Posttraumatic Stress Disorder as a Mediator Between Trauma Exposure and Comorbid Mental Health Conditions in North Korean Refugee Youth Resettled in South Korea

Abstract

A structural equation model was used to investigate the relationship between trauma exposure and comorbid mental health problems and the mediation effect of posttraumatic stress disorder (PTSD) between trauma and mental health variables. The research model is based on the stress-vulnerability conceptual framework in which PTSD as a comorbid disorder mediates the relationship between trauma exposure and mental health problems. A self-administered survey was administered to 144 North Korean refugee youth residing in South Korea. Trauma exposure, both interpersonal and noninterpersonal, had no direct relationship with comorbid mental health problems. However, interpersonal trauma contributed to comorbid mental health problems through PTSD, demonstrating the mediation effect of PTSD and supporting the stress-vulnerability hypothesis of the current research model. Clinical implications of the study and future direction for research are discussed.

Keywords

trauma North Korean refugee youth simple PTSD complex PTSD psychopathologies

Background/Literature Review

Research has demonstrated that exposure to traumatic stressors can result in long-term psychological distress and mental disorders (Beiser, Turner, & Ganesan, 1989; Koenen, Lyons, & Goldberg, 2003; Mollica, Wyshak, & Lavelle, 1987). Likewise, widespread exposure to trauma and the prevalence and chronicity of psychological problems of North Korean refugees resettled in South Korea have been extensively documented. Previous studies on North Korean refugees have shown a dose-response relationship between trauma exposure and psychopathologies such as posttraumatic stress disorder (PTSD), depression, and anxiety (Cho, Jeon, Yoo, Eom, & Hong, 2005; Jeon et al., 2005; Kim, Cho, & Jeon, 2010). Nonetheless, most of the previous studies on North Korean refugees have focused on the adult population and the impact of trauma on North Korean refugee youth has been researched in only a few (Cho, Kim, & Kim, 2011; Yang & Hwang, 2008).

Previous studies on North Korean refugee youth documented the gravity and chronicity of their trauma. Common trauma, for example, includes chronic malnutrition, separation from or death of family members in childhood, witnessing public execution, experiencing physical and sexual violence, victimization of human trafficking, torture and incarceration, beggardom, and homelessness (Harden, 2012; Keum, Kwon, & Lee, 2004; Yang & Hwang, 2008). An international food aid organization has substantiated the grave reality in North Korea as it reported an acute malnutrition (moderate and severe wasting) rate of 16% and chronic malnutrition (moderate and severe stunting) rate of 62% among North Korean children (World Food Programme, 2000). The impact of trauma exposure is reflected in the poor indicators of psychosocial adjustment and academic attainments among North Korean youth in South Korea (Cho et al., 2011; Chung, Yang, Lee, Lim, & Hwang, 2006; Kim, 2009).

Studies have demonstrated the grave consequences of trauma. They show close associations between trauma exposure and psychopathologies such as PTSD, depression and anxiety, and general physical functioning (Hubbard, Realmuto, Northwood, & Masten, 1995; Suliman et al., 2009; Ward, Flisher, Zissis, Muller, & Lombard, 2001). In particular, trauma exposure in childhood has been proven to contribute to negative developmental outcomes in adolescence and physical and psychological pathologies later in life, including a wide variety of mental health problems (Heim & Binder, 2012; Kerig, Ward, Vanderzee, & Moeddel, 2009; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Montgomery, 2008; Ward et al., 2001). Early parental loss has been found to be related to depression and anxiety disorders (Kendler, Neale, Kessler, Heath, & Eaves, 1992). Early stress has also been associated with increased risk for other disorders such as schizophrenia and substance abuse, as well as physical illnesses such as diabetes, heart disease, and immune disorders (Heim & Nemeroff, 2001; Kendler et al., 2000; Pine, 2003).Traumatic stress disturbs information processing as well, which can lead to subsequent behavioral and academic problems in adolescence such as conduct disturbance, teen pregnancy, and school dropout (Miller & Resick, 2007; Porche, Fortuna, Lin, & Alegria, 2011). Immigration during adolescence increased the risk of poor adjustments such as school dropout in the case of North Korean refugee youth (Porche et al., 2011).

