Adolescents’ perspectives on the psychological effects of natural disasters in China and Nepal

Abstract

Adolescents are disproportionately represented in nations vulnerable to humanitarian crises. The mental health effects of exposure to trauma are significant, but evidence concerning the experience of disaster-affected adolescents in Asia is limited. The current study aimed to investigate expressions of psychological distress and behavioral effects of exposure to natural disasters among adolescents in China and Nepal. Key informant interviews and focus group discussions were conducted with adolescents, caregivers, teachers and experts in disaster-affected districts of Yunnan Province, China (n = 79), and Kathmandu Valley, Nepal (n = 62). Open coding and thematic content analysis were employed to examine themes within the data. Indicators of distress were categorized in four domains that reflected expressions of anxiety and stress, mood difficulties, somatic complaints, and behavioral changes for adolescent disaster survivors. Differential reports of psychological concerns by gender were evident in Nepal but not China. Post-traumatic growth and strengthened connections between adolescents and their families were described in both settings. The findings complement similar reports from disaster-affected populations globally that have highlighted cross-cultural elements manifest in adolescents’ descriptions of distress. Sustainable mental health services that are sensitive to adolescents’ experiences of trauma and their unique capabilities will be a necessary component of long-term rehabilitation following disasters.

Keywords

adolescent health Asia global mental health natural disasters trauma

The Asia Pacific region experiences more disasters than any other area (Guha-Sapir, Hoyois, & Below, 2016). Recently, a series of severe natural disasters in China and Nepal have caused widespread death and destruction, with lingering effects for physical and mental health (Chan, 2008; Guha-Sapir et al., 2016; Kane et al., 2018). The risk of mental health difficulties for children and adolescents is concerning, given the potential for untreated psychological distress to impact future education, relationships and wellbeing (Patel, Flisher, Hetrick, & McGorry, 2007; Patton et al., 2016). Although the countries that are most vulnerable to disasters, violence and poverty often have large youth populations (UNICEF, 2011), adolescent mental health is a relatively overlooked issue in many parts of Asia (Fazel, Patel, Thomas, & Tol, 2014; Patel et al., 2007). Accordingly, targeted mental health programming for disaster-affected youth is severely lacking (Chen et al., 2014).

Recent calls for adolescent-responsive mental health care have highlighted the critical role of social determinants (Patton et al., 2016; Viner et al., 2012), but less attention has been paid to specific expressions of distress among young people. Ethnographic research conducted in Nepal prior to the 2015 earthquakes indicated that psychological trauma was understood in a multifaceted framework without a single linguistic representation (Kohrt & Harper, 2008; Kohrt & Hruschka, 2010). While trauma and fear have been described in terms similar to the diagnostic criteria for post-traumatic stress disorder (Kohrt et al., 2011), the concepts are not perfectly aligned, and Nepali perspectives incorporate a greater focus on gender, social status and heart-mind disturbance (Kohrt & Hruschka, 2010; Pettigrew & Adhikari, 2009). Traditional perceptions related more closely to a mind-body-spirit connection (Brenman, Luitel, Mall, & Jordans, 2014; Kohrt & Hruschka, 2010) and emphasized the importance of interpersonal relationships – particularly the role of social identity and potential impact of shame, social exclusion, and loss in shaping expressions of trauma-related distress (Muldoon et al., 2017; Pettigrew & Adhikari, 2009). Some ethnographic studies have noted a greater emphasis on the role of karma and self-blame in psychological trauma, which was surmised to exacerbate stigma, and reduce treatment-seeking (Brenman et al., 2014; Lauber & Rössler, 2007). However, few studies have examined the perceptions of adolescents affected by trauma in Nepal.

In China, a holistic systems approach with minimal distinction between mind and body has traditionally been employed to describe mental health (Liu, Liu, Zhang, Chen, & Hannak, 2014). During the 20th century, personal or interpersonal distress was reported to be more commonly expressed as somatic complaints or neurasthenia (Kleinman, 1982; Ryder et al., 2008). Some accounts suggest that the depiction of physical complaints rather than psychological symptoms may have represented safer expressions of distress in a context of exceptional socio-political upheaval (Kleinman & Kleinman, 1991; Lee, 2011). Recent examinations of post-traumatic stress response have highlighted the need to include indicators of somatization in post-traumatic stress disorder (PTSD) assessment (Liu et al., 2014). Yet the view that presentations of somatization are more common in Asian settings has been strongly critiqued (Kawanishi, 1992; Kohrt, 2005), and multiple studies have demonstrated valid models of PTSD that include hyperarousal, intrusive thoughts and memories, dysphoria and avoidance among disaster-affected populations in China (Chen, Zhang, Liu, Liu, & Dyregrov, 2012; Jin, Xu, & Liu, 2014; Liu et al., 2014; Zhang, Shi, Wang, & Liu, 2011). Expressions of trauma response may be further differentiated by ethnic background. A qualitative study of adults affected by the Sichuan earthquake from Han and Qiang backgrounds suggested that Han people were more prone to concealing their emotions and behaviors than the more direct expressions offered by members of the Qiang population (Chen, Zhang, Liu, Zhang, & Wu, 2011). Given the cultural heterogeneity of the Asia Pacific region and limited evidence to guide the conceptualization of adolescent mental health, there is an imperative to develop an empirically based understanding of adolescents’ psychosocial response to disasters in both nations, to inform culturally appropriate practices and policy. Documentation of the range of expressions of distress used in each setting will guide clinical practice for adolescents affected by traumatic events.

Study Settings

The current study focused on the experience of adolescents in disaster-affected areas of China and Nepal. Although culturally distinct, China and Nepal share a number of features that were of interest for the current study: the recent occurrence of severe natural disasters, a large adolescent population, and little evidence to inform mental health service provision for young people affected by trauma.

