Structure and prevalence of PTSD symptomology in children who have experienced a severe tornado

STRUCTURE AND PREVALENCE OF PTSD SYMPTOMOLOGY IN CHILDRENWHO HAVE EXPERIENCED A SEVERE TORNADO

LINDA GARNER EVANS AND JUDY OEHLER-STINNETT

Oklahoma State University

Children served by school psychologists are frequently impacted by natural disasters. In theUnited States, tornadoes are a particular threat but have been studied very little. The currentinvestigation developed a scale for assessing posttraumatic stress disorder (PTSD) in children inKindergarten to Grade 6 impacted by a severe tornado. Six factors were found: Avoidance,Re-experiencing, Interpersonal Alienation, Interference with Daily Functioning, PhysicalSymptoms/Anxiety, and Foreshortened Future. Prevalence rates for PTSD symptomology rangedfrom 34 to 44% for factor scores and 41% for meeting all three Diagnostic and Statistical Manualof Mental Disorder, fourth edition-text revision (DSM-IV-TR; American Psychiatric Associa-tion, 2000) criteria; 40% indicated no symptoms. Children’s fear during the tornado and damageto their school were related to many factor scores. © 2006 Wiley Periodicals, Inc.

School psychologists increasingly deliver services within a community health perspective(Friedman, 2003; Strein, Hoagwood, & Cohn, 2003) and intervene when communities are exposedto traumatic events (Allen et al., 2002; Motta, 1995; Stein, 1997). They should know the effects oftrauma on children for screening, diagnosis, and intervention planning; be members of the responseteam; use their knowledge of the local system; provide continued services following rapid responseinterventions (Cook-Cottone, 2004); and consider differential diagnosis and comorbidity of post-traumatic stress disorder (PTSD) when children are referred for other symptoms (Ford et al.,2000). Most training programs include brief coverage of PTSD; few cover in-depth the effects ofnatural disasters on children despite exposure in every state to potential disaster from naturalphenomena such as tornadoes, floods, drought, blizzards, earthquakes, volcano eruptions, fires,heatwave, and hurricanes (Abbott, 2004). This study focuses on children impacted by a severetornado since there is little research on this type of disaster despite widespread occurrence andhigh frequency, short warning time for precise location, and severity and resulting significantdamage. The National Severe Storms Laboratory (National Oceanic and Atmospheric Adminis-tration, 1999) reported that approximately 1,000 tornadoes every year occur from the EasternRockies to the Atlantic Ocean, with tornadoes of a severe F5 magnitude occurring about every5 years. While those in “tornado alley” have the advantage of being located near the NationalSevere Storms Laboratory in Norman, Oklahoma, which contributes significantly to tornado aware-ness, education, and prediction (Stumpf, Smith, & Thomas, 2003), children throughout the UnitedStates are at risk for tornado strikes in areas where preventative actions are less systematic (Con-cannon, Brooks, & Doswell, 2000).

A review of the literature over the last half-century yields few social science studies involv-ing tornadoes. Penick, Powell, and Sieck (1976) found that long-term, tornado victims had sig-nificant mental health problems. Madakasira and O’Brien (1987) found PTSD symptoms in themajority of tornado survivors. Steinglass and Gerrity (1990) compared victims in flood and tor-nadoes and found very high short-term PTSD symptom rates in both communities. After 16 monthssymptoms decreased, but those in the tornado had higher rates of PTSD (21 vs. 14.5%) even withbetter relief and recovery services. Greening and Dollinger (1992) found adolescents who had

The authors thank the students, families, and schools who allowed us to ask sensitive questions in order to help others.This article is part of the first author’s dissertation, which she conceptualized. Correspondence to: Judy Oehler-Stinnett,School of Applied Health and Educational Psychology, 434 Willard Hall, Oklahoma State University, Stillwater, OK,74078. E-mail: [email protected]

Psychology in the Schools, Vol. 43(3), 2006 © 2006 Wiley Periodicals, Inc.Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pits.20150

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experienced tornadoes, lightning, floods, or no disasters perceived tornadoes to have a higherfatality risk than lightning. Stoppelbein and Greening (2000), in comparing children who had beenin a tornado, lost a parent, or had social or academic stressors, found that children in the parental-loss group had more severe PTSD symptoms. They did not note whether children in the tornadohad lost loved ones. People exposed to tornadoes can suffer from PTSD as they do when exposedto other traumas (Steinglass & Gerrity, 1990).

