Seedat et al, 2004

BRITISH JOURNAL OF P SYCHIATRY ( 2 0 0 4 ) , 1 8 4 , 1 6 9 ^ 17 5

Trauma exposure and post-traumatic stress symptoms in urban African schools

Survey in CapeTown and Nairobi

S. SEEDAT, C. NYAMAI, F. NJENGA, B. VYTHILINGUM and D. J. STEIN

Africa

1140 Cape Town, South African and 901 Nairobi, Kenyan students participated mean age 15.8 years and in grade 10 – chosen in each city to be representative of the ethnic and socio-economic make-up of the population in the year 2000

completed anonymous self-report questionnaires under supervision in their classrooms – voluntary participation – used age adjusted assessment tools

more than 80% of the 2041 respondents reported lifetime exposure to at least one DSM-IV trauma — mean number of trauma exposures was 2.49, comparisons between countries was not significant

for both countries most common PTEs were

63% witnessing community violence

35% being robbed or mugged

33% witnessing a family member being hurt or killed

Significantly more in the Kenyan group had witnessed violence, been physically hurt or beaten by a family member, or been sexually assaulted  Seedat et al, 2004, p 170

Symptoms of PTSD

+ (a)  avoidance of activities, places or people that aroused recollections of the trauma

33.3% South African group (SA)

53.2% Kenya group (Kenya)  Seedat et al, 2004, p 170

+ (b)  avoidance of thoughts, feelings or conversations associated with the trauma

32.4% SA

50.5% Kenya

+ ( c) irritability or outbursts of anger

31.1% SA

23.1% Kenya

+ (d) intense psychological distress at exposure to trauma reminders

21.3% SA

28.0% Kenya

“The South African students had higher scores across all the three symptom clusters of re-experiencing, avoidance and hyperarousal, and more PTSD symptoms, than Kenyan respondents:  SA, 4.9…Kenya, 2.3….

In the whole group, 14.5%…of adolescents met the symptom criteria for full PTSD, and an additional 10%…met symptom criteria for partial PTSD.

Notably, 22% of South African adolescents had a full PTSD diagnosis compared with only 5% of Kenyan adolescents…,

and 12% [SA] met the symptom criteria for partial PTSD compared with 8% in the Kenyan group….”  Seedat et al, 2004, p 171

relationship between trauma exposure and PTSD symptoms:

Remained significant for each country that PTSD endorsed more traumas on the Trauma Checklist, and by gender

Total for both countries full symptoms:  PTSD positive – 3.5 traumas —  PTSD negative – 2.3 traumas

KENYA  – PTSD positive – 2.9 traumas— PTSD negative – 2.4 traumas

SA – PTSD positive – 3.6 traumas — PTSD negative – 2.2 traumas

Males:      PTSD positive – 3.7 traumas — PTSD negative – 2.5 traumas

Females:  PTSD positive – 3.2 traumas — PTSD negative – 2.2 traumas

Those with full PTSD endorsed a higher number of traumas 3.7 than those with partial-symptom PTSD 2.9 or no PTSD 2.3

Gender and trauma exposure

Boys – 2.7 – as a whole had more trauma exposures than girls – 1.9

witnessed community violence: Boys 67% – significantly more likely than girls – 60%

been robbed or mugged:  Boys 39% – significantly more likely than girls – 33%

been beaten by someone not a family member:  Boys 26% -sig more likely than girls 15%

to have been victim of sexual assault: Boys 19%- sig more likely than girls 13%

“‘sexual assault’ was operationalized in the survey as ‘any unwanted and forceful sexual experience that made (171) you feel uncomfortable’.  When responses for boys and girls were analysed by country, these differences remained significant in the Kenyan sample but not in the south African sample…” Seedat et al, 2004, p 172

boys and girls did not differ in symptom clusters or in rate of full symptom PTSD

lifetime exposure

Asian (SA) 86%, of those, 32% PTSD

Asian (Kenya) 60%, of those, 0% PTSD

Black (SA) 75%, of those, 34% PTSD

Black (Kenya) 85%, of those, 5% PTSD (majority race in Kenya)

Mixed Race (Coloured) (SA) 85%, of those, 29% PTSD (majority race in South Africa)

Mixed Race (Coloured) (Kenya) —–

White (SA) 86%, of those, 20% PTSD

White (Kenya) 100%, of those, 0% PTSD  Seedat et al, 2004, p 172

3 traumas most likely to be rated most frightening or upsetting:

sexual assault – physical assault by a family member – serious accidents

same risk of PTSD following sexual assault:  24% of girls and 25% of boys

traumas that constituted independent predictors for PTSD were:  sexual assault; witnessing family members injured, beaten, hurt or killed; being in a bad accident; being robbed or mugged; being beaten or physically hurt by a family member; witnessing violence in the street, neighbourhood or school.  Seedat et al, 2004, p 172

