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Traumatology
Lifetime Trauma Exposure, Gender, and DSM–5 PTSD
Symptoms Among Adolescents in Malaysia
Siti Raudzah Ghazali, Ask Elklit, M. Ameenudeen Sultan, Rekaya Vincent Balang, and Yoke Yong
Chen
Online First Publication, September 29, 2016. http://dx.doi.org/10.1037/trm0000088
CITATION
Ghazali, S. R., Elklit, A., Sultan, M. A., Balang, R. V., & Chen, Y. Y. (2016, September 29). Lifetime
Trauma Exposure, Gender, and DSM–5 PTSD Symptoms Among Adolescents in Malaysia.
Traumatology. Advance online publication. http://dx.doi.org/10.1037/trm0000088
Lifetime Trauma Exposure, Gender, and DSM–5 PTSD Symptoms Among
Adolescents in Malaysia
Siti Raudzah Ghazali
Universiti Malaysia Sarawak
Ask Elklit
University of Southern Denmark
M. Ameenudeen Sultan, Rekaya Vincent Balang, and Yoke Yong Chen
Universiti Malaysia Sarawak
Adolescents who have multiple traumatic experiences may suffer from posttraumatic stress disorder
(PTSD) or other mental health problems later in life. Study of trauma exposure and PTSD among
adolescents is very limited in Malaysia. This study explored the prevalence of lifetime trauma, demo-
graphic risk factors, and PTSD symptoms among Malaysian adolescents. This cross-sectional study
recruited 1,016 adolescents aged 13 to 17 (M
age
⫽14.9 years). Results showed that 83% participants had
at least 1 traumatic exposure (TE), whereas prevalence of PTSD symptoms was 11.7%. Adolescents with
multiple TEs and those with violent and self-inflicted TE were at significantly higher risk to develop
PTSD symptoms. Findings suggest that a large proportion of Malaysian adolescents are exposed to a
variety of traumatic events since childhood. Trauma exposure should be included as an important
component in our adolescent mental health assessment, allowing early psychological intervention to be
provided to those affected.
Keywords: PTSD, adolescents, lifetime trauma, Malaysia
In the past decades, several studies have been carried out to
investigate the lifetime prevalence of victimization and trauma
among adolescents (Elklit, 2002; Finkelhor, Turner, Ormrod, &
Hamby, 2009; Rasmussen, Karsberg, Karstoft, & Elklit, 2013).
Results have corroborated one another on multiple points, but
lifetime prevalence of traumatic exposure (TE), PTSD, and types
of TE have ranged widely. Approximately 40 –90% of the adoles-
cent population in United States and Denmark has experienced a
potentially traumatic exposure (Breslau, 2009; Elklit, 2002; Kes-
sler, Sonnega, Bromet, Hughes, & Nelson, 1995).
Children and adolescents who experience multiple TEs are very
likely to develop PTSD and other psychosocial impairments later
in life (Trickey, Siddaway, Meiser-Stedman, Serpell, & Field,
2012). Lifetime prevalence of PTSD was found to be around 7.8%
in United States (Kessler et al., 1995), 9% in Denmark (Elklit,
2002), and 10% in India (Rasmussen et al., 2013). Briere, Kalt-
man, and Green (2008) showed that adults who experienced two or
more TEs in childhood had greater vulnerability to PTSD effects
when compared with those who had no previous history of TE.
Ogle, Rubin, Berntsen, and Siegler (2013) found among older
adults in United States that events that occurred with greater
frequency early in life were associated with more severe PTSD
symptoms than events that occurred with greater frequency during
later decades.
In a community setting, the most commonly reported TE in
Denmark was the death of a family member, followed by a threat
of being beaten, humiliation, near drowning, and traffic accident
(Elklit, 2002). In India, the most common TE, as in Denmark, was
the death of a family member, but followed by traffic accident,
serious illness, witnessing an injury, and coming close to being
injured or killed (Rasmussen et al., 2013).
Previous studies consistently found that female adolescents have
higher risks for PTSD than male adolescents (Elklit, 2002; Bre-
slau, 2009; Elklit & Petersen, 2008; Kessler et al., 1995). Simi-
larly, significant gender differences have been found in types of
TE. For example, Elklit (2002) reported that female adolescents
were more likely to have family related TEs such as domestic
violence and sexual abuse while male adolescents were more
likely to experience violent TEs such as physical assaults and
threats of injury (Elklit, 2002).
