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TRAUMATOLOGY
VOLUME V, ISSUE 3
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Child Development and Post-traumatic Stress Disorder
After Hurricane Exposure
Alan M. Delamater, and E. Brooks Applegate
University of Miami School of Medicine
This study examined child development in relation to post-traumatic stress disorder
(PTSD) after hurricane exposure. The study subjects were 175 3 to 5-year old minority
children enrolled in Head Start programs. Children were evaluated 12 and 18 months
after Hurricane Andrew struck south Florida. Mothers were interviewed concerning
symptoms of PTSD and completed a questionnaire regarding their children’s
development. Results indicated that 16.5% of exposed children met DSM-IV
diagnostic criteria for PTSD at 12 months, and 11.6% had PTSD at 18 months posthurricane. Children who had PTSD at 12 months were more likely to be delayed in
their development at 18 months, and those with PTSD at 18 months similarly were
more likely to be delayed. These findings indicate that children with PTSD are at risk
for delays in their overall development.
Natural disasters often result in destruction of
property, major economic losses for affected
communities, serious injuries, and loss of life. The
psychological toll of natural disasters is also quite
significant. Studies with children indicate increases
in psychological problems following natural
disasters such as lightning strikes (Dollinger,
O’Donell, & Stanely, 1984)), tornados (Bloch,
Silber, & Perry, 1956)), floods (Burke, Borus,
Burns, Millstein, & Beasley, 1982; Earls, Smith,
Reich, & Jung, 1988; Gleser, Green, & Winget,
1981; Newman, 1976), earthquakes (Galante & Foa,
1986), bushfire (McFarlane, 1987), and hurricanes
(La Greca, Silverman, Vernberg, & Prinstein, 1996;
Shaw, Applegate, Tanner, Perez, Rothe, CampoBowen, & Lahey, 1995; Vernberg, La Greca,
Silverman, & Prinstein, 1996). However, there is
limited controlled epidemiological data available on
psychological morbidity of children following
exposure to major disasters (Pefferbaum, 1997;
Shannon, Lonigan, Finch, Taylor, & Sallie, 1994;
Vogel & Vernberg, 1993).
A number of psychological symptoms have
been observed in children following disasters,
including fears, sleep problems, depression,
separation anxiety, somatic complaints, and conduct
problems. More recently, as the concept of post-
traumatic stress disorder (PTSD) has been applied to
children, studies have found symptoms of PTSD in
children following natural disasters (Lonigan,
Shannon, Finch, Daugherty, &Taylor, 1991;
Pefferbaum, 1997; Vogel & Vernberg, 1993). For
example, recent studies have shown a high rate of
PTSD symptoms in school-age children following
exposure to a severe hurricane (La Greca, Silverman,
Vernberg, & Prinstein, 1996; Vernberg, La Greca,
Silverman, & Prinstein, 1996). There is also
evidence of PTSD among children exposed to other
types of severe trauma such as sniper attack (Pynoos,
Frederick, Nader, Arroyo, Steinberg, Eth, Nunez, &
Fairbanks, 1987)), kidnapping (Terr, 1983),
witnessing violence (Kinzie, Sack, Angell, Manson,
& Rath, 1986; Saigh, 1989), and sexual abuse
(Kiser, Ackerman, Brown, Edwards, McColgan,
Pugh, & Pruitt, 1988). Available studies of children
suggest that symptoms of PTSD are related to degree
of exposure to life threat (Pynoos et al., 1987) and
levels of parental distress (McFarlane, 1987), and
may persist for long periods after the disaster
(Galante & Foa, 1986; Kinzie et al., 1986; Terr,
1983).
