Predisaster Child Characteristics and Family and Social Context
Demographics. Although the extant research is mixed, the consensus seems to be that girls report more PTSD symptoms than boys.1,3 Other symptoms may vary with, for example, boys showing more externalizing symptoms than girls.12 Girls and boys may interpret or report experiences and responses differently;16 for example, in some cultures, boys may face greater stigma if their distress is known.17 Studies of the relationship between age and severity of posttraumatic consequences are inconclusive1 and reveal a number of mediating factors, such as how children make sense of their experiences at different developmental stages and the level of influence a parent has on the child's perception of danger or safety.16 Children of racial and ethnic minority groups in the US tend to report higher levels of PTSD symptoms that are also more prolonged, but these associations may be compounded by socioeconomic factors.9
Child personality and experiences. Data on predisaster functioning are rarely available for comparison, making it difficult to accurately study the impact of predisaster functioning on postdisaster outcomes.3 Although retrospective reporting of predisaster functioning may lack objectivity, correlations have been found between predisaster anxiety and postdisaster PTSD, and between predisaster depression and stress reactions after a natural disaster.3
The question of whether previous trauma operates in a protective capacity (inoculation) or increases risk for negative outcomes of subsequent traumas (sensitization) is not well understood.3,17 The theory of inoculation poses that if a person has experienced a traumatic event previously and has the time and capacity to find resolution, the previous trauma may support mastery, self-efficacy, and resilience.3 Alternately, if the previous trauma overwhelmed the child's capacity to adapt and if they have not had the time or resources to recover, the result can be increased vulnerability due to cumulative stress.17
Disaster Event
Disaster typology. Both the type (eg, natural, manmade, technologic) and characteristics (eg, location of event, number of casualties) of the disaster have been examined in association with disaster outcomes.18,19 A meta-analysis of child disaster studies found comparable effects for natural and man-made events.18 Various characteristics of the disaster are likely more determinative of outcome than the type of the disaster. For example, disasters in developing countries appear to generate more severe impairment than those in the US or other developed countries.19 The number of disaster deaths contribute to PTS in children exposed to disasters.18
Exposure. Exposure is a central determinant of disaster outcome. Exposure can be measured in terms of geographic proximity, relationships to people who are directly exposed, initial subjective reaction,18 and the amount or frequency of media contact.17 A meta-analysis of child disaster studies examining PTS outcomes found significant effects for physical proximity, perceived threat at the time of the disaster, general distress at the time of the disaster, and loss of a loved one or friend.18 A recent meta-analysis found significant media effects for PTS in children and adults exposed to mass trauma.20
Posttraumatic/Recovery Environment
Disruption. Disaster-related life disruption, such as displacement from home or school, separation from family or friends, disrupted schedules, missed social or recreational activities, and changes in family finances can be long-lasting stressors that contribute to adverse outcomes in children exposed to disasters.3
Family complications. Family conflict and violence, substance use, divorce, marriage, and birth all tend to increase after a disaster1,3 and may complicate disaster recovery for children.1 In addition, overall family stress and parental burden tend to be elevated after a disaster, which may be especially critical in families with preexisting chronic stress, vulnerability, and/or cumulative trauma.1
Family support. The importance of parental warmth, attunement, and availability in children's disaster recovery cannot be overstated.6,17 Positive parent-child relationships seem to reduce the risk of PTS, anxiety, and depression.21 The quality of the parent-child relationship and the child's perception of relational safety are predictors of resilience.17 For example, child perceptions of strong attachment, trust, open communication, parental acceptance, and parental control prior to Hurricane Katrina were associated with lower levels of anxiety postevent.22
Parent reaction to a traumatic event is one of the strongest predictors of children's reactions3,6 especially in young children, as the child's perception of a traumatic event is largely filtered through the caregiver's perspective.4 If children perceive parental distress, they may attempt to hide their own reactions and concerns to avoid further upsetting their caregivers.5 Due to their own distress and their focus on other issues, parents may underestimate or inadvertently overlook their child's distress or falsely assume the child does not need additional support or reassurance.3 Alternately, overprotective caregiving may undermine children's resilience, self-confidence, and self-efficacy.17
Social support. Social support is a widely recognized protective factor contributing to reduced depression, anxiety, and PTSD symptoms, as well as improved adaptive capacities in children exposed to mass trauma.3,21 Schools are especially important to the recovery of youth, as they are a site for connection, nurturance, play, learning, routine, and both giving and receiving peer support.17,21 Social support derived through the school environment can be especially important when parents are overwhelmed or emotionally unavailable.17