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Keywords:

  • Posttraumatic stress disorder;
  • children and adolescents;
  • executive function;
  • earthquake

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Acknowledgements
  10. References

Background

While several studies have found executive function deficits in adults and maltreated children with posttraumatic stress disorder (PTSD), there are few data on executive function in children and adolescents with PTSD related to natural disasters. The objective of this study was to test executive function changes over time in children and adolescents with PTSD after a magnitude 8.0 earthquake in Sichuan, China.

Method

A sample of 34 children and adolescents with diagnosed PTSD following the Sichuan earthquake and 66 matched controls exposed to the same earthquake but without PTSD participated in the study. Executive function was assessed using a battery of interviewer-rated neuropsychological tests and the guardian-rated Behavior Rating Scale of Executive Function (BRIEF) at 4- and 12-month after the earthquake.

Results

Children and adolescents with PTSD performed similar to controls in executive function at 4-months after the earthquake. Both groups improved significantly in similar domains of cognition during the following 8 months. The PTSD group exhibited daily deficits in emotional control compared with the controls at the 4-month assessment, but the differences disappeared during the following 8 months.

Conclusions

Children and adolescents with PTSD related to a natural disaster have deficits only in the emotional control domain of executive function compared with controls exposed to the same disaster, but even these deficits did not persist.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Acknowledgements
  10. References

Posttraumatic stress disorder (PTSD) is associated with significant impairments in social, work, and relational functioning that could lead to long-lasting disability (Breslau, Davis, Andreski, & Peterson, 1991). Previous studies on adults have found neurocognitive deficits in combat veterans (Beckham, Crawford, & Feldman, 1998; Gilbertson, Gurvits, Lasko, Orr, & Pitman, 2001; Koso & Hansen, 2006; Vasterling et al., 2002), rape victims (Stein, Kennedy, & Twamley, 2002), and natural disaster survivors (Eren-Kocak, Kilic, Aydin, & Hizli, 2009; Golier et al., 2002) with PTSD. Although the results are inconsistent, executive function including working memory, inhibition, cognitive shifting, and verbal fluency are the domains that are found primarily to be impaired (Beckham et al., 1998; Eren-Kocak et al., 2009; Gilbertson et al., 2001; Kanagaratnam & Asbjornsen, 2007; Koso & Hansen, 2006; Stein et al., 2002; Vasterling et al., 2002). Executive function is central to many developmental tasks, from navigating peer relationships to performance in academic settings (DePrince, Weinzierl, & Combs, 2009). Some studies on children exposed to social traumas have found that deficits in executive function in children exposed to social traumas disrupted a range of developmental tasks including personal relationships (Copeland, Keeler, Angold, & Costello, 2007) and school achievement (Eckenrode & Doris, 1993; Kendall-Tackett & Eckenrode, 1996; Shonk & Cicchetti, 2001). Compared to adults, relatively few studies have explored executive function in children and adolescents with PTSD (Beers & De Bellis, 2002; Schoeman, Carey, & Seedat, 2009). Therefore, it is not clear whether the observed executive function deficits were caused by trauma exposure, PTSD symptoms, or both. Thus, the extension of systematic studies of executive function to children and adolescents with PTSD is particularly important for a better understanding of cognitive characteristics of PTSD.

Studies using standard neuropsychological tests have found similar impairments in executive function in children with maltreatment and PTSD (Beers & De Bellis, 2002; De Bellis, Hooper, Spratt, & Woolley, 2009). The presence of PTSD itself is associated with executive function deficiencies in adolescents exposed to various traumatic events (Schoeman et al., 2009), most of which were still social traumas like rape or witnessing violence. Different types of trauma can result in PTSD with different attributable risks (Breslau et al., 1998; Bromet, Sonnega, & Kessler, 1998); violent or sexual traumas, for example, are associated with the highest rate of PTSD symptoms (Copeland et al., 2007). In addition, differences in overall PTSD severity and symptom patterns associated with cognitive deficits were also found in different trauma types (Kelley, Weathers, McDevitt-Murphy, Eakin, & Flood, 2009). Therefore, it should be presumed that not all forms of trauma or PTSD are identical with respect to the neuropsychological abnormalities they cause (Stein et al., 2002).

