Twenty-One-Month Follow-up Study of School-AgeChildren Exposed to Hurricane Andrew

JON A. SHAW, M.D., BROOKS APPLEGATE, PH.D., AND CARYN SCHORR, M.D.

ABSTRACT

Objective: To explore the 21-month course of posttraumatic stress symptomatology (PTSS) and psychological morbidity

in 30 school-age children (7 to 13 years) after exposure to Hurricane Andrew. Method: Pynoos' Posttraumatic Stress

Disorder Reaction Index and Achenbach's Teacher's Report Form were administered at 8 and 21 months after Hurricane

Andrew. Results: At 21 months 70% of the children endorsed moderate-severe PTSS. The reduction in PTSS was

greater for boys than girls. Psychopathology as measured by the Teacher's Report Form increased over the 19-month

period. Boys demonstrated significant increases in internalizing symptoms and in Withdrawn, Anxious/Depressed, Social

Problems, and Attention Problems scales, and girls showed a significant increase in the Anxious/Depressed scale.

Conclusions: Twenty-one months after exposure to Hurricane Andrew, there were continuing high levels of PTSS and

evidence of increasing emotional and behavioral problems. While girls sustained higher levels of PTSS, boys demon­

strated higher indices of other psychopathology. The enduring effects of disaster associated with secondary stressors

and "traumatic.reminders" continue to be etiologically important for continuing psychological morbidity. J. Am. Acad.

Child Ado/esc. Psychiatry, 1996, 35(3):359-364. Key Words: children, disaster, psychopathology.

The psychological effectsof natural disaster on childrenand adolescents have become an emerging focus ofstudy (Lipovsky, 1991). In recent years reports havebeen published on the psychological responses of chil­dren and adolescents to hurricane, fire, earthquake,and flood (Bloch et al., 1956; Bradburn, 1991; Burkeet al., 1986; Garrison et al., 1993; Green et al., 1991,1994; Honig et al., 1993; McFarlane et al., 1987;Newman, 1976; Pynoos et al., 1993; Shannon et al.,1994; Yacoubian and Hacker, 1989). The spectrumof posttraumatic stress symptomatology in childrenand adolescents generally parallels the psychologicalresponses of adults to overwhelming disaster. Acutepsychological responses to natural disaster includetrauma-specific fears, fears of recurrence, regressive

Accepted May 26, 1995.Dr. Shaw is Professor and Director, and Dr. Applegate isAdjunctAssistant

Professor, Division ofChildandAdolescentPsychiatry, Department ofPsychiatry,University ofMiami School ofMedicine. Dr. Schorr, a former childpsychiatryfellow in the Division of Child and Adolescent Psychiatry, is now in privatepractice.

Reprint requests to Dr. Shaw, University of Miami School of MedicineDepartment of Psychiatry D-29, P.O. Box 016960, Miami, FL 33101;telephone (305) 585-6862; fax: (305) 325-8355.

0890-8567/96/3503-0359$03.00/0©1996 by the American Academyof Child and Adolescent Psychiatry.

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:3, MARCH 1996

behavior, externalizing symptoms, behavioral reen­actment, posttraumatic play, avoidance of "traumaticreminders," detachment, anxiety and depressive disor­ders, school problems, symptoms of physiological hy­perarousal, and changed attirudes about the self,world,and future (Bloch et al., 1956; Burke et al., 1986;Green et al., 1991, 1994; Newman, 1976; Pynooset al., 1987; Terr, 1981, 1983). Terr (1991) has sug­gested that psychological trauma associated with expo­sure to an overwhelming stressor is etiological for anumber of psychiatric disorders.

While there are a number of reports on the acutepsychological responses of children to disaster, thereis a relative absence of longitudinal studies. It is onlyrecently that investigators have begun to attempt todelineate between the short-term and long-term psy­chological effects associated with exposure to disaster(Lipovsky, 1991; Pynoos, 1993). Concurrently therehas been increasing attention focused on the psychologi­cal and psychiatric comorbidity found with the coreposttraumatic symptomatology (Breslau et al., 1991;Saigh, 1991; Sullivan et al., 1991). The question arises,is there a consistent configuration or pattern in theevolution of psychological and behavioral distress inthe postdisaster experience over time?