China is affected by more natural disasters than any other nation (Guha-Sapir, Hoyois, & Below, 2015). Our study was located in Yunnan Province, in China’s Southwest, which borders Laos, Burma and Vietnam. Yunnan’s population of 47 million is diverse (National Bureau of Statistics China, 2016), and the province is home to 25 of China’s 55 ethnic minority groups. Yunnan Province is frequently hit by natural hazards, including earthquakes, floods, landslides and a four-year drought that has impacted urban and rural water supplies (Zhou & Yang, 2016). The 2014 Ludian Earthquake killed 731 people and 1.1 million were affected (Guha-Sapir et al., 2015).

Nepal experienced a series of catastrophic earthquakes and aftershocks in 2015. A low-income nation with a recent history of political and economic instability, the nation was poorly prepared to respond to the earthquakes. An estimated 8,831 people died, 22,000 were injured and hundreds of thousands displaced from their homes (Guha-Sapir et al., 2016). One thousand health facilities were destroyed and in some areas, entire villages were decimated (Adhikari, Mishra, & Raut, 2016).

Study Aims

Our aim was to investigate the range of expressions of psychological distress and any behavioral changes arising from exposure to natural disasters among adolescents in China and Nepal. First, we explored the depictions and patterns of psychological and behavioral change to illuminate adolescents’ experiences in the aftermath of disasters. Second, reports of protective factors and post-traumatic growth were examined to determine means for supporting adolescents in future emergencies.

Methods

Study sites

The study sites were chosen through collaborative consultation with our study partners (Kunming Medical University in China and the Centre for Victims of Torture in Nepal), with a focus on communities that had experienced recent exposure to major disasters. Data were collected between November 2015 and February 2016. In China, key informant interviews and focus group discussions were conducted in three regions of Yunnan Province: 1) Kunming, the capital city of Yunnan, where many NGOs and government offices are based; 2) Longtoushan in Ludian County, the epicenter of the 2014 Ludian earthquake; and 3) Changning County in the southwest of Yunnan where an earthquake struck in 2015. In Nepal, data were collected in three districts of Kathmandu Valley, each severely affected by the 2015 earthquakes: 1) Kathmandu, the capital city of Nepal; 2) Bhaktapur, and 3) Lalitpur.

Sampling and participants

Participants were identified by purposive recruitment to portray a diverse range of views from stakeholders who were knowledgeable about the effects of disasters on young people. The sample comprised adolescents, their parents and caregivers, schoolteachers, community leaders, disaster response experts and child health professionals. We sought to recruit both male and female participants across a large age range, with varying socioeconomic status, caste (where relevant) and educational backgrounds. The study focused on adolescents aged 13 to 19. The investigators in each country identified a list of potential participants who were knowledgeable about adolescent mental health and disaster response. Adolescent students who were willing to discuss their experiences were identified by their teachers and nominated for participation. These students were approached by the research team and invited to participate. Snowball sampling was employed to broaden the range of stakeholders. Prior to data collection, the study investigators estimated a sample size that would capture a broad range of perspectives, and recruitment ceased when saturation of the results was achieved. The proportion of adolescents, caregivers and experts varied in each country in line with the local investigators’ networks and the snowball sampling strategy. All of the participants had been personally affected by disasters or worked in disaster response. The final sample comprised 34 adolescents and 45 adults in China, and 35 adolescents and 27 adults in Nepal. The participants’ demographic details are outlined in Table 1.
Table 1.
Demographic characteristics for participants in China and Nepal.

Total Adolescent Parent Experts by Profession

Child and Youth Disaster Response Mental Health Teachers Police & Community Leaders

China

Total 79 34 15 4 4 2 17 3

Female 37 (46.8%) 18 (52.9%) 9 (60.0%) 2 (50%) 2 (50%) 1 (50%) 4 (23.5%) 1 (33.3%)

Male 42 (53.2%) 16 (47.1%) 6 (40.0%) 2 (50%) 2 (50%) 1 (50%) 13 (76.5%) 2 (66.7%)

Age

Mean (S.D.) 28.6 (13.8) 15.4 (1.7) 39.8 (4.8) 43.5 (10.1) 48.8 (12.7) 40.0 (14.1) 31.8 (9.1) 49.7 (7.6)

Range 13–66 13–18 35–52 33–57 37–66 30–50 22–50 43–58

Nepal

Total 62 35 11 3 2 2 3 6

Female 32 (51.6%) 17 (48.6%) 9 (81.8%) 2 (66.7%) 1 (50%) 0 (0%) 2 (66.7%) 1 (17%)

Male 30 (48.4%) 18 (51.4%) 2 (18.2%) 1 (33.3%) 1 (50%) 2 (100%) 1 (33.3%) 5 (83%)

Age

Mean (S.D.) 27.4 (15.3) 15.3 (1.8) 43.6 (8.0) 45.0 (9.8) 29.0 (8.5) 39.5 (9.2) 47.0 (10.2) 44.8 (12.1)

Range 13–58 13–19 34–57 37–56 23–35 33–46 38–58 28–57

Data collection

Data were collected via in-depth semi-structured interviews and focus group discussions. The interviews were designed to elicit a broad range of expressions of distress, resilience and behavioral change, captured in the participants’ own words. Focus group discussions facilitated a range of perspectives via debate and consensus formation; while key informant interviews enabled a deeper examination of psychological and behavioral indicators. In total, 23 key informant interviews and 8 focus group discussions were conducted in China, and 20 key informant interviews and 5 focus group discussions in Nepal.

The research team developed semi-structured interview guides in consultation with local collaborators, who comprised medical and health professionals and university academics working in adolescent health. The interview guides covered topics related to the impacts of disasters, expressions of distress arising from trauma exposure, and the specific vulnerabilities and strengths of disaster-affected adolescents. Questions were open-ended and non-directional, asking about feelings and behaviors, difficulties faced after disasters, and coping. Questions included ‘What, if anything, has been challenging for adolescents since the disaster?’ and ‘Do some adolescents cope very well despite these problems? If so, what helps them to cope with these difficulties?’ Participants were invited to describe the feelings and behaviors raised at their own pace and in their own terms. Interviews and focus group sessions typically lasted between one and two hours.

