A question of who, not if: Psychological disorders in Holocaust survivors' children.

OBJECTIVE: Because findings on the mental health status of Holocaust survivors' offspring have been inconsistent, we aimed to identify factors that place some offspring at greater risk for developing mood or anxiety disorders. METHOD: Using a web-based survey and structured clinical interviews with adult children of survivors, we attempted to predict disorders from offspring's circumstances, perceptions of parents' posttrauma adaptational styles, and self-reported reparative adaptational impacts. Posttrauma adaptational styles encompass intrafamilial and interpersonal psychological, social and behavioral coping, mastery, and defense mechanisms used by each parent. Reparative adaptational impacts reflect the offspring's self-reported insecurity about their own competence, reparative protectiveness, need for control, obsession with the Holocaust, defensive psychosocial constriction, and immature dependency. RESULTS: Of the disorders studied, generalized anxiety disorder was most frequent, followed by major depressive episode and posttraumatic stress disorder (PTSD). Only 2 variables independently predicted these disorders: participants' age and reparative adaptational impacts. Parents' styles were correlated with the presence of disorder, but had no effect when the child's reparative impacts were controlled. The age effect was consistent with epidemiologic research showing lower prevalence of psychological disorder in older cohorts. The severity of participants' reparative impacts was unequivocally the most important (OR = 5.3) or at least the most proximal precursor to the development of psychological disorders. When reparative impacts were low, frequency of disorder was low (8%); when reparative impacts were high, frequency of disorder was high (46%). CONCLUSION: Reparative adaptational impacts could guide clinicians in treating children of survivors. (PsycINFO Database Record

Cognitive behavioral therapy for postdisaster distress: A promising transdiagnostic approach to treating disaster survivors.

OBJECTIVE: Cognitive-behavioral therapy for postdisaster distress (CBT-PD) is a transdiagnostic intervention that has been used following major disasters such as the 9/11 terrorist attacks and Hurricane Katrina. In this study, we report findings from a community-based treatment program that offered CBT-PD to individuals who experienced Hurricane Sandy. METHOD: Eight trained community therapists delivered CBT-PD to 342 adults who had been exposed to Hurricane Sandy. Participants were assessed at referral, pretreatment, intermediate treatment, posttreatment and 5-month follow-up. RESULTS: The overall prepost effect size was 1.41, indicating large improvement pre to posttreatment. Gains were maintained at follow-up. Timing of the intervention did not affect outcome. Participants who received the intervention early (i.e., 10 to 15 months after Sandy) had the same improvement as those who received it later (i.e., 21 to 26 months after Sandy). Similarly, there was no difference in outcome between individuals with severe as compared with moderate distress at pretreatment. CONCLUSIONS: Results suggest that CBT-PD is appropriate for a range of individuals with moderate to severe distress and that it has benefit both early on as well as two years postdisaster. Findings add to growing literature that CBT-PD should be considered as one important component of a larger disaster response system. (PsycINFO Database Record

Mapping concentrations of posttraumatic stress and depression trajectories following Hurricane Ike.

We investigated geographic concentration in elevated risk for a range of postdisaster trajectories of chronic posttraumatic stress symptom (PTSS) and depression symptoms in a longitudinal study (N = 561) of a Hurricane Ike affected population in Galveston and Chambers counties, TX. Using an unadjusted spatial scan statistic, we detected clusters of elevated risk of PTSS trajectories, but not depression trajectories, on Galveston Island. We then tested for predictors of membership in each trajectory of PTSS and depression (e.g., demographic variables, trauma exposure, social support), not taking the geographic nature of the data into account. After adjusting for significant predictors in the spatial scan statistic, we noted that spatial clusters of PTSS persisted and additional clusters of depression trajectories emerged. This is the first study to show that longitudinal trajectories of postdisaster mental health problems may vary depending on the geographic location and the individual- and community-level factors present at these locations. Such knowledge is crucial to identifying vulnerable regions and populations within them, to provide guidance for early responders, and to mitigate mental health consequences through early detection of mental health needs in the population. As human-made disasters increase, our approach may be useful also in other regions in comparable settings worldwide.