Although retrospective and cross-sectional studies (Bremner, Vermetten, Afzal, & Vythilingam, 2004) have found memory and executive function impairments in adults with childhood sexual abuse, it was not possible to interpret the progression of these impairments over time. To our knowledge, there have only been two studies that examined neuropsychological functioning in PTSD longitudinally in older patients (over 40 years), both focusing on memory. One study found that with the symptoms lessened, significant differences between subjects with and without PTSD memory functioning deficit at baseline disappeared at follow-up (Huang et al., 2006; Yehuda et al., 2006), suggesting that the improved performance was secondary to the improvement in PTSD symptoms (Yehuda et al., 2006). The second study found a subtle decline in memory in subjects with chronic PTSD (Samuelson et al., 2009). Whether the similar progression of executive function exists in children and adolescents with PTSD is unknown. Considering that neurological mechanisms underlying these functions develop more rapidly around puberty, suffering from PTSD during this period could lead to profound and long-lasting impairments in cognition, including intellectual/emotional developmental delays in language and psychomotor deficiencies (Palmer, Armsworth, & Swank, 1997).

In terms of instruments, most previous studies on PTSD were limited to conventional performance-based tests. These tests are thought to reflect executive function performance in highly structured laboratory situations, but are not sufficient to capture deficits in real-world behavior (Chan, Shum, Toulopoulou, & Chen, 2008). Recent studies suggest the superiority of using both conventional performance-based tests and ecologically valid measures when testing functioning in daily life over using either of them alone to assess executive dysfunction in clinical samples (Riccio, Homack, Jarratt, & Wolfe, 2006).

The magnitude 8.0 earthquake that took place in Wenchuan, Sichuan province on May 12th, 2008, killed more than 70,000 people and leaving thousands of orphans. Five hundred and twenty-three orphans were moved from the disaster area (midwest of China) to Shandong province (mideast of China) by the authorities one month after the earthquake and adopted there by workers of a local steel company. The adopting families were thoroughly evaluated and also received regular training on how to care for the orphans (feeding, dressing, bathing and comforting, etc.). The health status of the orphans was closely monitored by local health authorities and those presenting with any physical and psychological problems immediately received appropriate medical and/or psychological treatment.

We interviewed this group of orphans to examine if executive dysfunction would be observed in children and adolescents with PTSD following a major earthquake, and to explore the progression of dysfunction over time. Based on earlier findings on neurocognitive deficits in PTSD (Eren-Kocak et al., 2009; Golier et al., 2002) and their change over time (Yehuda et al., 2006), we hypothesized that children and adolescents with PTSD related to the earthquake would show executive function deficits and these deficits would change over time.

Method

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Acknowledgements
  10. References

Subjects

All 523 earthquake-exposed adopted children and adolescents were screened. The inclusion criteria included the following: (a) Diagnosis of PTSD. The International Neuropsychiatry Interview for Child (MINI-KID) was used to screen PTSD (Sheehan et al., 1998), and then a semistructured interview using the Chinese version of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Life Version (K-SADS-PL) (Kaufman, Birmaher, Brent, Ryan & Rao, 2000) was administered by trained psychiatrists to ascertain the diagnoses; (b) Age between 9 to 17 years at study entry, 4 months after the earthquake; (c) Being right-handed; (d) Speaking fluent Mandarin Chinese language; and (e) IQ of at least 80 based on the Chinese–Wechsler Intelligence Scale for Children (C-WISC) (Gong & Cai, 1993) to ensure that subjects have the ability to complete the neuropsychological tests. Exclusion criteria included (a) history of, or current diagnosis of head injury associated with loss of consciousness; (b) Substance abuse; (c) Axis I psychiatric comorbid diagnosis; and (d) color-blindness or hearing impairment. As all these children and adolescents were orphans, informed written consent was obtained from their guardians and the authority of the residence responsible for caring for them following a detailed introduction of the study. The study protocol was approved by the Ethics Committee of Peking University Institute of Mental Health.