In China, two authors (FJ, XG) conducted the interviews and facilitated the focus group discussions in either Mandarin or a local dialect. The interviewers were male and female public health experts from China, one of whom worked for a local university, the other worked for an international university. Both have had extensive experience in conducting qualitative interviews and participatory research with adolescents and adults. The interviews and focus groups were recorded and then transcribed verbatim. Some of the participants preferred not to have their interviews recorded, in which case, detailed notes in Mandarin were taken. In Nepal, most interviews and focus group discussions were conducted in Nepali and recorded, led by an author (LG) and two research assistants. The three Nepali interviewers were female, and held Bachelor’s degrees in health sciences, with one completing her Master of Clinical Psychology (LG). One was from a Muslim community dressed in modern attire, and two from high caste, middle-class Hindu backgrounds. Two key informant interviews were conducted in English, based on participants’ choice of language, led by a Nepali researcher, and attended by two American research assistants who worked on the project and were visiting Nepal to assist with the study. Research personnel received training in research ethics, interview techniques, and the study aims. All of the recordings were transcribed and translated into English. The interview transcriptions reproduced all spoken words and sounds made by participants and the interviewers including laughs, pauses, silences, and hesitations. Specific terms that did not translate well to English were transcribed in the local language and meanings were explored among the study team.

Ethics

Ethics approvals for the study were granted by the Harvard T.H. Chan School of Public Health Institutional Review Board (IRB15-3009), University of Western Australia Human Research Ethics Committee (RA/4/1/7858), Kunming Medical University Medical Ethics Committee, Nepal Health Research Council (267/2015), and Curtin University Human Research Ethics Committee (HRE2017-0692). Written informed consent was obtained from all adult participants, and assent from participants below the age of 18 together with consent from their adult caregivers. Compensation for participants’ time and effort was provided in the form of a small household item or stationery (approximately US$3-5 in value).

Data analysis

Thematic content analysis was employed as the means of identifying key themes within the data (Braun & Clarke, 2006). The analyses proceeded through five key phases as prescribed by Braun and Clarke (2006): familiarization with the data, generating initial codes, searching for themes, reviewing themes, and defining and naming themes. An inductive approach was taken so that coding was guided by the research questions, but ultimately determined by themes identified within the data. Expressions of psychological distress were defined as thoughts, feelings and behavioral changes related to or emerging following exposure to disasters. The second and third authors independently analyzed and coded the data, and cross-checked the coding to ensure consistency. The first author cross-coded a random subsample of interviews to further ensure consistency of the thematic framework. The coding occurred simultaneously across both datasets and with the same codebook, and a single thematic framework emerged. However, to ensure cultural specificity, phenomena that arose in one country might be coded (but remain absent) in the other, and this would be noted in the results.

The research team engaged in frequent discussion of the coding and thematic structures throughout the analytic process, to determine the validity of codes, resolve queries related to the coding structure and discuss the fit of Chinese and Nepali terms to English language and concepts. Any disagreements in the coding structure were discussed by the analysis team, and poor agreement provided grounds for refining the codebook. For example, the definition of risky or disruptive behaviors was discussed at length to ensure that behaviors within the normal continuum of adolescent conduct were not included in the coding. Patterns of meaning were elicited throughout the data collection phase and formal analysis. At stage 5 (Defining Themes) comparisons between the emerging thematic framework and diagnostic criteria for psychological disorders (American Psychiatric Association, 2013) were explored by health professionals and psychological researchers on the team. Additional members of the research team provided input on the thematic structure and interpretation of data at multiple time points. The exact terms used by participants to describe issues related to thoughts, feelings and behaviors have been listed in Mandarin or Nepali in the results. However, many of these terms have multiple meanings when translated into English, and thus should not be interpreted without consideration of the specific context.

Results

Psychological concerns among adolescents affected by disasters

Natural disasters created a broad range of risks for adolescent mental health in the study districts. Issues related to thoughts, feelings and behaviors following exposure to disasters were raised in all key informant interviews (KIs) and focus group discussions (FGDs) conducted with Nepali participants, and in 16 of 23 KIs and 4 of 8 FGDs with Chinese participants. Only psychological or behavioral issues described in the context of disaster exposure were included in the analysis. The extent of harm was more evident in the Nepali sites than Chinese sites, likely due to the scale and recency of the Nepali earthquakes, and this may have led to a stronger emphasis on reports of psychological distress in the Nepali interviews.

Psychological difficulties were described as being caused or exacerbated by exposure to trauma and loss. Despite the use of open questions to capture a broad range of expressions of distress, psychological difficulties were described in both countries in terms that reflected anxiety and post-traumatic stress, mood disturbance, somatic complaints, and behavioral difficulties. Not all psychological concerns indicated symptomatology. Rather, expressions of distress reflected a continuum: from normal reactions to acute trauma and loss, through to long-term concerns that hampered aspects of adolescents’ daily functioning. In some cases, emotional and behavioral changes appeared to be a response to ongoing post-disaster adversity.

Traditional expressions of distress or spiritual manifestations of psychological phenomena were rarely mentioned by adolescents in our sample, but were sometimes depicted in reports from adults in Nepal. A number of Nepali participants noted that females appeared to be more affected by psychological distress than males; whereas only one participant in China noted a gender difference, with females considered to be more severely affected. Participants in both settings described experiences of post-traumatic growth and strengthening interpersonal connections following exposure to disasters.