A Longitudinal Study of the Bidirectional Relationship Between Social Support and Posttraumatic Stress Following a Natural Disaster.

There is ample evidence that social support is protective against posttraumatic stress (PTS) symptoms through social causation processes. It is also likely that PTS is associated with decreased social support through social selection processes. Few studies, however, have examined the longitudinal and bidirectional associations between social support and PTS in a postdisaster context, and whether such associations vary by type of support (e.g., emotional, informational, or tangible). We examined these relationships using Galveston Bay Recovery Study data. Participants (N = 658) were interviewed 2-6 months (W1), 5-9 months (W2), and 14-19 months (W3) after Hurricane Ike in 2008. Longitudinal relationships between each support type and PTS were examined in cross-lagged models. W1 emotional support was negatively associated with W2 PTS (Estimate = -.13, p = .007), consistent with social causation. W1 PTS was negatively associated with W2 emotional support (Estimate = -.14, p = .019), consistent with social selection. In contrast, pathways were nonsignificant at subsequent waves and for informational and tangible support. Results suggested that postdisaster social causation and selection were limited to emotional support and diminish over time. Based on these findings, postdisaster services should emphasize restoring supportive social connections to minimize the psychiatric consequences of disaster, especially among those with prior evidence of distress.

Multigenerational legacies of trauma: Modeling the what and how of transmission.

To operationalize the theory of Trauma and the Continuity of Self: A Multidimensional, Multidisciplinary, Integrative Framework (Danieli, 1998), we created a testable model using factors in Holocaust survivors' lives that may have affected their offspring's adaptation. A web-based sample of 422 adult children of survivors completed a 3-part inventory assessing multigenerational legacies of trauma. To explain the severity of the child's reparative adaptational impacts, we conducted hierarchical regression analyses (Phase 1) and path analyses (Phase 2). We hypothesized that these impacts followed largely from the (child-reported) intensities of parents' victim, numb, and fighter posttrauma adaptational styles. These styles, in turn, followed from family history and post-Holocaust family milieu. With all effects of family history and milieu on offspring specified as indirect (through parents' victim styles), the initial path model fit the data well with one exception: Broken generational linkages had direct as well as indirect effects. While survivors' Holocaust experiences-especially internment-had significant indirect effects on their children, each component of post-Holocaust family milieu had one or more associations with mothers' and fathers' victim, numb, and/or fighter styles. The strongest relationships emerged for broken generational linkages-a risk factor for negative effects-and sociocultural setting (living in Israel rather than North America)-a protective factor. Because the healing processes that underlie observed effects of family milieu are malleable, survivors' and offspring's suffering might be reduced through efforts to recapture meaning, purpose, identity, connectedness of past, present and future, and attachments to community and place. (PsycINFO Database Record

The Geography of Mental Health and General Wellness in Galveston Bay After Hurricane Ike: A Spatial Epidemiologic Study With Longitudinal Data.

OBJECTIVES: To demonstrate a spatial epidemiologic approach that could be used in the aftermath of disasters to (1) detect spatial clusters and (2) explore geographic heterogeneity in predictors for mental health and general wellness. METHODS: We used a cohort study of Hurricane Ike survivors (n=508) to assess the spatial distribution of postdisaster mental health wellness (most likely resilience trajectory for posttraumatic stress symptoms [PTSS] and depression) and general wellness (most likely resilience trajectory for PTSS, depression, functional impairment, and days of poor health) in Galveston, Texas. We applied the spatial scan statistic (SaTScan) and geographically weighted regression. RESULTS: We found spatial clusters of high likelihood wellness in areas north of Texas City and spatial concentrations of low likelihood wellness in Galveston Island. Geographic variation was found in predictors of wellness, showing increasing associations with both forms of wellness the closer respondents were located to Galveston City in Galveston Island. CONCLUSIONS: Predictors for postdisaster wellness may manifest differently across geographic space with concentrations of lower likelihood wellness and increased associations with predictors in areas of higher exposure. Our approach could be used to inform geographically targeted interventions to promote mental health and general wellness in disaster-affected communities.

