Department of Psychological Medicine, University of Wales College of Medicine, Cardiff
St Cadoc's Hospital, Caerleon, Newport
Raeside Clinic, Birmingham
Department of Psychological Medicine, University of Wales College of Medicine, Cardiff, UK
Correspondence: Louise Morgan, Department of Psychiatry and Behavioural Sciences, Royal Free Hospital, Pond Street, Hampstead, London NW3 1YD, UK. E-mail: L.Morgan{at}rfc.ucl.ac.uk
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ABSTRACT |
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Aims To examine the long-term effects of surviving the 1966 Aberfan disaster in childhood.
Method Survivors (n=41) were compared with controls (n=72) matched for age and background. All were interviewed using the Composite International Diagnostic Interview, measures of current health and social satisfaction, and the General Health Questionnaire. The survivor group also completed the Impact of Event Scale to assess current levels of PTSD.
Results Nineteen (46%; 95% CI 3161) survivors had had PTSD at some point since the disaster, compared with 12 (20%; 95% CI 1030) controls (OR=3.38 (95% CI 1.408.47)). Of the survivors,12 (29%; 95% CI 1543) met diagnostic criteria for current PTSD. Survivors were not at a significantly increased risk of anxiety, depression or substance misuse.
Conclusions Trauma in childhood can lead to PTSD, and PTSD symptoms can persist for as long as 33 years into adult life. Rates of other psychopathological disorders are not necessarily raised after life-threatening childhood trauma.
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INTRODUCTION |
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Studies suggest that children can develop post-traumatic stress disorder (PTSD) and other psychological problems following traumatic events (e.g. Terr, 1983; McFarlane, 1987; Yule et al, 1990; Green et al, 1991, 1992; Bolton et al, 2000; Breslau et al, 2000). However, there is some controversy over the persistence of PTSD that started in childhood. The aim of this study was to examine the long-term psychological impact of the Aberfan disaster on the children (aged 411 years) who had attended the junior school, survived its engulfing and who were, at follow-up, adults in their late thirties and early forties.
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METHOD |
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Instruments
All participants were interviewed using a computerised version of the
Composite International Diagnostic Interview (CIDI;
World Health Organization,
1997), a fully structured, standardised interview that generates
ICD10 diagnoses. Disorders were then grouped into depressive, anxiety
and substance misuse disorders (World
Health Organization, 1992). Depressive disorders included F32.0,
F32.1, F32.10, F32.11, F32.2, F33.10, F33.11, F33.2 and F34.1. Anxiety
disorders included F40.0, F40.00, F40.01, F40.1, F40.21, F40.22, F40.23,
F40.24, F41.0, F41.01, F41.1 and F42.1. Substance misuse included F10.1, F10.2
and F11.2. The diagnostic code for PTSD was F43.1.
Lifetime incidence of PTSD
In the PTSD section of the CIDI, the survivors were questioned with
specific reference to the Aberfan disaster. This section provides a diagnosis
of lifetime PTSD; that is, whether participants have experienced PTSD as a
direct result of the disaster at some time in their subsequent lives. The
comparison group were asked which traumatic events, from a specific list, they
had experienced in their lifetime. They were then questioned in relation to
the one that they felt was the most traumatic of these experiences. Survivors
were not asked about other traumatic experiences because the PTSD questions
within the CIDI relate only to a single specific incident, and as the Aberfan
disaster was the main focus of the study, it was decided to restrict questions
to this incident.
Current levels of PTSD
To assess current PTSD levels, the survivors completed the 15-item Impact
of Event Scale (Horowitz et al,
1979). A score of 35 or above on this scale was used to define a
case. This threshold was chosen on the basis of an existing data-set that used
the same measure. All participants also completed the 28-item General Health
Questionnaire (GHQ), and questionnaire measures of current health and social
satisfaction. A score of 5 or above on the GHQ was used to define a case
(Goldberg & Hillier, 1979;
Goldberg & Williams, 1988).
The interviews were carried out by experienced health care professionals and
academically trained researchers.
Analyses
Odds ratios were calculated for all outcome measures, namely GHQ scores,
PTSD, anxiety disorders, depressive disorders, substance misuse, and any
psychopathological disorder. The risk of PTSD was then assessed taking into
account the possible effects of gender, marital status, age, employment and
education, using the MantelHaenszel method and performed using STATA 6
software. The MantelHaenszel method assesses relative risk and adjusts
for the confounding effects of other variables (see
Breslow & Day, 1987).
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RESULTS |
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Demographic data
Table 1 shows, for both
survivor and comparison groups, the mean age at the time of the disaster and
at follow-up, the range of time of follow-up after the disaster, the gender of
the participants, marital status, education, current employment status and
prevalence of unemployment. Although most of the variables are similar in the
two groups, it is notable that the survivors achieved higher levels of
education. Participants were also asked whether they had any difficulties in
relationships with friends or relatives and whether they had any concerns
about their children, either at home or at school. No significant difference
emerged between the groups on these measures.
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Representativeness of the survivor group
The majority of the survivors did not want to take part in the study, so it
is important to know how representative our subgroup was. Unfortunately,
definitive claims about the group's representativeness cannot be made. Ethical
restrictions prevented us from obtaining any information about the survivors
who had not consented to take part in the research. However, some of the
survivors were seen by a psychiatrist after the disaster at the request of
solicitors requiring medico-legal reports. As these records are now in the
public domain, we were granted access to them. Of the 41 survivors who did
agree to take part, 24 (59%) had been referred to the psychiatrist (11 men, 13
women). Of the 74 who did not take part in the study, 28 (38%) had been
referred (13 men, 15 women) (odds ratio 2.22, 95% CI 1.732.84).
