Post-traumatic Stress Disorder Symptoms in Children After the 1999 Marmara Earthquake

in Turkey
Author(s): Ozgür Yorbik, Derya Iren Akbiyik, Pinar Kirmizigul and Teoman Söhmen
Source: International Journal of Mental Health, Vol. 33, No. 1, Disasters: The Mental Health
Component (II) (SPRING 2004), pp. 46-58
Published by: Taylor & Francis, Ltd.
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International Journal of Mental Health , Vol. 33, No. 1, Spring 2004, pp. 46-58.
© 2004 M. E. Sharpe, Inc. All rights reserved.
ISSN 0020-74 1 1 /2004 $9.50 + 0.00.

OZGÜR YORBIK, CERVA IREN AKBIYIK,

Pinar Kirmizigul, and Teoman Söhmen

Post-traumatic Stress Disorder

Symptoms in Children After
the 1999 Marmara Earthquake
in Turkey

ABSTRACT: Objective : The aim of this study is to evaluate the

symptoms of post-traumatic stress disorder in different age groups
of children after the 1999 Marmara earthquake in Turkey.
Method : The study included thirty-five patients , two to sixteen
years old , who presented to the child and adolescent psychiatry
department with symptoms ofPTSD after the earthquake. An Earth-
quake Information Form and a Post-traumatic Stress Disorder
Symptoms Checklist werefdled out with clinical interviews of cases

Ozgíir Yorbik, MD, is a psychiatrist at Gulhane Military Medical School

[GATA], Child and Adolescent Psychiatry Department. Correspondence to: GATA
Çocuk ve Ergen Psikiyatrisi 06018, Ankara, Turkey; tel.: 0 [901 312- 304 45 63;
e-mail: [email protected]; Derya Iren Akbiyik, MD, a physician specializing
in family practice, has a postgraduate degree in social psychiatry and works at
Bayindir Medical Center in Ankara, Turkey. Correspondence to: Bulbulderesi
cad. 50/5 06660 Ankara, Turkey; tel.: 0 [90]-532-635 99 1 1 ; e-mail:
[email protected], [email protected]. Pinar Kirmizigul, a nurse
practitioner specializing in psychiatry, works in the psychiatry department of
Gulhane Military Medical School. Teoman Söhmen, MD, is a psychiatrist, pro-
fessor, and head of the Child and Adolescent Psychiatry Department at Gulhane
Military Medical School.
46

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 SPRING 2004 47

and their relatives. Different age groups were compared with

each other.
Results: There are age-related differences in the perception of
trauma or response to trauma of children and adolescents.
Conclusion: Developmental factors are important in the per-
ception of and response to trauma in children and adolescents.
The Diagnostic and Statistical Manual of Mental Disorders-IV
criteria are not sensitive enough to make the diagnosis ofPTSD in
preschoolers. New sensitive development criteria for the diagno-
sis ofPTSD in children are needed.

Although the Diagnostic and Statistical Manual of Mental Dis-

orders-IV (DSM-IV) [4] criteria are used for diagnosing post-
traumatic stress disorder (PTSD) in children, appropriate childhood
age diagnostic criteria are still controversial. The limited cognitive
and verbal expression capabilities of children may restrict their
expression of thoughts and feelings. Many authors propose that
developmental age-specific diagnostic criteria for PTSD must be
improved [2, 15]. Trauma and the child's response to trauma may
disturb normal development, affecting the child's adaptation, cog-
nitive function, attention, social abilities, self-concept, and moti-
vation control [13, 14]. Although it is difficult to diagnose PTSD
in young children, various studies have shown that children under
school age are also affected by trauma [9, 15, 17].
While children do not usually meet all of the criteria for PTSD,
there are some frequent symptoms that may cause functional dis-
orders. Because fulfilling all the diagnostic criteria can take some
time, it is important to be aware of the chronic course of PTSD,
especially in children because of the probability that PTSD will
disturb the child's development. Many studies suggest that treat-
ment must be considered even if all of the diagnostic criteria are
not fulfilled [3, 14]. In general, the more mature the child is, the
more similar to adult DSM criteria [18].
The aim of this study is to research PTSD symptoms in different
age groups of children and adolescents presenting after the Au-
gust 17 and November 12, 1999, earthquakes in Turkey.

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4H INTERNATIONAL JOURNAL OF MENTAL HEALTH

Hypotheses of this study

1. Post-traumatic stress disorder symptoms change related to

the age of children and adolescents.
2. Children and adolescents who were trapped under wreckage,
lost family members, had wounded family members, ruined houses,
and low economic status show more PTSD symptoms.