Fear, Anxiety and Stress

About one week ago, I took my daughter to eat out. The road was under repair where we were eating. That machine was pressing the road. Her first reaction, after she sat down and felt the movement, she quickly got up and was ready to run. I asked her what happened, and she said “Mom, it is the earthquake again”. I told her, no, it was just [the machine] rolling the road. She was mentally like this … It has been more than one month … and she still has this mental response. Her first reaction was to run. (Female parent, China)
The most common cluster of expressions of distress identified within the data reflected symptoms of anxiety, fear and stress. Reports of anxiety, initiated or exacerbated by disaster, arose in all interviews with participants from Nepal. Interviewees frequently described a fear of earthquakes recurring (bhukampa pheri aaucha bhanne dar), panic or fright (attine), and anxiety (chinta) associated with related triggers such as loud sounds, unexpected movements, and weather-related cues. Fear and anxiety were reported to extend to sights that adolescents associated with earthquakes such as schools, damaged roads and houses, and appeared to be compounded by the unsafe nature of many of these structures post-earthquake. Related to these concerns was the reported occurrence of nightmares (naramro Sapana dekhne, darlagdo Sapana dekhne), and an exaggerated startle response (ekdam jhaskine), with many interviewees noting a sense of hyperawareness of their surroundings and constantly anticipating aftershocks. A number of Nepali interviewees also disclosed fear and anxiety associated with talking about the earthquakes (bhukampa ko barema sochda ni dar lagcha), intrusive memories and thoughts regarding the earthquake (bina karan tarsauna auune), and involuntary, uncontrollable rumination (aniyantrit bichar wa sochai airahancha). The respondents’ recollections were often emotive, with well-articulated descriptions of anxiety and fear that continued to affect many adolescents in the months following trauma exposure.
They say the sound of people shouting when the houses collapsed haunts them … I have not seen but my friends say they are afraid to go anywhere in the dark, the sound of people shouting is heard. (Female adolescent, 15, Nepal)
Chinese participants echoed these themes, with anxiety-related expressions of distress discussed in 12 of 23 KIs and 4 of 8 FGDs. They noted a common experience of fear (hài pà, koˇng jù, bèi xià dào, daˇn chàn xīn jīng), nervousness (jiˇn zhāng), anxiety (jiāo lù) and hypervigilance (yī yoˇu dòng jìng jiù hài pà) following disasters, and apprehension about places that were associated with earthquakes (such as schools). In both countries generalized worries such as fear of the dark, of being alone, and of going to school frequently occurred for adolescent disaster survivors. Participants noted agitation, confusion and a propensity towards worry. One mother stated,
[After the earthquake] My kid was afraid to sleep alone. He slept with us for a week. Although he was already 15 years old, he was afraid to sleep alone. He told us so. (Female parent, 38, China)
Exacerbating tensions related to the earthquakes, Nepali participants reported ongoing concerns related to their future (bhabisyako chinta), worries regarding their physical safety and integrity post-earthquake, fear of death (marinchha ki bhanne dar), daily hardships (tatkalin chaso) and existential concerns about their lives and what it meant to be alive (asthitwa sambandhi chaso). These reports suggest an experience of stress that was conceptually distinct from, but closely related to, anxiety following exposure to disasters.
The stress we felt after the earthquake is stress about whether it will come again, stress about whether or not we will live. (Male adolescent, 13–15 years, Nepal)
Nepali adolescents also reported anxious ruminations related to the impact that the disaster may have on their future prospects and livelihoods. Disruptions to their opportunities for education, work, and training, as well as new or increased responsibilities within their family were key concerns, raised by most participants. Worry and rumination associated with personal safety and integrity were described in connection with daily stressors including inadequate living conditions, unsafe buildings, poor sanitation and hygiene, and risk of violence and harassment. In some cases social connections, expectations, and conflicts raised challenges for adolescents experiencing stress; although one adult participant in Nepal described a social healing process for trauma, whereby repeated questions from family and friends to assess one’s wellbeing lessened the trajectory of trauma. Existential and physical integrity concerns were not widely observed in the China data.

Mood Difficulties

The boy watched his little sister die in his arms … he was crushed and injured, and he became aphasic, couldn't speak any more. He didn't eat or talk, and the total reaction was basically gone. [After I spoke with him:] he just cried, and felt, actually he felt guilty, he felt sorry for his sister. Then when he was crying, I hugged him. He just kept crying, and his whole body was shaking. (Female psychologist, 50, China)
Mood disturbance was a commonly reported experience for adolescent survivors in both countries (raised in 15 of 21 KIs and 3 of 5 FGDs in Nepal, and 9 of 23 KIs and 0 FGDs in China). The respondents identified feelings of helplessness, low mood, and anger, as well as rumination, social withdrawal, and suicidality. Among Nepali respondents, mood difficulties were described as ‘mood nahunu’ (low mood or absence of feeling), ‘sabai bata alaginu’ (being away from all), and ‘dikka lagnu’ (frustration), whereas in China the terms ‘mèn mèn bú lè’ (low mood, sullen), ‘yù yù guˇa huān’ (unhappy), ‘xīn liˇ yoˇu fù dān’ (burden on the mind) and ‘xīn liˇ yīn yiˇng’ (shadow on the mind) were used. The symptoms appeared more pronounced in severity in the Nepal data. However interviewees in both countries reported indicators such as crying, frustration and irritation, lack of motivation, a sense of being alone, and sadness. Interviewees also identified a sense of fatalism among adolescents, connected to a fear of recurrence of disaster and negative cognitions regarding death and the future. Emotional numbing (gaˇn qíng dàn mò) was described in relation to reduced mood, social withdrawal and a loss of interest in activities. In both countries, issues related to adolescents’ mood were more often observed by adult participants.

Suicide risk (atmahatya ko jokhim) was repeatedly reported as an issue affecting adolescents in Nepal and mentioned by one health expert in China. It was suggested by both adolescent and adult participants in Nepal that the rate of suicide had increased since the earthquake, creating a significant cause for concern among participants. Suicide risk was more often reported as an issue affecting young males.
The suicide rate is very high in [district] … every month one or two male adolescents are committing suicide. It is a matter of great worry for me. (Male health professional, 33, Nepal)

