Disasters occur once a day on average in the world (International Strategy for Disaster Reduction, n.d.
). As traumatic events, they are potentially strong stressors due to their disruptive nature, high extent of impact, production of terror and horrors scenes, undesirable and uncontrollable occurrences, and prolonged alterations in the social and material environment (Davidson and Baum 1986
). The scientific understanding of the impact of disasters on child and adolescent psychological functioning has greatly increased in recent times and various excellent recent reviews of the literature have been published (e.g., La Greca et al. 2002
; Norris et al. 2002a
). When children experience a life-threatening disaster, they may show a wide range of psychological reactions, especially symptoms of post traumatic stress disorder (PTSD), depression, generalized anxiety and pathological grief reactions (La Greca et al. 1998
; Vogel and Vernberg 1993
; Weems et al. 2007
; Yule 2001
An important clinical issue regarding psychological responses to disasters is the persistence of these reactions. Existing evidence indicates that youth who are heavily exposed to a disaster may experience psychological distress that may last for years after the event (Vogel and Vernberg 1993
). For some children who experience catastrophic levels of trauma exposure in these events, initial posttraumatic stress (PTS) symptoms common in PTSD and separation anxiety often develop over time into serious levels of depression (Vernberg 2002
). Generally, a decline in symptomatology is observed over the first years following natural disasters (La Greca and Prinstein 2002
). However, following Hurricane Katrina, studies on children and adults show an increase in PTS, anxiety, and distress symptoms over time, possibly due to prolonged stress in the recovery context (Kessler et al. 2008
; Weems et al. 2010
Although these advancements in the scientific understanding of the impact of natural disasters on youth functioning are significant, research is still needed in some important areas, which this study can address. Most child disaster studies examine PTS and/or depression symptoms. However, reactions may include other internalizing disorders and the acting out, aggressive, and delinquent behaviors associated with externalizing reactions to stress. These reactions may persist for long periods of time for some children. For example, Weems and colleagues (2010
) found mental health problems among youth survivors at 24 and 30 months post-Hurricane Katrina. In addition, how the types of trauma reactions may vary by the age of the child needs further exploration, but most studies of child survivors of disasters have had a limited age range. Thus, to better understand the range of traumatic reactions among children and youth, a wide range of psychopathology needs to be assessed across age ranges.
Likewise, few studies have investigated if psychological post-disaster reactions meet criteria for a disorder, which our study can address. This line of research is needed to distinguish “normal” or adaptive reactions, which are likely self-corrective, from what could be considered “pathological” effects that require intervention (La Greca and Prinstein 2002
). Most studies examine symptoms only, and fail to assess for psychosocial impairment, although DSM-IV includes it as a criterion in the classification of disorders. The consideration of this criterion would make disaster studies more reflective of clinical reality, since the impairment that results from symptoms is what usually leads to a child being referred to services rather than the mere manifestation of symptoms (Angold et al. 1999
). La Greca and Prinstein (2002
) acknowledged, however, that the disaster studies they reviewed did not assess impairment of youth’s functioning.
The few studies that have examined the reaction of children and adolescents to disasters at the disorder-level have mainly focused on the presence of PTSD related to the post-disaster time (3 months to 1 year), reporting rates that fluctuate between 2% and 7.3% (La Greca and Prinstein 2002
). However, the persistence of these disorders through time has not been studied since the use of longitudinal designs involving multiple assessments post-disaster is sparse.
Conceptual Model of Post-Disaster Trauma Reactions
Rather than merely documenting that exposure to disasters evokes symptoms and disorders, disaster studies need to identify factors that influence the development and maintenance of disaster-related reactions in children and adolescents. To guide this research and organize its findings, a conceptual model (e.g., Silverman and La Greca 2002
; Vernberg et al. 1996
) has been developed to overcome the atheoretical nature of many studies in the field. The model presented by Vernberg, La Greca and colleagues (La Greca et al. 1996
; Silverman and La Greca 2002
, Vernberg et al. 1996
) proposes that aspects of the disaster experience (e.g., life threat, loss & disruption), along with preexisting child characteristics (e.g., demographic characteristics & pre-disaster functioning), influence efforts to cope with the events. Efforts to cope have a reciprocal relationship with PTS symptoms. Exposure to traumatic events influences aspects of the post-disaster recovery environment (e.g., social supports and major life events or stressors) which also has a reciprocal relationship with efforts to cope with events. The authors found empirical support for their model in predicting PTSD after Hurricane Andrew, but further research is needed in order to look at other psychiatric disorders within other populations.
In support of the model, research shows that the more children perceive their lives, or the lives of loved ones to be threatened, the closer proximity to the event, and greater loss, the higher the report of PTS symptoms (Silverman and La Greca 2002
). This is likely true for other internalizing disorders, and may extend to externalizing problems as well. Conversely, children who do not perceive their lives or loved ones lives to be at danger, or who do not experience significant loss, may not report PTS symptoms following a disaster. In terms of pre-existing child characteristics, some research indicates that being female, younger, and/or having prior psychosocial or learning problems are related to higher post-disaster PTS (La Greca and Prinstein 2002
; Silverman and La Greca 2002
). For young children, it is unclear if the risk stems from developmental differences in younger children’s perceptions of disaster trauma, or from the tendency of young children to engage in behavior that is more readily identifiable by caregivers as distress (e.g., trauma-themed play La Greca and Prinstein 2002
). In contrast, Norris et al. (2002a
) report that among the child and adolescent studies they reviewed, the findings on age were inconsistent. They also report that poverty is a risk factor for worse post-disaster functioning, perhaps due to greater exposure or less resources to facilitate recovery.