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In an earlier article we reported on the psychologicaleffects of exposure to Hurricane Andrew on a schoolpopulation at 2 and 8 months. Sixty-two elementaryschool-age children (6 to 11 years) (HI-IMPACTschool) who were directly in the pathway of HurricaneAndrew were compared with a group of 44 childrennorth of Miami (Shaw et al., 1995). Eight weeksafter the hurricane, both groups were administered aninstrument measuring the degree of severity of exposureto the hurricane and Pynoos's Posttraumatic StressDisorder Reaction Index (PTSDRI). In addition, thestudents' primary classroom teacher completed anAchenbach's Teacher's Report Form (TRF) for eachchild. The PTSDRI and the TRF were repeated 32weeks after the hurricane.

We found that at 8 weeks, 85% of the children inthe HI-IMPACT school endorsed at least moderatelevels of posttraumatic symptomatology. At 32 weeksafter the hurricane, we were able to repeat the PTSDRImeasures on 47 of 62 children previously tested inthe HI-IMPACT school. Eighty-nine percent of thestudents were rated in the "moderate" and "severe"to "very severe" categories, which indicated continuingpsychological distress. We speculated that the initialhigh levels of posttraumatic stress symptomatologywere related to an "event trauma ," i.e., the impact ofHurricane Andrew, a stressor that was well circum­scribed in time and associated with both bodily andlife threat. The continuing high level of posttraumaticstress symptomatology at 32 weeks, we believe, not onlywas related to the continuing exposure to "traumaticreminders" but also was due to the emergence of"process" trauma (Terr, 1991), i.e., an array of"second­ary stressors" to include community and school disrup­tion , flight of refugees, unemployment, and loss ofhome and logisticalsupport systems (Shaw et al., 1995).

One of the most interesting findings was the signifi­cant reduction in the manifestations of other emotionaland behavioral problems in the HI-IMPACT schoolimmediately after the hurricane, with a gradual rise inthese measures subsequently. Children in the pathwayof Hurricane Andrew manifested reduced indices ofpsychopathology as measured by the TRF across allscales relative to the comparison group. While thistrend was consistent, the findings were more significantfor girls. The boys demonstrated lower scores on theAnxious/Depressed scale, while the girls in the HI­IMPACT school showed significantly lower mean

360

scores on the Internalizing and Externalizing globalscales, as well as Anxious/Depressed, Social Problems,Delinquent Behavior, and Aggressive Behavior, thanchildren in the comparison group.

This finding of reduced TRF indices of psychopa­thology in the immediate aftermath of Hurricane An­drew was confirmed by other measures of reporteddisruptive behavior which were also significantly lowerin the HI-IMPACT school relative to the comparisongroup and the previous year's level of reported disrup­tive behavior in the HI-IMPACT school. We examinedthe relative risk of 21 disruptive behaviors reported tothe Dade County Public School Central Office forthe HI-IMPACT school and its respective educationaldistrict, for each grading period for the school yearafter the hurricane compared with the previous schoolyear. Disruptive behaviors measured included generaldisruptive behavior, defiance of school authority, dis­ruption on the school bus, assault, theft , vandalism,battery on a student or staff member, fighting, robbery,continuous disruptive behavior, damaging school prop­erty, aggravated assault, use of provocative language,cutting class, dress code violations, excess unsatisfactoryabsences, being in an unauthorized location, leavingclasswithout permission, rude and discourteous behav­ior, excessive tardiness, and trespassing.

School-based disruptive behavior showed a markeddecrease in prevalence for the grading period immedi­ately after the hurricane in the HI-IMPACT school,with a rebound effect 3 to 4 months after the hurricane.We speculated that this initial decline in observedpsychopathology was the result of a generic shocklike,numbing effect in the immediate aftermath of thehurricane which dampened the behavioral responsesto the disaster.

At the 32-week reevaluation, there were no statisti­cally significant changes on the TRF scales for boysand girls, although the trend in means across all scalesevidenced a higher value at week 32 for both genders.

In an effort to explore further the evolution of thepsychological and behavioral effects in the postdisasterperiod, we have undertaken a 21-month follow-up ofthe elementary school-age children who were directlyin the pathway of Hurricane Andrew.

METHOD

Thirty of the original cohort of children who were initiallyevaluated at 2 and 8 months after Hurricane Andrew were adminis-

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HURRICANE ANDREW

46.746.7

6.6

305317

2-8 Months 2-21 Months

% Improved% No change% Worsened

can be seen in this figure there is a progressive decreasein children rated in the severe-very severe categoryof posttraumatic stress symptomatology with slightchanges in the children rated in the moderate categorybut a twofold increase in children rated doubtful-mild.In essence there has been a cascading of children fromthe severe-very severe to the doubtful-mild category.At 21 months 70% of the children endorsed moderate­severe posttraumatic symptomatology.