Study Rationale

The first criteria for PTSD according to the Diagnostic and Statistical Manual of MentalDisorders (DSM), Fourth Edition-Text Revision (DSM-IV-TR; American Psychiatric Associa-tion, 2000) is that one has a significant fear response to a stressful, traumatic event (Muran &Motta, 1993). Additionally, the three primary-symptom clusters, established with combat veter-ans, are (a) Re-experiencing of the event; (b) Avoidance of event stimuli, numbing, and a sense offoreshortened future; and (c) Arousal, including cognitive, affective, and physiological compo-nents. Duration must be greater than 1 month, and symptoms must impact social and occupational(for children, school) functioning. There is concern about whether these dimensions have empir-ical support with children, based on descriptions of children’s behavior that differ from adults(Terr, 1979). The DSM-III-R, DSM-IV, and DSM-IV-TR specify guidelines for PTSD in children;however, some symptoms are not on the actual diagnostic criteria list (American Psychiatric Asso-ciation, 1987, 1994, 2000; McNally, 1991).

Development of PTSD self-report rating scales with appropriate items is critical for quickscreening of large groups of children from the child’s perspective. Most self-report instrumentsfocus on the three DSM clusters of Re-experiencing, Avoidance, and Arousal as described indifferent versions of the DSM (Cook-Cattone, 2004; National Center for Post-Traumatic StressDisorder, 2004; Ohan, Myers, & Collett, 2002). Children’s scales appropriate for disaster-relatedtraumas include the Children’s PTSD Inventory (Saigh et al., 2000; Saigh, Yasik, Oberfield, Hala-mandaris, & McHugh, 2002); the Impact of Events Scale (IES; Yule, Bruggencate, & Joseph,1994); the Child Post-Traumatic Stress Disorder Reaction Index (CPTSD-RI; see Pynoos (2002)for adaptation from Frederick, Pynoos, & Nader, 1992); the Child PTSD Symptom Scale (CPSS;Foa, Johnson, Feeny, & Treadwell, 2001); When Bad Things Happen (WBTH; Fletcher, 1996);and the Kauai Recovery Index (KRI), patterned on the CPTSD-RI (Hamada, Kameoka, Yanagida,& Chemtob, 2003). While measures are scored by adult DSM categories, Anthony, Lonigan, andHecht (1999) used confirmatory factor analysis of symptoms in youth victims of Hurricane Andrewand found three symptom clusters of intrusion/active avoidance, numbing/passive avoidance, andarousal. Anthony et al.’s model diverges from DSM-IV-TR in finding two subgroups of avoidanceand placing fear of reoccurrence/hypervigilance items on the Intrusion/Active Avoidance factorrather than Arousal. Carrion, Weems, Ray, and Reiss (2002) and Cook-Cottone (2004) called fordevelopmental multifactored measurement of PTSD. Inclusion of additional items relevant tochild reactions based on the theoretical and empirical literature, and specific trauma (e.g., torna-does) might lead to additional factors in a comprehensive, yet parsimonious measure. Consider-ation of frequency and intensity of symptomology using DSM-IV-TR clusters compared to factorscores for diagnosis and prevalence estimation in children also is important (Carrion et al., 2002).Finally, the relationship of severity of trauma, known to impact disaster adjustment, should beexamined to interpret functioning from a broader ecological perspective.

Theoretical Considerations for Predicted Factor Structure

Explanations for the mechanisms of PTSD, and which components should be measured,primarily include biological, cognitive, and affective theory. Biological explanations include

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Psychology in the Schools DOI: 10.1002/pits

psychophysiological conditioning through elicitation of the fear network (DeBellis, 2001; LeDoux,2000; Yehuda & McFarlane, 1997). Pynoos, Steinberg, and Piacentini’s (1999) model of child-hood PTSD emphasizes that these neurobiological changes disrupt normal developmental pro-cesses. Hypervigilance and an exaggerated startle reflex are critical symptoms for PTSD (Carrionet al., 2002; Ornitz & Pynoos, 1989). These primary symptoms, currently on the Arousal DSM-IV-TR cluster, are more likely to factor with avoidance items, as activation of the fear systemcould be related to avoidance of trauma-related stimuli (Anthony et al., 1999). Other items onthe Arousal (supposedly a physiological) dimension include anger outbursts and difficulty con-centrating, which are emotional and cognitive results of the hyperaroused system. Sleep distur-bances are more related to trauma dreams than to physiological arousal and are more likely tofactor with reexperiencing items. Somatic complaints may factor with physiological items orwith anxiety.