It remains unclear whether certain types of TE are more likely
to lead to PTSD. Ford, Chapman, Connor, and Cruise (2012) found
in a sample of delinquent adolescents that traumatic exposure to
sexual abuse and physical assault were important risk factors in
predicting adolescent mental health without specifically investi-
gating PTSD. A study by Ariga et al. (2008) on TE type as a
predictor for PTSD among delinquent female adolescents did not
find a significant result. Haller and Chassin (2012) showed that
Siti Raudzah Ghazali, Faculty of Medicine and Health Science, Univer-
siti Malaysia Sarawak; Ask Elklit, National Centre for Psychotraumatol-
ogy, University of Southern Denmark; M. Ameenudeen Sultan, Rekaya
Vincent Balang, and Yoke Yong Chen, Faculty of Medicine and Health
Science, Universiti Malaysia Sarawak.
This study was funded by the National Centre for Psychotraumatology,
University of Southern Denmark, Grant UNIMAS L18403 F05 00 PTSD.
Correspondence concerning this article should be addressed to Siti Raudzah
Ghazali, Department of Psychological Medicine, Faculty of Medicine and
Health Science, Universiti Malaysia Sarawak, 94300 Kota Samarahan, Sara-
wak, Malaysia. E-mail: gsraudzah@fmhs.unimas.my
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Traumatology © 2016 American Psychological Association
http://dx.doi.org/10.1037/trm0000088 1085-9373/16/$12.00
1
assaultive violence yielded on odd ratio of 2.28 in predicting
PTSD, but the association did not reach the level of significance.
Therefore, the present study will further investigate the association
of different trauma types with higher risk of PTSD symptoms.
As community studies among national populations have exhib-
ited a wide range of results, it is appropriate to ask what the
prevalence is for understudied regions such as Southeast Asia.
Studies on exposure to a variety of trauma at the community level
among adolescents in Malaysia have yet to be conducted. The
incidence and seriousness of TEs experienced by Malaysian ado-
lescents remains unknown. Considering the impact of exposure to
traumatic events early in life can be devastating, baseline data
should be established. Thus the objectives of this study were (a) to
estimate prevalence of lifetime trauma exposure, (b) to determine
if multiple trauma exposure is related to PTSD symptoms, and (c)
to assess if gender and types of trauma were risk factors in
developing PTSD symptoms among Malaysian adolescents.
Method
Participants
Data were collected from a total population of 1,016 adolescents
aged 13 to 17 (Mage ⫽14.9, SD ⫽1.4; 638 female adolescents,
378 male adolescents) attending government secondary school
(Grade 7 to Grade 11). A minimum sample size of 331 was
determined using Epi Info 6 based on an estimated prevalence of
14.6% (Elklit & Petersen, 2008), precision rate of 5% and confi-
dence interval of 99%.
Procedure
Following ethical approval from the Faculty of Medicine and
Health Sciences, the University Malaysia Sarawak Ethics Com-
mittee, the Malaysian Ministry of Education, and the Sarawak
Education Department, 35 schools were randomly selected from
the 11 divisions of the state and 56.7% (n⫽17) agreed to take part
in the study. Parent and adolescent written consent was a prereq-
uisite for participating, after which a date for data collection was
set. During data collection, both parents and adolescents were
briefed on issues related to confidentiality and questionnaire col-
lection procedures.
Measures
Demographic questionnaire. A one-page survey design was
used to solicit information regarding participant age, gender, eth-
nicity, parental education, and living arrangements.
Traumatic Events Checklist. This questionnaire contains a
list of 20 traumatic and negative life events in the first column with
direct exposure and indirect exposure (i.e., witnessing or experi-
encing an event themselves or having a person close to them
experience an event) in the other two columns. The list of trau-
matic events was selected from the literature and clinical experi-
ence, covering traffic accident, other serious accident, physical
assault, abuse, rape, coming close to being injured or killed,
near-drowning, attempted suicide, robbery, severe childhood ne-
glect, humiliation or persecution by others, and other trauma. The
validity of this checklist is supported by previous research (Elklit,
2002).