In the present study we focus on aspects of the disaster experience and pre-existing child characteristics. For the former, it is known that the extent and intensity of exposure is key to predicting children’s psychological reactions (La Greca et al. 2002
). Whether this holds after more than a year has passed has rarely been studied with youth. But as recovery can be prolonged, mental health outcomes can persist (e.g., Weems et al. 2010
). We examine this at 18 and 30 months post-disaster, and have an unexposed comparison group. We also explore the influence of gender, age, and poverty status for internalizing and externalizing disorders. Females may have been more at risk in past studies because PTS or other internalizing disorders were examined. A different result may emerge with the inclusion of externalizing problems. A wide age range was assessed in this study and the functioning of younger (age 4–10 years) and older (age 11–17 years) can be assessed. As prior findings have been equivocal (Norris et al. 2002a
), and most studies do not have a large age range, this study can assist in clarifying this relationship at a basic level. Financial strain, as a pre-existing demographic characteristic, is also explored. Poverty level is already high in this sample; however the perception of poverty can influence ability to recover.
Post-Disaster Distress Among Latino/as
Our study assesses the range of psychiatric disorders post-disaster among Puerto Rican children and youth. How our findings potentially generalize to other U.S. populations, including mainland Puerto Ricans, is important to consider. Thus, we briefly summarize relevant research that can guide the interpretation of our findings and lends some support to the ability to generalize the results. As the cross-ethnic research on youth mental health following a natural disaster is scant, we review many types of studies, including those on adults, studies following terrorism, and general cross-ethnic studies of youth mental health.
In their review of the literature, Adams and Boscarino (2005
) noted inconsistent findings when Latino and White adults were compared on rates of PTSD following the 9/11/01 World Trade Center attack. After adjusting for demographics, stressors, and stress moderators, they report little support for the idea that Latinos may suffer from worse mental health following a disaster than Whites. In contrast, Perilla et al. (2002
) found that White survivors of Hurricane Andrew showed the lowest rates of PTSD, whereas Spanish-preferring Latino/as showed the highest rates. However, this could partially be explained by differential exposure as the Latino/a group had greater exposure. Child disaster studies have also explored the role of ethnicity, exposure, and post-disaster mental health. Vernberg and associates (1996
) did not find an effect for ethnicity on PTS symptoms. Overall, these findings support that the rates in a Latino population are likely similar to other populations if level of exposure is similar and demographic characteristics, for example socioeconomics, are controlled.
Issues of the influence of acculturation and cultural stress on mental health are also important to consider in terms of generalizability. The hypothesis that Puerto Ricans living on the mainland US may differ from those living in Puerto Rico (PR) on mental health due to differences in acculturation and cultural stress was explored by Duarte and colleagues (2008
). Using two samples of Puerto Rican youth (one group living in South Bronx, the other in PR), the same measures and methods, they found that the influence of acculturation and cultural stress on psychiatric symptoms was similar for mainland and island-bound Puerto Rican youth. Consequently, this also lends some support to the generalizability of the findings of this current study to mainland populations.
An unusual opportunity arose in 1998 in the Spanish-speaking Caribbean island of PR to study some of the issues previously mentioned, especially the persistence of disorders in the post-disaster period. A longitudinal two-wave epidemiological study was already planned and funded to study psychopathology and mental health services in a random sample of the island’s population of children and adolescents when Hurricane Georges struck. At the time, a pilot study to assess the psychometric properties of the instruments was on the verge of starting and data collection for the survey’s first wave began a year later. Hurricane Georges hit the Caribbean and Eastern United States as a category two hurricane, in late September 1998. Two days after it struck PR, many communities reported property damage, 416 government shelters were opened for approximately 28,000 persons, 700,000 persons were without water and 1,000,000 had no electricity for some time (Center for Disease Control and Prevention 1998
). The destruction left many families affected psychologically. For example, in the eastern part of the island, 2,238 individual cases were reported as receiving crisis counseling in a 3-week period, including approximately 467 cases of children that were exhibiting acute reactions to stress (Prewitt 1999
). Although PR regularly experiences tropical storms, a hurricane hitting the island is a rarer event, compared to the frequency in which hurricanes inundate Florida, for example. To date, a hurricane has not hit the island since Hurricane Georges. Prior to Hurricane Georges, the last hurricane to strike the island was Hurricane Hugo, which made landfall in September, 1989. Thus, the level of devastation experienced by the children and families in this study is beyond what they experience in a regular hurricane season.
The present study, due to its inception in a large, comprehensive two-wave study, overcomes some methodological limitations identified in the disaster literature (Norris et al. 2006
; La Greca et al. 2002
). The availability of a large random sample of the population enables the comparison of exposed and unexposed groups and the use of control variables in the analysis to better study the disaster-disorder relationship; it also allows for the detection of interaction effects. This study examined the persistence of post-disaster disorders in youth (4–17 years old), at approximately 18 (T1) and 30 (T2) months post-disaster. We predicted that greater hurricane exposure would be related to internalizing, externalizing, and any psychiatric disorder at both 18 and 30 months post-disaster. Given the large age range, we assessed for differential affects by age group (ages 4–10 years and 11–17 years). We could not divide the age range further due to loss of statistical power. We explored the moderating effects of preexisting characteristics of the child (i.e., sex, age) and the family (poverty level) in the youth’s disaster response. Finally, we provide frequencies for specific disorders if there was significant relation between exposure and the higher rank disorder categories.