Children must contend with trauma despite developmental limitations in encoding and retriev-ing memories, cognitive regulation of emotion, and understanding trauma experiences filteredthrough attentional bias toward threatening internal and external stimuli (Salmon & Bryant, 2002).Cognitive intrusions describe re-experiencing, such as dreaming, thinking, and talking about theevent or perception of unavoidable trauma cues; these items should be related (Orr, Metzger, &Pitman, 2002). In her team’s work with children from the Oklahoma City bombing, Pfefferbaumet al. (2001) noted that television reexposure can have a significant impact on children. Carrionet al. (2002) found that reexperiencing symptoms was related to PTSD diagnosis, making thesesymptoms important markers.

Trauma-related information interferes with the child’s schema development (Pynoos et al.,1999). Beliefs regarding safety and security may be shattered by trauma, impacting expectationsfor self, others, and the future. The perceived uncontrollability of traumatic events is salient in thedevelopment of anxiety and PTSD (Foa, Zinbarg, & Rothbaum, 1992). Helplessness experiencedduring the trauma and concomitant reduced interest from lowered self-efficacy should be criticalmarkers for PTSD and related to active avoidance of situations in which helplessness would occur,and an avoidance factor should emerge.

These cognitive aspects of PTSD are similar to the depression cognitive triad or view of theworld, self, and the future (Beck, 1976; Chorpita, Albano, & Barlow, 1998). Hopelessness towardthe future in PTSD items is endorsed less frequently and may constitute a factor that is important(March, 2003; Salmon & Bryant, 2002). In adult populations, trauma experiences are not typicallyrelated to irrational cognitive distortions seen in generalized anxiety and depression (Muran &Motta, 1993), but an internalized locus of control for the traumatic event is related to adjustmentdifficulties (March, 2003; Seligman, 1992). Items measuring guilt and omen formation are likelyto factor together to capture this dimension. Features considered associated, interpersonal func-tioning and daily functioning with life and school after the event, may constitute a factor and bediagnostic of children’s PTSD. Carrion et al. (2002) found detachment from others predictive forPTSD. Children may see people who elicit trauma cues as aversive stimuli, avoid them, and haveanger due to a lack of ability of others to understand and/or protect them.

Across child and adult clinical groups, PTSD also impacts basic cognitive processes of con-centration, working memory, and selective attention (McFarlane, Weber, & Clark, 1993). Neuro-cognitive deficits imply that children with PTSD are likely to experience learning problems and bereferred for learning and/or attention problems rather than PTSD (Caffo & Belaise, 2003). Wein-stein, Staffelbach, and Biaggio (2000) outlined the differential diagnosis guidelines between PTSDand attention deficit hyperactivity disorder. Items reflective of concentration and school problemsattributed by the child to the trauma are likely to be related and can inform differential diagnosis.In summary, empirical studies are needed that provide a preliminary PTSD scale for use with child

Children’s PTSD From Tornadoes 285


tornado victims, as indicated by studies of diagnostic efficacy of the PTSD symptoms in otherdisasters (Anthony et al., 1999).

Rationale for Predicted Prevalence Rates

Prevalence rates of PTSD, which vary by type and severity of trauma, time elapsed, andcriteria utilized, generally range from 30 to 95% shortly after a trauma; long-term symptoms oftenpersist in a third of impacted children (Carrion et al., 2002; Cook-Cottone, 2004). Norris, Fried-man, and Watson’s (2002) meta-analytic review showed that youth are more impacted by traumathan adults, but rates for natural disasters are often less severe than violence-related disasters.While prevalence rates have not been examined in children exposed to tornadoes, rates have beenstudied with other natural disasters. Vernberg, LaGreca, Silverman, and Prinstein (1996) foundsignificant rates of PTSD in children exposed to Hurricane Andrew, with 86% reporting somelevel of symptoms, 56% mild to moderate symptoms, and 30% severe symptoms. Russonielloet al. (2002) found some symptoms in 95% of children affected by Hurricane Floyd. Prevalencerates in Hurricane Andrew for severe symptoms were lower at 10-month follow-up; for the threedimensions of PTSD, 78% met re-experiencing, 24% avoidance, and 49% arousal criteria (LaGreca,Silverman, Vernberg, & Prinstein, 1996). Only 18% met criteria for all three symptom clusters,indicating a need to look at specific symptomology in children. Prevalence rates for tornadoes arelikely to be similar to or higher than those reported with hurricanes. While girls and minoritieswere sometimes more severely affected, this finding is not stable enough to predict finding suchdifferences with the current sample (Shannon, Lonigan, Finch, & Taylor, 1994; Vernberg et al.,1996). Participants were selected from elementary grades only to control for age differences.While not the focus of this study due to the small sample, gender and age also were correlated withPTSD symptoms. Due to the severity of the tornado, these variables were not predicted to besignificant.

