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Research Article

Child Survivors Struggle with Peer Relationships 42 Months after the Great East Japan

Earthquake：Series of Questionnaire-Based Cross-Sectional Surveys

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Abstract

Background

The Great East Japan Earthquake and tsunami of 2011 traumatized many children. The aim of

this study was to assess changes in peer relationship problems among child survivors between

30 and 42 months after the disaster.

Methods

In September 2014 (42 months after the disaster), copies of the Strengths and Difficulties

Questionnaire (SDQ), a questionnaire on children’s strengths and difficulties in home and

school activities, were distributed to the parents and teachers of all 8,559 4th to 9th grade

students in the elementary and junior high schools of Ishinomaki, Japan. These were

completed by both the parents and the teachers, and the scores were compared with those of a

similar survey 12 months previously. The children also completed a self-assessed post-

traumatic stress symptoms questionnaire.

Results

The SDQ scores evaluated by parents were significantly worse after 42 months than after 30

months (p < 0.001), with the effect size greatest for the scores for peer relationship problems.

Peer relationship problem scores did not differ significantly between school grades or genders.

Spearman correlation coefficients relating SDQ scores to the children’s self-assessed trauma

scores were all <0.25.

Conclusions

This study showed that the experience of the disaster affected children’s peer relationships at

home and school. In particular, the peer relationship problems of child survivors at 42 months

after the disaster were exacerbated compared with at 30 months.

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INTRODUCTION

The Great East Japan Earthquake struck Japan on March 11, 2011 [1]. A massive

earthquake and tsunami destroyed houses, city halls, public shelters, hospitals, kindergartens,

elementary schools, junior high schools, and high schools situated along the coast [2]. The

tsunami caused tremendous damage and traumatized many people, including children [3-17].

Following any disaster, the potential mental health problems of children, including

posttraumatic stress disorder (PTSD), should be given careful consideration by health care

providers [18-33]. The diagnostic criteria for PTSD in the Diagnostic and Statistical Manual

of Mental Disorders, 5th edition (DSM-5) include childhood traumatic symptoms, such as

repetitive play and nightmares; patients typically experience significant difficulties in their

daily lives because of their traumatic symptoms [34]. To plan a treatment strategy for children

after a traumatic event, it is of great importance to evaluate them and establish any diagnoses

of psychiatric disorders. In doing so, clinicians should evaluate the daily activities of the

children such as rebellious behaviors, peer relationship problems, prosocial behaviors, and

emotional problems at home and school [35-37].

Since 2011, we have collected information on the daily activities of children who

survived the earthquake and tsunami in Ishinomaki city, a badly affected city of

approximately 150,000 people in Miyagi Prefecture in the north-east coast of Japan’s main

island [3-8]. Ishinomaki (population 162,822) is the second largest city in Miyagi Prefecture,

Japan [5]. Nationwide, 126,574 buildings were completely destroyed and 272,302 were

heavily damaged by the earthquake and tsunami, with approximately 120,000 buildings

completely destroyed by the tsunami in the flooded areas. In Miyagi Prefecture, the death toll

from the disaster was 10,449, with 1,299 missing people; 82,889 buildings were completely

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destroyed and 155,099 were heavily damaged. In Ishinomaki, the death toll was 3182, and as

of February 15, 2012, 557 people were missing. A total of 33,378 houses and buildings

collapsed or partially collapsed, and 7298 temporary houses were constructed.

In previous studies we identified relationships between post-traumatic symptoms and home

damage, sleep duration, evacuation experience, and bereavement experience using the

Posttraumatic Stress Symptoms for Children, 15 items tool (PTSSC-15), a self-completion

questionnaire on the stress reactions of children after disasters [5,6]. Of nearly 12,000

children included in the study, more than 2000 had experienced the bereavement of a close

family member or classmate, 4500 had experienced total or partial collapse of their home, and

4000 had lived in an evacuation center or temporary housing.