The homelessness and dislocation secondary to
property damage from a major disaster interrupts
peer friendship patterns. The loss of social support
may result in isolation and increases in dependency
upon adults. Post-traumatic stress reactions may
exacerbate this situation so that children's
progression through social, cognitive, and emotional
developmental tasks may be obstructed. The effects
of major stress on general child development have
not been adequately investigated (Pynoos & Nader,
1989), although clinical reports suggest severe stress
may result in personality changes even in young
children (Terr, 1979). Basic information is also
needed concerning developmental effects in
children's response to natural disaster. Some studies
have reported no age effects after major trauma
(Burke et al., 1982; Pynoos et al., 1987), while
others indicate older school-age children have more
symptoms than younger preschool-age children
(Gleser, Green, & Winget, 1981; Handford, Mayes,
Mattison, Humphrey, Bagnato, Bixler, & Kales,
1986). A number of clinical studies indicate that
preschool-age children display PTSD after
witnessing violent acts (Eth & Pynoos, 1985;
Schetky, 1978; Zeanah & Burke, 1984). However,
little is known about preschool-age children's
psychological responses to natural disaster, and few
studies have examined the role that socioeconomic
and cultural factors may play.
Thus, while studies have shown symptoms of
PTSD may occur in school-age children following
exposure to natural disasters and other major stress
involving life threat, little is known about PTSD in
younger, pre-school aged children, and how PTSD
may affect their overall development. Therefore, the
purpose of this study was to determine the effects of
PTSD on child development in a sample of low
income, preschool-aged children, exposed to
Hurricane Andrew in south Florida during August,
1992. We hypothesized that PTSD would have
deleterious effects on children’s attainment of
developmental skills.
Method
Participants
The subjects for this study were 175 children (ages 3-5
years) enrolled in Head Start programs of Miami-Dade County.
All of the children were from socio-economically
disadvantaged families, in accordance with eligibility criteria
for Head Start. Families were recruited from two Head Start
programs in the south part of the county, which was where the
hurricane hit, and two programs from the north part of the
county, approximately 40 miles away from where the eye of
the hurricane passed. The south (n=101) and north (n=74)
samples were similar in terms of age (4.4 vs. 4.3 years), gender
(45% vs. 48% male), and marital status (63% vs. 64% single).
However, there were differences (p<.001) in race/ethnicity,
with the southern sample being 14% white, non-Hispanic, 42%
Hispanic, and 43% black, while the northern sample was 1%
white, non-Hispanic, 25% Hispanic, and 74% black. In
addition, the highest grade completed by mothers in the south
was lower than in the north sample (11.7 vs. 12.5, p<.02).
Measures
The measures for this study included assessment of
demographic variables, symptoms of PTSD in children, and
overall child development.
Demographic Variables. Demographic variables included
age, gender, racial/ethnic status, marital status, and highest
grade completed by mothers. This information was obtained by
interview with the mother.
Symptoms of PTSD. The child was assessed for PTSD
using the methodology developed by Pynoos and colleagues,
the Child PTSD Reaction Index (Nader, Pynoos, Fairbanks, &
Frederick, 1990; Nader, Stuber, & Pynoos, 1991; Pynoos et al.,
1987; Stuber, Nader, Yasuda, Pynoos, & Cohen, 1991). Parents
were interviewed concerning the symptoms their child has
shown since the stressful event. All of the 17 symptoms listed
in the DSM-IV for PTSD are included in this measure in
addition to other symptoms young children may exhibit after
exposure to significant stress. Parents were asked to indicate
whether or not their child was currently exhibiting each of the
symptoms since the time of the hurricane. A diagnosis of PTSD
was made on the basis of data obtained from this assessment
procedure, using the 17 items included in the DSM-IV criteria.
The Child PTSD Reaction Index has been shown to have
acceptable reliability and vailidity (Nader et al., 1990, 1991;
Pynoos et al., 1987; Stuber et al., 1991).
Child Development. General child development was
measured by the Preschool Development Inventory (PDI), a
60-item scale based on parental report (Ireton, 1981). Each of
the items in this screening inventory represents a
developmental task that the parent indicates the child has either
succeeded with or not. The items cover language
comprehension, expressive language, fine and gross motor
skills,
self-help
skills,
personal-social
skills,
and
comprehension of situations. The number of items the child has
not passed is compared with norms for their age to determine
whether or not they exhibit a developmental delay, defined as
25% below age cutoff scores. A child would be considered to
be possibly delayed if he or she obtained a score that was lower
than the average score for children who are 25% younger. The
PDI has adequate psychometric properties and is well normed
for children in the age range of 3-6 years (Ireton, 1988).