While all forms of trauma have adverse effects on children and youth, the nature of trauma and its duration have shown varying impact on the victim. Trauma from interpersonal violence such as child abuse and sexual assault, in comparison with noninterpersonal violence (i.e., natural disasters and accidents), poses greater risk of mental health problems (Gladstone et al., 2004; Ward et al., 2001). Moreover, prolonged and repeated victimization in childhood increases risk as it interferes with important developmental attainments in adolescence such as self-respect, self-regulation, and interpersonal trust. Failure to attain them may result in diminished sense of future, self-destructive behaviors, and antisocial behaviors, and increase vulnerability to chronic psychopathologies (Ford, Chapman, Mack, & Pearson, 2006). North Korean refugee youth are at great risk of mental health problems as they report various kinds of interpersonal violence such as physical violence and sexual assault, human trafficking, and violence by the regime in the forms of torture, imprisonment, and public execution coupled with chronic deprivation and neglect.

The most common trauma-related psychopathology is PTSD. The Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) criteria for PTSD focus on discrete, dramatic, single-incident stressors that result in what has been termed simple PTSD (Herman, 1992). Simple PTSD is evidenced by symptoms of re-experiencing, avoidance, and increased arousal. However, North Korean refugee youth who are exposed to prolonged, repeated, interpersonal stressors present a different symptom picture and would be better understood with additional assessment criteria termed complex PTSD (Herman, 1992). Complex PTSD describes symptoms resulting from exposure to interpersonal trauma, a combination of physical and sexual abuse, and chronicity of the trauma (Roth, Newman, Pelcovitz, van der Kolk, & Mandel, 1997). The psychological impact of rather prolonged, interpersonal stressors occurring in formative years depletes one’s ability to regulate affect, and causes a rigid cognitive style and a limited repertoire of coping strategies. It subsequently compromises the individual’s self-development and affect regulation, and impairs relationships (Cloitre et al., 2011; Cloitre et al., 2009; Kerig et al., 2009; Pelcovitz et al., 1997; Resick et al., 2012). The symptoms of complex PTSD are more prevalent in those with a history of early onset and longer lasting interpersonal trauma with deprivation and neglect in multiple aspects in life, as is the case for many North Korean refugee youth (van der Kolk et al., 2005). Therefore, a combination of simple and complex PTSD would better capture the complex clinical picture of North Korean refugee youth and is used to measure PTSD in the present study.

Studies have shown that exposure to repeated or multiple traumas, particularly in the childhood years, result in not only PTSD but also impairment in developmental processes related to growth of affective and interpersonal self-regulatory capacities such as anxious arousal, dysphoria, anger, and aggressive or socially avoidant behaviors (Cloitre et al., 2009; van der Kolk et al., 2005). This implies that the focus of trauma research needs to extend beyond PTSD as the sole outcome of traumatization and to attend to the full range of disturbances in affect regulation, impulse control, information processing, and personality development. In most cases, PTSD is not only the most common condition resulting from trauma exposure but also the initiating disorder in all comorbid conditions including depression, anxiety, somatization, substance abuse, personality disorders as well as physical health (Boscarino, 2004; Luft et al., 2012; Mazza & Reynolds, 1999; Mueser, Rosenberg, Goodman, & Trumbetta, 2002; Subica, Claypoole, & Wylie, 2012; van der Kolk et al., 2005). Subica et al. (2012) showed that PTSD mediated the relationships between trauma and depression and overall mental health functioning. Other studies corroborated the mediation effect of PTSD between trauma exposure and other mental health conditions such as depression, suicidal behavior, and personality disorder (Mazza & Reynolds, 1999; Powers, Thomas, Ressler, & Bradley, 2011; Subica et al., 2012), and trauma and physical illnesses (Boscarino, 2004; Luft et al., 2011).

North Korean youth draw attention of school counselors or social workers usually for aggression, delinquent behaviors, failure in role functioning, depressive episodes, and suicidal behavior. Focus solely on manifestation of behavioral and affective symptoms, however, may miss the possible root causes of the observed condition and the mechanism of causal relationship between stress and signs of distress. Therefore, this study investigates the relationship between trauma and various mental health problems and the mediation effect of PTSD between trauma and comorbid mental health problems. The research model is based on the stress-vulnerability conceptual framework in which trauma exposure in childhood impairs developmental processes of North Korean refugee youth related to emotion regulation and associated interpersonal behaviors and increases vulnerability to chronic mental health problems. The present study addresses the following questions. First, it tests whether cumulative trauma is predictive of various mental health conditions. Second, it determines whether the nature of trauma is predictive of mental health problems differently. Third, it addresses the role of PTSD in development of other mental health conditions in response to trauma exposure. Clarification of the relationship between trauma, PTSD, and other comorbid mental disorders will lead to comprehensive assessment, and effective treatment approaches to this least understood population.

