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Anxiety, Stress, & Coping,
October 2008; 21(4): 377
386

Factors associated with traumatic symptoms and

internalizing problems among adolescents who
experienced a traumatic event

MAJA DEKOVIĆ1, INA M. KONING2, GEERT JAN STAMS3, &

KIRSTEN L. BUIST1
1
Department of Child and Adolescent Studies, Utrecht University, The Netherlands; 2Department of
Interdisciplinary Social Science, Utrecht University, The Netherlands & 3Department of Educational
Studies, University of Amsterdam, The Netherlands

Abstract
The aim of the present study was to identify factors that are related to the traumatic symptoms and
problem behavior among adolescents who experienced the New Years fire in 2001 in Volendam, The
Netherlands. Three groups of factors were considered: pre-trauma (personality and coping), trauma-
related (physical and emotional proximity to disaster), and post-trauma factors (received social
support). Forty-five adolescents completed the questionnaire. Two years after the disaster, these
adolescents experienced significant traumatic stress reaction (70% within the clinical range) and
showed clinically significant levels of internalizing problems (37%). Pre-trauma, individual factors
were identified as the most important predictors of distress, followed by received social support. The
indicators of physical and emotional proximity to disaster explained little variance in distress.

Keywords: Traumatic symptoms, problem behavior, adolescence, human-made disaster, factor

associated with trauma

On New Years Eve 2001 an immense disaster struck Volendam, a small and close
community at the coast of The Netherlands. A fire started in a popular bar where about 300
young people were celebrating the New Year. The fire took the lives of four adolescents
immediately, and in the months that followed, 10 more adolescents died due to severe
injuries. There were about 200 wounded who were admitted to the nearby hospitals mainly
for burns, 40 of which had to stay for longer than a month. The consequences for survivors
and the whole community were huge. Normal daily life in the community was disrupted;
adolescents had to deal with extremely painful physical injuries, the loss of loved ones and
friends, and the memories of witnessing gruesome deaths or maimed bodies. Given that all
victims came from the same small community (i.e., centripetal disaster), even those who
were not directly involved in the fire were affected, as they knew at least some of the victims
and were daily confronted with the bereaved and the visible reminder of the event by
encountering those who survived and were severely injured.

Correspondence: Maja Deković, Department of Child and Adolescent Studies, Utrecht University, P.O. Box
80.140, 3508 TC Utrecht, The Netherlands. E-mail: M.Dekovic@fss.uu.nl

ISSN 1061-5806 print/ISSN 1477-2205 online # 2008 Taylor & Francis

DOI: 10.1080/10615800701791161
378 M. Deković et al.

Although there is a large variety in reaction to traumatic experience, trauma is considered

