MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Stellenbosch, CapeTown, South Africa
Chiromo Lane Medical Center, Nairobi, Kenya
MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Stellenbosch, CapeTown, South Africa
Correspondence: S. Seedat, MRC Unit on Anxiety and Stress Disorders, PO Box 19063, Tygerberg 7505, CapeTown, South Africa. Tel: 21 9389374; fax: 21 9335790; e-mail: sseedat{at}sun.ac.za.
Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims We assessed trauma exposure, post-traumatic stress symptoms and gender differences in adolescents from two African countries.
Method A sample of 2041 boys and girls from 18 schools in CapeTown and Nairobi completed anonymous self-report questionnaires.
Results More than 80% reported exposure to severe trauma, either as victims or witnesses. Kenyan adolescents, compared with South African, had significantly higher rates of exposure to witnessing violence (69% v. 58%), physical assault by a family member (27% v. 14%) and sexual assault (18% v. 14%). But rates of current full-symptom post-traumatic stress disorder (PTSD) (22.2% v. 5%) and current partial-symptom PTSD (12% v. 8%) were significantly higher in the South African sample. Boys were as likely as girls to meet PTSD symptom criteria.
Conclusions Although the lifetime exposure to trauma was comparable across both settings, Kenyan adolescents had much lower rates of PTSD. This difference may be attributable to cultural and other trauma-related variables. High rates of sexual assault and PTSD, traditionally documented in girls, may also occur in boys and warrant further study.
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INTRODUCTION |
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Previous studies
Few surveys have described the extent of violence exposure and its
associated psychological outcomes in African youth. A South African survey by
Ward et al (2001) of
104 adolescents in four secondary schools in Cape Town found that the majority
were exposed to at least one type of violent event either as a victim or a
witness, and 6% were likely to meet criteria for PTSD. Symptoms of PTSD and
depression were related to most types of violence exposure. In other
cross-sectional studies of youth in rural and urban settings in South Africa,
high rates of violence exposure, ranging from 67% to 95%, have been
documented, with 8.4% to 40% of children less than 17 years of age fulfilling
PTSD diagnostic criteria (Ensink et
al, 1997; Peltzer,
1999). A significant positive relationship has also been
identified between the extent of exposure and the development of PTSD
(Peltzer, 1998).
With these data underscoring the fact that adolescents are at high risk of becoming victims of violent crime, the purpose of our study was to compare trauma exposure and its sequelae, in particular rates of current full-symptom and partial-symptom PTSD, in adolescents in grade 10 at public and private schools in two African cities. The statistical differences of interest were type of trauma, gender and risk of PTSD in the context of setting. In a preliminary survey conducted at three secondary schools (n=307) in Cape Town (Seedat et al, 2000) we noted high rates of PTSD (12.1%), with girls reporting more trauma exposures and PTSD symptoms than boys. Given these preliminary findings and given the current high rates of criminal violence in South Africa (Victims of Crime Survey, 1998), we predicted that South African respondents, especially females, would endorse considerably higher rates of trauma and PTSD compared with Kenyan respondents.
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METHOD |
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Procedure
The protocol was approved by the institutional review board (University of
Stellenbosch) and the Departments of Education in Cape Town and Nairobi.
Students and parents were notified in advance of the study. Participation was
entirely voluntary and no student or parent opposed participation. All grade
10 students present on the day of the survey completed anonymous self-report
questionnaires in English under the supervision of classroom teachers and
research assistants (educated to master's level) during a 4560 min
classroom period at their schools.
Instruments
Demographics questionnaire
We devised a questionnaire to obtain demographic information on age,
gender, ethnicity, composition of the home, parental marital status, parental
occupation, family income and substance use.
Trauma Checklist
The Trauma Checklist, a list of DSMIV qualifying traumas (e.g. being
robbed or mugged, being physically hurt or attacked, being raped;
American Psychiatric Association,
1994) was adapted from the Schedule for Affective Disorders and
Schizophrenia for School-age Children Present and Lifetime version
(KSADSPL; Kaufman et
al, 1997). Respondents were also required to circle the most
frightening or upsetting event that had ever happened to them.
Child PTSD Checklist
After ascertaining the event that was the most frightening or upsetting,
the Child PTSD Checklist (further details available from the authors upon
request) was administered. This is a 28-item structured interview developed to
diagnose childhood and adolescent PTSD; no information about its psychometric
properties has yet been published. For this survey, the Checklist was
administered as a self-rated measure. The Child PTSD Checklist rates the
presence in the past month of each of the 17 symptoms required for a
DSMIV diagnosis of PTSD, to assess current disorder. The scale uses a
four-point Likert format, with 0 corresponding to not at all and
3 to all the time. For the purpose of the study, respondents
were asked to rate PTSD symptoms according to the most upsetting event
endorsed on the Trauma Checklist. A conservative threshold score of 2
(most of the time) was used to endorse the presence of a
symptom. Partial-symptom PTSD was defined as having at least one symptom in
each DSMIV symptom criterion category (reexperiencing, avoidance,
hyperarousal) (Stein et al,
1997; Marshall et al,
2001).