Method

Participants

Of 161 survey responses, 17 incomplete ones were eliminated and the remaining 144 responses were used for the research analysis. This study sample resembled the 13- to 21-year-old North Korean refugee youth population residing in South Korea in regard to distribution of gender, age, and residence location (Ministry of Education, 2012). The gender distribution of the study sample was even with 74 males and 70 females. The average age of the respondents was 18 to 20 years. The mean length of stay in South Korea was 37 months. The average migration time of departure from North Korea to arrival in the South was 24 months.

The average years of education was 8 years with a 3-year difference between the years of schooling completed and the number of years of education expected for students of this age, which is partially explained by the average migration time of 2 years. The disruption in education suggested by this gap was reflected in their schools as only 28.5% of the sample was in regular schools, compared with 45.9% in alternative schools and 17.5% attending vocational training schools. The 23% who did not respond to inquiries about their education were very likely to have dropped out of school or never attended school in South Korea.

Of the respondents, 71% reported experiencing one or more traumatic incidents in the past and an average of 2.6 traumatic events. The types of incidents most frequently reported were witnessing traumatic incidents such as death or arrest of their family members (39.6%) or hearing about it (40.3%), followed by suffering violence or abuse by family or acquaintances (33.3%), natural disaster (27.8%), and incarceration (24.3%). Only 27.8% of the respondents were living with both parents, whereas 54.9% lived with only one parent, 10.9% lived with relatives or acquaintances, and 8.5% did not have any family members in the South.

Procedure

All efforts were made to recruit a sample population that was representative of all North Korean youth in South Korea. North Korean refugee youth are relatively few, scattered throughout South Korea and highly mobile, which makes it very difficult to conduct randomized sampling. Therefore, the cooperation of youth agencies, schools, and churches working with North Korean refugee youth in different parts of the country was critical to obtaining a good representative sample in terms of geographical location and functioning levels. The questionnaire obtained information about basic demographic characteristics, along with mental health characteristics such as trauma exposure, PTSD, and other mental health outcomes. The main instruments to measure mental health conditions, the Posttraumatic Diagnostic Scale (PDS) and the Hopkins Symptoms Checklist (HSCL)-37 were not validated for this study population previously. Therefore, the two-stage process of community consultation and pilot testing was conducted to ensure the cultural sensitivity and appropriateness of the survey tools and procedure, and time allotment. A draft of the survey questionnaire was reviewed by three North Korean youth, two teachers at alternative schools for North Korean students, and two therapists working with North Korean people to evaluate the appropriateness and wording of the items to be measured. A pilot test with the draft questionnaire was conducted with 30 North Korean youth at a residential facility for recent arrivals.

Measures

Mental health outcome

The HSCL-37 was used to assess the mental health outcome of the respondents (Bean, Derluyn, Eurelings-Bontekoe, Broekaert, & Spinhoven, 2007). The HSCL-37 is a modified version of the Hopkins Symptoms Checklist–25, a well-known screening instrument that measures symptoms of depression and anxiety used for refugees/non-Western populations (Mollica et al., 1987). It consists of 37 items: 10 for measuring anxiety, 15 for depression, and 12 for externalizing problematic behaviors related with trauma. The scale for each question includes four response categories with respect to the past month from 1 = never to 4 = always. Cronbach’s alpha value of the HSCL-37 measured in the present study was .927. Cronbach’s alpha values of the subscales of HSCL-37 for anxiety, depression, and behavioral disturbance in the current study were .860, .866, and .800, respectively.

Trauma exposure

The first section of the PDS (Foa, Cashman, Jaycox, & Perry, 1997) was used to measure the level of trauma exposure. PDS is a 49-item self-report measurement of PTSD designed to assess all DSM-IV diagnostic criteria for PTSD. The first section is comprised of a list of common potential traumatic events and asks respondents to indicate whether they have been exposed to 12 specific traumatic events. Examples of traumatic events were modified to fit the experiences of North Korean refugee youth such as “arrest by Chinese police” and “repatriation to North Korea.” The number of events endorsed was summed to create a total trauma exposure score. Out of 12 trauma events, 7 were categorized as interpersonal trauma, and 5 as noninterpersonal trauma.