Altogether 34 subjects satisfied the study criteria and participated in the study. To achieve an adequate power, the controls were recruited on a 1:2 ratio; a consecutive cohort of 66 orphans with no psychiatric diagnoses who were matched to the PTSD subjects in age (±6 months) and education (±2 years) were recruited from the same population as the control group. Considering the developmental qualities of executive functions (Palmer et al., 1997), the participants were divided into two groups in the analyses: children (9–13 years) and adolescents (14–17 years).

Measures

Conventional neuropsychological tests

Visual working memory was assessed with the Rey–Osterrieth Complex Figure Test (ROCFT) (Lezak, 1995; Shin, Park, Park, Seol, & Kwon, 2006). Subjects were asked to reproduce the figure after having observed it initially for 30 s and 20 min later. Immediate and delayed recall scores were recorded. The Digit Span of the Wechsler Intelligence Scale for Children, including the forwards and backwards subtests, was used to assess auditory memory.

The Stroop Colored Word Test (Stroop, 1935) was used to capture the inhibition component of executive function. The test consists of four parts, represented by three different cards with either 30 color words in black ink (card 1), 30 color squares (card 2), or 30 incongruent words (i.e. ‘blue’ written in green, card 3). Subjects were required to read the words (part 1), name the color of squares (part 2), and name the words (part 3) and the color (part 4) of the incongruent words, as quickly and correctly as possible. The time to complete all 30 items was recorded for each part. The time of part 3 subtracted from part 1 indicated color interference; the time of part 4 subtracted from part 2 indicated word interference.

Part A of the Trail Making Test (TMT-A) (Reitan & Wolfson, 1985) was used to assess visual scanning and psychomotor speed. Subjects were instructed to connect 25 number circles randomly distributed over a sheet of paper as quickly and correctly as possible. The time taken was recorded. Part B of the Trail Making Test (TMT-B) (Reitan & Wolfson, 1985) measured cognitive shifting/flexibility. Subjects were required to connect 25 circles that contained numbers or letters and they had to sequentially alternate between numbers and letters (i.e., 1-A-2-B, and so forth). The time taken was recorded.

The Animal Naming Test (Tucha et al., 2005) of the Controlled Oral Word Association Test (COWAT) was used to assess the verbal fluency component of executive function. Subjects had 2 min to name as many animals as they could. The total number was recorded.

Ecologically valid measures

The Behavior Rating Scale of Executive Function (BRIEF)—Parent Form for School Age Children (Gioia, Isquith, Guy, & Kenworthy, 2000) was used to assess the subjects' executive function in daily life including eight domains: inhibition, shift, emotional control, initiation, working memory, plan, organization and monitor. The BRIEF comprises 86 items, with each one rated in three ranks. A higher score indicates more severe impairment. The Chinese version of the scale has demonstrated satisfactory reliability and validity (Qian, Shuai, Cao, Chan, & Wang, 2010).

Procedures

The assessments were conducted in September 2008 (4 months after the earthquake) and May 2009 (12 months after the earthquake). The 34 PTSD subjects and 66 controls received the assessments of neuropsychological tests by trained psychiatrists who were blind to the subjects' diagnoses at entry. At the same time, the BRIEF assessment was completed by the subjects' guardians in a separate room. At the 12-month assessment after the earthquake, all the subjects (except for one PTSD subject who had moved away) and their guardians received the same set of assessments. At the 12-month assessment, four subjects in the PTSD group still met the diagnostic criteria of PTSD. In total, 31 guardians (5 in the PTSD group and 26 in the controls) did not complete the BRIEF assessment; therefore, their data were not entered in the statistical analyses (Table 2).