Life Events Questionnaire Adolescent version
The Life Events Questionnaire Adolescent version (LEQA;
Masten et al, 1994),
a 45-item measure of negative and positive life events, was used to measure
non-PTSD events that can happen in the life of any adolescent or in any
family. Respondents were required to indicate (yes or
no) if an event had happened to them or their families in the
past year. Discrete, negative life events included school failure and
suspension, pregnancy, legal difficulties, and trouble with drugs or
alcohol.
Beck Depression Inventory
The Beck Depression Inventory (BDI) is a widely used 21-item self-report
measure of cognitive, affective, somatic and behavioural symptoms of
depression with excellent psychometric properties
(Beck & Steer, 1987). Each
item consists of four statements rated from 0 to 3; high scores indicate more
severe depression. In a school sample of adolescents who were screened with
the BDI, a screening score of 16 produced 100% sensitivity and 93% specificity
(Barrera & Garrison-Jones,
1988).
Statistical analysis
All data were analysed using the Statistical Package for the Social
Sciences (version 10.0 for Windows). Demographic characteristics, exposure by
trauma type, posttraumatic stress and depressive symptoms were assessed using
frequency and descriptive statistics. Chi-squared tests (and odds ratios) for
categorical variables and Student's t-tests for numeric variables
were used to explore the relationship between country, gender, trauma
exposure, PTSD and depression. Pearson's correlation statistics were used to
correlate PTSD symptoms with BDI total scores. Fisher's exact tests were done
in place of 2 tests for independence when one or more cells in
a 2x2 table had an expected count of less than 5. All tests were
two-tailed and significance was set at P<0.05.
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RESULTS |
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Pattern of trauma exposure
More than 80% of the 2041 respondents reported lifetime exposure to at
least one DSMIV trauma. The mean number of trauma exposures was 2.49
(s.d.=1.99, range 011). Results of comparisons by country were not
statistically significant. For both groups the most common traumas were
witnessing community violence (63%), being robbed or mugged (35%), and
witnessing a family member being hurt or killed (33%). However, significantly
more of those in the Kenyan group had witnessed violence, been physically hurt
or beaten by a family member, or been sexually assaulted
(Table 2).
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Symptoms of PTSD
The most common PTSD symptoms (in descending order of frequency) were:
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 (s.d.=5.5) v. Kenya, 2.3 (s.d.=2.9); t=13.2, P<0.001. In the whole group, 14.5% (n=295) of adolescents met the symptom criteria for full PTSD, and an additional 10% (n=210) met symptom criteria for partial PTSD. Notably, 22% of South African adolescents had a full PTSD diagnosis compared with only 5% of Kenyan adolescents (P<0.001), and 12% met the symptom criteria for partial PTSD compared with 8% in the Kenyan group (P<0.01).
Relationship between trauma exposure and PTSD symptoms
Adolescents meeting the symptom criteria for full PTSD (PTSD-positive,
n=295) endorsed more traumas on the Trauma Checklist than adolescents
without PTSD (PTSD-negative, n=1748): 3.5 (s.d.=2.6) v. 2.3
(s.d.=1.8); t=-9.7, P<0.001)). These differences remained
significant in the analysis by country: Kenya, PTSD-positive 2.9 (s.d.=2.1)
v. PTSD-negative 2.4 (s.d.=1.7) mean exposures, t=-2.1,
P<0.05; SA, PTSD-positive 3.6 (s.d.=2.7) v. PTSD-negative
2.2 (s.d.=1.9) mean exposures, t=-9.1, P<0.001; and by
gender: males, PTSD-positive 3.7 (s.d.=2.6) v. PTSD-negative 2.5
(s.d.=1.9) mean exposures, t=-6.3, P<0.001; females,
PTSD-positive 3.2 (s.d.=2.5) v. PTSD-negative 2.2 (s.d.=1.8) mean
exposures, t=-6.3, P<0.001. Respondents with full PTSD
were more likely to endorse a higher number of traumas (mean 3.7, s.d.=2.5)
than those with partial-symptom PTSD (mean 2.9, s.d.=1.9) or no PTSD (mean
2.3, s.d.=1.8); F=58.9, P<0.001).