PTSD symptoms. Symptoms of PTSD were measured by
Harvard Trauma Questionnaire (HTQ; Mollica et al., 1992), a
cross-cultural instrument to measure traumatic symptoms associ-
ated with diagnostic criteria for PTSD. It consists of 16 items on
a 4-point Likert scale ranging from 1 (not at all)to4(extremely)
corresponding to the three major symptoms cluster of PTSD in
DSM–IV, avoidance (seven items), re-experiencing (four items),
and hypervigilance (five items). In DSM–5, additional symptoms
cluster is included, namely cognitive and mood symptoms. Cog-
nitive and mood symptoms essentially report feeling of detach-
ment, diminished interest in daily life, inability to recall the key
feature of the traumatic event, persistently having negative beliefs
about oneself or the world, persistently blaming self or others
regarding the incident of trauma, and persistently unable to have
positive emotion. In HTQ, there are additional eight items can be
classified as cognitive and mood symptoms (e.g., Item 4: “Feeling
detached or withdrawn from people,” Item 5: “Unable to show
positive emotion,” Item 13: “Less interest in daily activities”).
Participants who rated 2, 3, or 4 for at least two symptoms in
avoidance, one symptom in re-experiencing, three symptoms in
hyper vigilance, and two symptoms in mood and cognitive cluster
would be considered to have PTSD symptoms. Thus, we analyzed
the data using DSM–5 algorithm, which in our analyses we ana-
lyzed a total number of 24 items. The internal consistency of this
questionnaire in the present study was high (␣⫽.94).
Translation
All instruments were translated into the Malay language (Ba-
hasa Malaysia) and were back-translated by two academicians who
are experts in both English and Malay languages.
Results
Eighty-three percent of the participants reported having at least
one direct or indirect TE. Out of this population, 527 (63%) were
female and 313 (37%) were male. The five most prevalent TEs
overall were death of someone close (15.4%), traffic accident
(14.5%), near-drowning (9.2%), serious illness (9.0%), and humil-
iation/bullying (6.1%). The five most common direct TEs were
death of someone close (21%), near drowning (16%), traffic ac-
cident (15%), serious illness (9%), and humiliation/bullying (8%;
Table 1). Least prevalent were rape (0.6%), sexual abuse (0.6%),
and pregnancy/abortion (0.3%). The five most common indirect
TEs were traffic accident (14%), death of someone close (12%),
serious illness (9%), other serious accidents (8%), and divorce
(6%).
Most of the adolescents (52.1%) reported both direct and indi-
rect TE, 19.2% reported only experienced direct TE, and 11.4%
reported only experience indirect trauma among the total cases
reported. For direct TE, 28.7% reported no TE, 28.8% experienced
one TE, 17.9% had two, 9.7% had three, 5.5% had four, 3.8% had
five, and 5.4% reported experiencing more than five TEs. For
indirect TE, 36.5% reported having no TE, 17.2% had one, 11.4%
had two, 8.6% had three, 7.3% had four, 5.2% had five, and 13.8%
had more than five indirect TEs.
HTQ analysis of Pearson’s chi-square showed significant dif-
ference between those who reported PTSD symptoms and those
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2GHAZALI, ELKLIT, SULTAN, BALANG, AND CHEN
who did not,
2
(1, N⫽1,016) ⫽22.93, p⬍.001. Adolescents
with TE (11.1%) were 5.59 times more likely to report PTSD
symptoms than those who had one or no TE (2.2%) with a 95% CI
of 2.55⫺12.26. There was a significant correlation between the
total number of TEs and PTSD symptoms. Bivariate correlation
showed that the total number of TEs correlated significantly with
HTQ score, r⫽.43, p⬍.001, indicated that the more number of
TEs reported the higher the HTQ score.
Pearson’s chi square showed significant gender differences for
several TEs in both direct and indirect exposure (see Table 1).
Male adolescents had significantly more direct exposure to traffic
accident, other serious accidents, physical assault, witnessing other
people injured or killed, nearly being injured or killed, threats of
beating, serious illness, physical abuse, and humiliation or bully-
ing. On the other hand, female adolescents had significantly more
direct exposure to death of someone close. With regard to indirect
exposure, male adolescents witnessed or knew others who had
experienced physical assault, robbery/theft, sexual abuse, nearly
being injured or killed and threats of beating significantly more
often than female adolescents.
Of 1,016 adolescents, 11.7% (n⫽119; 81 female and 38 male)
reported PTSD symptoms with DSM–5 algorithm on the HTQ. A
significant number of them (6.3%) had both direct and indirect TE
compared to those who had only direct TE (1%),
2
(1, N⫽724) ⫽
7.54, p⫽.006, odds ratio (OR)⫽2.55, or only indirect TE (0.8%),
2
(1, N⫽645) ⫽2.60, p⫽.107, OR ⫽1.86. The ttest analysis
showed no significant difference in PTSD symptoms between
genders among those with TE except for avoidance symptom
cluster in which showed merely significant result with more fe-
males reported more avoidance symptoms than the males.