PTSD

Potential PTSD was assessed at two levels of simple and complex PTSD. Simple PTSD included typical symptoms described in DSM-IV diagnostic criteria and were measured by the PDS (Foa et al., 1997). It consists of 17 items that correspond with three diagnostic criteria of the DSM-IV: intrusion, avoidance, and arousal. The measure uses a 4-point Likert-type scale with 0 being never and 3 being almost every day. The Cronbach’s alpha of the measure in the current study was .928. Complex PTSD was operationalized as Disorders of Extreme Stress Not Otherwise Specified (DESNO; Pelcovitz et al., 1997) and measured by the Complex PTSD Scale developed by Boroske-Leiner, Hofmann, and Sack (2008), which is in close correspondence with the diagnostic criteria for DESNO. The Cronbach’s alpha of the complex PTSD measure in the present study was .843.

Data Analytic Plan

Amos 8.0 software was used in combination with SPSS 20.0 to investigate the causal relationship between the main variables in structural equation modeling (SEM) analysis, and SPSS was used for descriptive statistics. Descriptive statistics and correlational analyses were conducted among the scales used in the theoretical model. To test the theoretical model proposed for the present study (see Figure 1), the model with a mediator variable was analyzed using the two-step modeling approach recommended by Anderson and Goldberg (1988). First, a confirmatory factor analyzing measurement model was tested to see whether there was an acceptable fit of the data. The second step tests the structural relationships among latent constructs. Parcels are formed to reduce the number of observed variables and to improve the reliability and normality of the resulting measures and to produce better fit-values (Kline, 2005) given the relatively few cases used in the present study. To evaluate the overall model fit, we used indices including chi-square statistics, comparative fit index (CFI = .95 or greater), the incremental fit index (IFI = .95 or greater), and root-mean-square error of approximation (RMSEA = .08 or less; Hu & Bentler, 1999; Kline, 2005). The proposed model included interpersonal trauma and noninterpersonal trauma, PTSD as mediator variable, and mental health as outcome variable.

Figure 1.

Structural model.

Results

Descriptive Statistics and Correlations

The respondents reported an average of 2.58 trauma exposures in their past. The most frequently reported trauma was “hearing about traumatic events involving their family members” followed by “witnessing traumatic events involving their family members,” and “physical violence by family, relatives or acquaintances.” Overall, 1 in 4 youth had experienced incarceration/imprisonment and 1 in 10 youth had experienced torture, which indicated the gravity of these youth’s trauma exposure. Male respondents reported a greater number of trauma incidents in total than females (3.1 vs. 2.0). Male respondents were also exposed to significantly greater number of interpersonal trauma such as physical violence, sexual assault, and torture as well as natural disaster. The extent of trauma exposure for each trauma category and the average number of trauma exposures are presented in Table 1.

Table 1.

Trauma Exposure Level and Comparison by Gender.

		Percent of Youth Exposed
	Trauma Event	Total	Male	Female	χ²
1	Serious accident, fire, or explosion	24.3	26.6	19.2	1.74
2	Natural disaster: flood, landslide, earthquake, typhoon	27.8	41.4	15.1	12.32***
3	Violence by family, relative, or acquaintance	33.3	37.1	28.8	1.14
4	Violence by strangers	16.7	22.9	11.0	3.62*
5	Sexual assault by family, relative, or acquaintance	4.9	8.6	1.4	3.98*
6	Sexual assault by strangers	4.2	4.3	2.7	0.25
7	Sexual relationship before 18 with one 5 years or more older	3.5	4.3	1.4	1.17
8	Incarceration (imprisonment, being taken hostage, abduction)	24.3	27.1	20.5	0.86
9	Torture	9.7	15.7	4.1	5.49**
10	Having a life threatening serious illness	23.6	28.6	19.2	1.74
11	Witnessing traumatic incident involving family member (death, arrest, etc.)	39.6	42.9	37.0	0.51
12	Hearing about traumatic incident involving family members.	40.3	40.0	41.1	0.01
Average number of trauma exposure = 2.58

p < .05. **p < .01. ***p < .000.

