Children’s Disaster Reactions: the Influence of Exposure and Personal Characteristics

Abstract

This paper reviews children's reactions to disasters and the personal and situational factors that influence their reactions. Posttraumatic stress disorder (PTSD) and posttraumatic stress reactions are the most commonly studied outcomes, though other conditions also occur including anxiety, depression, behavior problems, and substance use. More recently, traumatic grief and posttraumatic growth have been explored. New research has delineated trajectories of children's posttraumatic stress reactions and offered insight into the long-term consequences of their disaster experiences. Risk factors for adverse outcomes include pre-disaster vulnerabilities, perception of threat, and loss and life disruptions post-disaster. Areas in need of additional research include studies on the timing and course of depression and anxiety post-event and their interactions with other disorders, disaster-related functional and cognitive impairment, positive outcomes, and coping.

Full text

CHILD AND FAMILY DISASTER PSYCHIATRY (B PFEFFERBAUM, SECTION EDITOR)
Children’s Disaster Reactions: the Influence of Exposure
and Personal Characteristics
Betty Pfefferbaum
1,2
&Anne K. Jacobs
2
&Natalie Griffin
2
&J. Brian Houston
3
#Springer Science+Business Media New York 2015
Abstract This paper reviews children’s reactions to disasters
and the personal and situational factors that influence their
reactions. Posttraumatic stress disorder (PTSD) and posttrau-
matic stress reactions are the most commonly studied out-
comes, though other conditions also occur including anxiety,
depression, behavior problems, and substance use. More re-
cently, traumatic grief and posttraumatic growth have been
explored. New research has delineated trajectories of chil-
dren’s posttraumatic stress reactions and offered insight into
the long-term consequences of their disaster experiences. Risk
factors for adverse outcomes include pre-disaster vulnerabil-
ities, perception of threat, and loss and life disruptions post-
disaster. Areas in need of additional research include studies
on the timing and course of depression and anxiety post-event
and their interactions with other disorders, disaster-related
functional and cognitive impairment, positive outcomes, and
coping.
Keywords Adolescents .Anxiety .Children .Coping .
Depression .Disaster .Exposure .Mental health .
Posttraumatic growth .Posttraumatic stress .Posttraumatic
stress disorder (PTSD) .Recovery .Resilience .Terr o r ism .
Trauma .Traumatic grief
Introduction
Children have been recognized as especially vulnerable to
disasters [1]. A nationally representative survey conducted in
the USA established a lifetime rate of disaster exposure at
13.9 % in children and adolescents [2]; almost one fourth of
those who experienced a lifetime disaster reported more than
one disaster. In another nationally representative US survey of
adolescents, exposure to natural or human-caused disasters
was 14.8 %, second only to unexpected death of a loved one
at 28.2 % as the most common potentially traumatic event [3].
Rates in other parts of the world, especially in less developed
regions, are likely to be higher due to less durable infrastruc-
tures, rapid expansion of populations and industrialization,
and political conflict.
This paper reviews children’s emotional and behavioral
reactions to disasters with a focus on recent studies that have
explored an expanded range of outcomes, trajectories of re-
sponse and long-term disaster effects, and nuances of expo-
sure and children’s personal characteristics that affect their
recovery. A companion paper reviews the environmental in-
fluences, such as family and community factors, on children’s
reactions [4••].
This article is part of the Topical Collection on Child and Family Disaster
Psychiatry
*Betty Pfefferbaum
Betty-Pfefferbaum@ouhsc.edu
Anne K. Jacobs
akzerg@yahoo.com
Natalie Griffin
Natalie-Griffin@ouhsc.edu
J. Brian Houston
houstonjb@missouri.edu
1
Department of Psychiatry and Behavioral Sciences, College of
Medicine, University of Oklahoma Health Sciences Center,
P.O. Box 26901, WP3217, Oklahoma City, OK 73126-0901, USA
2
Terrorism and Disaster Center, University of Oklahoma Health
Sciences Center, P.O. Box 26901, WP3217, Oklahoma
City, OK 73126-0901, USA
3
Department of Communication, University of Missouri, 115 Switzler
Hall, Columbia, MO 65211-2310, USA
Curr Psychiatry Rep (2015) 17:56
DOI 10.1007/s11920-015-0598-5