Mental Health Service Utilization Among Natural Disaster Survivors With Perceived Need for Services.

OBJECTIVE: This study explored predisposing, illness-related, and enabling factors as predictors of mental health service use among disaster survivors with perceived need for services. METHODS: Participants (N=658) were part of a three-wave, population-based study of Hurricane Ike survivors. At each wave, participants were asked whether they perceived having a need for mental health services, for example, information about stress reactions and medication for emotional problems. Those with perceived need were asked about use of eight services, such as a psychiatrist or physician, to address needs. Generalized estimating equations examined predisposing, illness-related, and enabling factors as predictors of service use among participants with perceived need (N=304). RESULTS: More general stressors (predisposing factor) and insurance coverage (enabling factor) predicted service use among participants with perceived need. CONCLUSIONS: The results suggest that expanded access to services that do not require insurance coverage could better address survivors' mental health needs after a disaster.

The Danieli Inventory of Multigenerational Legacies of Trauma, Part I: Survivors' posttrauma adaptational styles in their children's eyes.

A comprehensive valid behavioral measure for assessing multidimensional multigenerational impacts of massive trauma has been missing thus far. We describe the development of the Posttrauma Adaptational Styles questionnaire (Part I of the three-part Danieli Inventory of Multigenerational Legacies of Trauma), a self-report questionnaire of Holocaust survivors' children's perceptions of each parent and their own upbringing (60 items per parent). The items were based on literature and cognitive interviewing of 18 survivors' offspring. A web-based convenience sample survey was designed in English and Hebrew and completed by 482 adult children (M age = 59; 67% women) of Holocaust survivors. Exploratory factor analyses were conducted by using maximum likelihood extraction with Geomin rotation to examine the factor structure of the original 70 items for each parent. Conducted hierarchically, the analysis yielded three higher-order factors reflecting intensities of victim, numb, and fighter styles. The 30-item Victim Style Scale (α = .92-.93) and 18-item Numb Style Scale (α = .89) had excellent internal consistency; the consistency of the 12-item Fighter Style Scale (α = .69-.70) was more modest. English-Hebrew analyses suggested good-to-excellent congruence in factor structure (φ = .87-.99). Further research is needed to evaluate the validity of the measure in other samples and populations.

Incorporating the sampling design in weighting adjustments for panel attrition.

We review weighting adjustment methods for panel attrition and suggest approaches for incorporating design variables, such as strata, clusters, and baseline sample weights. Design information can typically be included in attrition analysis using multilevel models or decision tree methods such as the chi-square automatic interaction detection algorithm. We use simulation to show that these weighting approaches can effectively reduce bias in the survey estimates that would occur from omitting the effect of design factors on attrition while keeping the resulted weights stable. We provide a step-by-step illustration on creating weighting adjustments for panel attrition in the Galveston Bay Recovery Study, a survey of residents in a community following a disaster, and provide suggestions to analysts in decision-making about weighting approaches.

The Danieli Inventory of Multigenerational Legacies of Trauma, Part II: Reparative Adaptational Impacts.

The impacts of the Holocaust on children of survivors have been widely investigated. However, consensus is limited, and no validated measures have been tailored with or to them. We aimed to develop and validate a scale that measures these specific impacts (Part II of the Danieli Inventory of Multigenerational Legacies of Trauma). We studied 484 adult children of survivors who participated in a cross-sectional web-based survey in English or Hebrew; of these, 191 participated in a clinical interview. Exploratory factor analyses of 58 items to reduce and refine the measure yielded a 36-item scale, Reparative Adaptational Impacts, that had excellent internal consistency (α = .91) and congruence between English and Hebrew versions (φ ≥ .95). Associations between impacts and SCID-based diagnoses of major depressive episode, posttraumatic stress disorder, and generalized anxiety disorder were moderate to strong (ds = 0.48-0.89). Strong associations also emerged between severity of offspring's reparative adaptational impacts and intensity of their parents' posttrauma adaptational styles (Multiple R = .72), with intensity of victim style, especially the mother's, having the strongest effect (ß = .31-.33). Having both research and clinical relevance for assessing Holocaust survivors' offspring, future studies might investigate the scale's generalizability to other populations affected by mass trauma.