The trend in posttraumatic stress symptomatologywas examined for statistical significance via CATMOD(SAS, 1990). A repeated-measures analysis (time: 2, 8,21 months posthurricane) with PTSDRI as the ordinaldependent variable revealed a statistically significanteffect for time (X2 [2, N = 29] = 13.82, P < .001),and post hoc follow-up indicated that the relativepattern in posttraumatic stress symptomatology didnot change between 2 and 8 months but did changebetween 2 and 21, and 8 and 21 months (p values< .01). Although the above analysis strongly implicatesa general group trend toward improvement, it doesnot adequately reveal how individual children's symp­tomatology changed. Table 1 presents individual pat­terns in posttraumatic stress symptomatology between2 and 21 months.

If one considers a clinically relevant level ofPTSDRIsymptomatology to be in the severe-very severe cate­gory, then it is also important to identify those childrenwhose condition seemed to get worse over the 19­month period. While 17% (8) were worse at 8 months,only two continued to exhibit more posttraumaticstress symptomatology at 21 months than they did at2 months after the hurricane. Fifty percent of thechildren (4) who worsened at 8 months did so bymoving into the severe-very severe category. The chil­dren whose condition worsened over time would bean interesting sample for further study.

A similar set of analyses was conducted separatelyfor both boys and girls (Fig. 2). For boys, the same

TABLE 1Individual Patterns in Posttraumatic Stress Disorder

Reaction Index Symptomatology

21Months8 Months2 Months

~ 40+----

RcENT 20

The prevalence of posttraumatic stress symptomatol­ogy at 2, 8, and 21 months is noted in Figure 1. As

I_NO.- Mild _Moderate III Severe I

Fig. 1 Prevalence of Posttraumatic Stress Disorder Reaction Index symp­tomatology at 2, 8, and 21 months after Hurricane Andrew.

RESULTS

60,-------.,..-------,---------,

tered repeated measures at 21 months. Once again our measuresincluded the PTSDRI and the TRF.

The PTSDRI is an instrument designed to assess the degree ofposttraumatic symptomatology in children. Its items conform toDSM-III-R posttraumatic stress disorder (PTSD) symptoms andare rated on a 5-point ordinal scale from "none of the time" to"much of the time." A total PTSD score is obtained by summingacross all items after adjusting for reverse-scored items (Pynoos,personal communication). The PTSDRI was standardized on 750children and 1,350 adult casesof stress-laden events and has showna correlation of .91 with a positive PTSD diagnosis in children(Frederick, 1985). More recently, Shannon et al. (1994) andLonigan et al. (1994) used the PTSDRI in a study with morethan 5,500 children exposed to Hurricane Hugo. Shannon et al.(1994) reported high internal consistency values (ex = .83) for thefull instrument and values ranging from .55 to .86 for symptomclusters corresponding to the DSM-III-R Lonigan et al. (1994)provided validity evidence for the PTSDRI by demonstrating thatthe presence of PTSD symptomatology assessed by the PTSDRIwas strongly related to self-reported hurricane severity, degree ofhome damage, and continued displacement. Similarly, using our2-month posthurricane data, we estimated coefficient ex at .75,and the test-retest reliability between 2 and 8 months posthurricanewas .59.

The TRF requires classroom teachers to rate various studentbehaviors on a 3-point scale (not true, sometimes true, often true)and provides eight behavioral syndrome scale scores and twocomposite scale scores: Withdrawn, Somatic Complaints, Anxious!Depressed, Social Problems, Thought Problems, Attention Prob­lems, Delinquent Behavior, Aggressive Behavior, and Internalizingand Externalizing, respectively. The TRF has been standardizedon 1,100 children aged 4 to 18 years (Achenbach and Edelbrock,1986), and studies have shown a mean test-retest reliability (15­day retest interval) across various samples to be .92 (Achenbach,1991), while interteacher agreement was generally greater than .60(Achenbach, 1991). There have been a multitude of validity studiesinvestigating the TRF scales (refer to Achenbach [1991] for specificinformation regarding the construct and criterion-related validityof the TRF).

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:3, MARCH 1996 361

SHAW ET AL.