This study established preliminary prevalence rates in children who have been exposed to asevere tornado 1 year post-tornado. Factor scores were examined for frequency and intensity ofendorsement to determine rates of symptomology. To compare factor score rates to DSM-IV-TRdiagnoses and previous studies’ diagnostic rates, items also were manually grouped by the threerational/theoretical clusters of DSM-IV-TR and scored as subtests. It was expected that a clearerpicture of symptomology would emerge from the factor-score interpretation, but that prevalencerates would be similar to other severe natural disasters. Most of the children had not receivedpsychological intervention and reported that the tornado was seldom talked about. Thus, it waspredicted that rates would capture a preadjustment phase of PTSD rather than a full adjustmentand resolution (Miller, 1994). Social support was high within the community, families, and school.Children in other countries experiencing natural disasters may be more affected due to less sup-port structure and fewer emergency services.

Tornado Severity Related to Symptomology

It is important that contextual as well as within-child variables be considered for diagnosisand treatment consideration. The child participants had been affected by the May 1999 tornado,the deadliest in U.S. history in over 20 years (Brooks & Doswell, 2002), in which 11,602 homesand other buildings were destroyed or damaged and two public schools were obliterated, and 45people were killed and 597 were injured (National Oceanic and Atmospheric Administration,1999). All children included in the study were impacted through direct (their own) or indirect (afamily member or friend) loss of schools, homes, churches, and major businesses in their com-munities. All were in or near the direct path of the tornado when it hit. In addition, another tornadothat was smaller had hit in December following the record-setting tornado. Data were collected at



the 1-year anniversary, which was again the spring storm season during which teachers werereporting children’s continuing fear of storms. The school and community had received extensivesupport services from the Federal Emergency Management Administration right after the tornado;rebuilding was still continuing, and the new school was still not finished.

There is extensive evidence that such severity of trauma damage, as well as the child’s actualexposure to the trauma, increases levels of PTSD (Archer, 1997; Kreuger & Stretch, 2003; Norris,Friedman, & Watson, 2002). This study was most interested in the children’s direct experienceduring the tornado as it relates to OSU PTSD-CF scores, as these experiences are most likely toelicit the fear network. The child’s report of their proximity to the tornado and how scared theywere, along with whether their own school or home was damaged, were correlated with factorscores and the total score.

Method

Participants

Participants were 152 children in Stroud and Mulhall, two small rural communities in Okla-homa that experienced the tornado described previously. There were 68 males and 78 females, and98 White, 12 Native American, 1 Asian, 2 Hispanic, 2 Multiracial, and 31 who did not discloseethnic background. Ages ranged from 6 to 12 years (M � 9.47), and grades ranged from kinder-garten to Grade 6, with the majority being between Grades 3 and 5 (M � 3.56). Where item valueswere missing, they were replaced with the mean. These children represented approximately 50%of the children in that age group and all of those for whom parent permission was received. For themajority of children, this was the first direct tornado they had experienced (68%), they were withtheir family at the time of the tornado (78%), and the family sought shelter in a cellar (67%). For32%, there was damage to their home, for 37% to an immediate family member’s home, 39% to anextended family member’s home, and 71% to a close-friend’s home. None of the children directlyexperienced injury or witnessed injury or death.

Instruments

OSU PTSD Scale-CF. This self-report scale was developed by the authors through inclu-sion of items relevant to the DSM-IV-TR criteria involving re-experiencing, avoidance, and arousal.Items were primarily selected through adaptation of items from other scales, including the IES,CPTSD-RI, CPSS, WBTH, and KRI. Authors of some available children’s scales, Fletcher andHamada, gave the current authors permission to adapt their scales for the present study. Items weremodified to include reference to tornadoes, and additional items were added to address constructsas addressed earlier. Other items not on the DSM-IV-TR criteria checklist were based on a reviewof the literature on PTSD (for complete review, see Evans, 2003). A total of 33 original items wereincluded. The children rated their current experiences in a 0 to 4 Likert format, with 0 � never and4 � always. For comparison purposes, items also were interpreted according to DSM-IV-TRcriteria for PTSD diagnosis and utilized in determining which children would be considered ashaving PTSD.