Lifetime psychopathology
The survivors were more likely than the comparison group to have suffered
from PTSD (Table 2): odds ratio
3.38, 95% CI 1.408.17. The traumas suffered by the comparison group
included witnessing someone being badly injured or killed (20%), being
seriously attacked or assaulted (14%) and being involved in a fire, flood or
other natural disaster (14%). There was no statistically significant
difference in the prevalence of anxiety disorders, depressive disorders or
substance misuse disorders.
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Table 3 shows the odds ratios for PTSD after adjustment for gender, marital status, age, current employment, ever unemployed and level of education. After adjustment for gender, there was a slight reduction in the odds. However, after adjustment for marital status and education, there was a slight increase.
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Current psychiatric morbidity
When assessed with the GHQ, 23% of the survivors (95% CI 1037) and
21% of the comparisons (95% CI 1230) were designated as cases. The odds
ratio was 1.21 (95% CI 0.453.22). This was not substantially altered
after adjustment for confounding variables.
The data from the CIDI assessment showed that 25 (61%) of the survivors had experienced at least one PTSD symptom in the preceding 2 weeks (13 men, 12 women) (95% CI 1238). The Impact of Event Scale revealed that 12 (29%) of the survivors met diagnostic criteria for current PTSD (4 men, 8 women) (95% CI 1543). Table 4 shows a summary of more detailed information obtained from the latter scale: 54% reported that any reminder brought back feelings about the disaster and that pictures popped into their minds; 49% reported thinking about it without meaning to and experiencing strong feelings about it: 46% tried not to think about it, avoided talking about it and tried to remove it from their memories; and 34% reported still experiencing bad dreams or difficulty sleeping due to intrusive thoughts about the disaster.
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DISCUSSION |
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Affective disorders
Previous research suggests that affective disorders are almost as common a
response to trauma as is PTSD. In our study there was no significantly
increased risk in the survivor group of suffering from psychiatric disorders
other than PTSD. High levels of psychopathological disorder, including PTSD,
were observed in the comparison group. This should be interpreted with
caution. It could indicate a response bias, in that the people who agreed to
participate in the research were those who were more likely to experience
psychological problems. This is supported by the large number of survivors in
the research group who had been referred to a psychiatrist after the disaster.
The 1998 Welsh Health Survey (National
Assembly for Wales, 1999) also found the highest prevalence of
psychiatric disorder in the economically deprived industrial valleys of South
Wales, an area in which all participants lived.
Alternatively, this finding could indicate a ceiling effect. As baseline rates for psychopathological disorders were so high in this study, it could simply be that developing PTSD does not raise these rates any higher.
Current PTSD
Yule et al's
(2000) conclusion that PTSD
symptoms can persist into adult life is also supported here, as this study
found that 12 (29%; 95% CI 1543) of the survivors met diagnostic
criteria at follow-up. For many, the disaster still evoked intense feelings,
intrusive thoughts and efforts to avoid thinking or talking about itall
key components of PTSD. This suggests that even 33 years after the disaster
the intensity of experience, characteristic of PTSD, was still very much
present in many of their lives.
Limitations
The response rates in the study are low, but this is understandable given
that the disaster had happened 33 years before. The comparison group members
were chosen to be as similar as possible to the survivors and the non-response
bias may well be similar in both groups. It seems that low response rates are
characteristic of this type of research. Yule's study of survivors of the
sinking of the cruise ship Jupiter
(Yule et al, 1990)
involved just 25 of the 217 children only 58 years after the disaster.
The follow-up of survivors of the Buffalo Creek dam collapse
(Green et al, 1991)
included 193 out of 207 survivors. Three years later this number had dropped
to 99 (Green et al,
1994).
Previous research suggests that people living near to the scene of disasters and other traumatic events may also show signs of PTSD. The comparison group came from a nearby village and attended the same secondary school as the survivors. This is the main strength of the design, and if anything the increased risk among the survivors of PTSD may be an underestimate, given the proximity to the disaster.
Given the essentially retrospective nature of this type of research, the years that have passed may be obscuring our understanding of what has happened to the people over the course of their lives, and with this sample the true extent of the experience may never be known. The disaster still undoubtedly affects the people of Aberfan in ways poorly recorded by diagnoses and standardised assessments. A few of the survivors talked about the fear evoked at the sound of a lorry passing their house, or of an aircraft flying overhead. Intense memories of the disaster are aroused by the slightest noise or smell. A number of the survivors now have children the age that they were at the time of the disaster. This seems to arouse new feelings, as they are now able to see the disaster from their parents' perspective. Many are reluctant to let their children leave the house when the weather is bad, as they are reminded of the appalling weather preceding the disaster.
The future
Experiencing trauma in childhood is not substantially different from
experiencing trauma in adulthood, in terms of the subsequent development of
PTSD. It does not appear that children are more adaptable and malleable than
adults in the face of adversity; rather, they respond in similar ways, and
traumatic events in childhood can have effects on psychological health that
persist for many years. These findings have important implications for the
ways in which children and young people are treated following a traumatic
event. In cases of adults with PTSD full remission is usually attainable
(Connor et al, 1999;
Hembree & Foa, 2000); we
have no reason to assume that this will be different with younger
populations.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication July 29, 2002. Revision received November 26, 2002. Accepted for publication December 9, 2002.
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