to be a significant and pervasive risk for development of psychopathology. Over the past 20
years there has been a substantial body of research on the effects of traumatic experiences
on adults (Norris et al., 2002), however, the responses of children and adolescents to
disaster is still a relatively neglected area of study (Ickovics et al., 2006). Moreover, studies
concerning these age groups have frequently focused on the effects of individual trauma,
such as (sexual) abuse, rather than on the effects of community disasters (Pfefferbaum,
1997). Even when community disasters have been studied, they dealt mostly with natural
disasters, such as earthquakes or hurricanes, rather than human-made disasters (i.e., caused
by human failures or accidents), a type of disaster that potentially has more negative effects
on mental health (Norris et al., 2002). In short, few studies have documented the effects of
community, human-made disasters in samples of adolescents.
In the present study, the psychological consequences of disaster are operationalized as
Posttraumatic Stress Disorder (PTSD) symptoms (i.e., intrusive thoughts, re-experiencing
of trauma, avoidance, numbing symptoms, and increased arousal) and as internalizing
problem behaviors (i.e., anxiety and depression). The aim of the study was to identify
factors that are related to these two outcomes. These factors can be grouped into three
major categories of predictors: pre-trauma factors, trauma-related factors, and post-trauma
factors (e.g., Gil, 2005).
Pre-trauma factors include preexisting, stable individual characteristics such as person-
ality and coping style. Certain personality traits, such as neuroticism and introversion, make
individuals especially vulnerable for PTSD (Jaycox, Marshall, & Orlando, 2003; Yehuda,
1999). Trait-like coping style is often divided into two basic types: active or approach
coping (attempts to manage the problem) and avoidance coping (ignoring the problem and
focusing on emotions) (Compas, Conner-Smith, Saltzman, Harding Thomsen, & Wafs-
worth, 2001). In general, approach coping is considered to be a more effective strategy,
associated with better outcomes, whereas avoidant coping seems to increase risk for
development of PTSD (Gil, 2005).
Trauma-related factors refer to features of the traumatic event itself, e.g. type of event,
severity, and exposure, defined as both physical and emotional proximity to the traumatic
event. Physical proximity refers to physical distance from the event and witnessing injury or
death, whereas emotional proximity represents emotional involvement such as injury and
death of a loved one. Many models of trauma consider the level of exposure to traumatic
events as the most salient risk factor for negative outcomes (Pfefferbaum, 1997; Yehuda,
1999). The closer the physical and emotional proximity to the event, the greater the
negative consequences of the traumatic event.
The final category, post-trauma factors, includes received social support. The con-
temporary models of stress emphasize the role of social support in promoting recovery of
psychological resources needed to deal with a stressful experience (Kaniasty & Norris,
1995). The ability of social support to reduce distress after experiencing a trauma has been
demonstrated repeatedly (Bal, Crombez, Van Oost, & Debourdeaudhuij, 2003; Norris,
2002). The extreme communitywide disasters, however, often lead to deterioration of
helping resources and lower levels of perceived social support (the belief that help would be
available if needed). According to the social support deterioration deterrence model (Norris
& Kaniasty, 1996), however, when support is adequately mobilized and victims actually
receive social support after disaster, the otherwise deleterious impact of disaster on
perceived support and, ultimately, on the experienced distress, may become suppressed.
 Traumatic symptoms 379

Because it is rare that all of these different factors are examined within the same study,
little is known about the relative effects of these factors on post-trauma distress. The present
study attempts to specify more precisely the importance of these particular factors by
examining their combined and unique predictive power in explaining adolescents’
traumatic symptoms and internalizing problems. Given the characteristics of this particular
traumatic event (communitywide disaster, threatening physical harm, exposure to grue-
some bodily injury, and the sight of dead or maimed bodies), and literature showing that
such event can have significant long-term effects (Tolin & Foa, 2006; Lawrence, Fauerbach,
& Thombs, 2006), we expect that many of the adolescents would report traumatic
symptoms and problem behaviors within the clinical range, even after a period of 2 years.
Regarding the factors related to adolescent distress, we expected that certain personality
characteristics (neuroticism), avoidant coping style, and closer proximity to the traumatic
event would increase vulnerability to distress, whereas received social support was
hypothesized to exhibit a salutary effect on well-being.

Method
Sample and Procedure
The sample included 45 adolescents (31 girls and 14 boys), with a mean age of 19.5 years
(SD 2.4 years, range 17 to 23 years). The adolescents were approached through the
clinicians employed at the clinical center of Volendam. The researchers provided clinicians
with a package including a letter for adolescents in which the aims of the study were
explained and participation in the study was requested, a set of questionnaires, and a post-
free envelope in which the adolescent could send the questionnaire directly to the
researchers. The clinicians were asked to distribute the packages (n 40) among
adolescents who were on the center’s list as having been involved in the fire. These
included (a) adolescents who had been admitted to a hospital after the disaster; (b)
adolescents whose brother or sister had died; and (c) youngsters who had been in contact
with the center. In addition, the clinicians were asked to distribute the packages (n 15)
among the adolescents who were not registered on the center’s list, but probably knew
people who were burned or who died in the fire. Of 55 distributed packages, 45 were
returned (82%). Due to confidentiality requirements, no information was available
regarding those adolescents who did not return the packages.

Measures
Traumatic Symptoms. The presence and frequency of posttraumatic stress symptoms was
assessed by the Impact of Event Scale (IES) (Horowitz, Wilner, & Alvarez, 1979). The IES
consists of two scales: Intrusive symptoms, measured by seven items (intrusive thoughts,
nightmares, intrusive feelings, and imagery), and Avoidance symptoms, tapped by eight
items (numbing of responsiveness, avoidance of feelings, situations, or ideas). Respondents
were asked to indicate the frequency with which they may have experienced a given
symptom within the past week on a 4-point scale: 0not at all, 1 rarely, 3 sometimes,
and 5 often. The internal consistency coefficient (Cronbach’s alpha) for the score on the
Intension scale was .87 and for the score on the Avoidance scale was .86. Given the high
correlation among the two subscales (.67) and similar patterns of findings obtained with the
two subscales, only the results for the total score are presented.
380 M. Deković et al.