Children’s Reactions to Disasters
The literature describes a range of disaster outcomes in
children from transient emotional distress and behavior
changes to enduring psychopathology and impaired func-
tioning [5,6]. Many children, while experiencing distress
in association with their disaster experiences, do not de-
velop psychopathology, but instead adapt to their experi-
ences and environment. Commonly studied post-disaster
outcomes are internalizing reactions and conditions such
as posttraumatic stress disorder (PTSD) and posttraumatic
stress reactions, anxiety, and depression. Externalizing be-
havior problems including substance use, cognitive ef-
fects, and traumatic grief have also been investigated.
Some children are resilient, and some experience posttrau-
matic growth. Recent studies have illustrated the trajecto-
ry of children’s reactions over time, but few long-term
follow-up studies have been conducted.
Rates of PTSD and posttraumatic stress in children post-
disaster vary depending on the samples assessed, the specific
outcomes measured, and the research methodology used. For
example, rates of significantly elevated symptom severity
have been estimated to be below 30 % [7], and the rate of
moderate posttraumatic stress symptoms in the acute post-
disaster period has been estimated at 50 % [6]. A recent
meta-analysis of studies of children and adolescents from
countries around the world revealed that overall, 15.9 % of
youth exposed to a traumatic event developed PTSD,
which reflects 9.7 % of children exposed to non-
interpersonal trauma, such as accidents and natural disas-
ters, and 25.2 % of youth exposed to interpersonal trauma
[8]. Posttraumatic stress symptoms appear to be common
in the first months post-event with a decline over the first
year or longer [7].
Depression and anxiety are common reactions to disas-
ters often comorbid with PTSD or posttraumatic stress [7,
9]. Depression may occur secondary to loss and grief, un-
resolved trauma and posttraumatic stress, and/or secondary
adversities [9]. Depression also may precede posttraumatic
stress symptoms [10]. Lai and colleagues [10]foundco-
morbid posttraumatic stress and depression in their hurri-
cane study in which loss of life was relatively low with 10
and 7 % of children evidencing comorbid posttraumatic
stress and depression symptoms 8 and 15 months post-di-
saster, respectively; recovery was slower in those with co-
morbid posttraumatic stress and depression. A recent re-
view study reported elevated prevalence rates for post-
disaster depression ranging from 2 to 69 % in children
relative to cited general populationratesfrom1to9%
[11••]. Another review of depression in children after nat-
ural disasters revealed prevalence rates in children ranging
from 7.5 to 44.8 % across studies [12•]. Given these high
rates, more empirical work is warranted to explore the
varied etiologies and time course of depression as well as
its relationship to other disorders.
Disaster exposure may initiate a path to the develop-
ment of anxiety disorders such as specific phobias, panic
disorder, and separation anxiety [6]. Studies have docu-
mented increases in children’s generalized anxiety in re-
lation to disaster exposure [7], but post-disaster anxiety
may represent the continuation of pre-event anxiety or
trait anxiety [13•]. Not all longitudinal studies have con-
firmed an increase in anxiety symptoms post-event,
though this may simply reflect an absence of the normal
decline in rates over the course of development [14].
Thus, additional work is needed to clarify findings relat-
ed to post-disaster anxiety in children, to identify predis-
posing influences, and to explore the progression of anx-
iety symptomatology and its relationship to other disaster
reactions.
Behavior problems also have been studied in children in
the context of disasters with conflicting results. For example,
research has documented both an increase in externalizing
conditions [e.g., 15,16] and improvement in children’sbehav-
ior post-event with a return to pre-event levels over time [e.g.,
17,18]. Recent work in the Middle East suggests that expo-
sure to chronic terrorism and political violence is linked to
behavior problems [e.g., 19]. For example, Pat-Horenczyk
and colleagues [19] found that preschool children exposed to
ongoing political violence had higher rates of behavior prob-
lems as well as PTSD and depression symptoms than children
without chronic exposure. Moreover, maternal distress was
associated with child distress in the form of externalizing,
internalizing, and posttraumatic stress symptoms, and the ac-
cumulated and continuous exposure to political violence and
danger increased maternal distress which further affected the
child [19].
Recent literature has examined substance use in association
with disaster exposure in youth [e.g., 20–24]. In a sample of
New York City high school students assessed 6 months after
the September 11 attacks, increased smoking was associated
with prior trauma and PTSD while increased drinking was
associated with direct exposure to the attacks [24]. A longitu-
dinal study of adolescents assessed 5 months following a
deadly café fire in the Netherlands revealed that students in
the affected school had significantly greater increases in ex-
cessive drinking than students in unaffected schools [22].
Twelve months later, increases in excessive use of alcohol
from baseline to follow-up also were significantly greater in
students from the affected school than in the comparison
group but the effects had decreased compared to those at
5 months, and there were no differences between the two
groups in behavioral and emotional problems or in the use
of other substances [23]. Long-term follow-up studies also
suggest that problem alcohol [25] and problem substance
[26] use may not persist in disaster samples.
56 Page 2 of 6 Curr Psychiatry Rep (2015) 17:56