Somatic Issues

There are a lot of physical symptoms, headache, stomach ache, a lot of fainting. (Male psychiatrist, 46, Nepal)
A smaller number of participants (9 of 21 KIs and 3 of 5 FGDs in Nepal, and 4 of 23 KIs and 0 FGDs in China) described associations between physical and mental health complaints. Across both settings descriptions of somatic symptoms included insomnia, disturbed sleep, and lack of appetite. In Nepal, additional somatic complaints included stomach-aches, pains and vomiting, headaches, tremors, sweating, difficulty breathing and hypersomnia. Girls were sometimes described as being at greater risk of psychological problems due to their physical weakness in comparison to boys.
Talking about fear, girls are more afraid than boys … girls’ heart is soft, so maybe due to that. (Female government official, 37, Nepal)
Several Nepali health professionals with expertise in psychosocial assessment also noted the presence of conversion disorder or what was sometimes termed possession episodes, described as being afflicted by spirits time and again (bela belama lagu lagne). Several professionals stated that they had observed episodes of fainting, dizziness, unusual physical movements, and nonsensical speech for which there was no obvious medical aetiology among female adolescents in schools following the earthquake. These experts noted the occurrence of these symptoms in groups, where adolescents would exhibit behaviors en masse such as fainting, spitting, scratching, biting, appearing possessed, and making bizarre physical movements.
Also you see physical symptoms, in Nepal what we call conversion disorders, which include fainting attacks, dizziness, falling down, and different kinds of physical attacks … Culturally it is what they call … possession episodes. There was a whole school with mass hysteria. (Male psychiatrist, 46, Nepal)
All but one of the participants who reported observing conversion disorder stated that it occurred in females, with the other participant not specifying gender differences. One Nepali participant described a broken connection between the earth and society (prithvi ra samaj) following the earthquake, resulting in distress:
The belief of people towards the earth has been broken … about how to search for ‘feeling’ in life. (Male counselor, 33, Nepal)

Behavioral Changes

After the earthquake, problems like smoking marijuana, consuming soft drugs are at one side, on the other side roaming in isolated places … at nights they watched something even in front of here, I don't exactly know what, on their mobile phones. Due to that, I feel, they have gone on the wrong path. (Male social worker, 54, Nepal)
Behavioral changes arising from exposure to disasters were evident in both settings (raised in 14 of 21 KIs and 3 of 5 FGDs in Nepal, and 4 of 23 KIs and 0 FGDs in China). In China, parents and experts described alterations that included disruptive behaviors, aggression (gōng jī xìng), crying (kū), screaming (haˇn), social withdrawal, selective mutism (shī yuˇ) and reluctance to communicate (bú yuàn gēn bíe rén jiāo liú).

To a greater degree, adolescents’ engagement in a number of unsafe, antisocial, and/or disruptive behaviors was observed in Nepal following the earthquakes. The interviewees noted an increase in young males’ consumption of alcohol, tobacco, and marijuana. Several of the participants informed the researchers that this behavior appeared to occur in the context of adolescents grouping together unaccompanied at night and engaging in other disruptive behaviors (kulat janya byabahar), and some noted that boys were more likely to engage in substance use and aggressive behaviors than girls. Respondents discussed criminality, with some noting an increase in crime, violence and thefts perpetrated by mainly male adolescents, and the formation of gangs. Inappropriate touching, sexual harassment, and rapes were both experienced and perpetrated by adolescents, with females frequently described as victims of physical and sexual abuse.

More generally, participants in Nepal noted an increase in a subset of adolescents displaying disrespectful behaviors (apamanjanak byabahar) towards elders and towards their peers, in the form of harassing behaviors, bullying, prank phone calls, frightening others by making loud noises and simulating earthquake triggers, stubbornness, disobeying orders, and risk-taking behaviors. Several of the adults interviewed expressed concern regarding the viewing of vulgar and inappropriate materials on the internet via mobile phones, and questioned the influence this may exert on adolescent behavior more broadly. One adolescent male described the roles of peer pressure and the media in encouraging risky behaviors: ‘things from abroad are influencing them the most, they want to do the same’.

Participants observed an increase in premature sexual activity and marriage between adolescents, which some hypothesized may be related to the previously mentioned sense of fatalism, poverty or insecurity with regard to their future. Females were described as being particularly likely to marry early or engage in premature sexual activity, which was frequently argued to in part stem from economic stressors. In China, risky behaviors were described by parents, teachers and experts but not in the context of disaster exposure.

Post-traumatic Growth

And next is, being positive, feeling more love towards the family. During this time after the earthquake, it is more. After the earthquake, we realized the importance of our family … If I only run away and can't rescue my parents, what will happen to them? So the responsibilities towards them are more. (Female adolescent, 15–19 years old, Nepal)
Post-traumatic growth, conceptualized as positive self-expressions, interactions or community minded thoughts, attitudes, and behaviors initiated or exacerbated by traumatic events (Calhoun & Tedeschi, 2014), was frequently associated with concomitant positive psychosocial outcomes for adolescents. Across all settings, adolescents mentioned resilience and post-traumatic growth more frequently than adults, although many parents, teachers and experts noted positive changes. The nature of post-traumatic growth to emerge from the China data was centered around greater willingness to help others, with interviewees identifying that adolescents engaged in learning about disaster response and associated skills with the intention of disseminating this information to other more vulnerable members of their community, such as their grandparents or to younger children. It was also noted that adolescents were more engaged in disaster preparedness efforts after experiencing an earthquake.
I can guide elder people at home. My grandpa has received a few years of education. My grandma does not know anything [about preparedness]. I have the knowledge of how to escape from an earthquake, and I can teach them. (Female adolescent, 15, China)
Nepali interviewees similarly identified that some adolescents felt an increased sense of social responsibility (samajik uttardaitwa badeko mahasus hunu), altruism (sewamulak), and community mindedness (samudayik soch) post-disaster. Post-traumatic growth was not ascribed to a particular gender, but was more commonly reported as occurring in older adolescents. A number of respondents noted that adolescents engaged in learning about disaster response efforts and disseminated that information to others in their community. Some provided care and support for more vulnerable members of their community such as younger children and their peers.
The older adolescents think and interact with elders about how to solve the problems, be in peace, be patient. (Male police officer, 46, Nepal)
Several of the respondents noted that some adolescents felt a greater sense of community spirit and unity, with one respondent noting that this community spirit transcended social mores associated with the existing caste system in Nepal. In this context, many reported that adolescents were integral participants in the disaster response and recovery efforts, with groups of adolescents independently mobilizing to collect and distribute resources, consulting with elders in the community, assisting with education and security efforts in camps, fundraising, and working with NGOs.
The feeling that they should take care of others and social responsibility, after the earthquake they realized such feelings. (Male community leader, 54, Nepal)
In both countries, parental support was reported to be a positive protective factor for adolescent mental health. In some cases, the experience improved family cohesion where adolescents actively sought more support from parents after disasters, and came to value their families more. At a broader level, a number of respondents identified a sense of coping, self-efficacy, and mastery post-disaster, described as ‘samana’, ‘aatmasakti’ and ‘dakskyata’ (respectively) in Nepal. Several of the adolescent interviewees expressed sentiments regarding a desire to overcome adversity, hopefulness for increased equity and improvements in living situations for all citizens irrespective of economic or social background, a desire to become leaders in their community, and a sense of preparedness and efficacy should future disasters occur. These sentiments were augmented by adult interviewees who commented on the resilience, positivity, confidence, and capability of a large number of adolescents they had come into contact with post-disaster.