Internalizing Problems. The degree to which adolescents experience internalizing problems

was assessed with 32 items (e.g., ‘‘I feel unhappy and depressed’’) of the Youth Self Report
(YSR) (Achenbach, 1991). The adolescents were asked to indicate how true each item is
now or was within the past year on a 3-point scale: 0 not true, 1 somewhat or sometimes
true, and 2 very or often true. In the present study, the alpha was .94.

Personality. A Dutch adaptation (Branje, van Aken, van Lieshout, & Mathijssen, 2003) of 30
adjective Big Five personality markers selected from Goldberg (1992) was used to assess the
following personality dimensions: Neuroticism, Extraversion, Openness, Agreeableness,
and Conscientiousness. Each scale consisted of six items. Respondents rated themselves on
a 7-point scale ranging from 1strongly disagree to 7 strongly agree. The internal
consistencies of the scores on the scales in this sample were satisfactory (alpha’s ranged
from .67 to .88).

Coping. The Utrecht Coping List for Adolescents (UCL-A) (Schreurs, van de Willige,
Broschot, Tellegen, & Graus, 1993) was used to assess two broad domains of coping: active
(12 items, e.g., ‘‘I try to solve the problem right away’’) and avoidant coping (11 items; e.g.,
‘‘I try to forget my worries and to get away from it’’). The adolescents were asked to indicate
how often they engage in each of the activities when they encounter a difficult, stressful, or
upsetting situation (1rarely or never to 4 very often). The psychometric properties
(factor structure, reliability, and concurrent validity) of the UCL-A were shown to be
adequate (Bijstra, Jackson, & Bosma, 1994). The internal consistencies of the scales in this
study were .81 for active and .84 for avoidant coping, respectively.

Proximity. Two aspects of disaster exposure were assessed: physical proximity and emotional
proximity. Assessment of physical proximity involved two questions: location during the fire
and whether the adolescent received injuries and/or burns. The answers to these two items
were combined into a 3-point index: 0 not present at the site (n 12 adolescents, 27%),
1 present at the site, but uninjured, or only slightly injured (n 22, 49%), and 2present
at the site and injured (n 11, 24%).
On two items assessing emotional proximity, the adolescent could indicate whether they
knew someone who got burned or died. If they knew someone, they could indicate whether
this person was an acquaintance, a friend, or a relative. The responses on these two items
were combined into a single score. Adolescents were assigned a score of 0 if they knew no
one died (n 2, 5%), a score of 1 if they had an acquaintance (but no friends and relatives)
who got burned or died (n 13, 29%), and a score of 2 if those who got burned or died
were their friends or relatives (n 30, 67%).

Received Social Support. The adolescents were asked to indicate on a 5-point scale, ranging
from 1  not at all to 5 quite a lot, the amount of support they received following the
disaster from the following sources (10 items): mother, father, siblings, friends, neighbors,
acquaintances, other inhabitants of Volendam, clinical center in Volendam, organized
support group, and psychologist. Internal consistency coefficient for the score on this scale
was .77.
 Traumatic symptoms 381