Method

The study included thirty-five children and adolescents, seven-

teen male and eighteen female, two to sixteen (9.2 ± 3.9) years
of age, who presented to the Gülhane Military Academia of Medi-
cine (GATA), Child and Adolescent Psychiatry Department be-
tween September 1999 and December 1999 with psychiatric
symptoms after the earthquake. After reviewing the literature, a
PTSD Symptom Screening List was created to record the symp-
toms seen in children and adolescents, and also included DSM-
IV criteria. An earthquake information form and PTSD Symp-
tom Screening List were filled out by one of the authors after
interviewing patients and their relatives. The patients included
in the study were divided into three age groups, two to six, seven
to eleven, and twelve to sixteen years, and PTSD symptoms evalu-
ated according to these comparison groups. Statistical analysis
of the data was carried out using the SPSS statistical software
application.

Results

Table 1 shows the age distribution of the patients.

No statistically significant difference was found between the
groups based on sex.
The most frequent symptoms in all patients, excessive fear, help-
lessness and feelings of horror during the earthquake (82.9 per-
cent), beginning or increasing sleep starts (80.0 percent), difficulty

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 SPRING 2004 49

Table 1

Age Distribution of the Patients

Groups N Age (years) Mean

I 9 2-6 4.0 ± 1 .4
II 16 7-11 9.2 ±1.3
III 10 12-16 14.0 ± 1 .2

in falling asleep or remaining asleep (80.0 percent), and fear of

darkness (77.1 percent).
Table 2 lists the symptoms based on age groups.
Although it is not statistically significant, fewer PTSD symp-
toms are seen in the case of those living with their families com-
pared to those have been separated from their families. Symptoms
such as feeling intense distress, crying, and restlessness when con-
fronted with objects, movies, conversations, and sounds reminis-
cent of the event were significantly higher for those separated from
their families ( p < .04). Nine of the ten cases who were trapped
under the wreckage had family members who were injured and seven
of them witnessed the death of a family member. Eight of the ten
children were physically injured. It was found that 88.9 percent of
the children in Group I, 75.0 percent of children in Group II, and
82.9 percent of the adolescents in Group III had experienced PTSD
symptoms for more than a month. No significant difference was
observed for the onset of symptoms following the event among the
age groups ( p < .72) (see Table 3).
Forty percent of the children and adolescents included in the
study were had a diagnosis of PTSD according to DSM-IV cri-
teria. While none of the children between two and six years of
age years met the full diagnostic criteria, 56.3 percent of the chil-
dren in the age group seven to eleven years old, and 50 percent
of those in the age group of twelve- to sixteen-year-old adoles-
cents show all the criteria. Only one child in the age group seven
to eleven years old had a diagnosis of acute stress disorder.

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50

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 SPRING 2004 53

Table 3

Period for the Onset of Symptoms

First day More than

after the 2-7 8-14 30 Total
event (%) days (%) days (%) days (%) (%)

Group I:
2-6 years old 66.7 11.1 11.1 11.1 100.0
Group II:
7-11 years old 75.0 18.8 6.2 0.0 100.0
Group III:
12-1 6 years old 80.0 10.0 10.0 0.0 100.0

Total (n = 35) 74.3 14.3 8.6 2.9 100.0

Discussion and conclusion

It has been reported that developmental factors are important in a

person's perception of, and response to, trauma [2, 15]. In this
study, too, excessive fear, helplessness, feelings of horror while
living through the earthquake, freezing during the event, reliving
and being distressed by the events frequently in dreams or night-
mares, and being easily startled were the most frequent symptoms
noted in groups I, II, and III. Feeling anger toward people who are
seen as responsible for causing the damage was statistically more
frequent in adults. Being unable to remember some parts of the
event was statistically higher in children older than school age.
This may be the result of cognitive differences in trauma percep-
tion between children and adolescents. The results support our first
hypothesis.
In this study, it is found that children play games reminiscent of
the earthquake or tell about it significantly more often than do
adolescents. This situation shows that "reliving" the events repre-
sents traumatic play by children. It has been reported that play in
which the main theme is the trauma does not heal the anxiety,
repeats the trauma in a compulsive manner. Repeating the trauma