OSU Demographic Questionnaire. This researcher-made paper-and-pencil device askeddemographic information such as age, gender, ethnicity, and grade. It also asked severity itemssuch as exposure to the tornado event and resulting damage.

Procedure

Research permission was obtained from the Oklahoma State University Institutional ReviewBoard and the respective school districts. One year following the tornado, children whose parentshad returned the parent permission form and parent questionnaires, as part of the larger study,



completed the forms during times scheduled by the schools with the primary investigator or trainedgraduate assistants present. Following data collection, all school children were offered counselingassistance, and most study participants received empirically supported group therapy by membersof the team.

Results

Scale Development

Preliminary analyses of the OSU PTSD-CF items indicated that the Kaiser-Meyer-Olkinmeasure of sampling adequacy was .85 and above the criterion of .60, the Bartlett’s test of sphe-ricity was significant, the correlation matrix indicted many significant correlations, and the anti-image correlation matrix yielded low negatives of the partial correlations, all of which support theuse of factor analytic techniques (Gorsuch, 1983; Stevens, 1992; Tabachinick & Fidell, 1989). Theparticipant-to-variable ratio met the minimum criteria of 5 participants per variable (Stevens,1992), and factors were examined for predicted marker items and high loadings to support relia-bility of results.

Various principal components exploratory analyses, including oblique and orthogonal rota-tions, were conducted to obtain the most parsimonious and theoretically sound factors. While itmight be expected that subcomponents of the PTSD construct would be correlated (Anthony et al.,1999), inclusion of items not on the DSM-IV-TR criteria, such as those related to daily function-ing, also would suggest that an orthogonal solution could be appropriate. Orthogonal solutions aremore advantageous with a small sample size and result in more easily interpretable solutions(MacCallum, Widaman, Zhang, & Hong, 1999). Solutions with highly correlated factors defeatthe purpose of a factor analysis, and those with low correlations indicate that correlated factors arenot necessary; only with moderate correlations should the oblimin solution be retained. Becausethe oblimin solution factor intercorrelations were under .30 and did not suggest significant over-lapping variance, the orthogonal solution was retained (Stevens, 1992; Tabachnick & Fidell, 1989).The oblimin solution yielded similar factors; however, it allowed many overlapping items onfactors which would reduce specificity and interpretability of the components. Significance ofthe factor loadings, the scree plot, and eigenvalues were used in decision making regardingnumber of factors and item retention on factors, which is more critical than the type of rotation(Tabachnick & Fidell, 1989). Loadings of .40 or larger were retained on a factor (Stevens, 1992),and cross loadings on factors were eliminated if one factor was higher and elimination of the crossloading made sound theoretical sense.

A Varimax rotation with Kaiser Normalization was retained as the most appropriate solutionfor the OSU PTSD Scale-CF, and six factors were yielded that explained 63.8% of the variance(somewhat below the recommended level of 70%; Stevens, 1992). Table 1 presents the factorloading matrix. A total of 29 items was retained. The factors are Factor 1, Avoidance; Factor 2,Re-Experiencing; Factor 3, Interpersonal Alienation; Factor 4, Interference with Daily Function-ing; Factor 5, Anxiety/Physical Symptoms; and Factor 6, Foreshortened Future. A Total Scorealso was calculated. Examination of the results indicates that the solution met criteria for anadequate solution with a small sample size, high communalities, well-determined factors, andgood convergence in the factor solution (MacCallum et al., 1999).

Prevalence Rates

Descriptive statistics and standardized alpha coefficients for OSU PTSD-CF raw scores aswell as percentages falling at 1, 2, and 3 SDs above the mean are reported in Table 2. The overallalpha was .91, indicating support for the PTSD construct. Factor alphas ranged from .70 to .88; all



scale interitem correlations were significant, thus no further items were eliminated based on thisanalysis. A decision was made to score the guilt item on the Physical Symptoms/Anxiety Scalebased on these data and theoretical considerations rather than to remove the item due to crossloadings. Alphas are adequate, particularly given the small number of items (Cortina, 1993).