Procedure
Families were recruited to the study by a research
assistant who met with parents as they dropped off or picked up
their children at the Head Start Center. After the parents (in
almost all cases, mothers) were told about the study, and their
questions answered, they completed informed consent
according to a protocol approved by the Institutional Review
Board for the Protection of Human Subjects.
Mothers were interviewed on two occasions: the first time
occurred between nine and 15 months post-hurricane, and the
second was in the interval of 15 to 21 months post-hurricane.
The average time since the hurricane for the first and second
assessments was 12 and 18 months, for the study sample as a
whole. Mothers were given $10 as an incentive for
participation in each of the two assessments, which were held
at the Head Start Center. The second measure of child PTSD
was obtained for 153 (87.4%) of the original 175 children in
the study sample, and the second measure of child development
was obtained for 163 (93.1%) of the original study sample.
Results
PTSD in Children
At 12 months post hurricane, more symptoms of
PTSD were reported by mothers in the hurricaneexposed southern sample than in the northern sample
(6.7 vs. 3.9, t(174) = 5.19, p<.0001). Similarly, at 18
months post-hurricane, children in the south still
exhibited more PTSD symptoms (6.0 vs. 3.8, t(148)
= 5.19, p<.0001).
Mothers' responses from the Child PTSD
Reaction Index were also utilized to categorize
children into two groups: those with PTSD vs. those
not having enough symptoms to meet DSM-IV
diagnostic criteria. At 12 months post-hurricane,
16.5% of the southern sample vs. 4.0% of the
northern sample had PTSD (chi-square (1) = 6.55,
p<.01). At 18 months post-hurricane, 11.6% of
children in the south had PTSD, vs. 3.1% in the
north (chi-square (1) = 3.60, p<.058).
More data concerning children’s psychological
responses and PTSD symptoms are detailed in a
separate report, including various exposure-related,
demographic, and psychosocial predictors of PTSD
(Delamater, Applegate, Kerdyk, & Shaw, 1999). For
the present study, we report only the overall findings
concerning PTSD as it relates to the primary
outcome variable, child development.
Child Development
At 12 months post-hurricane, 30.9% of the
entire study sample were rated as being delayed in
their overall development. There was a marginal
effect (chi-square (1) = 2.93, p<.087) for the south
vs. north site effect, with 31.2% in the south and
22.8% of children in the north rated as delayed. At
18 months post-hurricane, 15.3% of the children
were rated as delayed, but there was no effect of site
(14.3 vs. 10.7% in the south vs. north).
PTSD and Child Development
There was no relationship between PTSD
diagnostic status and developmental delay at 12
months post-hurricane. However, there was a
significant relationship between PTSD status at 12
months and developmental delay at 18 months (chi
square (1) = 8.64, p<.003): children with PTSD at 12
months were more likely to be developmentally
delayed at 18 months post-hurricane than those
without PTSD (Odds Ratio = 4.5, 95% confidence
intervals, 1.7 to 12.3). Similarly, there was a
significant relationship between PTSD status at 18
months and developmental delay at 18 months (chi
square (1) = 6.48, p<.01): children with PTSD at 18
months were more likely to be developmentally
delayed at 18 months post-hurricane than those
without PTSD (Odds Ratio = 7.9, 95% confidence
intervals, 1.6 to 38.7).
Discussion
These findings demonstrate that young
preschool-age children who were exposed to the
stress of a major hurricane were more likely to
exhibit symptoms of PTSD than a comparison group
of children who were less exposed to life threat by
being geographically removed from the most
damaging winds of the storm. Even one year after
experiencing the hurricane, PTSD symptoms were
fairly common and 16.5% of exposed children met
diagnostic criteria for PTSD on the basis of their
mothers’ reports. At eighteen months post-hurricane,
11.6% of children who lived in the south part of the
county where the hurricane did the most damage,
still met criteria for PTSD. It is noteworthy that a
small percentage of children living in the less
exposed, northern part of the county met diagnostic
criteria for PTSD, and many children exhibited some
symptoms, although less than the more exposed
children. This attests to the fact that the entire county
was under threat of the hurricane, and even in the
north, very high winds and some damage was
experienced, and the disruption associated with the
aftermath was felt throughout the entire county.