Frequencies and predictors of barriers to mental health service use: a longitudinal study of Hurricane Ike survivors.

BACKGROUND: The majority of disaster survivors suffering from psychological symptoms do not receive mental health services. Research on barriers to service use among disaster survivors is limited by a lack of longitudinal studies of representative samples and investigations of predictors of barriers. The purpose of this study was to address these limitations through analysis of a three-wave population-based study of Hurricane Ike survivors (N = 658). METHODS: Frequencies of preference, outcome expectancy, resource, and stigma barriers among participants with unmet mental health needs were documented and logistic regression using a generalized estimating equations approach explored predisposing (e.g., age), illness-related (e.g., posttraumatic stress) and enabling (e.g., insurance coverage) factors as predictors of each type of barrier. RESULTS: Preference barriers were most frequently cited at each wave, whereas stigma barriers were least frequently cited. Older age and higher emotional support predicted preference barriers; being a parent of a child under 18-years old at the time of the hurricane, higher generalized anxiety, and lack of insurance predicted resource barriers; and higher posttraumatic stress predicted stigma barriers. CONCLUSIONS: These findings suggest that postdisaster practices targeting subpopulations most likely to have barriers to service use may be indicated.

Religious Coping and Psychological and Behavioral Adjustment After Hurricane Katrina.

Positive and negative religious coping are related to positive and negative psychological adjustment, respectively. The current study examined the relation between religious coping and PTSD, major depression, quality of life, and substance use among residents residing in Mississippi at the time of Hurricane Katrina. Results indicated that negative religious coping was positively associated with major depression and poorer quality of life and positive religious coping was negatively associated with PTSD, depression, poorer quality of life, and increased alcohol use. These results suggest that mental health providers should be mindful of the role of religious coping after traumatic events such as natural disasters.

Immediate and longer-term stressors and the mental health of Hurricane Ike survivors.

Previous research has documented that individuals exposed to more stressors during disasters and their immediate aftermath (immediate stressors) are at risk of experiencing longer-term postdisaster stressors. Longer-term stressors, in turn, have been found to play a key role in shaping postdisaster psychological functioning. Few studies have simultaneously explored the links from immediate to longer-term stressors, and from longer-term stressors to psychological functioning, however. Additionally, studies have inadequately explored whether postdisaster psychological symptoms influence longer-term stressors. In the current study, we aimed to fill these gaps. Participants (N = 448) were from population-based study of Hurricane Ike survivors and completed assessments 2-5 months (Wave 1), 5-9 months (Wave 2) and 14-18 months (Wave 3) postdisaster. Through path analysis, we found that immediate stressors, assessed at Wave 1, were positively associated with Wave 2 and Wave 3 stressors, which in turn were positively associated with Wave 2 and Wave 3 posttraumatic stress and depressive symptoms. Wave 2 posttraumatic stress symptoms were positively associated with Wave 3 stressors, and Wave 1 depressive symptoms were positively associated with Wave 2 stressors. The findings suggest that policies and interventions can reduce the impact of disasters on mental health by preventing and alleviating both immediate and longer-term postdisaster stressors.

Prevalence, risk, and correlates of posttraumatic stress disorder across ethnic and racial minority groups in the United States.

OBJECTIVES: We assess whether posttraumatic stress disorder (PTSD) varies in prevalence, diagnostic criteria endorsement, and type and frequency of potentially traumatic events (PTEs) among a nationally representative US sample of 5071 non-Latino whites, 3264 Latinos, 2178 Asians, 4249 African Americans, and 1476 Afro-Caribbeans. METHODS: PTSD and other psychiatric disorders were evaluated using the World Mental Health-Composite International Diagnostic Interview (WMH-CIDI) in a national household sample that oversampled ethnic/racial minorities (n=16,238) but was weighted to produce results representative of the general population. RESULTS: Asians have lower prevalence rates of probable lifetime PTSD, whereas African Americans have higher rates as compared with non-Latino whites, even after adjusting for type and number of exposures to traumatic events, and for sociodemographic, clinical, and social support factors. Afro-Caribbeans and Latinos seem to demonstrate similar risk to non-Latino whites, adjusting for these same covariates. Higher rates of probable PTSD exhibited by African Americans and lower rates for Asians, as compared with non-Latino whites, do not appear related to differential symptom endorsement, differences in risk or protective factors, or differences in types and frequencies of PTEs across groups. CONCLUSIONS: There appears to be marked differences in conditional risk of probable PTSD across ethnic/racial groups. Questions remain about what explains risk of probable PTSD. Several factors that might account for these differences are discussed, as well as the clinical implications of our findings. Uncertainty of the PTSD diagnostic assessment for Latinos and Asians requires further evaluation.