Logistic regression results indicated that age (OR ⫽1.33, 95%
CI [1.143–1.530]), and father with higher secondary school edu-
cation (OR ⫽3.42, 95% CI [1.046 –11.211]) were significant
demographic variables in the model,
2
(18) ⫽39.21, p⫽.003, in
assessing the risk of PTSD, which explained 10% of the total
variance. The overall predictive accuracy was 88.3%.
The next model adjusted for the demographic and TEs signifi-
cantly predict PTSD symptoms,
2
(38) ⫽126.94, p⬍.001.
Logistic regression results indicated that male (OR ⫽1.84, 95% CI
[1.120 –3.024]), age (OR ⫽1.32, 95% CI [1.120 –1.557]), history
of violent attack (OR ⫽1.91, 95% CI [1.018 –3.585]), threats of
beating (OR ⫽2.20, 95% CI [1.240 –3.917]), attempted suicide
(OR ⫽2.19, 95% CI [1.158 –4.150]), and humiliation (OR ⫽2.03,
95% CI [1.207–3.414]) were significant trauma variables in the
model for assessing the risk of PTSD, which explained 23% of the
total variance. The overall predictive accuracy was 90%.
Discussion
The present study found that a large proportion of Malaysian
adolescents (83%) are directly and indirectly exposed to one or
more traumatic events since childhood. This finding is high but
within the range reported in other community based studies (Elklit
& Petersen, 2008; Rasmussen et al., 2013). The five most preva-
lent TEs reported were death of someone close, traffic accidents,
near-drowning, serious illness, and humiliation or bullying. Al-
though similar to findings from Denmark (Elklit & Petersen, 2008)
and India (Rasmussen et al., 2013), in this study, traffic accidents
were ranked higher, as the second most prevalent TE. Death
caused by road traffic accidents in Malaysia has reached 7.85% of
total deaths, making it the 4th leading cause of death nationwide
(World Health Organization, 2011). An average of 18 people is
killed on Malaysian roads daily, with the number expected to rise
to 29 by 2020 (Malaysian Institution of Road Safety Research,
Table 1
Trauma and Negative Life Events Based on Type of Exposure and Gender, Statistical Gender Differences Based on Pearson
Chi-Square Analyses (N ⫽1,016)
Event
Direct exposure Indirect exposure
Females
(n⫽638) (%)
Males
(n⫽378) (%)
2
Females
(n⫽638) (%)
Males
(n⫽378) (%)
2
Traffic accident 21 34.9 23.79
ⴱⴱ
37.1 35.4 .30
Other serious accidents 3.4 7.4 7.95
ⴱ
18.2 22.5 2.77
Physical assault/violent attack 2.5 6.3 9.26
ⴱ
7.4 16.4 20.23
ⴱⴱ
Rape .9 1.3 .32 4.2 5 .35
Witnessed other people injured/killed 4.9 10.1 10.12
ⴱ
9.7 13.5 3.42
Come close to being injured/killed 2.8 7.1 10.47
ⴱ
5.3 10.3 8.86
ⴱ
Threatened to be beaten 3.3 14.3 41.96
ⴱⴱ
10.3 15.3 5.54
ⴱ
Near-drowning 26.8 29.1 .62 11.9 12.4 .06
Attempted suicide 5.3 3.7 1.39 6.1 8.2 1.61
Robbery/theft 2.7 4.5 2.47 11.4 16.4 5.07
ⴱ
Pregnancy/abortion .9 0 3.58, p⫽.059 7.7 8.2 .089
Serious illness 12.4 21.2 13.87
ⴱⴱ
23.5 23.3 .01
Death of someone close 39.8
ⴱ
31.5 7.09 32.1 26.5 3.64
Divorce 4.1 3.2 .54 16.3 15.1 .27
Sexual abuse .9 1.1 .03 2.8 5.3
ⴱ
4.02
ⴱ
Physical abuse 2.8 5.8
ⴱ
5.64
ⴱ
6.6 8.5 1.25
Severe childhood neglect 3.6 3.2 .13 6.3 7.9 1.03
Humiliation (bullying) 11.3 17.2
ⴱ
7.11
ⴱ
11.8 14.8 1.98
Absence of a parent 7.5 5.8 1.07 10.3 12.4 1.05
Other trauma 1.7 3.2 2.26 .3 2.4
ⴱ
9.47
ⴱ
Note. Total percentage is not 100 because the percentage presented in each cell is the percentage within participant’s gender.
ⴱ
p⬍.05.
ⴱⴱ
p⬍.001.