Twenty and 30 months after the earthquake and tsunami, we used the Strengths and

Difficulties Questionnaire (SDQ) to collect information on the strengths and difficulties faced

by parents and teachers when dealing with the traumatic symptoms of children who survived

the disaster [4]. This showed that the difficulties they faced were not significantly related to

these children’s traumatic symptoms [4]. Thus, clinicians should not only evaluate traumatic

symptoms but also try to evaluate objectively whether there are difficulties in daily activities

due to those symptoms [4]. The study showed that the experience of the disaster affected the

prosocial behaviors of those children toward teachers and friends at school. However, no

significant changes in their prosocial behaviors were seen at home, where they maintained

respect and caring feelings for parents [38].

Following the disaster, the number of children in Ishinomaki City who could not attend

their school increased [39,40]. Over the school years 2005 to 2010, prior to the disaster, the

mean rate of non-attendance of children at elementary and junior high schools was 0.33% ±

0.05% (0.25%–0.39%) in Ishinomaki. In the school years 2011 to 2013 after the disaster, the

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mean rate increased to 0.54% ± 0.07% (0.46%–0.59%) in Ishinomaki [40]. Children in

schools destroyed by the tsunami joined other schools, where they may have faced difficulties

such as making new friends and becoming accustomed to new teachers. Some children

traveled on the school bus for one or two hours every weekday, which would involve an early

start and prevent play with new friends after school due to the bus journey home. These

environmental changes potentially affected the mental condition of the surviving children.

In the present study, conducted 42 months after the earthquake and tsunami, we used the

PTSSC-15 and SDQ to collect information similar to that collected in the studies conducted 8,

20 and 30 months after the disaster. This article was reproduced from previous our studies

under the Creative Commons Attribution 4.0 License. [4,38]

For the first time, we discussed child survivors’ daily activities surveyed 42 months after

the disaster. The aim of this study was to evaluate peer relationship problems and prosocial

activities in child survivors’ daily activities, as experienced by their parents and teachers 42

months after the disaster, comparing these with the results 30 months after. Our main

hypotheses, based on findings of previous studies [4,38,40], were that peer relationship

problems and prosocial activities in surviving children at 42 months would not have changed

significantly compared with those at 30 months.

MATERIALS AND METHODS

Study Design and Setting

This study and our previous studies 8, 20, 30, and 42 months after GEJE were series of

questionnaire-based cross-sectional surveys of surviving children [4-7,38,41,42]. The total

numbers of children evaluated at 8, 20, 30 and 42 months after surviving the disaster were

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11,639, 10,597, 10,812, and 10,467, respectively, with almost equal numbers of boys and girls.

Table 1 shows their PTSSC-15 total scores. Strictly, this study was not a cohort study as the

population of Ishinomaki City was changing between each survey, with older children leaving

and younger children entering the population. Our previous study investigated associations

between traumatic symptoms among children and the aftermath of the earthquake and tsunami.

Recruitment and Participants

This study was approved by the Ethics Committee of Japan’s National Center for Global

Health and Medicine and was conducted in accordance with the Declaration of Helsinki. The

study was based on the fourth of a series of surveys, and the subjects were elementary school

and junior high school students who survived the tsunami.

This survey was conducted in September 2014 (42 months after the disaster) as part of the

school education program by the Board of Education of Ishinomaki City. Survey sheets were

distributed to all 11,341 children who attended the municipal schools in the city (five

kindergartens, 43 elementary schools, and 21 junior high schools). In addition, the SDQ was

distributed to the teachers of all the students and to the parents of the 8559 children attending

elementary schools (4th to 6th grade) and junior high schools (7th to 9th grade). The present

study included only these 8559 children in elementary and junior high schools, in the 4th to 9th

grades. The data for children in kindergartens and the 1st to 3rd grades were not included as

their survey forms were completed by their parents.

The survey had previously been conducted in November 2011 (8 months after the disaster),

November 2012 (20 months after the disaster), and September 2013 (30 months after the

disaster).