The Communities Advancing Resilience Toolkit (CART): development of a survey instrument to assess community resilience.

While building community resilience to disasters is becoming an important strategy in emergency management, this is a new field of research with few available instruments for assessing community resilience. This article describes the development of the Communities Advancing Resilience Toolkit (CART) survey instrument. CART is a community intervention designed to enhance community resilience to disasters, in part, by engaging communities in measuring it. The survey instrument, originally based on community capacity and related literature and on key informant input, was refined through a series of four field tests. Community organizations worked with researchers in a participatory action process that provided access to samples and helped to guide the research. Exploratory factor analysis performed after each field test led to the identification of four interrelated constructs (also called domains) which represent the foundation for CART Connection and Caring, Resources, Transformative Potential, and Disaster Management. This model was confirmed using confirmatory factor analysis on two community samples. The CART survey can provide data for organizations and communities interested in assessing a community's resilience to disasters. Baseline data, preferably collected pre disaster can be compared to data collected post disaster and/or post intervention.

Displacement, county social cohesion, and depression after a large-scale traumatic event.

BACKGROUND: Depression is a common and potentially debilitating consequence of traumatic events. Mass traumatic events cause wide-ranging disruptions to community characteristics, influencing the population risk of depression. In the aftermath of such events, population displacement is common. Stressors associated with displacement may increase risk of depression directly. Indirectly, persons who are displaced may experience erosion in social cohesion, further exacerbating their risk for depression. METHODS: Using data from a population-based cross-sectional survey of adults living in the 23 southernmost counties of Mississippi (N = 708), we modeled the independent and joint relations of displacement and county-level social cohesion with depression 18-24 months after Hurricane Katrina. RESULTS: After adjustment for individual- and county-level socio-demographic characteristics and county-level hurricane exposure, joint exposure to both displacement and low social cohesion was associated with substantially higher log-odds of depression (b = 1.34 [0.86-1.83]). Associations were much weaker for exposure only to low social cohesion (b = 0.28 [-0.35-0.90]) or only to displacement (b = 0.04 [-0.80-0.88]). The associations were robust to additional adjustment for individually perceived social cohesion and social support. CONCLUSION: Addressing the multiple, simultaneous disruptions that are a hallmark of mass traumatic events is important to identify vulnerable populations and understand the psychological ramifications of these events.

The Communities Advancing Resilience Toolkit (CART): an intervention to build community resilience to disasters.

Community resilience has emerged as a construct to support and foster healthy individual, family, and community adaptation to mass casualty incidents. The Communities Advancing Resilience Toolkit (CART) is a publicly available theory-based and evidence-informed community intervention designed to enhance community resilience by bringing stakeholders together to address community issues in a process that includes assessment, feedback, planning, and action. Tools include a field-tested community resilience survey and other assessment and analytical instruments. The CART process encourages public engagement in problem solving and the development and use of local assets to address community needs. CART recognizes 4 interrelated domains that contribute to community resilience: connection and caring, resources, transformative potential, and disaster management. The primary value of CART is its contribution to community participation, communication, self-awareness, cooperation, and critical reflection and its ability to stimulate analysis, collaboration, skill building, resource sharing, and purposeful action.

Trajectories of posttraumatic stress symptomatology in older persons affected by a large-magnitude disaster.