Functioning and Cognitive Impairment
While the importance of addressing children’s post-disaster
functioning in general has been recognized for some time,
little research has focused on cognitive effects or on the rela-
tionship between functioning and other post-disaster prob-
lems. Impairment in children’s functioning post-disaster may
be most evident in school where they are required to perform
both academically and socially, sometimes in altered environ-
ments with damaged school facilities and disruptions in sched-
ules and routines. Scrimin and colleagues found difficulties in
attention, memory [27,28], and visual-spatial performance as
well as lower grades [28] in children exposed to the Beslan
school hostage crisis. In a study examining six domains of
school and interpersonal functioning in relationship to alcohol
and drug use in middle and high school students attending
schools near the World Trade Center at the time of the Sep-
tember 11 attacks, students with increased substance use ex-
perienced more impairment in school work and school behav-
ior compared to those without increased substance use
18 months post-incident [20].
Grief, Complicated Grief, and Traumatic Grief
Children who lose loved ones in a disaster suffer grief which
may be exacerbated in the context of the family’ssocialand
economic adversities such as financial problems and lack of
housing [29]. Some children suffer complicated grief—the per-
sistence of acute grief or the development of complications in
the context of the grief process [30•]—and/or traumatic grief—
the intrusion of trauma symptoms into the bereavement pro-
cess [31]—in relationship to their loss. Little empirical re-
search has addressed these grief reactions. Dyregrov and col-
leagues [32] found a high prevalence of complicated grief,
posttraumatic stress reactions, and general psychological dis-
tress in parents and siblings 1.5 years after a 2011 terrorist
attack on a youth camp in Norway that killed 69 youth and
adults. Intense contemporaneous exposure through telephone
or text messaging with the victims as the event unfolded, ex-
tensive media coverage, and the previously peaceful context of
the environment were thought to influence reactions [32].
Posttraumatic Growth
Posttraumatic growth includes psychological (e.g., greater ap-
preciation for life, modified values, increased sense of person-
al strength), interpersonal (e.g., improved relationships), and/
or functional (e.g., ways of coping) gains that were not appar-
ent pre-disaster but arose from the disaster experience [33,
34]. Posttraumatic growth and distress are not two ends on a
spectrum, and they may co-occur [35]. The traumatic circum-
stances that cause distress can also mobilize the coping at-
tempts and adaptation that result in growth. For example,
posttraumatic stress predicted posttraumatic growth in a study
of children from the Gulf Coast 1 year after Hurricane Katrina,
demonstrating that distress may spark growth [36].
Trajectories of Response and Long-Term Recovery
Recent research examining trajectories of children’sdisaster
reactions has identified adaptive and maladaptive outcomes
[13•,37,38••]. For example, La Greca and colleagues [13•]
identified three trajectories of posttraumatic stress symptoms
in children during the first year (3, 7, and 10 months) after
Hurricane Andrew. Approximately 20 % of the sample had a
chronic course, 43 % of the sample was characterized as re-
covering, and 37 % of the sample was described as resilient.
Mean posttraumatic stress symptom scores decreased signifi-
cantly over time in all three trajectories. Removing children
with minimal exposure in recalculating their findings, Weems
and Graham [38••] found the proportion of resilient children
in their sample dropped from 43 % to only 16 %, highlighting
the importance of considering exposure in determining resil-
ience. La Greca and colleagues [13•] found that children’s
disaster exposure—both perceived and actual threat—did
not distinguish the recovering and chronic trajectories from
the resilient trajectory, but that children who reported per-
ceived life threat and/or more loss and disruption were more
likely to fit in the recovering or chronic trajectories rather than
the resilient trajectory.
Long-term follow-up studies suggest recovery for most
children following disasters. In a 20-year follow-up study,
McFarlane and Van Hooff [25] reported no significant differ-
ence in PTSD rates in Australian children exposed to a mas-
sive bushfire relative to a non-exposed comparison group, and
the risk of developing an anxiety disorder was small relative to
the controls except in those exposed to multiple traumas. Mor-
gan and colleagues [26] reported that 29 % of the child survi-
vors of a deadly 1966 coal pile collapse had current PTSD
33 years after the disaster though the comparison group from a
village nearby in the same economically depressed area of the
country also had high rates of psychopathology. Survivors
were at no greater risk for developing anxiety, depression, or
substance use than controls [26].
The Influence of Exposure on Children’s Disaster
Reactions
The extant research supports a dose-response relationship be-
tween disaster exposure and outcomes, with the severity of
outcomes associated with the intensity or severity of expo-
sures [39,40••]. In their meta-analysis of 96 child disaster
studies, Furr and colleagues [39] concluded that it is not mere
proximity to an event but specific aspects of exposure that
Curr Psychiatry Rep (2015) 17:56 Page 3 of 6 56