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3
LIFETIME TRAUMA EXPOSURE AMONG SCHOOL CHILDREN
2012). Other recent reports show that Malaysia ranks 8th in road
fatalities worldwide (Sivak & Schoettle, 2014). The high fre-
quency of road accidents in Malaysia would appear to explain why
adolescents report this TE more widely than their global peers.
Total number of TEs was significantly correlated with PTSD
symptoms, corroborating previous studies among adolescents
(Elklit, 2002; Elklit & Petersen, 2008; Kessler et al., 1995). Fre-
quency of trauma serves as a major risk factor for PTSD, regard-
less of the type of TE. This finding indicates the need for imme-
diate intervention programs among those with multiple TEs, even
if the types of TE may individually seem less significant. From
researchers’ clinical experience and field study, many of our
surveyed adolescents did not recognize the impact of trauma
experience on their mental health.
Significant gender differences in types of TE were found, with
male adolescents having significantly more TE to violence, acci-
dents, and humiliation, and female adolescents having signifi-
cantly higher rates of experiencing death of someone close. Pre-
vious studies found similar results. Breslau and Anthony (2007)
reported that men experienced more assaultive violence than
women. Elklit and Petersen (2008) found female adolescents more
likely to report family-related events such as death of someone and
absence of a parent, and male adolescents more likely to be
exposed to traffic accidents, threats, and coming close to being
injured or killed (Elklit & Petersen, 2008). However, humiliation
is a TE that has not been significantly gendered in previous studies
and deserves further attention in the Malaysian context.
There were no significant gender differences in PTSD symp-
toms among adolescents in the present study. The apparent dis-
crepancy may be explained in part by a study conducted by Benoit,
Lacourse, and Claes (2013), describing the onset of psychological
disorder among genders as based on level of puberty status and
timing, especially in late adolescence. In the present study, nearly
half (49.1%) of the participants were in early adolescence (aged
13–14) and another half was in mid-adolescence (aged 15–17).
Further investigation on the influence of trajectories of puberty
over time with PTSD symptoms may be appropriate here.
The present study found that certain TEs, namely violent attack,
beating, attempted suicide, and humiliation, were associated with
significantly greater risk for PTSD symptoms. Previous studies
have linked violent attack and self-inflicted TE (e.g., attempted
suicide) to greater likelihood of exhibiting PTSD symptoms
(Elklit, 2002; Petersen, Elklit, & Olesen, 2009). The risk from
traumatic exposure to humiliation may be explained by a study
showing overwhelming feelings of shame serve as a moderator for
PTSD onset and its persistence into adulthood (Andrews, Brewin,
Rose, & Kirk, 2000).
Limitations and Future Study
One caveat of this study is the potential for response bias. The
results in the study were all based on adolescent self-reports. It is
unavoidable that there might be some memory bias and lack of
willingness to share traumatic experiences. The ability to express
and recognize one’s own feelings while recalling an awful expe-
rience, and the stability of the adolescent emotional state in gen-
eral, were some uncertain factors in this study. However, some
participants reported that this study provided them the opportunity
to express and understand their emotions, facilitating their mental
well-being. Furthermore, Hulme (2004) argued that self-reported
retrospective data were applicable and comparable with the cor-
roborating data of victimization and etiology of PTSD.
Although the instruments used in this study have not yet been
validated in Malaysia, the HTQ was originally designed to mea-
sure refugees in South-East Asia and has been validated with other
South-East Asian populations (Mollica et al., 1992; Smith Fawzi et
al., 1997). The scoring of HTQ in the present data was calculated
manually depending on DSM–5 algorithm. Given the broad cul-
tural similarities in the Association of Southeast Asian Nations
(ASEAN) region, the authors are optimistic about their use in
Malaysia. A pilot study with a smaller sample of adolescent
participants has been conducted and showed that the instruments
used in the present study were appropriate (Ghazali, Elklit, Balang,
Sultan, & Kana, 2014).
In summary, this study supports previous studies and fills a void
in evidence on the prevalence of TE and PTSD symptoms among
Malaysian adolescents and the ASEAN region by extension. The
findings highlight the importance of assessing trauma exposure
and PTSD symptoms during routine mental health screening of
adolescents. It is strongly hoped this data will allow federal mental
health promotion and intervention programs to focus more re-
sources on the adolescents who need it most.
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Received February 19, 2016
Revision received July 26, 2016
Accepted August 12, 2016 䡲
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LIFETIME TRAUMA EXPOSURE AMONG SCHOOL CHILDREN
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