With 0 � never, 1 � sometimes, 2 � often, 3 � most of the time, and 4 � always for the OSUPTSD-CF, means indicate most children reported reactions somewhere between never and often,

Table 1OSU Post-Tornado Stress Disorder Form Rotated Component Matrix

Component

Items 1 2 3 4 5 6

F1: Avoidancedon’t like to hear people* .777jumpy, startle*** .692don’t go places* .678 .434can’t remember* .635not think about* .598 .411not interested* .541 .435alert*** .541couldn’t help self .460

F2: Re-Experiencingscared thinking about** .649dream about** .698talk about a lot** .658upset if see on TV .652have bad dreams about** .612feel happening again** .430 .610

F3: Interpersonal Alienationmore problems friends .699not see people remind .562get angry*** .559different from others* .447 .460

F4: Interference with Daily Functioningtrouble thinking*** .729problems in school .464 .663problems in life .579

F5: Physical Symptoms/Anxietyheadache, stomachache .875not away from parents .855feel outside body** .433 .589feel guilty .532 .407

F6: Foreshortened Futurewon’t marry* .792won’t have children* .676might die* .426

Note. Extraction Method: Principal Component Analysis. Rotation Method: Varimax with Kaiser Normalization.Rotation converged in 13 iterations. Factor loadings below .40 are suppressed for clarification. *DSM IV-TR Avoidance;**Re-experiencing; *** Arousal.



and mean scores mostly represented a response of sometimes. For all but one item at 31%, over40% reported never, suggesting a relative lack of symptoms in a significant minority of children.Item responses of sometimes ranged from 4.6 to 16.4%, often from 2.0 to 12.5%, most of the timefrom 1.3 to 7.2%, and always from 1.3 to 18.6%. Standard deviation units indicate the percentageof children who show more severe symptoms relative to other children impacted by the tornado.For Factors 2 through 5 and the Total Score, only 1 to 3% fell at 2 or 3 SDs, where for these factors2 SDs indicates responses between often and most of the time while a score at 3 SDs indicates aresponse between most of the time and always. For RE, 7% fell at 2 SD, and for FF, 10% did so,indicating responses of most of the time. Percentages for these two factors at 1 SD were thus lower,5 and 2%, respectively. For the remainder of the factors, percentages at 1 SD were Factor 1, 13 to15%; Factor 3, 9%; Factor 4, 10%, and Factor 5, 15%, indicating larger percentages of childrenreporting these symptoms occurring as often. When responses are dichotomized into yes and nobased on often to always, similar to the DSM-IV-TR, prevalence of positive symptoms are Factor1, 34%; Factor 2, 39%; Factor 3, 44%, Factor 4, 41%, Factor 5, 40%; and Factor 6, 34%.

Relevant items were then manually grouped by DSM-IV-TR criteria to determine the per-centage of children who would be identified as having PTSD (see Table 1 Note). Using the DSM-IV-TR yes/no dichotomy, with not at all representing symptom not present, and ratings fromsometimes to always representing symptoms present, 65% met Criteria B for Re-experiencing,47% met Criteria C for Avoidance, 54% met Criteria D for Problems in daily living, and 41% metall criteria and would be considered as having PTSD. Using the more stringent criteria of ratingsfrom often to always, 40% met Criteria B, 34% met Criteria C, 36% met Criteria D, and 25% metall criteria for a diagnosis of PTSD. The Severity item regarding fear during the tornado was usedto examine Criteria A. Of the children who met the lesser criteria ( yes/no) for PTSD, 98% of theseindicated that they were at least a little scared during the tornado, and 60% indicated that theywere very scared. Of those who met the stricter criteria for PTSD, 90% said they were at least alittle scared, and 76% indicated they were very scared during the tornado. A percentage of .06 ofthose who met the yes/no criteria and 10% of those who met the stricter criteria indicated that theywere not scared during the tornado. This would reduce the prevalence rates to 38 and 22%, respec-tively, but calls into question Criteria A for all children.

Related Variables

Correlations for age as well as differences for gender and ethnicity were examined. Correla-tions between age and the amount of PTSD expressed via factor scores on the OSU PTSD Scale-CFwere not significant (Factors 1– 6 rs were �.16, �.13, �.08, �.03, �.13, and �.06, respectively).