Statistical analyses

Data were analyzed using the SPSS 20.0 for Windows. The comparison of the two groups with regard to their demographic characteristics and performance on cognition at the 4-month assessment was performed with independent sample t-test, Mann-Whitney U test, and chi-square test, as appropriate. The comparison of the two groups with regard to performance on neuropsychological tests and executive function at the 12-month assessment was made with repeated measures ANOVA with gender and age group as covariates. The one-sample Kolmogorov-Smirnov test was used to check the normality of distribution of the continuous variables. The level of significance was set at 0.05 (two-tailed).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Acknowledgements
  10. References

Table 1 shows the sociodemographic and clinical data and the results of the neuropsychological tests of the two groups at both the 4- and 12-month assessments. Compared with the controls, the participants in the PTSD group had more positive items on the K-SADS at both assessments. Repeated measures ANOVA revealed that the performance of the neuropsychological tests between the two groups did not significantly differ at the 12-month assessment. There were significant changes between the 4- and 12-month assessments in scores of ROCFT immediate (F(1, 94) = 8.5, p = 0.004) and delayed (F(1, 94) = 8.5, p = .004), and TMT-part A (F(1, 94) = 4.1, p = .046) and B (F(1,94) = 14.1, p < .001). There were also significant interactions between time and gender of ROCFT delayed (F(1, 94) = 6.5, p = .01) and interactions between time and age group in TMT-part B (F (1, 94) = 5.5, p = .02).

Table 1. The sociodemographic and clinical data and performance of interviewer-rated neuropsychological tests of the two groups
 4-month12-month
PTSD (n = 34)Controls (n = 66)StatisticsPTSD (n = 33)Controls (n = 65)Statistics
  1. K-SADS, the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children; ROCFT, Rey–Osterrieth Complex Figure Test; TMT, Trail Making Test; COWAT, the Controlled Oral Word Association Test.

  2. a

    Mann–Whitney U-test.

  3. b

    Repeated measures ANOVA with gender and age group as covariates.

  4. c

    Change between the two assessments (F(1, 94) = 8.5, p = .004), interaction (IA) time by gender (F(1, 94) = 3.9, p = .053), IA time by age group (F(1, 94) = 1.0, p = .3), IA time by group (F(1, 94) = 0.5, p = .5).

  5. d

    Change between the two assessments (F(1, 94) = 8.5, p = .004), IA time by gender (F(1, 94) = 6.5, p = .01), IA time by age group (F(1, 94) = 0.8, p = .4), IA time by group (F(1, 94) = 0.2, p = .7).

  6. e

    Change between the two assessments (F(1, 94) = 0.03, p = .9), IA time by gender (F(1, 94) = 0.01, p = .9), IA time by age group (F(1, 94) = 0.1, p = .8), IA time by group (F(1, 94) = 0.3, p = .6).

  7. f

    Change between the two assessments (F(1, 94) = 0.01, p = .9), IA time by gender (F(1, 94) = 0.4, p = .5), IA time by age group (F(1, 94) = 0.03, p = .9), IA time by group (F(1, 94) = 3.1, p = .08).

  8. g

    Change between the two assessments (F(1, 94) = 0.01, p = .8), IA time by gender (F(1, 94) = 0.1, p = .7), IA time by age group (F(1, 94) = 1.2, p = .3), IA time by group (F(1, 94) = 0.7, p = .4);

  9. h

    Change between the two assessments (F(1, 94) = 4.1, p = .046), IA time by gender (F(1, 94) = 3.4, p = .07), IA time by age group (F(1, 94) = 0.1, p = .8), IA time by group (F(1, 94) = 0.9, p = .3);

  10. i

    Change between the two assessments (F(1, 94) = 14.1, p < .001), IA time by gender (F(1, 94) = 0.01, p = .9), IA time by age group (F(1, 94) = 5.5, p = .02), IA time by group (F(1, 94) = 3.2, p = .07).

  11. j

    Change between the two assessments (F(1, 94) = 1.1, p = .3), IA time by gender (F(1, 94) < 0.001, p = .99), IA time by age group (F(1, 94) = 2.2, p = .1), IA time by group (F(1, 94) = 0.1, p = .7).