Gender and trauma exposure
Boys had a higher mean number of trauma exposures than girls (2.7, s.d.=2.0
v. 2.3, s.d.=1.9; t=3.7, P<0.002). Boys were
also significantly more likely than girls to have witnessed community violence
(67% v. 60%; Fisher's exact text, P<0.001); to have been
robbed or mugged (39% v. 33%; Fisher's exact test,
P<0.03); to have been beaten by someone not a family member (26%
v. 15%; Fisher's exact test, P<0.001); and to have been
victims of sexual assault (19% v. 13%; Fisher's exact test,
P<0.002); sexual assault was operationalised in the
survey as any unwanted and forceful sexual experience that made 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 (Table
3).
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Gender and PTSD symptoms
Boys and girls were equally likely to meet symptom criteria for full PTSD
(2=0.96, P<0.18, n.s.) and partial PTSD (Fisher's
exact test, P<0.07, n.s.), and PTSD symptom clusters
(re-experiencing, avoidance and hyperarousal symptoms) also did not differ
significantly by gender (Table
4).
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Lifetime trauma exposure, PTSD and ethnicity
Table 5 shows lifetime
trauma exposure rates and rates of PTSD across the major ethnic groups in the
sample. Of those belonging to the majority ethnic group in the sample (mixed
race) 85% reported exposure to trauma, with 25% of those exposed meeting
criteria for a PTSD symptom diagnosis. In the Kenyan sample, 75% of the
majority ethnic group (Black) endorsed trauma exposure, but only 5% met PTSD
symptom criteria.
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Trauma type and PTSD risk
Based on respondents' selection of the most frightening or upsetting event,
the three traumas most likely to be associated with a PTSD symptom diagnosis
were:
The risk of PTSD following sexual assault was the same for girls (24% of sexually assaulted girls; Fisher's exact test, P<0.001, OR 2.3) as it was for boys (25% of sexually assaulted boys; Fisher's exact test, P<0.001, OR 2.3).
Regression analysis
All trauma exposures were then entered as independent variables into a
stepwise regression equation to examine the relationship between type of
trauma exposure and the risk for PTSD. The dependent variable was a PTSD
full-symptom diagnosis. Traumas that constituted independent predictors for
PTSD were:
Physical attack by someone outside the family (P<0.432) and natural disaster (P<0.096) were not independently predictive of a PTSD symptom diagnosis.
Depression
For the sample as a whole, BDI scores were in the mild range
for depression (mean 11.5, s.d.=16.7). No significant difference was observed
either for country (Kenya 12.2 (s.d.=23.2) v. SA 11.1 (s.d.=10.5)) or
gender (males 10.8 (s.d.=9.7) v. females 11.4 (s.d.=10.0)). In the
Kenyan group, but not in the South African group, girls reported more
depressive symptoms and had significantly higher scores on the BDI than boys:
females 12.4 (s.d.=9.3) v. males 9.5 (s.d.=7.9); t=-3.6,
P<0.001 (see Table
4).
Correlation between PTSD and depression
The number of PTSD symptoms endorsed on the Child PTSD Checklist correlated
significantly with total BDI scores (r=0.29, P<0.001).
Statistical significance was retained in the analysis by country (Kenya,
r=0.20, P<0.001; SA, r=0.52,
P<0.001) and gender (males, r=0.48, P<0.001;
females, r=0.51, P<0.001). Respondents with full-symptom
PTSD also had higher mean BDI scores (mean 20.0, s.d.=11.4) than those with
partial-symptom PTSD (mean 13.6, s.d.=9.6) and those with no PTSD (mean 9.4,
s.d.=17.8; F=37.5, P<0.001).
Substance use
More South African adolescents than Kenyan adolescents reported smoking ten
or more cigarettes a day (5.3% v. 0.4%, P<0.001) and
using cannabis (10.6% v. 1.7%, P<0.001). In the sample as
a whole, more boys than girls reported cannabis use (8.7% v. 4.6%,
P<0.001). However, no significant gender difference was noted for
cigarette or alcohol use. Use of these substances did not correlate
significantly with PTSD symptoms.
Negative life events
South African respondents reported a higher number of past-year exposures
to negative life events on the LEQA (mean 9.2, s.d.=5.2) than did the
Kenyans (mean 8.3, s.d.=4.7; t=4.2, P<0.001); these
events included doing much worse than expected in a test or examination and
breaking up with a boyfriend/girlfriend. Negative life event exposure was not
significantly associated with PTSD symptoms (total sample P=0.170, SA P=0.372,
Kenya P=0.562). Further, adolescents who reported one or more traumas plus one
or more negative life events were not more likely to meet PTSD symptom
criteria (2=0.66, P=0.363).