This study examined the nature and determinants of longitudinal trajectories of disaster-related posttraumatic stress disorder (PTSD) symptoms in older persons affected by a large-magnitude disaster. Two hundred six adults age 60 or older (mean = 69, range = 60-92) who resided in the Galveston Bay area when Hurricane Ike struck in September 2008 completed telephone interviews an average of 3-, 6-, and 15-months after this disaster. Latent growth mixture modeling was employed to identify predominant trajectories of disaster-related PTSD symptoms over time; and pre-, peri-, and post-disaster determinants of these trajectories were then examined. A 3-class solution optimally characterized PTSD symptom trajectories, with the majority (78.7%) of the sample having low/no PTSD symptoms over all assessments (i.e., resistant); 16.0% having chronically elevated symptoms (i.e., chronic); and 5.3% having a delayed onset course of symptoms (i.e., delayed-onset). Lower education, greater severity of Hurricane Ike exposure (i.e., Ike-related physical illness or injury and high level of community destruction), and greater number of traumatic and stressful life events after Hurricane Ike, particularly financial problems, were associated with a chronic PTSD trajectory. Greater number of traumatic and stressful life events, particularly financial problems after Hurricane Ike, was also associated with a delayed-onset trajectory. These findings suggest that there are heterogeneous trajectories of disaster-related PTSD symptoms in older adults and that these trajectories have common and unique determinants. They also underscore the importance of prevention efforts designed to mitigate the deleterious effects of post-disaster stressors, most notably financial distress, in older persons affected by disasters.

Public health consequences of terrorism on maternal-child health in New York City and Madrid.

Past research provides evidence for trajectories of health and wellness among individuals following disasters that follow specific pathways of resilience, resistance, recovery, or continued dysfunction. These individual responses are influenced by event type and pre-event capacities. This study was designed to utilize the trajectories of health model to determine if it translates to population health. We identified terrorist attacks that could potentially impact population health rather than only selected individuals within the areas of the attacks. We chose to examine a time series of population birth outcomes before and after the terrorist events of the New York City (NYC) World Trade Center (WTC) attacks of 2001 and the Madrid, Spain train bombings of 2004 to determine if the events affected maternal-child health of those cities and, if so, for how long. For percentages of low birth weight (LBW) and preterm births, we found no significant effects from the WTC attacks in NYC and transient but significant effects on rates of LBW and preterm births following the bombings in Madrid. We did find a significant positive and sustained effect on infant mortality rate in NYC following the WTC attacks but no similar effect in Madrid. There were no effects on any of the indicator variables in the comparison regions of New York state and the remainder of Spain. Thus, population maternal-health in New York and Madrid showed unique adverse effects after the terrorist attacks in those cities. Short-term effects on LBW and preterm birth rates in Madrid and long-term effects on infant mortality rates in NYC were found when quarterly data were analyzed from 1990 through 2008/2009. These findings raise questions about chronic changes in the population's quality of life following catastrophic terrorist attacks. Public health should be monitored and interventions designed to address chronic stress, environmental, and socioeconomic threats beyond the acute aftermath of events.

The burden of disaster: Part I. Challenges and opportunities within a child's social ecology.

Child development and adaptation are best understood as biological and psychological individual processes occurring within the context of interconnecting groups, systems, and communities which, along with family, constitute the child's social ecology. This first of two articles describes the challenges and opportunities within a child's social ecology consisting of Micro-, Meso-, Exo-, and Macrosystems. The parent-child relationship, the most salient Microsystem influence in children's lives, plays an influential role in children's reactions to and recovery from disasters. Children, parents, and other adults participate in Mesosystem activities at schools and faith-based organizations. The Exosystem--including workplaces, social agencies, neighborhood, and mass media--directly affects important adults in children's lives. The Macrosystem affects disaster response and recovery indirectly through intangible cultural, social, economic, and political structures and processes. Children's responses to adversity occur in the context of these dynamically interconnected and interdependent nested environments, all of which endure the burden of disaster Increased understanding of the influences of and the relationships between key components contributes to recovery and rebuilding efforts, limiting disruption to the child and his or her social ecology A companion article (R. L. Pfefferbaum et al., in press) describes interventions across the child's social ecology.