  N % N %χ2 df p N % N %χ2 df p
Male1647.13756.10.71.41545.53655.40.91.4
Age group    1.31.3    0.91.4
9–13 years1544.13756.1   1545.53655.4   
14–17 years1955.92943.9   1854.52944.6   
 Mean SD Mean SD t df p Mean SD Mean SD t df p
Education6.21.55.91.70.998.46.21.55.91.70.796.5
IQ105.811.4106.812.2−0.498.7105.811.6106.712.3−0.496.7
No. of positive K-SADS items11.92.9.761.624.798<.0012.13.50.70.32.896.006
 Mean SD Mean SD t/z df p Mean SD Mean SD F b df p
ROCFT immediate12.96.213.36.9−0.398.815.95.615.56.60.31, 94.6 c
ROCFT delayed12.46.512.96.7−0.398.815.15.915.16.60.41, 94.5 d
WISC Digit Span total12.21.812.42.3−0.598.612.32.312.32.00.21, 94.6 e
Stroop Colored Word Test – color4.24.93.24.9−0.7 a.53.24.35.05.70.21, 94.7 f
Stroop Colored Word Test - word16.99.520.59.0−1.8 a.0715.06.816.87.12.71, 94.1 g
TMT – part A46.115.950.422.4−1.098.341.513.642.516.30.21, 94.6 h
TMT – part B156.987.2140.764.1−0.6 a.5118.845.7120.149.11.51, 94.2 i
COWAT total23.86.823.76.40.0698.922.87.223.55.80.31, 94.6 j

Table 2 presents the sociodemographic and clinical data and performance of executive function in daily life measured by the guardians at the 4- and 12-month assessments. Compared with the controls, the PTSD subjects had more positive items on the K-SADS at both assessments and a higher score for emotional control at the 4-month assessment, but the difference became only marginally significant by the 12-month assessment (p = .06).

Table 2. The socio-demographic and clinical data and performance of guardian-rated executive functions in daily life
 4-month12-month
PTSD (n = 29)Controls (n = 40)StatisticsPTSD (n = 29)Controls (n = 40)Statistics
  1. K-SADS: the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children.

  2. a

    Repeated measures ANOVA with gender and age group as covariates.

  3. b

    Change between the two assessments (F (1, 65) = 0.1, p = .8), interaction (IA) time by gender (F (1, 65) = 1.1, p = .3), IA time by age group (F (1, 65) = 0.3, p = .6), IA time by group (F (1, 65) = 0.01, p = .9);

  4. c

    Change between the two assessments (F (1, 65) =0.004, p = 0.9), IA time by gender (F (1, 65) =0.3, p = 0.6), IA time by age group (F (1, 65) =0.2, p = 0.7), IA time by group (F (1, 65) =0.7, p = 0.4);

  5. d

    Change between the two assessments (F (1, 65) =0.1, p = 0.8), IA time by gender (F (1, 65) =1.2, p = 0.3), IA time by age group (F (1, 65) =0.001, p = 0.98), IA time by group (F (1, 65) =0.7, p = 0.4);

  6. e

    Change between the two assessments (F (1, 65) = 0.4, p = .5), IA time by gender (F (1, 65) = 0.5, p = .5), IA time by age group (F (1, 65) < 0.001, p = .9), IA time by group (F (1, 65) = 0.1, p = .8).

  7. f

    Change between the two assessments (F (1, 65) =0.1, p = .8), IA time by gender (F (1, 65) = 0.1, p = .8), IA time by age group (F (1, 65) = 0.1, p = .8), IA time by group (F (1, 65) = 0.1, p = .8).

  8. g

    Change between the two assessments (F (1, 65) = 0.1, p = .7), IA time by gender (F (1, 65) = 0.1, p = .7), IA time by age group (F (1, 65) =0.01, p = 0.9), IA time by group (F (1, 65) =0.01, p = 0.9).

  9. h

    Change between the two assessments (F (1, 65) = 2.0, p = .2), IA time by gender (F (1, 65) = 2.1, p = .2), IA time by age group (F (1, 65) = 1.7, p = .2), IA time by group (F (1, 65) < 0.001, p = .9).

