not specifically control for objective and subjective features of exposure. In the present study, even
though loss of a family member was significantly correlated with PTSD severity at step 0, it did not make an additional contribution toward predicting PTSD severity beyond level of impact (city), aspects of hurricane exposure,
sex, and thoughts of revenge.
In this study, sex was predictive of the severity of posttraumatic stress reactions at steps 1 and 2. However, after
controlling for the contribution of subjective features of
exposure, sex no longer made an independent contribution. A number of prior disaster studies have found that
girls scored higher than boys on PTSD measures (1, 4, 5, 9,
13), but none of these controlled for subjective exposure.
This finding raises new questions in regard to sex differences in PTSD. Do girls experience higher levels of posttraumatic stress reaction because they experience more
fear, horror, and helplessness (items on the subjective exposure scale) during a catastrophic disaster than boys? Or
do the sex differences reflect a more general willingness on
the part of girls to endorse items on both the subjective exposure and PTSD scales?
This study found that three variables, Child PTSD Reaction Index score, death of a family member, and sex, accounted for 59% of the variance in depression, 55% of
which was due to severity of posttraumatic stress reaction.
There was also a high correlation between Child PTSD Reaction Index and Depression Self-Rating Scale scores. One
explanation may be that adolescents in the heavily affected cities both 1) had the most extreme hurricane-related traumatic exposures (resulting in severe levels of
posttraumatic stress reaction) and 2) suffered the harshest
posthurricane losses and adversities (resulting in severe
levels of depression). In addition, PTSD symptoms may
have given rise to, or exacerbated, depressive symptoms
(9, 19), or prior history of depression may increase vulnerability to PTSD (20). The significant contribution of the
death of a family member to severity of depression is congruent with the childhood bereavement and trauma literature (9, 21, 22). The significant contribution of sex toward
predicting severity of depression is consistent with the results of epidemiological studies indicating that depressive
793
ADOLESCENT REACTIONS TO HURRICANE
disorders show a change in sex distribution after puberty,
when rates for girls begin to exceed those for boys (23).
This study indicates that after a category 5 hurricane,
adolescents in heavily affected areas with extreme objective and subjective hurricane-related traumatic exposure
experience chronic and severe levels of posttraumatic
stress and depressive symptoms. There is accumulating
evidence that these sequelae have adverse effects on their
future development, including conscience functioning,
academic achievement, economic productivity, health,
and the stability they bring to marriage, family life, and
their societal role (24–27). The recovery of adolescents in
Nicaragua is vital to the social and economic recovery of a
country already ravaged by years of political violence and
poverty. Comprehensive disaster recovery programs need
to incorporate modern public health approaches, including systematic screening of affected populations, stratification of interventions on the basis of risk assessment,
provision of trauma/grief-focused interventions, and
monitoring course of recovery (28).
Received July 5, 2000; revision received Oct. 31, 2000; accepted
Nov. 16, 2000. From the Trauma Psychiatry Program, Department of
Psychiatry and Biobehavioral Sciences, University of California at Los
Angeles. Address reprint requests to Dr. Goenjian, 501 Via La Selva,
Redondo Beach, CA 90277; [email protected] (e-mail).
Supported in part by the Bing Fund.
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