Table 2Descriptive Statistics and PTSD Prevalence Rates for OSU PTSD Scale-Child Form

Factor Score M SD SE a % at 1 SD % at 2 SD % at 3 SD

Factor 1 1.03 1.07 .10 .88 5 7 2Factor 2 .78 .96 .78 .86 13 3 2Factor 3 .74 1.01 .74 .87 9 3 3Factor 4 .72 1.12 .72 .83 10 1 3Factor 5 .82 1.50 .15 .81 15 3 2Factor 6 .90 .81 .08 .70 2 10 3Total score .67 .67 .07 .91 2 1 1



The t tests for gender indicated that there were no significant differences observed in the averageamount of PTSD reported by the children for males versus females, t(df � 150) � �.47, �1.43,�1.62, 1.10, .87, and .28 for Factors 1 to 6, respectively. Cell numbers were low for ethnicity, andno group differences were significant. Fs(df � 150) ranged from .114 to 1.26.

Correlations for factor scores and the Total Score with tornado severity items are presented inTable 3. How scared the child was during the tornado was significantly correlated with Avoidance,Re-experiencing, Interpersonal Alienation, and the Total Score. Correlations were low, likely dueto restriction of range in the sample that all had high severity. Whether the school was damagedwas related to Avoidance, Foreshortened Future, and the Total Score. Whether the child’s homewas damaged and how close the child was to the tornado were not significantly related to the OSUPTSD-CF, most likely due to restriction of range.

Discussion

This study examined the effects of the largest tornado in the history of the United States,1-year postdisaster, upon children. The primary focus was on the development of an appropriateassessment instrument and determining prevalence of symptoms. The OSU PTSD-CF, whichincluded unique items, produced a six-factor solution with high internal consistency. This is notconsistent with the DSM-IV-TR which includes three clusters, or with the empirical work ofAnthony et al. (1999) in their study of the Hurricane Hugo children, which found three symptomclusters. However, inclusion of items in the literature, but not other scales, would explain produc-tion of additional factors which deserve further research to adequately assess children who haveexperienced natural disasters. In relation to DSM criteria, a separate arousal factor did not emerge;these items loaded with other factors. A startle reaction loaded on Avoidance, trouble concentrat-ing loaded with Daily Functioning, anger loaded with Interpersonal Alienation, and sleep prob-lems did not load on any factor (although dream disturbances loaded on Re-Experiencing). ARe-experiencing factor did emerge that is somewhat consistent with DSM criteria. The childrenexperienced intrusive recollections, dreams, mental distress when hearing the tornado discussedor seeing information about it on television, and flashback-type experiences (i.e., feeling it ishappening again). Physiological components, however, loaded with other factors.

An Avoidance factor also emerged. Inclusion of the startle response and hypervigilance withAvoidance would indicate physiological as well as cognitive and behavioral components to avoid-ance. Remaining hypervigilant may be an attempt to avoid re-experiencing; however, this chronicstress reaction cannot be considered an adaptive coping mechanism. Two separate avoidancefactors did not emerge as have been found in previous studies, but some items that have beencalled passive avoidance loaded on adjustment factors below. However, many items from the

Table 3OSU PTSD Scale-Children’s Form Correlated with Tornado Severity

Factor1 2 3 4 5 6

TotalScore

How scared .30** .36** .29** .10 .07 �.02 .42**Home damaged .13 .15 .08 .12 �.09 �.03 .14School damaged .30* .05 .009 .00 �.07 .29** .29**Tornado proximity .17 �.02 �.06 .09 �.01 �.02 .06

*p � .05. **p � .01.



DSM avoidance cluster loaded on factors different from Avoidance, specifically sense of fore-shortened future, which constituted a separate factor, as predicted and discussed. Currently, thesesymptoms are clustered with others in the DSM and are not considered critical to the diagnosis.Sense of foreshortened future as a separate component may reveal children who are at particularrisk for severe problems.

An Anxiety factor also emerged which contains anxiety and somatic complaint items. DespitePTSD being described in DSM-IV-TR as a distinct form of anxiety, it does not include a separateanxiety cluster in the diagnosis. Interestingly, items in the children’s PTSD literature that arementioned in the DSM, but not included in the formal diagnostic list, loaded on this factor: guilt,omen formation, and separation anxiety, indicating their importance for children. This factor con-stitutes a unique contribution to the assessment literature and may help identify children in waysnot currently in the DSM. Separation of anxiety from depressive symptoms also is consistent withthe tripartite models which found that anxiety corresponded to high negative affect (Chorpitaet al., 1998). Guilt also loaded with interpersonal difficulties; inclusion of more items and a largersample may establish separate factors for anxiety and guilt separate from somatic complaints.