“Physical attack by someone outside the family…and natural disaster…were not independently predictive of a PTSD symptom diagnosis.”  Seedat et al, 2004, p 172

depression

mild depression with no significant differences between countries

except in Kenya where girls reported more depressive symptoms and significantly higher scores than boys

number of PTSD symptoms correlated significantly with total depression scores overall and within each country; significant gender difference also found

full symptom PTSD also had higher depression scores than those with partial-symptom and those with no PTSD

substance use

more South African than Kenyan adolescents reported smoking ten or more cigarettes a day (SA -5.3%, Kenya – 1.7%) and using cannabis (SA -8.7%, Kenya 4.6%).  As a whole more boys (8.7%) than girls (4.6%) reported cannabis use, no significant gender use for cigarettes or alcohol.  Use of these substances did not correlate significantly with PTSD symptoms.  Seedat et al, 2004, p 173

negative life events over previous year

(SA) 9.2 negative life events – (Kenya) 8.3

included such things as doing much worse than expected on a test, breaking up with a boyfriend/girlfriend, pregnancy, legal difficulties

Negative life event exposure was not significantly associated with PTSD symptoms

DISCUSSION

PTSD and trauma

Whole group:  14.5% met criteria for full PTSD; 10.3% fulfilled partial criteria for PTSD

(14.8% of those exposed to more than one trauma met full PTSD; 11.4%of those traumatised met partial PTSD criteria)

“These rates are strikingly similar to rates previously documented in trauma samples.  In a study by Giaconia et al (1995), 14.5% of affected youths (6.3% of the total sample) met DSM-III-R criteria for PTSD (American Psychiatric Association, 1987), while Lipschitz et al (2000) found that 14.4% and 11.6% of traumatised girls met DSM-IV symptom criteria for full and partial PTSD, respectively.  Both countries [in this study] had high rates of trauma exposure, with 83% of South African adolescents and 85% of Kenyan adolescents reporting at least one DSM-IV trauma in their lifetime, echoing the findings of other local (South African) and international studies….”  Seedat et al, 2004, p 173

“The most striking finding was the discrepancy in the rate of PTSD between South African and Kenyan adolescents in the context of equally high rates of trauma exposure (and even higher for specific types of trauma in the Kenyan sample).  The lower rate of PTSD in Kenya adolescents is difficult to explain.”  Seedat et al, 2004, p 173

“Our assessments did not measure the severity or chronicity of trauma exposure or past PTSD, variable that may contribute to PTSD risk.  For example, difference in toxicity of exposure between the samples (much higher levels of exposure to violent crime in South African adolescents) may be operant here, accounting to some extent for the differences inn PTSD rates.” Seedat et al, 2004, p 173

possible cultural factors  in way concept of trauma are operationalized

questionnaires were not culturally validated for the various ethnic groups

SA was far more culturally diverse composition

Kenya relatively homogeneous – 97% Black, compared with only 20% of South Africans

Gender

Surprising finding was absence of gender difference in overall rate and presentation of PTSD (as per Silva 2000)

More boys in this study than girls had experienced sexual trauma, surprise finding

“Sexual abuse [for both genders], compared with all other traumas, was also associated with the highest risk of PTSD.”  Seedat et al, 2004, p 173

depression but not substance abuse was correlated with depression

study limitations – PTSD criteria not based on functional impairment – age of onset and duration of PTSD were not documented, nor was symptom chronicity –

“exposure to trauma was measured as a count of trauma types, rather than as the number of exposures or severity of exposure to a particular trauma.  This might have contributed to the failure to detect significant differences between the samples, particularly as cumulative and toxic trauma exposure is associated with a higher PTSD risk.  It does not, however, account for higher rates of PTSD in the South African students, despite higher rates of exposure in Kenyan youth to both sexual assault and physical assault by a family member, as these are traumas that are likely to be repeated.  Further, these traumas were most likely to be associated with a PTSD full-symptom diagnosis.  This discrepancy is one for which we do not have an adequate explanation.”  Seedat et al, 2004, p 174

This would seem to go against Silva’s (2000) findings about threats within the home contributing to higher risk of PTSD in children.

to be eligible all had to read and write English at 10^th grade level, although English was not the home language of the majority of respondents

survey questionnaires were not culturally validated