7'~--,-------,-------r-------,

PERCENT

I •Male • Female IFig. 2 Percentage of Posttraumatic Stress Disorder Reaction Indexsymp­tomatology for males and females at 2, 8, and 21 months after Hurri­cane Andrew.

pattern of results as found in the combined samplewas observed. That is, there was an overall statisticallysignificant group decrease in PTSDRI symptomatology(X2 [2, N = 14] = 15.04, P < .0005) such that symptom­atology at 2 months was not statistically different fromthat at 8 months bur symptomatology at 2 monthswas higher than at 21 months and symptomatologyat 8 months was higher than at 21 months (p values< .001). This trend, however, was not observed forgirls, in whom there was not a statistically significanteffect for time. The reduction in posttraumatic symp­tomatology was greater for boys than for girls.

The reduction in posttraumatic stress symptomatol­ogy over the 19-month interval is predominantly ex­plained by boys, who experienced a decrease in thePTSDRI mean from 37.3 to 24.9 , while girls decreasedfrom 41.4 to 37.2.

We were able to obtain repeated measures on theTRF on 25 of the original sample. A comparison ofTRF scores for all subjects tested at 2 and 21 monthsis noted in Table 2.

There was an evident trend toward increasing psy­chopathology over the 19-month period. Several signifi­cant differences were found in subjects at 21 monthscompared with subjects at 2 months. At 21 months,compared with the immediate posthurricane period ,the boys demonstrated a significant increase in indicesof being withdrawn, being anxious/depressed, havingsocial problems, having attention problems, and in thegeneral category of internalizing symptoms (all p values< .05). Girls demonstrated a significant increase inthe dimension of anxiety/depression (p < .05).

362

TABLE 2Teacher's Report Form (T RF) Scales for Boys and Girls:

Analysis of the Mean Difference between 2 and 2 1 Monrhs

Male (n ~ 12) Female (n ~ 12)

T RF Scale Mean Diff. SD Mean Diff. SD

Wi thdrawn 1.75* 2.22 0.85 2.70Somatic Complainr 0.42 1.16 0.08 0.49Anxious/Depressed 3.42* 3.80 1.77* 2.52Social Problems 3.17* 4.61 0.46 1.45Thought Problems 0.67 1.67 0.46 0.97Attention Problems 7.25* 10.71 0.23 6.7 1Delinquenr Behavior 1.00 1.60 0.77 2.24Aggressive Behavior 7.08 13.55 1.92 6.81Inrern alizing Behavior 5.58** 5.86 2.69 4.61Externalizing Behavior 8.08* 14.79 2.69 8.51

* P < .05; **P < .01.

DISCUSSION

Our findings are in accord with the stud ies thathave demonstrated sustained and continuing psycho­logical and behavioral responses associated with expo­sure to disaster (Bloch er al., 1956; Breslau et al.,1991; Garrison et al., 1993; Green et aI., 1991; Loniganet aI., 1994; Lyons, 1987; Newman, 1976; Pynooset aI., 1987; Shannon et al., 1994). Our finding that70% of the children continue to demonstrate moderateto very severe postt raumatic stress symptomatology 21months after the hurricane speaks to the enduringstressors associated with the secondary effects of thedevastation wrought by Hurricane Andrew and theoccurrences of "traumatic reminders."

Not only did we find persistent and sustained post­traumatic stress symptomatology, bur we found indicesof increased psychopathology over the 19-month pe­riod. In an earlier article, we found that children inthe immediate pathway of the hurricane demonstrateddecreased indices of psychopathology on the TRF anddiminished behavioral problems in the immediate after­math of the hurricane compared with a comparisongroup bur that there was a subsequent rise in problembehaviors by the end of the year (Shaw et a1., 1995).In this study we demonstrated that 21 months afterthe hurricane there cont inue to be increased indicesof psychopathology for both boys and girls. At 21months compared with the immediate posthurricaneperiod, the boys demonstrated a significant increase inindices of being withdrawn, having social problems,having attention problems, being anxious/depressed ,and in the general category of internalizing symptoms .

] . AM. ACAD . CHILD ADOLESC. PSYC H IAT RY, 35:3, MARCH 1996

Girls demonstrated a significant increase in the dimen­sion of anxiety/depression. It should also be noted thatthe largest increase in teacher ratings was for boys'externalizing symptoms, but this increase also camewith a vety large standard deviation, thus mitigatingits statistical significance.