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54 INTERNATIONAL JOURNAL OF MENTAL HEALTH

in a compulsive manner, this kind of play does not involve cre-

ativity and imagination [15]. Another reaction to trauma seen
among children is the reenactment game. In reenactment games,
trauma is again the subject but it decreases as it is replayed over
and over, and it begins to more resemble games that preceded
the trauma [15].
Gender differences affect defense and coping mechanisms, so-
cial support, and response to treatment of PTSD [14]. While some
PTSD studies report that girls show more symptoms [5, 6], others
report the opposite or no difference between boys and girls [12,
16]. In this study, no meaningful difference was found related to
gender.
In this study, there were no meaningful differences between
children and adolescents in the time of onset of symptoms. For all
groups, the symptoms appeared primarily on the first day. It has
been reported that PTSD symptoms may decrease or increase over
time, remain the same, differ, or appear a long time after the trauma
[3, 7, 8]. As this is a cross-sectional study, it was not known if new
symptoms would appear later or PTSD would emerge over time.
In a study performed 1 .5 years after an earthquake in Armenia,
feeling guilty, which is not listed in DSM-IV, is seen in a signifi-
cant proportion of children and adolescents [8]. In our study, none
of the children below school age, 1 2.5 percent of children at school
age, and 30 percent of adults reported some feelings of guilt.
Studies have reported that separation of children from their fami-
lies just after the disaster, mothers' continuous coping with the
traumatic event, and changes in family functioning are more pre-
dictive of symptom development than the experience of the trauma
[10, 11]. Our findings support this; fewer PTSD symptoms are
observed in cases of those living with their families than in cases
of those who are separated from their families. This shows that
after the trauma, children should remain living with their families
in order to prevent the emergence of PTSD symptoms.
Because babies, toddlers, and children under school age do
not have enough cognitive and verbal expression skills, in these

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 SPRING 2004 55

children, besides the expected DSM-IV criteria, anxiety symp-

toms such as fear of separation, strangers, and animals, avoidance
of situations directly or indirectly related to trauma, and avoid-
ance of certain words or symbols that remind of the trauma are
seen [3]. In this study, too, some symptoms are seen in a signifi-
cant proportion of children and adults, including recently devel-
oped fears, such as a fear of darkness, insistence on not sleeping
alone, increased dependence on and fear of separation from mother,
father, or caregiver, and fear of other things and situations not
related to the event. This situation shows that PTSD symptoms
must be sought in children and adults who present to child psy-
chiatry polyclinics with complaints of fear. It may be that the
absence of fear as a symptom in the DSM-IV PTSD diagnostic
criteria for children and adolescents is a deficiency that needs
further evaluation.

It is known that regression in speech and the loss of acquired

developmental abilities such as toilet training are frequent symp-
toms after trauma [15]. In this study, 55.6 percent of the children
under school age showed regressive behavior, which is reason to
consider whether regression in some behaviors should be consid-
ered a PTSD symptom for this age group. The limited cognitive
and verbal expression capabilities of children also limit their ex-
pression of feelings and thoughts. Many authors have reported that
DSM-IV criteria specific to the development stage need to be up-
dated for PTSD diagnosis [3, 15].
While none of the children between two and six years old met
all of the criteria, 56.3 percent of school age children between
seven and eleven years old and 50.0 percent of adolescents be-
tween twelve and sixteen years old did. There is a statistically
significant difference among the groups. This situation suggests
the importance of differences in the perception of and response to
the trauma as well as the insufficiency of the DSM-IV criteria for
PTSD, especially in children under school age.
In the literature, it is proposed that not all of the PTSD diagno-
sis criteria are applicable to both children and adults and that often

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56 INTERNATIONAL JOURNAL OF MENTAL HEALTH

only some of the symptoms are seen, but these may nevertheless
cause functional problems [3, 14]. This has also been observed in
this study, which confirms that sometimes PTSD criteria emerge
over time. Even when all the diagnosis criteria do not apply, treat-
ment must be considered. Because trauma and the response of the
child to trauma may disturb normal development of the child, it
may affect the child's adaptation, cognitive functioning, attention,
social abilities, self-concept, and motivation control [1,2, 13, 14].
This study demonstrates the following results:
1 . The perception of trauma and response to it differ according
to age in children and adults. This situation implies the impor-
tance of cognitive development in PTSD.
2. Families play a protective role in preventing the develop-
ment of PTSD symptoms in children and adults. For this reason
children and adults must not be separated after the trauma.
3. Symptoms of PTSD must be sought in children and adults
who present to child psychiatry polyclinics with complaints of
"newly developed fears."
4. "Newly developed fear" and "regressive behavior" must be
included in diagnostic criteria for children under school age.
5. DSM-IV diagnostic criteria are not sufficient for PTSD diag-
nosis in children under school age. New diagnostic criteria appro-
priate to cognitive development must be elaborated.
6. In some children and adults exposed to trauma, only some of
the DSM-IV PTSD diagnostic criteria are seen. Even when not all
of the diagnostic criteria are present, treatment must be consid-
ered in order to prevent functional problems.

References

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To order reprints , call 1 -H00-3 52-22 10; outside the United States, call 717-632-3535.

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