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DISCUSSION |
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Differences between the South African and Kenyan groups
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 rates for specific types of trauma in the
Kenyan sample). The lower rate of PTSD in Kenyan adolescents is difficult to
explain. Our assessments did not measure the severity or chronicity of trauma
exposure or past PTSD, variables that may contribute to PTSD risk. For
example, differences 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 in PTSD rates.
Could cultural factors be responsible? Cultural differences in the way that concepts of trauma, trauma exposure and PTSD symptoms are operationalised and understood in different ethnic groups are known to exist. Our survey questionnaires were not culturally validated for the various ethnic groups in which they were used, and the likelihood of cultural response bias to questionnaire items cannot be excluded. Further, compared with the South African sample, in which the cultural contexts of the different communities were diverse, the ethnic composition of the Kenyan sample was relatively homogeneous (more than 97% of the Kenyan students were Black, compared with only a fifth of the South Africans).
Gender
In this study, boys had a higher mean number of trauma exposures and higher
rates of exposure to certain types of assaultive violence (e.g. robbing or
mugging, beating by a person other than a family member, sexual assault)
compared with girls. Not all studies have noted gender differences in trauma
exposure. Giaconia et al
(1995), in a community study
of 18-year-olds, found that overall rates of trauma were the same for both
boys and girls. Other studies have reported a greater incidence of trauma
exposure in boys (Breslau et al,
1991; Vrana & Lauterbach,
1994; Schwab-Stone et
al, 1999). A surprising finding was the absence of a gender
difference in the overall rate and presentation of PTSD. Several studies have
demonstrated a much greater risk for PTSD (up to 6-fold) in females
(Breslau et al, 1991; Green et al, 1994;
Giaconia et al,
1995). For example, Singer et al
(1995) surveyed a diverse
sample of high-school students (n=3735) selected from large-city,
small-city and suburban schools, and reported that female gender was the
strongest demographic predictor of trauma symptoms, including post-traumatic
stress, depression, anxiety, anger, dissociation and total trauma symptoms.
Our observations are consistent with those of Silva et al
(2000) who, in a clinic sample
of traumatised inner-city youths (n=59), found no significant
difference in terms of the interaction of traumatic experience (including
sexual abuse) and gender, and no difference in the mean number of PTSD
symptoms. More than a fifth of these children met full criteria for PTSD, a
third had partial symptoms and nearly half had no PTSD symptom.
Another unexpected finding was that, although boys and girls were equally likely to have experienced at least one lifetime trauma, more boys than girls endorsed sexual trauma. The risk of developing PTSD following sexual assault was the same for both genders (OR 2.3). Sexual assault, compared with all other traumas, was also associated with the highest risk of PTSD. This finding parallels that of other workers who have found a relatively higher risk for PTSD (up to 12-fold) following rape or sexual assault compared with other types of trauma (Breslau et al, 1991; Green et al, 1994; Giaconia et al, 1995).
We found that depression, but not substance use, correlated with PTSD. Girls had higher depression scores than boys, consistent with previous work (Lewinsohn et al, 1993; Schraedley et al, 1999). Further, respondents with more PTSD symptoms (i.e. those with full PTSD) tended to have more depressive symptoms than those with partial symptoms or no PTSD. In contrast, a recent study of children aged 714 years found no significant difference in comorbidity (e.g. major depressive disorder) or functional impairment between children with full or partial PTSD (Carrion et al, 2002).
Limitations
Several limitations of this study are worth mentioning. First, although we
used a relatively high symptom threshold of most of the time to
establish PTSD criteria, diagnoses of current PTSD (full and partial) were
based solely on symptom status and not on functional impairment. For partial
PTSD, the presence of at least one symptom from each symptom category
(criteria sets: re-experiencing; avoidance; and hyperarousal) was employed
(Stein et al, 1997;
Marshall et al,
2001). Second, as the age of onset and duration of PTSD were not
documented, we were not able to establish symptom chronicity. Third, 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. Finally, all
questionnaires were administered in English (to be eligible participants had
to be able to read and write English at tenth grade level), although English
was not the home language of the majority of respondents.
In conclusion, replication across other ethnic and cultural settings in the African context is required to establish more clearly the nature and extent of trauma exposure and its psychological repercussions in African youth. Nevertheless, these findings share many similarities with studies undertaken in Western countries. They highlight the high rates of violence exposure and PTSD in both boys and girls and suggest a need for health care professionals to be more vigilant in screening for victimisation and trauma-related distress.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication November 19, 2002. Revision received May 2, 2003. Accepted for publication August 12, 2003.
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