Table 2 presents bivariate analyses of the major variables by gender. There is no significant difference between male and female respondents even though, in general, women show higher prevalence in PTSD and depression (Kessler et al., 1995). The findings may be explained by a significantly greater exposure of male respondents to both interpersonal and accidental trauma. In all, 64.6% of respondents indicated mild condition of PTSD (PDS scores: 1-10), followed by 24.3% of moderate (scores: 11-20), 9.0% of moderate to severe (scores: 21-35), and 2.1% of severe condition (scores: 36 and higher; McCarthy, 2008). The prevalence is similar to that of South Korean youth (Ahn, 2005). A partial explanation for the result is the tendency of North Korean youth to underreport negative experiences. However, the finding suggests future exploration into whether there is some protective mechanism that ameliorates the impact of trauma exposure and adversities on the mental health of North Korean youth.

Table 2.

Comparison of Major Variables by Gender.

Variables	Gender	M	SD	t Test
Trauma
Total	M	3.10	2.63	2.64**
Total	F	2.04	2.12	2.64**
Interpersonal	M	1.62	1.71	2.16**
Interpersonal	F	1.06	1.36	2.16**
Accidental	M	1.47	1.29	2.52**
Accidental	F	.97	1.06	2.52**
PTSD
Simple	M	9.24	9.18	−0.52
Simple	F	10.04	9.18	−0.52
Complex	M	2.48	3.22	−0.39
Complex	F	2.69	3.24	−0.39
HSCL-37
Depression	M	12.51	9.89	0.67
Depression	F	11.53	7.50	0.67
Anxiety	M	8.37	6.70	0.29
Anxiety	F	8.05	5.94	0.29
Behavioral disturbance	M	5.27	5.41	1.97*
Behavioral disturbance	F	3.63	4.52	1.97*

Note. PTSD = posttraumatic stress disorder; HSCL = Hopkins Symptoms Check List.

Table 3 presents descriptive statistics and correlations for all variables. All correlation coefficients between the variables were in the expected direction and reached significant levels. As expected, trauma exposure demonstrated positive associations with PTSD and other mental health conditions such as depression, anxiety, and behavioral disturbance. PTSD subconstructs showed stronger associations with other mental health conditions than with trauma exposure. The above findings provided preliminary evidence for the hypothesized relationships among the variables and allowed for further analyses to examine the hypothesized mediation model.

Table 3.

Correlations Coefficients for Major Variables (n = 144).

	TI	TA	SP	CP	AN	DE	BE
TI	1
TA	.53**	1
SP	.27**	.27**	1
CP	.23**	.24**	.86**	1
AN	.30**	.23**	.64**	.66**	1
DE	.34**	.26**	.66**	.66**	.88**	1
BE	.35**	.29**	.66**	.63**	.69**	.69***	1
M	1.31	1.22	9.58	2.57	8.2	11.9	4.42
SD	1.57	1.20	9.16	3.2	6.3	8.72	5.0

Note. TI = interpersonal trauma; TA = noninterpersonal trauma; SP = simple PTSD; CP = complex PTSD; AN = anxiety; DE = depression; BE = behavioral disturbance; PTSD = posttraumatic stress disorder.

p < .05. **p < .01. ***p < .000.

Measurement Model

Confirmatory factor analysis was used to determine whether the measurement model fits the sample data adequately. The indices generally indicate good fit: χ²(144, 11) = 21.146, p = .032, CFI = .98, IFI = .98, Tucker–Lewis Index (TLI) = .97, RMSEA = .080. Standardized factor loadings ranged from .75 to .94 and were all significant at the p < .001 level. As the measurement model showed an adequate fit, the analysis proceeded to structural model analysis.

Structural Model

The structural model was analyzed to test the path relations among variables using the maximum likelihood estimation. The results of SEM of the proposed research model are as follows: χ²(144, 10) = 20.575, p = .024, CFI = .98, IFI = .98, TLI = .96, RMSEA = .086. In SEM, a cutoff value close to .95 for CFI, IFI, and TLI and a cutoff value close to .06 for RMSEA (Hu & Bentler, 1999) or .08 for RMSEA (K. Kim, 2010) are needed to support a conclusion of a relatively good fit between the hypothesized model and the observed data. However, TLI and RMSEA tend to overreject true-population models at small sample size and are hence less preferable when sample size is small (Hu & Bentler, 1999). Therefore, it is safe to conclude that this research model yielded a satisfactory fit based on high values of CFI, IFI, and TLI indexes, even though the RMSEA value did not reach the cutoff values suggested for a good fit.