determine risk for adverse outcomes. For example, the child’s
perception of threat and other subjective reactions; the extent
of disruption, destruction, injury, and death; and the child’s
specific disaster experiences such as being injured, witnessing
the event, and loss of loved ones are aspects of disaster expo-
sure that influence posttraumatic stress [39] and depression
[11••,12•]. The dose-response relationship applies to interper-
sonal disaster exposure through, for example, the closeness of
family and associates [41•].
The Influence of Personal Factors on Children’s
Disaster Reactions
A number of child characteristics affect children’s disaster
reactions and recovery including demographics, preexisting
vulnerabilities, and post-disaster experiences. Girls are com-
monly identified as being at greater risk than boys for adverse
outcomes such as posttraumatic stress reactions [39] and de-
pression [11••], but it may be that boys and girls display dis-
tress differently with girls suffering more internalizing symp-
toms and boys evidencing more externalizing difficulties.
Moreover, boys and girls may interpret and report events dif-
ferently [40••]. Children’s age or stage of development influ-
ences their understanding of an event, the specific presentation
of their reactions [42], and adaptation [40••], but findings on
the effects of age or development on outcomes are inconclu-
sive [40••]. Children of ethnic minority heritage may be at
greater risk for adjustment problems post-disaster than chil-
dren from the majority culture, but these differences may rep-
resent, or be influenced by, differences in disaster experiences,
socioeconomic status, exposure to prior trauma, and/or family
or other social influences [6]. Children’s pre-event emotional
status, prior trauma, and major life events post-incident influ-
ence their disaster reactions and recovery [6,11••,12•,40••].
Coping
Coping entails both involuntary and deliberate cognitive, be-
havioral, and emotional efforts to reconcile a perceived dis-
crepancy between the demands of environmental stressors and
the child’s own personal resources [43]. Coping strategies can
be adaptive or maladaptive depending on their relationship to
adverse outcomes [44••]. Children’s ability to cope, their ap-
proach to coping, and their repertoire for coping vary with age
and development [44••,45•], gender [45•], and culture [e.g.,
46]. Other factors that may influence coping include aspects of
the child’s event exposure [e.g., 47,48] or the interaction of
personal and exposure characteristics [e.g., 49], time since the
disaster [e.g., 50], the degree of perceived control the child has
over the situation [e.g., 51], and the child’s disposition [45•]
and self-esteem [e.g., 52]. The literature in general approaches
mass trauma as single incidents, though coping has been ex-
plored in the context of ongoing political violence [44••]. Lit-
tle disaster research has explored coping in relationship to
positive outcomes such as well-being [44••].
Conclusions and Future Directions
An impressive literature over several decades has documented
children’s reactions to disasters and the various event, exposure,
and personal factors that influence those reactions. Recent re-
search has extended the examination of outcomes beyond in-
ternalizing conditions (e.g., PTSD, anxiety, depression) to in-
clude externalizing conditions (e.g., behavior problems, sub-
stance use), functioning and cognitive impairment, traumatic
grief, and posttraumatic growth. With a primary focus on PTSD
and posttraumatic stress reactions, relatively little is known
about pre- and post-event comorbid conditions that may affect
outcome [13•]. Longitudinal assessment of children has charted
children’s reactions over several years post-disaster and delin-
eated trajectories of response. Many children exposed to disas-
ters are resilient. Studies suggest that in addition to aspects of
disaster exposure such as perceived life threat, preexisting child
characteristics and pre- and post-event life experiences are im-
portant determinants of the child’s disaster outcomes. The liter-
ature has begun to address children’s coping in the context of
disasters, but the studies are too few and too diverse to draw
definitive conclusions about the strategies and determinants that
influence outcomes. Additional research to benefit the field
would include exploring the timing and course of depression
and anxiety post-event and their interactions with other disor-
ders and the effects of disasters on children’s quality of life and
potential growth as well as on psychopathology.
Acknowledgments This work was conducted by the Terrorism and
Disaster Center (TDC), at the University of Missouri and the University
of Oklahoma Health Sciences Center, a partner in the National Child
Traumatic Stress Network (NCTSN). TDC is funded by the Substance
Abuse and Mental Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services (HHS). Points of view in this
document are those of the authors and do not necessarily represent the
official position of HHS, NCTSN, SAMHSA, the University of Missouri,
or the University of Oklahoma Health Sciences Center.
Compliance with Ethics Guidelines
Conflict of Interest Natalie Griffin and J. Brian Houston declare that
they have no conflict of interest.
Betty Pfefferbaum has received a grant from the Substance Abuse and
Mental Services Administration.
Anne K. Jacobs has received consulting fees/honorarium from the
University of Oklahoma Health Sciences Center and the University of
Missouri, Columbia, MO.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
56 Page 4 of 6 Curr Psychiatry Rep (2015) 17:56

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