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Procedure

The present survey was administered in the same manner as the previous three surveys.

First, the Education Committee of Ishinomaki City explained the survey method to the

principals of all schools. Subsequently, the teachers distributed a letter prepared by the

Education Committee that explained the survey to all children and their parents. The letter

clearly stated that by filling out the questionnaire, both the student and parents were

consenting to participate in the survey. The letter also specified that the survey results would

be used to provide psychological care to the children and to facilitate their education at school,

and that the results would be published as a medical research article. Written informed

consent was not explicitly obtained from the parents/guardians of the children from the

elementary and junior high schools. However, informed consent was obtained when the

students filled out the questionnaire. The Ethics Committee of the National Center for Global

Health and Medicine approved this consent procedure.

A total of 6914 (80.4%) SDQs and PTSSC-15 were received from 8599 parents, of which

6660 (77.5%) were valid. A total of 7,449 (86.6%) SDQs and PTSSC-15 were obtained from

teachers, of which 7,355 (85.5%) were valid. As all the responses were anonymous, they were

not directly linked with those of the previous surveys.

Measures

This paper-based survey involved asking children questions regarding their post-traumatic

symptoms using a self-report form, the PTSSC-15, for the children to complete. The

children's strengths and difficulties were assessed by their parents and teachers using the SDQ.

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Posttraumatic Stress Symptoms for Children - 15 items

The PTSSC-15 is a self-rated questionnaire on the stress reactions of children after a

disaster, developed in Japan. Its predecessor, the Posttraumatic Stress Symptoms 10 (PTSS10)

tool, has fewer questions and was used as a screening test after the Great Hanshin Earthquake

and Niigata–Chuetsu Earthquake; use of this instrument has been widespread in Japan [43].

Five questions were added to the PTSS10 that assess important psychosomatic characteristics

after a traumatic event (flashbacks, appetite loss, somatic reactions such as headache and

abdominal pain, attention deficit, and anxiety) to form the 15-item PTSSC-15 [3-5,8,9].

Each question is scored at six levels: 0 = completely disagree, 1 = mostly disagree, 2 =

partially disagree, 3 = partially agree, 4 = mostly agree, and 5 = completely agree. Higher

scores indicate more severe posttraumatic and depressive symptoms. Tominaga et al.

demonstrated the reliability and validity of PTSSC-15 in Japanese children and adolescents

[44].

Strengths and Difficulties Questionnaire

The SDQ is a brief behavioral questionnaire for adults asking about children aged around

3–16 years [28,31]. It has several versions, including versions for researchers, clinicians, and

educators, and it has been widely used in clinical pediatrics in Japan [43,45]. Each question is

scored at three levels: 0 = not true, 1 = somewhat true, and 2 = certainly true.

The SDQ tests 25 attributes, some of which are positive and others are negative. These

items are divided among five subscales: emotional problems (five items), conduct problems

(five items), hyperactivity/inattention (five items), peer relationship problems (five items),

and prosocial behavior (five items). The scores on the four problematic scales—emotional

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problems, conduct problems, hyperactivity/inattention, and peer relationship problems—are

added together to produce a total difficulty score (based on 20 items). Higher scores on the

problematic scales and a higher total difficulty score indicate a more serious burden for

parents or teachers. Conversely, a higher score on prosocial behavior indicates better

sociability.

Matsuishi et al. demonstrated the reliability and validity of SDQ scores in Japanese

children and adolescents [45]. The standard distribution of SDQ scores among Japanese

children was published by the Ministry of Health, Labour and Welfare [31], and Morikawa et

al. has reported normative data and the psychometric properties of SDQ among Japanese

school-aged children [43].

Statistical Analysis

In the analysis of the SDQ results, the parents’ and teachers’ SDQ median scores were

determined for two groups of grades: 4th to 6th grades (elementary school) and 7th to 9th grades

(junior high school).