In regard to relationships between predictive and outcome variables, both interpersonal trauma and noninterpersonal trauma exposures showed a weak link with comorbid mental health conditions. Interpersonal trauma, however, had a statistically significant relationship with PTSD, while the relationship between noninterpersonal trauma and PTSD did not reach statistical significance. PTSD showed a very strong relationship with comorbid mental health conditions. The SEM model with path coefficients is presented in Figure 1 for visual convenience. Total, direct, and indirect effects of exogenous variables on comorbid mental health conditions are presented in Table 4.

Table 4.

Direct, Indirect, and Total Effects of Variables on Mental Health Outcome.

	Noninterpersonal Trauma	Interpersonal Trauma	PTSD
Direct effect	.001	.131	.727
Indirect effect	.115	.157	.000
Total effect	.116	.289	.727

Note. PTSD = posttraumatic stress disorder.

To establish the mediation effect of PTSD in this model, the Sobel test was conducted (Baron & Kenny, 1986). The results showed that the mediation effect of PTSD between noninterpersonal trauma and comorbid mental health conditions was not statistically significant at p = .1. But the mediation effect of PTSD between interpersonal trauma and mental health was significant at p = .03 level, confirming a partial mediation effect of PTSD between interpersonal trauma exposure and comorbid mental health conditions.

Discussion

The present study investigated the relationships between trauma exposure of North Korean refugee youth, PTSD, and comorbid mental health conditions with a particular interest in the mediation effect of PTSD between trauma exposure and comorbid mental health conditions. The trauma North Korean refugee youth were exposed to was also divided into interpersonal trauma and noninterpersonal trauma to investigate their differential effects on mental health. PTSD was measured with a combination of simple PTSD and complex PTSD to capture the complex clinical pictures of many North Korean refugee youth due to trauma exposure that affected developmental processes and multiple aspects of their lives.

The study results are consistent with the previous studies in that these youth had been exposed to trauma events that posed serious threats to their physical and emotional integrity. Direct and indirect exposure to traumatic events such as death, torture, and arrest of family members was most common, followed by violence inflicted by intimate adults. Many empirical studies have linked acute trauma and enduring adversities to PTSD and other psychiatric pathologies (Heim & Nemeroff, 2001; Kessler et al., 1995; Montgomery, 2008). The present study shows that trauma plays an important role in mental health, and PTSD in particular, of North Korean refugee youth. Interpersonal trauma exposure was found to contribute to PTSD, whereas noninterpersonal trauma did not have any significant relationship with PTSD. The findings are consistent with previous research indicating a closer association between interpersonal trauma and PTSD. Previous studies showed that direct victimization by those with whom the youth has an intimate relationship or trauma caused by human malice such as torture and incarceration have a greater impact on a victim than natural disaster or accidents (Dorahy et al., 2009; Ford et al., 2006; Gladstone et al., 2004).

On the contrary, neither interpersonal nor noninterpersonal trauma exerted any significant direct effects on comorbid mental health conditions, which was operationalized as a combination of depression, anxiety, and problematic behaviors. However, the effect of interpersonal trauma exposure was exerted on comorbid mental health through PTSD. The finding suggests that it is not the exposure to trauma per se that results in depression, anxiety, and behavioral disturbance, but rather the development of PTSD after trauma exposure that increases the risk of a more complex course of those mental health problems. Previous empirical studies are consistent with the current findings in that trauma exposure showed a direct effect on PTSD symptomatology, but PTSD functioned more as a mediating variable between trauma exposure and other mental health conditions such as depression, suicidal ideation, conduct disturbance, or personality disorder (Boscarino, 2004; Heim & Binder, 2012; Kerig, Ward, Vanderzee, & Moeddel, 2009; Mazza & Reynolds, 1999; Miller & Resick, 2007; Porche et al., 2011; Subica et al., 2012; Suliman et al., 2009; Wolfe & Mash, 2006). The present study shows the dynamic interrelationships among trauma exposure, PTSD, and comorbid mental health problems.

While previous studies tended to investigate the relationship between trauma and PTSD or trauma and other mental health conditions such as depression and anxiety piecemeal, the present study has made a unique contribution by identifying the interrelationships and the mechanisms of influence among trauma exposure, PTSD, and other mental health conditions. Furthermore, the present study has demonstrated the differential effects of trauma exposure by the nature of the trauma on psychopathologies and indicated priorities in assessment and treatment interventions.