  10. i

    Change between the two assessments (F (1, 65) = 0.04, p = .8), IA time by gender (F (1, 65) = 0.1, p = .7), IA time by age group (F (1, 65) = 0.01, p = .9), IA time by group (F (1, 65) = 0.02, p = .6).

  N % N %χ2 df p N % N %χ2 df p
Male1241.41742.50.011.91241.41742.50.011.9
Age group    2.61.1    2.61.1
9–13 years1137.92357.5   1137.92357.5   
14–17 years1862.11742.5   1862.11742.5   
 Mean SD Mean SD t/z df p Mean SD Mean SD t df p
Education 6.41.56.01.61.167.36.41.56.01.61.167.3
IQ105.212.1106.213.2−0.367.8105.212.1106.213.2−0.367.8
No. of positive K-SADS items12.22.80.41.224.167<.0012.33.70.71.52.567.02
 Mean SD Mean SD t df p Mean SD Mean SD F a df p
Inhibition12.23.511.11.61.867.0712.23.111.22.25.31, 65.03 b
Shift10.02.59.41.71.267.29.42.19.52.00.61, 65.5 c
Emotional control12.52.911.32.02.167.03812.13.411.62.13.81, 65.06 d
Initiation 10.42.510.12.40.567.69.72.09.62.10.31, 65.6 e
Working memory12.93.212.02.01.567.112.93.312.43.42.31, 65.1 f
Plan 15.23.914.63.10.867.415.53.915.04.00.51, 65.5g
Organization 7.72.37.92.9−0.367.78.02.28.02.70.11, 65.8 h
Monitor 11.33.411.42.8−0.167.911.63.311.13.20.21, 65.7 i

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Acknowledgements
  10. References

This study assessed executive function in children and adolescents with and without PTSD at 4- and 12-months after a major earthquake in China. On neuropsychological testing, there was no significant difference between the PTSD group and the controls in any measure at both time points. The two groups improved in similar domains of executive function: the ROCFT immediate and delayed memories and TMT-A and –B.

Results of the BRIEF were somewhat different from those of the neuropsychological testing. Guardians' observation showed that children and adolescents with PTSD performed worse in day-to-day tasks 4 months after the earthquake whenever emotional control was needed, but there was no difference between the groups in their everyday performance at the 12-month assessment after controlling for the potential confounding effects of age and the 4-month rating. Daily executive function did not improve in either group during the 8-month period between test administrations.

These results are not consistent with the findings in adults (Eren-Kocak et al., 2009; Kanagaratnam & Asbjornsen, 2007; Koso & Hansen, 2006; Vasterling et al., 2002), or those of the only study conducted in children with PTSD, which found prevalent deficits in executive functions including working memory, inhibition, set shifting, and fluency (Beers & De Bellis, 2002). The difference between results of the current and earlier studies may be partly due to the different characteristics of the traumatic experience. Earlier findings were reported following man-made traumas, while this study examined children and adolescents with PTSD resulting from exposure to an earthquake. As Eren-KoÅak et al. (Eren-Kocak et al., 2009) noted that the type of trauma may create a sampling bias. There is preliminary evidence that prefrontal functions do not mature until early youth (Tranel, 1994), thus children and adolescents facing long-lasting traumas, such as abuse, are usually likely to be handicapped in their development of executive function. In contrast, natural disasters generally do not discriminate between individuals' level of cognitive competence allowing the collection of a more homogenous study sample (Tranel, 1994). The second reason for the discrepancy between the findings of current and earlier studies may be related to the characteristics of the control group. In the only earlier study on children with PTSD (Beers & De Bellis, 2002) nonabused children were chosen as the control group, while our study chose children exposed to the earthquake but not showing signs of PTSD. In a somewhat comparable study of subjects with common trauma exposure, female victims of intimate partner violence performed almost the same in every test related to executive function regardless of having PTSD or not (Stein et al., 2002). However, when compared with the nonvictimized comparison group, those with PTSD exhibited deficits in executive function. Whether the observed cognitive dysfunctions result from PTSD or the trauma itself, remains debatable. The ideal way to clarify this issue would be to employ two different control groups (Stein et al., 2002). In this study, it was impossible to find economically, culturally and socially comparable groups who had not experienced the earthquake in the same area.