Estrangement from others factored separately into a factor named Interpersonal Alienation.Anger loaded onto this factor, and not with hyperarousal, indicating that the anger is in relation toother people who perhaps could not completely protect the children. Adults should consider angerand interpersonal problems as possibly related to PTSD, and not just look for classic symptoms ofanxiety and depression (Friedrich, Beilke, & Urquiza, 1987). Finally, a factor called Interferencewith Daily Functioning also emerged, with items related to problems with school and life, poorconcentration, and loss of interest in daily activities. While this factor comes the closest to thepassive avoidance factor described in other studies, these results of problems in daily activities areconsistent with and best described as the negative cognitive style related to depression (Seligman,1992) and the tripartite model describing depression as corresponding to low positive affect (Chor-pita et al., 1998). Having items on a self-report scale that ask children about adjustment relative totrauma can aid in differential diagnosis, particularly for children who may be referred for otherdifficulties not attributed to trauma. These results strongly suggest that children referred for schoolor family difficulties should be screened for effects of natural disasters that frequent the area.

The design and results of this study also allowed examination of prevalence rates accordingto factor scoring and by DSM-IV-TR categories. Additionally, use of a Likert rating yielded knowl-edge of relative frequency of symptoms as well as their presence or absence. Use of any presenceof the symptoms yielded high rates similar to other studies. Use of a restricted definition offrequent symptoms reduced these rates somewhat, and use of standard deviation units for thefactor scores identified the most severely affected children. While for most symptoms over 40%indicated no presence, a significant minority of children clearly exhibited PTSD symptoms, indi-cating a need for long-term follow-up with this population.

The current study found no differences in the expression of PTSD symptoms by gender orethnicity or relationship with age; however, due to the small sample and the lack of representationacross cells, particularly for ethnicity, no conclusions regarding these variables can be drawn, andfurther work is needed. Note that this is one of the few studies with children who are NativeAmerican represented, and further studies employing larger groups should consider this popula-tion further. Finally, the DSM-IV-TR requires that the individual has experienced or been exposedto a traumatic event that involved real or threatened death or serious injury, and caused feelings ofintense horror or helplessness. That is, the fear network has been engaged. How scared the childwas during the tornado was related to the Total Score and to the primary PTSD factors, lendingsome support for the importance of this criterion. Damage was less correlated with factor scores.Further research is needed examining severity factors with children who have been in tornadoes.



Current results indicate that even 1 year following a devastating tornado, many children arestill experiencing both internalizing and externalizing symptoms. Children, who in general are ina safe, loving, rural environment, must now live with a possible future event that neither they northeir parents can control. In therapy groups, tornado preparation was part of the training, and thisshould be considered in any treatment and prevention program; however, children are dependenton the adults around them to implement tornado safety. Practitioners should note that behaviorsreported to them in referrals may be symptomatic of a more comprehensive disorder such asPTSD. Use of standard assessment measures alone may not reveal PTSD problems related totrauma, and the possibility that the child has experienced a serious traumatic event may not ever bedirectly addressed.

The limitations of this study have affected generalizability. The sample size was smaller thanwas optimal; however, there is no evidence that the sample was of children more severely affected.Additionally, this study was limited to a rural area. Further research utilizing a more stratifiedsample in a confirmatory factor analysis is needed. Additional work is needed before cutoff scoresfor diagnosis of PTSD are determined, including test-retest reliability. Additional items are neededto further capture the constructs measured and provide additional stability for the scale. Analysesmeasuring immediate as well as long-term response to the tornado are needed to provide appro-priate services just after a disaster as well as later. Because there are no other measures for responseto a tornado, and items were taken from related hurricane scales, there is no scale available forconcurrent validity studies presently; however, comparison to narrow band instruments such asspecific anxiety and depression scales might be conducted. Finally, a comparison parent scale isneeded, and this will be reported in a later article. Despite limitations, the current investigationprovides a much-needed addition to the tornado literature and a beginning dataset for additionalwork on trauma scales appropriate for children. Researchers working with Katrina survivors areencouraged to contact the investigators for use of the OSU-PTSD-CF.

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Structure and prevalence of PTSD symptomology in children who have experienced a severe tornado