Discussion

Adolescents exposed to natural disasters in China and Nepal were reported to be at heightened risk of psychological distress and behavioral changes related to their experience of trauma, which reflects evidence for adolescents in disaster-affected settings globally (Cobham & Newnham, 2018; Wang, Chan, & Ho, 2013). In their own terms, many adolescents described experiencing anxiety and worry, mood difficulties, somatic complaints, and behavioral changes in the aftermath of severe disasters. Behavioral changes were noted in both settings, although disruptive and risky behaviors in the context of disaster were reported only among Nepali adolescents, with potential for resulting risks to the safety and security of adolescent females. Suicide risk was more frequently described for Nepali males, supplementing recent reports of high suicide risk for females in the region (Cousins, 2016). The magnitude of the Nepali earthquakes was associated with a growing sense of existential worry among adolescents who were forced to examine their future in light of new and worsened hardships. In contrast, Chinese participants were less likely to describe stress associated with hardship and security concerns.

Our findings suggest that elements of adolescents’ responses to disasters may be universal – heightened levels of anxiety, worry, behavioral avoidance, hypervigilance and a desire to be closer to family. Psychological distress is a normal, adaptive response to disasters (Kirmayer, Kienzler, Afana, & Pederson, 2010), and many in our sample described common trauma reactions that did not cause meaningful changes to their mental health. However, some cases indicated elevated levels of disturbance that had caused long-term distress or impacted on daily function. Despite significant cultural differences between the study sites, patterns of distress were largely consistent, although psychological and behavioral changes were less pronounced in China where participants’ exposure to earthquakes and ongoing adversity was less severe. Our findings suggest that in both China and Nepal, adolescent conceptualizations may have moved away from traditional idioms of distress towards westernized notions of PTSD, anxiety disorders and depression. Descriptions of mind-body-spirit influences and traditional idioms of distress were absent in reports from China but sometimes mentioned by Nepali adults. Kohrt and Hruschka (2010) assert that reports of heart-mind disturbances in Nepal are not indications of pathological conditions, rather they represent natural levels of distress that evolve in response to certain events. Adolescents in our sample rarely used traditional expressions of trauma or manifest spiritual interpretations described in prior literature from Nepal (Kohrt & Harper, 2008; Kohrt & Hruschka, 2010; Sharma & Van Ommeren, 1998), but demonstrated an awareness of concepts emerging from globalized psychology likely via the influence of a range of media and social media platforms.

The current findings suggest that adolescents’ experience of hypervigilance, fear, behavioral avoidance and emotional numbing paralleled DSM-5 criteria for PTSD (American Psychiatric Association, 2013), although traumatic stress reactions were often described in close proximity to symptoms of anxiety. Recent findings emerging from China (Yang et al., 2017) and Nepal (Acharya, Bhatta, & Assannangkornchai, 2017; Kane et al., 2018) support the new diagnostic architecture for PTSD, and perhaps echo this trend. It has been hypothesized that the rapid influx of international aid workers responding to large-scale disasters, in combination with growing mass media coverage, globalization, and the expansion of pharmaceutical markets for psychiatric medicines in Asia have increased exposure to American and European notions of psychiatric diagnosis (Chen, 2011; He & Wang, 2012; Summerfield, 1999; Vallières et al., 2016). Young urban populations in Asia are heavily exposed to westernized perspectives on health and wellbeing via television, news media and social media (Wang & Liu, 2016). In particular, engagement with social networking sites has potential to heighten awareness of mental health and expressions of distress (Best, Manktelow, & Taylor, 2014), noted by some participants. Psychological manifestations have become more openly discussed, and depictions of psychological distress may have shifted away from neurasthenia and spiritual connections to expressions more closely reflecting western psychological symptoms (Lee & Kleinman, 2007; Yang et al., 2017). This transition has potential to heighten the visibility of psychological needs, expand avenues for psychological intervention, and reduce self-blame and stigma associated with treatment seeking if carefully managed (Schreiber & Hartrick, 2002; Xu, 2016).

Yet, in regressing to a single diagnostic framework, there is a significant risk of missing subtle nuances in expressions of distress, influencing ‘acceptable’ perceptions of mental health, and directing mental health funding to inappropriate programs (Kaiser, Kohrt, Keys, Khoury, & Brewster, 2013; Rasmussen, Katoni, Keller, & Wilkinson, 2011; Vallières et al., 2016). The terms used to describe mood difficulties and social disharmony in our study were consistent with prior ethnographic reports of the local lexicon among Chinese and Nepali populations (Lee, Kleinman, & Kleinman, 2007; Muldoon et al., 2017; Xu, 2016). Similarly, evidence of conversion disorder among female adolescents in Nepal may indicate a belief in spirit possession, and complement findings on mass psychogenic illness documented in other settings affected by mass-trauma (Barron, Leaning, & Rumack, 1993). Conversion disorder is not a new phenomenon in Nepal, and a number of participants described responding to episodes of fainting, dizziness, nonsensical talk, unusual physical movements, headaches and nausea among adolescent girls after the disaster. However, these episodes were described only by adults in our sample and thus it is difficult to determine adolescents’ interpretations. Although rare, somatic complaints were observed in both settings, and may reflect more holistic conceptualizations of mental health. The ongoing assessment of adolescents’ expressions of psychological trauma across a diverse range of stakeholders is vital to ensure that mental health services are appropriately tailored to local understandings of psychological health (Weaver & Kaiser, 2015). Mental health service providers and international aid organizations must be aware of the range of psychological expressions employed locally (Vallières et al., 2016), which may differ across age groups and urban and rural settings. Accordingly, it is important that clinicians be informed about the interaction between local perceptions of psychological health and engagement in treatment (Brenman et al., 2014; Newnham, McBain, et al., 2015; Wessells, 2009).