The clinical implication of the present study is the urgent need to develop assessment and treatment protocols for traumatized North Korean refugee youth to alleviate their mental health burden. Treatment for underlying trauma is important as the findings indicate that unresolved trauma is associated with significant psychological consequences with potential for chronic course into adulthood. Particular attention should be paid to the youth with interpersonal trauma and ones with multiple exposures to trauma as their impact on the mental health functioning of the youth is indicated to be more significant. Diagnosis of PTSD is critical for early identification of youth who are at higher risk of a long-term pathological trajectory. Simple PTSD criteria alone may not be sufficient to identify symptom manifestation in youth who have been exposed to multiple traumas in earlier formative years. Complex PTSD criteria should be incorporated in assessment tools for better understanding of the impact of trauma exposure on developmental processes and corresponding treatment approach. When refugee youth indicate behavioral disturbance or difficulty in affect regulation, assessment of a history of trauma exposure and PTSD condition should be included for a comprehensive understanding of the etiology of their clinical condition, and appropriate and effective interventions for these comorbid conditions (van der Kolk et al., 2005)

There are risks of using psychiatric diagnosis such as PTSD to capture and address the impact of enduring adversities and traumatic events in the lives of North Korean youth. Their life experiences get reduced to a technical issue of medicalized condition in Western mental health approach. Frequent use of psychiatric diagnosis for depiction of posttrauma condition emphasizes victimhood of these youth rather than their being resilient survivors or potential for growth. Since the constructs of mental health are social products and pose potent influences on people in terms of their interpretation of life experiences in the past, self-concept in the current situation, and self-fulfilling prophecy for future, they should be used with a great caution lest natural reactions and recovery process be overpathologized (De Jong, Komproe, & Van Ommeren 2003; Summerfield, 2001).

This study suffered several limitations. Although the best efforts were made to recruit a representative sample, it was selective in that only those youth who were involved in organized programs were included as the respondent recruitment was conducted through various organizations working with North Korean refugee youth. Those who are not participating in any such services may be different from those who are receiving services. Another major study limitation was that all study data were self-reported, and the respondents might have underreported negative aspects of their life experiences (Kim, Cho, & Kim, 2009). As the analysis was based on cross-sectional data with a small sample size, caution should be taken in interpreting the causal relationships among the study variables. Numerous studies have shown that PTSD consistently co-occurs with other mental disorders and PTSD mediates between trauma exposure and comorbid mental disorders (D’Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012; van der Kolk et al., 2005). However, it should be noted that some employed a reverse order of assessing depression and anxiety, and then assessing PTSD (Tremblay, Pedersen, & Errazuriz, 2009).

One major obstacle in conducting research with minority groups is lack of survey instruments that have been validated for the population of the research interest. The present study suffers the same limitation as the scales used for this study have not been validated for this population and the cultural sensitivity of the scales could have affected the outcome of the study, even though every effort was taken to make the questionnaires and the survey procedure culturally sensitive and appropriate. The number of instruments used was kept to a minimum in consideration of the growing yet limited attention span of the refugee adolescents and the greater amount of time and effort taken by the respondents to complete the survey. The small sample size also restricts the number of variables to be included in the statistical analysis. Additional measures such as resettlement stress and trauma exposure in South Korea would have enhanced the comprehensiveness of the study in understanding mental health of North Korean refugee youth.

Future research in this field should focus on testing multidimensional and interactive models that investigate moderating factors such as the resettlement experience in South Korea, the role of support systems such as family, socioeconomic status and the youth’s internal resources such as coping styles. A longitudinal study will provide a definitive understanding of the causal relationships among the study variables and of the long-term impact of trauma exposure on the trajectories of trauma victims. The estimate of pathology among North Korean refugee youth is based on the early lives of the youth. In later life, many hidden symptoms may surface as long-term consequences of trauma exposure these youth endured are largely unknown.

In conclusion, trauma has the potential to interfere with the major developmental tasks of adolescence such as affect regulation, impulse control, the formation of intimate relationships, and achievement mastery in school and at work, which may lead to a chronic course of psychopathology. Early identification of trauma exposure and PTSD, and proactive intervention would help North Korean refugee youth, who are at high risk of mental health problems, successfully navigate through the developmental stages and smoothly adjust to their adulthood in a new host society.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by 2012 Dague University research grant.

Author Biography

Yeunhee J. Kim is an associate professor of Dept. of Social Welfare, Daegu University. Her research interests include mental health of minority groups, migration and cultural competence.

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