The mean SDQ scores for the children’s emotional problems, conduct problems,

hyperactivity/inattention, peer relationship problems, total difficulty score, and prosocial

behavior in each rater group were calculated for 30 and 42 months after the disaster. The

differences between the mean SDQ scores recorded at these two time points were assessed

using a two-factor analysis of variance for each rater group and time point. Differences

between the mean SDQ scores rated by parents and by teachers were assessed

using a two-factor analysis of variance for each grade group and gender. All effect sizes were

then calculated on the basis of Cohen’s d.

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Spearman correlation coefficients were calculated to assess whether the self-rated problems

(the PTSSC-15 scores of the children) correlated with problems rated by others (the SDQ

scores assigned by parents and teachers).

A significance level of 0.05 was used in the two-sided tests. All calculations were performed

using PASW 18.0 J for Macintosh (SPSS, Tokyo, Japan) and Graph Pad Prism 5 for Mac OS

X (GraphPad Software, California, USA).

RESULTS

Comparing SDQ scores at 42 months and 30 months

The average SDQ scores evaluated by parents and teachers were compared for each grade

group (4th to 6th grade and 7th to 9th grade) and period (Table 2). The SDQ problem scores

(emotional problems, conduct problems, hyperactivity/inattention, peer relationship problems,

and total difficulty score) evaluated by parents and teachers of children 42 months after the

disaster were significantly higher than those after 30 months (Table 2, all p <0.001). The

effect sizes for emotional problems, conduct problems, hyperactivity/inattention, and the total

difficulty score were very small (<0.08); however, for peer relationship problems the effect

sizes were 0.54 and 0.48 for the 4th to 6th grade and 7th to 9th grade groups, respectively.

The SDQ prosocial behaviors score for 4th to 6th grade groups evaluated by parents and

teachers of children 42 months after the disaster were not changed compared with those after

30 months (Table 2). However, the SDQ prosocial behaviors score for 7th to 9th grade groups

evaluated by parents and teachers of children 42 months after the disaster were significantly

lower than those after 30 months (Table 2, p <0.001). That effect size for emotional problems,

conduct problems, hyperactivity/inattention, and the total difficulty score were very small

(<0.02).

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Differences in SDQ scores between school grades and between genders

The average SDQ scores evaluated by parents and by teachers after 42 months were

compared by grade group (4th to 6th grade and 7th to 9th grade) and gender (Tables 3 and 4).

The SDQ scores rated by parents for emotional problems, conduct problems,

hyperactivity/inattention, and prosocial behaviors differed significantly between grade groups

and between genders (all p < 0.001), but the effect sizes were very small (<0.02). The SDQ

total difficulty scores from the ratings by parents differed significantly between genders (p <

0.05), but the effect size was under 0.01. The SDQ score for peer relationship problems rated

by parents was not significantly different between grade groups or between genders.

The SDQ scores rated by teachers for conduct problems, hyperactivity/inattention, peer

relationship problems, prosocial behaviors, and total difficulty differed significantly between

grade groups and between genders (all p < 0.001), with all effect sizes less than 0.05. The

SDQ score for emotional problems rated by teachers did not differ significantly between

grade groups or between genders.

Relationship between the SDQ scores and the children’s PTSSC-15 scores

Spearman correlation coefficients calculated between the children’s total PTSSC-15 scores

and the SDQ scores assigned by their parents and teachers are shown in Table 5. Most

coefficients were small (<0.2). The largest coefficients were for the 7th to 9th grade group in

the SDQ emotional problems score (0.27–0.37) and total difficulty score (0.19–0.30). Notably,

there was no correlation between the peer relationship problem scores and the PTSSC-15

scores for the 4th to 6th grade group; for the older grade group, the pattern was mixed, with

small but significant correlations for boys when rated by their parents and girls when rated by

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the teachers.

