By using a community-based follow-up study, we found that symptoms of PTSD and depression seemed to persist among child and adolescent survivors of the 2008 Sichuan earthquake, and that different traumatic experiences predicted different longitudinal development of PTSD and depression for these children. The study also indicated that the earthquake might have a delayed impact on the psychosocial functioning of children and adolescents who were not directly affected by the disaster.
The persistence of the symptoms could possibly be related to unremitting multiple post-disaster adversities that aggravated the symptoms or impeded their remission [9, 18]. Conversely, continued symptoms of PTSD and depression seemed to contribute to secondary stresses and adversities, such as disturbances in school and social functioning, which in turn imposed more difficulties for them to cope with the symptoms. Our study showed that children who had family members or friends seriously injured, had lost family members, or had lost significant others still faced higher prevalence of PTSD and depression than children with other traumatic experiences 36 months after the earthquake. The result may help to screen out children with an elevated risk for persistent psychological problems so that appropriate mental health interventions could be allocated to them.
However, the severity of PTSD differed from previous reports. A study among child survivors after the 1999 Chi-Chi earthquake in Taiwan indicated that victims near the epicenter had moderate levels of PTSD one year after the earthquake ; Goenjian et al., using Child PTSD Reaction Index, reported moderate reaction scores in bereaved adolescents six and a half years after the 1988 Spitak earthquake , and severe levels of PTSD in adolescents from three public schools six months after hurricane Mitch . In contrast, our study found mild levels of PTSD. The differences may be attributed to different sampling frames. Our study was based on a large community-based sample, while previous studies primarily studied children with specific characteristics or in places with unique features (epicenter, etc.), which might result in a more severe estimation of PTSD symptoms.
A curious point deserves further notice, viz., children who were identified as not having been seriously injured, having lost family members, having lost significant others, or having felt guilt concerning someone’s death or injury reported an increase of PTSD score over the time. A possible speculation is that the earthquake, together with post-earthquake changes in social environment, had a delayed impact on the psychosocial functioning of children and adolescents who were not directly affected by the disaster. For example, while a child who lost his or her parent was likely to receive more support and care from families, relatives, friends and communities after the earthquake, a child without bereavement may get less help. Just as scarce mental health services may be especially allocated to children with more severe traumatic experiences while leaving children without a specific experience unnoticed, children with potential psychological symptoms may be ignored. Thus the finding that earthquake-related mental health utilization fell sharply from 34.6% in the first 15 months to 9.5% in the follow-up period raised great concerns over how to fulfill the unmet needs of psychological recovery for these children.
As the findings from the Japan and Pakistan earthquakes suggested that post-disaster chronic psychological needs were often inadequately managed and could lead to increased rates of complications and indirect morbidity after a disaster [34, 35], measures should be taken to ameliorate the persistent symptoms for child and adolescent survivors of the 2008 Sichuan earthquake. Efforts should be made in several ways. First, in order to facilitate the early identification of children with mental health problems, a comprehensive screening program should be established to evaluate the mental health conditions of these children at regular intervals. Schools may serve as an essential role in early identification and could be able to provide psychological interventions for these children. Second, as the children with mental health problems tend not to come for help, community-based mental health support—such as reaching out to them—may be a better option. In addition, all of those efforts should not be segregated from the other interventions, because these children not only have psychological needs but also require physical, economic, spiritual support as well.
Strengths and limitations
To our knowledge, this is the first community-based study that examines the longitudinal outcomes of mental health among child and adolescent survivors of an earthquake. Although community-based research has gained robust applications in indentifying and solving problems that exist in almost every corner of public health, the combination of a community-based study design and the context of a natural disaster is indeed a bold attempt. A major limitation of the study should also be recognized. All participants in the study experienced the earthquake, and they were not compared with controls from non-affected areas. It was because the Sichuan earthquake was so powerful and extensive that the shock spread over almost half of mainland China, Additionally, it is a challenge to select a significant sample size of children and adolescents who have not experienced the disaster. Even if children were selected as non-exposed, there is significant demographic and cultural variation between exposed and unexposed children. Nevertheless, as the study indicated that children with more earthquake-related experiences predicted more severe PTSD and depression, we are confident to assume that children affected by the earthquake have more severe mental health symptoms than those without the experience.