Another issue that has long been ignored is the impact of executive function deficits on the victims' daily life. Because of the complexity of real-world situations, those deficits that appear in the laboratory as a subtle deficit in executive functions could translate into significant impairment in activities of daily living, particularly under stress (Stein et al., 2002). To complicate the picture further, there are many more resources that could help compensate for the functional deficits of affected children and adolescents. For this reason, our study was particularly interested in assessing executive function in everyday life; the inconsistency between the two sets of tests is not surprising.

Limitations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Acknowledgements
  10. References

The findings of this study have to be treated with caution because of the following limitations: (a) Earthquake orphans were highly uniform in their trauma experiences, but their pretrauma background, such as socioeconomic status and school performance, were not measured. This might have decreased the comparability of the subjects as executive function could be associated with these factors (van Ijzendoorn, Juffer, & Poelhuis, 2005; Noble, Norman, & Farah, 2005); (b) The study sample consisted of children and adolescents who were exposed to a severe earthquake and also lost their parents creating a complex situation involving trauma and grief. Trauma and grief are closely associated (Brown & Goodman, 2005; Pfefferbaum et al., 2006) and the grief might mask the effects of the trauma to an uncertain extent (Green, 2000). In this study, however, the two groups were both selected from the same earthquake-exposed adopted population and were well matched, which minimized the potential bias. In addition, the guardians' knowledge about the children's behavior in daily life could not be estimated; (c) Normative data of the cognitive measures in Chinese children and adolescents are not available. Furthermore, an economically, culturally and socially comparable control group who did not experience the earthquake was also lacking; (d) The match for education (±2 years) may be a bit broad in the study design although the actual education level proved to be well matched between the two groups; (e) The children and adolescents were fortunate to be transferred out of the disaster area soon after the earthquake and moved into a place that was safe and comfortable. Compared with other children and adolescents who have experienced the same level of trauma, our subjects left the disaster scene sooner and received better care and education after the trauma. The effects of these variables on executive function are not clear making it premature to generalize the findings to all children and adolescents after a natural disaster. What factors protected the subjects from impairments of executive function and promoted their rehabilitation is a question that needs to be studied further; (f) The small sample size did not permit bivariate intercorrelation analyses between the components of neuro-psychological tests, BRIEF, and PTSD symptoms without risking type I error. Finally, the 523 orphans were aged between 4 and 17 years. However, the Chinese version of International Neuropsychiatric Interview for Child (MINI-KID) can only be used for children and adolescents aged 9 years and older, therefore children younger than 9 years of age had to be excluded, which might have biased the findings.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Acknowledgements
  10. References

In conclusion, our results suggest that children and adolescents with PTSD do not show obvious impairments in executive function compared with their trauma-affected counterparts without PTSD. Given a safe and stable environment, children and adolescents with and without PTSD both improve significantly in executive functions in 12 months after an earthquake.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Method
  5. Results
  6. Discussion
  7. Limitations
  8. Conclusion
  9. Acknowledgements
  10. References

This study was funded by National High Technology Research and Development Program of China (863 Program) (No. 2008AA022605) and the National Natural Sciences Foundation of China (No. 81000594).We thank Professor Myron L. Belfer in Department of Social Medicine at Harvard Medical School, Boston, MA, USA for his comments on this manuscript.

Key points
  • Children and adolescents with PTSD may have deficits in executive function.
  • Children and adolescents with PTSD may present different impairments in executive function following different types of trauma when assessed with different instruments; the changes in executive function impairments over time are yet to be studied.
  • The executive functions of children and adolescents with PTSD after a natural disaster were assessed
    • by comparing the performance between children and adolescents with and without PTSD using neuropsychological tests and a guardian-rated scale and
    • by comparing the performance on neuropsychological tests and executive function in daily life 4- and 12-months after the disaster.
  • Children and adolescents with PTSD following a natural disaster have only temporary deficits in the emotional control domain of executive function.

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