DISCUSSION

The results of this study showed that the SDQ scores evaluated by parents and teachers of

children who survived the severe earthquake and tsunami changed over time. In particular, the

peer relationship problems of child survivors 42 months after the disaster were exacerbated

compared with at 30 months. However, there were no major changes over that period in

emotional problems, conduct problems, hyperactivity/inattention, or the prosocial behaviors

of the child survivors. This partially confirmed the main hypothesis of this study, and these

results elucidated that peer relationship problems in surviving children would be more severe

after 42 months than after 30 months, and that prosocial behaviors in these children at 42

months would not have significantly changed.

This study is the first to show that peer relationship problem scores of a cohort of children

surviving a disaster increased with time.

The peer relationship scores, we suggest that you present data on whether the increase was

due to a greater number of children experiencing peer relationship problems or due to more

severe problems in a few children. The peer relationship problem scores rated by their parents

did not relate to their gender and school grade. However, The peer relationship problem

scores rated by their teachers relate to their gender and school grade. Furthermore, the peer

relationship problems for the 4th to 6th grade group did not related to the degree of traumatic

experience they suffered. However the peer relationship problems for the 7th to 9th grade

group related to the degree of traumatic experience they suffered. In Japan included

Ishinomaki City, the number of children who could not attend their schools more increased in

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junior high school than elementary school [39]. That reason might be included not only

disaster experiences, but also severe bullying, traffic accidents and severe abused experiences.

PTSSC-15 was self-rating questionnaires of traumatic symptoms. However PTSSC-15 did not

include a question about the sort of traumatic experiences. Therefore, these results indicated

clinical implications that clinicians should be more attention to peer relationship of junior

high school children than elementary school children. Additionally, clinician must evaluate

the sort of traumatic experiences in order to treat their psychiatric disorders such as PTSD.

Our previous studies based on the surveys 8, 20, and 30 months after the disaster showed

that some children who survived the disaster exhibited a reduction in their strengths (caring,

gentleness, and honesty toward their parents) in home activities, and an increase in their

emotional problems, conduct problems, hyperactivity, and peer relationship problems at

school and in home activities compared with children without traumatic experiences [4,38].

Our results also showed that at 42 months after the disaster, just as at 30 months, the

children’s prosocial behaviors such as caring, gentleness, and honesty toward their parents

had not changed, although it had toward their friends and teachers at their school. Thus, this

study shows that surviving children struggled with more severe peer relationship problems

after 42 months compared with 30 months and that prosocial behaviors were not affected by

their experiences of the disaster.

The reasons that peer relationship problems increased in severity between 42 and 30

months cannot be determined by this study. The peer relationship problems were that they

were usually alone and played alone, that they were not generally liked by other children, and

that they were teased by other children. The children’s peer relationship problems were not

statistically related to their individual problems such as their traumatic experiences. Our result

did not indicate why peer relationship problems worsened after 42 months. We think that that

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reason was the increasing number of children experiencing problems. Their social problems,

such as being part of a single parent family, low academic achievement, disruption in class,

and rebelliousness toward adults may be related to these problems. After the disaster,

surviving families experienced serious economical and emotional issues, as reported in many

media reports, scientific papers, and governmental statistical reports [2,40,46]. Some parents

lost jobs and some families had changed structure, for example due to the father’s death [46].

Surviving single mothers had to work during the day because of the deaths of fathers in the

disaster, and this meant that some surviving children were left alone at home until their

mothers returned at night. It is therefore clinically important to discuss with each child any

emotional and conduct problems that may have been caused by environmental changes.

PTSD should be considered after any disaster. One of the PTSD diagnostic criteria

included in the DSM-5 is that patients experience significant difficulties in their daily lives

because of their post-traumatic symptoms [12-16]. Our previous study reported that the

burden faced by parents and teachers when handling child survivors was not significantly

related to children’s post-traumatic symptoms and that difficulties between children and

parents and children and teachers significantly differed [4]. The results of the present study

showed that the peer relationship problems notably worsen after 42 months compared with 30

months. Clinicians should therefore evaluate not only children’s traumatic symptoms, but also

their economic situation, social problems, school activities, and family problems.