Beyond direct exposure, disasters created a foundation for further hardship and insecurity that had potential to cause or exacerbate psychological difficulties for adolescents. In particular, our respondents suggested that family discord and economic adversity had spiraling effects on adolescent anxiety and stress, through increased susceptibility to violence, poverty and disruption to schooling. Our findings reinforce the importance of parental support and family cohesion for youth affected by trauma (Masten & Narayan, 2012), and the need to address families’ economic insecurity that undermines isolated efforts to improve mental health (Miller & Rasmussen, 2010; Newnham, Pearson, Stein, & Betancourt, 2015). Despite an individual focus evident in some descriptions of adolescent mental health in our data, family relationships were regarded as integral to adolescent resilience, and parental support was heralded as a critical protective factor. These findings augment literature from other natural disaster settings that have highlighted the deleterious psychological impacts for individuals separated from close family members during emergencies (Gallagher et al., 2016). Accordingly, psychological interventions for parents, caregivers and families may be valuable in supporting adolescent mental health after disasters. Partnerships and coordinated efforts to improve health and economic outcomes in tandem are more likely to create cost-efficient processes for sustainable improvements in mental healthcare (Betancourt et al., 2014; Lund et al., 2011; Newnham, Pearson, et al., 2015).

Importantly, adolescents and adults highlighted a common experience of post-traumatic growth and interpersonal connectedness for young people affected by disasters in both settings. Many adolescents reported a sense of increased self-efficacy, the development of healthy coping behaviors and strengthening family cohesion following the disaster. In some cases, disasters presented an opportunity for adolescents to take on visible leadership roles within the community and to develop closer ties to their families. Although post-traumatic growth has rarely been examined in disaster-affected communities, the current findings were consistent with a growing literature on hope, personal growth and strengthened social cohesion that has emerged following the Sichuan Earthquake in China (Jin et al., 2014; Yu et al., 2010), and Nepal’s civil war (Gilligan, Pasquale, & Samii, 2014; Morley & Kohrt, 2013). Post-traumatic growth has been shown to have a positive association with post-traumatic stress symptoms among Chinese adolescents (Jin et al., 2014), and was predicted by social support and cohesion in studies from China and Nepal (Gilligan et al., 2014; Muldoon et al., 2017; Yu et al., 2010). Hope appears to have had a negative association with post-traumatic stress among war-affected youth in Nepal (Morley & Kohrt, 2013). Disaster preparedness and response programs that empower youth and strengthen community supports have demonstrated effectiveness in numerous countries (Fernandez & Shaw, 2016; Lockwood, Weaver, Munshi, & Simpson, 2016; Powell, Smith, & Black, 2016), and there is scope to expand the role of adolescent leadership following disasters in China and Nepal.

Adolescence is not recognized as a separate developmental stage in all societies (Larson & Verma, 1999; Patel et al., 2007), with many children expected to take on heavy work and family responsibilities, particularly in rural areas (Joshi, Sharma, & Shrestha, 2009; Tang, Zhao, & Zhao, 2018). Yet our findings suggest that identifying the specific concerns of young people, and engaging adolescents in decision-making processes and rebuilding initiatives, where appropriate, has potential to support resilient youth and highlight mental health needs. This sits in harmony with research from other disaster-affected settings underlining the importance of engaging youth and documenting their unique needs, experiences, and voices after disasters (Gibbs, MacDougall, & Harden, 2013; MacDougall, 2009). More broadly, our findings expand the evidence base on the psychosocial effects of disasters, and benefits associated with recognizing and valuing youth capacity and ability in all phases of disaster response and recovery (Peek, 2008). Our participants in China and Nepal echoed calls for youth to be recognized as active citizens who have a right to influence decisions that impact upon their health and wellbeing (Gibbs, Mutch, O'Connor, & MacDougall, 2013; MacDougall, 2009).

Limitations

There were several limitations. First, our investigation was limited to three sites in each country and the findings do not represent the full spectrum of adolescent mental health across China and Nepal. Given the important role of social identity in the expression and interpretation of psychological distress, data from other districts, particularly rural and remote areas may differ. Second, although extensive efforts were made to design the study, collect data, conduct analyses and interpret the findings in collaborative and culturally-informed partnerships, there is a possibility that the international authors’ training and experience influenced the interpretation of results. Third, the comparison of psychological responses in China and Nepal provide an interesting contrast, but should not be interpreted as a definitive examination of the similarities or differences between cultures, health systems or processes of adolescent development. Finally, the absence of baseline data collected prior to the onset of natural disasters in each setting limits our ability to determine changes in terminology or symptoms. This study was designed to illustrate adolescents’ and adults’ qualitative descriptions of distress and resilience among youth in China and Nepal, and future research that focuses on longitudinal assessments of psychological indicators would be of great value.

Conclusion

Detailed analysis of the expressions of distress reported by adolescents in China and Nepal is particularly important given the region’s history and likelihood of future high-impact disasters (Udomratn, 2008; van der Keur et al., 2016). Our data reflect a range of salient psychological concerns affecting adolescents and a growing transition towards globalized conceptualizations of distress among young people in China and Nepal, despite a continued emphasis on the importance of family and community for adolescent mental health. These descriptions should not be considered evidence of diagnostic equivalence across countries and cultures. Rather, participants depicted a range of expressions of psychological distress in the context of social and environmental determinants of health. The current study illustrates the importance of recognizing potential mental health risks within a group that may be ready to embrace responsibility, but continues to need strong parental support, stability, and access to schooling. There is a significant need for psychological and community services that operate in ways that are sensitive and open to culturally specific understandings of development and the unique capabilities of adolescents. These findings highlight the significant opportunities available for engaging young people in decisions regarding their own care and capacity to contribute to disaster-affected communities as they rebuild.