Pynoos (1993) has noted that the long-term post­traumatic stress-related pathologies include "chronicPTSD, comorbid mental and physical conditions, de­velopmental and personality disturbances, and age ap­propriate indications of dissatisfactions and lack of wellbeing" (p. 231). In follow-up studies of children afterthe Buffalo Creek disaster, Green et al. (1991, 1994)noted that 2 years after the disaster, 37% of the childrenand adolescents were given a "probable" diagnosis ofPTSD, and 17 years after the disaster 7% of thosereevaluated had PTSD and all of these individuals werewomen. Green et al. (1991) found that the risk factorsthat best predicted continuing posttraumatic symptom­atology was degree oflife threat, parental psychopathol­ogy, being female, and an irritable and/or depressedfamily atmosphere. Honig et al. (1993) observed thatthere was a spectrum of "adaptational possibilities"found in children 20 years after the Buffalo Creekdisaster which were related to the family's initial re­sponse to the disaster and that psychopathology in thechildren resonated with parental psychopathology.

Our finding that comorbid psychological and behav­ioral distress was lower than in a comparison groupin the immediate aftermath of the hurricane but in­creased over time is similar to findings of studiesof the children exposed to an Australian bush fire(McFarlane et al., 1987). The authors demonstratedthat children 5 to 12 years of age who were exposedto a bush fire manifested increased rates of psychiatricdisorders 8 and 26 months after the disaster. McFarlane(1987) speculated that the increased risk for psychiatricdisorder in children over time was related to increasingfamily dysfunction. Other studies have demonstratedincreased behavior and psychological distress in theposttraumatic experience. Breton et al. (1993) foundthat a year after an industrial accident, children aged6 to 11 years displayed more overall internalized andposttraumatic symptoms than did a control group.

The continuing high level ofPTSDRI symptomatol­ogy as well as increasing levels of psychological andbehavioral distress at 21 months, we believe, are relatedto the emergence of a "process" trauma (Terr, 1991).

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HURRICANE ANDREW

This may best be interpreted as exposure to an arrayof enduring "secondary stressors" such as traumaticreminders, continuing adversity, and demoralization.The effectof the hurricane was to destroy the infrastruc­ture of a community, resulting in high unemployment,family dwellings rendered uninhabitable, the exodusof a large proportion of the population, and the lossof electricity, telephones, and logistical support systemsfor many months. The initial hopefulness of recoveryafter the input of federal resources was followed byincreasing pessimism as families struggled with theinherent adversarial relationship with insurance compa­nies, contractors, and code inspectors; unemployment;and the "loss of community." The devastating effectsof natural disaster on the infrastructure ofa communitywith subsequent psychosocial adversity for its inhabit­ants has been well documented (Adams and Adams,1984; Erikson, 1976; Lifton and Olson, 1976).

It is our hypothesis that the impact of the "event"stressor was quickly followed by the enduring impactof an array of chronic stressors as the communitybegan the slow process of recovery and reparation. Theincreasing spectrum and frequency of emotional andbehavior problems in the children as the school yearprogressed resonated with this process.

The finding that girls demonstrated a smaller reduc­tion in the level of posttraumatic symptomatology overtime is congruent with the literature. A number ofstudies have demonstrated that being female is a riskfactor for PTSD and that being female predicts slowerrecovery from PTSD (Breslau et al., 1991; Garrisonet aI., 1993; Green et al., 1991; Shannon et aI., 1994).It is particularly interesting to note that while girlssustained higher indices of posttraumatic stress symp­tomatology over the 19-month period and a slowerincrease in other indices of psychopathology on theTRF, boys showed a greater reduction in posttraumaticstress symptomatology but a greater increase in TRF­reported psychopathology. This suggests that whileboys were able to move away from a preoccupationwith the hurricane, the psychological distress becamemanifested in other ways. While there are genderdifferences in expression, it is apparent that psychologi­cal stress remains high in the aftermath of HurricaneAndrew. It is evident that while a disaster may bewell circumscribed in time and quickly dissipates, theenduring effects associated with the destruction of acommunity, the secondary stressors, and the "traumatic

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reminders" continue to have an impact on the victimsof disaster.

These results support the general finding of continu­ing and sustained moderate levels of posttraumaticstress symptomatology and suggest that after a naturaldisaster there may be increasing psychopathology inchildren. It is important to note the limitations associ­ated with small sample sizes and the limited generaliz­ability because of the idiosyncratic nature of thecircumstances of natural disaster and its derivativeeffects on the infrastructure of a community.

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