This study had some limitations. The survey was conducted in only one district in Japan,

and the results regarding the children of Ishinomaki do not necessarily reflect the

characteristics of all the children who experienced the 2011 Japanese earthquake and tsunami.

This study only evaluated the traumatic symptoms of surviving children using self-rating

questionnaires, and, from the results of the survey, it is impossible to relate the peer

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relationship problems of the children to whether or not they were experiencing PTSD.

Conclusions

This study showed that the experience of the 2011 Great East Japanese earthquake and

tsunami affected the peer relationship problems of children at home and school and did not

affect prosocial behaviors at home. In particular, the peer relationship problems of child

survivors 42 months after the disaster were exacerbated, as compared with 30 months after.

These peer relationship problems were not statistically related to the children’s individual

traumatic experiences. The worsening of peer relationships is a clinical issue that needs to be

addressed. Clinicians should evaluate traumatic symptoms and other conditions such as the

children’s economic situation, social problems, school activities, and family problems

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 Tabl e s
Table 1. Characteristics of children from Ishinomaki affected by the 2011 Japanese earthquake and tsunami.

After 8 months After 20 months After 30 months After 42 months

Items
N = 11,639 N = 10,597 N = 10,812 N = 10,467

Gender Male 5939 (51.0%) 5302 (50.0%) 5434 (50.3%) 5273 (50.4%)

Female 5700 (49.0%) 5295 (50.0%) 5378 (49.7%) 5194 (49.6%)

Age at the time of the disaster

10.9 (SD = 2.7) 9.9 (SD = 2.7) 8.9 (SD = 2.7) 7.9 (SD = 2.7)
(years) (Mean)

PTSSC-15
20.5 (SD = 14.5) 18.8 (SD = 14.0) 19.7 (SD = 14.2) 19.１ (SD = 14.0)
Total score (Mean)

SD, standard deviation; N, number of cases; PTSSC-15, Posttraumatic Stress Symptoms for Children - 15 items; PTSD, posttraumatic stress disorder.

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 Table 2. Mean SDQ scores (by grade, rater, or time after the disaster)
Rater Months after disaster