	Total	Adolescent	Parent	Experts by Profession
China
Total	79	34	15	4	4	2	17	3
Female	37 (46.8%)	18 (52.9%)	9 (60.0%)	2 (50%)	2 (50%)	1 (50%)	4 (23.5%)	1 (33.3%)
Male	42 (53.2%)	16 (47.1%)	6 (40.0%)	2 (50%)	2 (50%)	1 (50%)	13 (76.5%)	2 (66.7%)
Age
Mean (S.D.)	28.6 (13.8)	15.4 (1.7)	39.8 (4.8)	43.5 (10.1)	48.8 (12.7)	40.0 (14.1)	31.8 (9.1)	49.7 (7.6)
Range	13–66	13–18	35–52	33–57	37–66	30–50	22–50	43–58
Nepal
Total	62	35	11	3	2	2	3	6
Female	32 (51.6%)	17 (48.6%)	9 (81.8%)	2 (66.7%)	1 (50%)	0 (0%)	2 (66.7%)	1 (17%)
Male	30 (48.4%)	18 (51.4%)	2 (18.2%)	1 (33.3%)	1 (50%)	2 (100%)	1 (33.3%)	5 (83%)
Age
Mean (S.D.)	27.4 (15.3)	15.3 (1.8)	43.6 (8.0)	45.0 (9.8)	29.0 (8.5)	39.5 (9.2)	47.0 (10.2)	44.8 (12.1)
Range	13–58	13–19	34–57	37–56	23–35	33–46	38–58	28–57

Footnotes

Acknowledgements

We are grateful to the research participants who dedicated their time and effort to this study. We wish to thank our research assistants in China and Nepal and our colleagues at The Hong Kong Jockey Club Disaster Preparedness and Response Institute, and appreciate support from Arlan Fuller, Satchit Balsari, Kaylie Patrick and Lindsey Garrison at the Harvard FXB Centre for Health and Human Rights.

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: The project received funding from The Hong Kong Jockey Club Charities Trust, and the first author was supported by a National Health and Medical Research Council Sydney Sax Fellowship and a Curtin Research Fellowship.

Elizabeth Newnham, MPsych (Clin), PhD, is a Research Fellow in the School of Psychology at Curtin University, and at the FXB Center for Health and Human Rights at Harvard University. Her central research focus is child and adolescent mental health in adverse environments, including conflict, disaster, forced migration, and remote settings. Dr Newnham has received a number of prestigious research grants and awards, including a National Health and Medical Research Council of Australia Sidney Sax Fellowship and the inaugural American Australian Association Pediatrics Fellowship. She is Principal Investigator of the Study on Adolescent Resilience after Disasters.

Xue Gao, PhD, MPH, is a Research Consultant at the School of Psychology, Curtin University, Perth, Australia. Her major research interests include child and adolescent health, disadvantaged children and youth, parent-child relationships, prevention and intervention approaches. In 2015, Dr Gao received an Endeavour Fellowship to conduct research in adolescent health in Australia and China.

Jessica E Tearne BA (Hons), MPsych (Clin), PhD, is a Clinical Psychologist in the State Major Trauma Unit, Royal Perth Hospital. She has a strong research and clinical interest in the impact of traumatic life events on mental health. Jessica previously held the position of Research Associate in the School of Psychology, Curtin University and is a Senior Research Officer at the Telethon Kids Institute. Her research to date has focused on women’s and children’s mental health, predictors of risk and resilience for developing acute and post-traumatic mental health diagnoses, and unique risks for women and girls post disaster.

Bhushan Guragain, MBBS, MPH, is Medical Director at the Centre for Victims of Torture, Nepal. Dr Guragain received his medical degree from the SSR Medical College, University of Mauritius, and completed his public health training at the Harvard School of Public Health. His research interests include service delivery for trauma and torture survivors, public health in rural and remote settings, and disaster response.

Jiao Feng, MD of Public Health, is an Associate Professor at the Public Health School, Kunming Medical University. He is mainly engaged in health communication and community health promotion, and child and adolescent health. Dr Jiao is also a consultant of UNICEF, ADB, International Plan and other NGOs. His published works focus on HIV/AIDS prevention, mental health, child neglect and risk behaviors, and disparities in service delivery.

Lajina Ghimire RN, BSN, is a Research Supervisor at the Centre for Victims of Torture Nepal. She has conducted training workshops in urban, rural and remote regions of Nepal, and contributed to a number of research programs. Her interests include adolescent mental health, disaster recovery, capacity building for communities in remote areas, and improving mental health for vulnerable children.

Emily Ying Yang Chan serves as Professor and Assistant Dean (Global Engagement), Faculty of Medicine, The Chinese University of Hong Kong (CUHK); Visiting Professor, Oxford University Nuffield Department of Medicine; Senior Fellow, Harvard T.H. Chan School of Public Health; and Co-chairperson, WHO Thematic Platform for Health Emergency & Disaster Risk Management (H-EDRM) Research Network. She is Director of the Collaborating Centre for Oxford University and CUHK for Disaster and Medical Humanitarian Response (CCOUC), the Centre for Global Health and the Centre of Excellence of Integrated Research on Disaster Risk. Her research interests include Health Emergency and Disaster Risk Management (H-EDRM), climate change and health, global and planetary health, remote rural and ethnic minority health. Professor Chan has published more than 200 international peer-reviewed academic/technical/conference articles.

Jennifer Leaning, MD, SMH, is a senior fellow at the Harvard FXB Center for Health and Human Rights, Professor of the Practice at Harvard School of Public Health and associate professor of medicine at Harvard Medical School. She directed Harvard FXB from 2010 through August 2018. Dr Leaning’s research interests focus on public health and international law in response to war and disaster, early warning for mass atrocities, and problems of human security in the context of forced migration and conflict. She has published widely on these topics, informed by her field experience in a range of crisis situations (including Afghanistan, Albania, Kosovo, the Middle East, Pakistan, Somalia, and the Chad-Darfur border).

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