While this study is one of the first to examine PTSD
in preschool age children after exposure to a natural
disaster, it is consistent with studies suggesting
PTSD may occur in children of this age who have
witnessed violent acts (Eth & Pynoos, 1985;
Schetky, 1978; Zeanah & Burke, 1984).
A significant percentage of children were rated
by their mothers as having delays in their overall
development: 31% at 12 months post-hurricane and
15% at 18 months post-hurricane. While these
numbers seem fairly high, they may not be elevated
for the population of children attending Head Start
programs, who are more likely to be from minority,
single-parent families experiencing a variety of
economic and social stressors. Children growing up
in such stressful environments may be at risk for
some delays in their development.
This study is among the first to examine the
effects of PTSD on the general development of
young children. The finding that the presence of
PTSD was associated with delays in overall
development of children supports the primary
hypothesis of the study. In fact, children with PTSD
at 12 months post-hurricane were four and a half
times more likely to have developmental delays at
18 months post-hurricane than children without
PTSD, and those with PTSD at 18 months posthurricane were nearly eight times more likely to
continue to have significant delays in general
development. These findings indicate that besides
the distressing symptoms of PTSD for children and
their families, the child with PTSD is also at risk for
more general delays in their overall cognitive, social,
emotional, and physical development, supporting
previous clinical reports that severe stress can have
debilitating consequences for the personality
development of young children (Terr, 1979).
Assessment of PTSD in young children can be
challenging, as subjective experience is important to
consider in making the diagnosis. With very young
children, as in the current study, it is necessary to
interview parents to determine the presence of
symptoms of PTSD. The Child PTSD Reaction
Index has previously been used to ascertain the
presence of clinically significant symptoms of
PTSD, in direct interviews of children. With
preschool-age children as the focus of our study, we
utilized the items of the Reaction Index in a
structured interview with the mothers. In the present
report, we utilized only the 17 items included in the
DSM-IV diagnostic criteria for PTSD in our
analyses. As part of our overall study, we also
interviewed children directly using the Child PTSD
Reaction Index. However, the question of the
relationship between child and parent reports of
PTSD symptoms is beyond the scope of the current
report.
This study has some limitations. First, the
measurement of both PTSD and general
development were made by mothers. As these were
self-report measures by structured interview and
questionnaire, they may be subject to bias related to
their own recall and/or their own levels of distress
related to the hurricane and its aftermath. Further
studies could benefit by inclusion of more than one
type of informant, e.g., by including children’s selfreports, teachers, or other adults who know the
children well. While the finding of a relationship
between PTSD and developmental delay is
important, it would be informative to know more
specifically about the nature of the delays, whether
for example, they are in social, emotional, and/or
cognitive areas. The measure utilized in the current
study provided only an overall indicator of general
development, rather than more precise measurement
of specific areas of child development. In addition,
while this study was limited by not having prehurricane data on the emotional and developmental
functioning of the children, the use of a comparison
group of demographically similar children did
provide some control and lend confidence to the
findings. Finally, the lack of data during the initial
nine to twelve months post-hurricane may be
considered a limiting feature of the study design.
Nevertheless, the fact that PTSD and its
developmental consequences were observed for up
to eighteen to twenty-one months after hurricane
exposure provides important data concerning the
time course and persistence of emotional and
developmental effects in young children.
These findings have implications for the
caregivers of young children. Because having PTSD
may place young children at risk for developmental
delays, parents and other caregivers of preschoolaged
children
should
make
sure
that
developmentally stimulating activities are routinely
provided to traumatized children after exposure to
natural disaster. Developmental status should be
formally evaluated in children when parents or other
caregivers express concerns about their attainment of
expected developmental skills.
In summary, this study has shown that young
preschool-age children commonly exhibit symptoms
of PTSD after exposure to a life-threatening
hurricane, with 16.5% of exposed children meeting
diagnostic criteria for PTSD by mother report one
year after the hurricane, and 11.6% continuing to
have PTSD eighteen months after the hurricane.
These findings indicate the presence of PTSD places
young children at increased risk for failure to
achieve normal development in cognitive, social,
and emotional skills. Further studies are needed to
specify how PTSD may interfere with normal child
development.
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