2013 2014
F P value Effect size
After 30 months After 42 months
M SD N M SD N
Emotional problems 4th–6th grade Parents 2.06 2.08 3491 1.96 2.02 3344 Gender × Period 7.357 <0.01 0.00
Teacher 0.96 1.60 3547 1.03 1.67 3577 Period 0.2291 N.S. 0.00
Rater 1049 <0.001 0.08
7th–9th grade Parents 1.74 2.02 3354 1.76 2.02 3316 Gender × Period 0.0 N.S. 0.00
Teacher 1.03 1.76 3384 1.05 1.78 3778 Period 0.3841 N.S. 0.04
Rater 484.1 <0.001 0.00
Conduct problems 4th–6th grade Parents 2.14 1.64 3491 2.37 1.25 3344 Gender × Period 225.5 <0.001 0.04
Teacher 1.16 1.56 3547 2.11 1.15 3577 Period 605.7 <0.001 0.05
Rater 668.9 <0.001 0.02
7th–9th grade Parents 1.85 1.55 3354 2.06 1.24 3316 Gender × Period 197.7 <0.001 0.04
Teacher 1.17 1.56 3384 2.03 1.04 3778 Period 535.9 <0.001 0.02
Rater 235.9 <0.001 0.02
Hyperactivity/inattentio
4th–6th grade Parents 3.47 2.26 3491 3.35 1.35 3344 Gender × Period 206.3 <0.001 0.01
n
Teacher 2.65 2.54 3547 3.48 1.34 3577 Period 115.3 <0.001 0.01
Rater 108.8 <0.001 0.02
7th–9th grade Parents 2.99 2.08 3354 3.23 1.30 3316 Gender × Period 29.28 <0.001 0.01
Teacher 2.65 2.46 3384 3.23 1.31 3778 Period 170.3 <0.001 0.00
Rater 29.28 <0.001 0.00
Peer relationship
4th–6th grade Parents 2.04 1.74 3491 4.13 1.26 3344 Gender × Period 5.822 <0.05 0.00
problems
Teacher 1.43 1.65 3547 3.64 1.13 3577 Period 7475 <0.001 0.54
Rater 489.2 <0.001 0.04
7th–9th grade Parents 2.03 1.75 3354 4.16 1.30 3316 Gender × Period 3.063 N.S. 0.00
Teacher 1.67 1.73 3384 3.71 1.21 3778 Period 6576 <0.001 0.48
Rater 248.1 <0.001 0.02
Prosocial behavior 4th–6th grade Parents 6.20 2.02 3491 5.96 2.54 3344 Gender × Period 17.01 <0.001 0.00
Teacher 5.83 2.58 3547 5.93 2.55 3577 Period 2.885 N.S. 0.00
Rater 23.55 <0.001 0.00
7th–9th grade Parents 6.00 2.00 3354 1.96 2.02 3344 Gender × Period 5.407 <0.05 0.00
Teacher 5.29 2.71 3384 1.03 1.67 3577 Period 12.60 <0.001 0.02
Rater 226.6 <0.001 0.00
Total difficulty score 4th–6th grade Parents 9.71 5.62 3491 1.76 2.02 3316 Gender × Period 547.3 <0.001 0.04
Teacher 6.19 5.50 3547 1.05 1.78 3778 Period 888.0 <0.001 0.06
Rater 511.3 <0.001 0.04
7th–9th grade Parents 9.71 5.62 3491 2.37 1.25 3344 Gender × Period 185.3 <0.001 0.01
Teacher 6.19 5.50 3547 2.11 1.15 3577 Period 973.8 <0.001 0.07
Rater 171.6 <0.001 0.01
SDQ, Strengths and Difficulties Questionnaire; M, mean; SD, standard deviation; N, number of cases; N.S., not significant.

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 Table 3. Differences in SDQ scores for the children rated by their parents, according to school grade and gender
SDQ score of teacher Grade Boys Girls F P Effect
value size
M SD N M SD N
Emotional problems 4th–6th 1.88 2.02 1685 2.04 2.02 1659 Gender School level 3.705 N.S. 0.00
7th–9th 1.59 1.92 1642 1.94 2.09 1674 Gender 26.69 <0.001 0.01
School level 15.61 <0.001 0.00
Conduct problems 4th–6th 2.46 1.29 1685 2.27 1.20 1659 Gender School level 0.244 N.S. 0.00
7th–9th 2.17 1.33 1642 1.95 1.13 1674 Gender 45.53 <0.001 0.01
School level 100.8 <0.001 0.02
Hyperactivity/inattention 4th–6th 3.41 1.39 1685 3.18 1.30 1659 Gender School level 7.117 <0.01 0.00
7th–9th 3.12 1.33 1642 3.06 1.17 1674 Gender 20.71 <0.001 0.00
School level 41.40 <0.001 0.01
Peer relationship problems 4th–6th 4.15 1.27 1685 4.12 1.24 1659 Gender School level 0.637 N.S. 0.00
7th–9th 4.15 1.32 1642 4.17 1.28 1674 Gender 0.026 N.S. 0.00
School level 0.637 N.S. 0.00
Prosocial behavior 4th–6th 5.98 1.97 1685 6.52 1.96 1659 Gender School level 0.043 N.S. 0.00
7th–9th 5.79 1.98 1642 6.31 2.00 1674 Gender 119.6 <0.001 0.02
School level 17.03 <0.001 0.00
Total difficulty score 4th–6th 10.18 3.90 1685 10.00 3.73 1659 Gender School level 5.489 <0.05 0.00
7th–9th 9.38 3.74 1642 9.63 3.60 1674 Gender 0.146 N.S. 0.00
School level 40.64 <0.001 0.01
SDQ, Strengths and Difficulties Questionnaire; M, mean; SD, standard deviation; N, number of cases; N.S., not significant.

Table 4. Differences in SDQ scores for the children rated by their teachers, according to school grade and gender
SDQ score of teacher Grade Boys Girls F P value Effect
size
M SD N M SD N
Emotional problems 4th–6th 1.02 1.64 1828 1.05 1.69 1749 Gender School level 0.000 N.S. 0.00
7th–9th 1.04 1.68 1926 1.07 1.87 1900 Gender 0.560 N.S. 0.00
School level 0.249 N.S. 0.00
Conduct problems 4th–6th 2.24 1.31 1828 1.97 0.94 1749 Gender School level 0.6249 N.S. 0.00
7th–9th 2.14 1.17 1926 1.91 0.87 1900 Gender 97.65 <0.001 0.01
School level 9.999 <0.01 0.00
Hyperactivity/inattention 4th–6th 3.68 1.49 1828 3.28 1.14 1749 Gender School level 16.64 <0.001 0.00
7th–9th 3.30 1.41 1926 3.15 1.19 1900 Gender 80.51 <0.001 0.01
School level 69.23 <0.001 0.01
Peer relationship problems 4th–6th 3.65 1.15 1828 3.63 1.11 1749 Gender School level 10.87 <0.001 0.00
7th–9th 3.81 1.27 1926 3.61 1.15 1900 Gender 16.24 <0.001 0.00
School level 6.578 <0.05 0.00
Prosocial behavior 4th–6th 5.25 2.56 1828 6.63 2.34 1749 Gender School level 11.16 <0.001 0.00
7th–9th 5.04 2.72 1926 6.02 2.64 1900 Gender 388.4 <0.001 0.05
School level 46.89 <0.001 0.01
Total difficulty score 4th–6th 10.58 3.78 1828 9.93 3.32 1749 Gender School level 0.367 N.S. 0.00
7th–9th 10.29 3.66 1926 9.74 3.41 1900 Gender 52.80 <0.001 0.01
School level 8.448 <0.01 0.00
SDQ, Strengths and Difficulties Questionnaire; M, mean; SD, standard deviation; N, number of cases; N.S., not significant.

Table 5. Spearman coefficients for correlations between the SDQ scores for the children and the children’s own PTSSC-15 scores.
SDQ Grade SDQ rated by parent SDQ rated by teacher
Boys Girls Boys Girls
Emotional problems 4th–6th 0.13 *** 0.20 *** 0.21 *** 0.23 ***
7th–9th 0.30 *** 0.27 *** 0.37 *** 0.35 ***
Conduct problems 4th–6th 0.05 * 0.06 * 0.09 *** 0.00 N.S.
7th–9th 0.17 *** 0.15 ** 0.25 *** 0.19 ***
Hyperactivity/inattention 4th–6th 0.04 N.S. 0.00 N.S. 0.02 N.S. 0.00 N.S.
7th–9th 0.16 *** 0.07 ** 0.11 *** 0.03 N.S.
Peer relationship problem 4th–6th -0.02 N.S. 0.04 N.S. 0.02 N.S. 0.03 N.S.
7th–9th 0.13 *** 0.05 N.S. 0.08 N.S. 0.14 ***
Prosocial behavior 4th–6th -0.07 ** -0.04 N.S. -0.07 ** 0.00 N.S.
7th–9th -0.03 N.S. -0.04 N.S. -0.01 N.S. -0.04 N.S.
Total difficulty score 4th–6th 0.07 ** 0.12 *** 0.14 *** 0.11 ***
7th–9th 0.26 *** 0.19 *** 0.30 *** 0.25 ***
* p<0.05, ** p<0.001, *** p<0.0001
SDQ, Strengths and Difficulties Questionnaire; PTSSC-15, Posttraumatic Stress Symptoms for Children - 15 items

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