Results
To assess the extent to which the adolescents in the present sample reported high levels of
traumatic symptoms, the clinical cut-off scores were used. A score of 26 on the basis of a
total IES is indicative of a diagnosis of PTSD, a score between 26 and 44 indicating a
moderate impact and a score above 44 indicating severe impact of the event (Horowitz et
al., 1979). All adolescents showed at least some traumatic stress reactions 2 years after the
disaster, and 70% reported a level of symptom that is indicative of the presence of PTSD.
According to the clinical YSR cut-off scores (Achenbach, 1991), 37% of adolescent in this
sample reported levels of internalizing problems within the clinical range.
Table I presents means, standard deviations, and intercorrelations among all assessed
variables. Several findings are worth noting. Both outcome measures correlated strongly
with neuroticism and avoidant coping, and, to a lesser degree, with extraversion (pre-
trauma factors). These high correlations indicate that there might be some overlap between
these measures. Two proximity measures (trauma-related factors) were not correlated
with each other. Although emotional proximity, as expected, correlated positively with
internalizing problems, physical proximity was, surprisingly, negatively correlated with both
outcomes; adolescents who were closer to the fire and had more severe burn injuries,
reported less traumatic symptoms and internalizing problems. Interestingly, physical
proximity (but not emotional proximity) was positively associated with received support.
In order to examine the possibility that received social support might be a reason for the
inverse relationship between physical proximity and outcomes, a supplementary analysis
was conducted using partial correlations. Although the relationships between physical
proximity and outcome measures remain negative, controlling for received support reduced
the magnitude of correlations to nonsignificance ( .17 and .25 for traumatic symptoms
and internalizing problems, respectively).
In order to examine the unique and combined ability of pre-trauma, trauma-related, and
post-trauma factors to predict two outcome measures, hierarchical regression analyses were
conducted separately for each outcome (Table II). Given the small sample, only those
variables that were significantly associated with at least one outcome measure were used. In
the first step, two demographic control variables were entered: gender and age, followed by
three pre-trauma factors (neuroticism, extraversion, and avoidant coping). In Step 3,
trauma-related, proximity factors were entered. Finally, in the last step, post-trauma factor
(received support) was entered.
The predictors explained 69 and 68% of the variance in traumatic symptoms and
internalizing problems, respectively. After controlling for age and gender differences,
personality variables significantly increased the amount of explained variance in both
outcomes. Although neuroticism proved to be a significant predictor for both traumatic
symptoms and internalizing problems, with higher score on neuroticism being predictive
of higher levels of both traumatic symptoms and internalizing problems, avoidant coping
significantly (and positively) predicted only traumatic symptoms. The two proximity
variables were not significant predictors. Finally, post-trauma factor (social support)
predicted both traumatic symptoms and internalizing problems. Adolescents who
received more support reported lower levels of traumatic symptoms and internalizing
problems. Taken together, the results suggest that pre-trauma factors explain a larger
amount of variance in both outcome measures than trauma-related or post-trauma
factors.
 382
M. Deković et al.
Table I. Intercorrelations, means and standard deviations for all assessed variables (N45).

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

1. Traumatic symptoms

2. Internalizing .67*

3. Neuroticism .72* .71*

4. Extraversion .40* .45* .58*

5. Openness .04 .05 .10 .04

6. Agreeableness .12 .04 .02 .05 .40*

7. Conscientiousness .03 .03 .19 .10 .10 .30*

8. Active coping .00 .11 .11 .03 .24 .27 .16

9. Avoidant coping .71* .64* .67* .25 .21 .02 .03 .23

10. Physical proximity .29* .37* .13 .10 .07 .01 .15 .18 .35*

11. Emotional proximity .20 .36* .27 .01 .03 .21 .02 .10 .28 .04

12. Support .45* .43* .24 .32* .06 .21 .31* .01 .35* .35* .14

M 35.67 17.93 4.09 4.03 4.52 5.28 4.57 1.93 2.07 .98 1.62 3.74
SD 12.32 12.32 1.30 .81 .94 .64 .75 .49 .50 .72 .58 .81

*p B.05.
 Traumatic symptoms 383
Table II. Results of regression analyses: predicting traumatic symptoms and problem behavior.

Traumatic symptoms Internalizing

Step/Predictors b DR2 b DR2

1. Demographic controls .26*** 19*

Gender .25* .23*
Age .21 .00
2. Pre-trauma factors .39*** .40***
Neuroticism .36* .51**
Extraversion .09 .08
Avoidant coping .34* .06
3. Trauma-related factors .01 .03
Physical proximity .01 .20
Emotional proximity .06 .10
5. Post-trauma factors .04* .06*
Support .24* .23*

*pB.05; **p B.01; ***p B.001.

Discussion
A large majority of adolescents in our sample reported elevated levels of distress 2 years
after the event. This is probably due to the severity of the traumatic event. Although there is
no standard measure to assess the severity of trauma, one dimension that appears to be
important is threat to one’s life or bodily integrity; individuals who felt that their life was in
greater danger tend to suffer more in aftermath of a traumatic event (Voges & Romney,
2003). Given that almost three quarters of participating adolescents were in the bar where
the fire started, they indeed experienced real threat to their lives, which can explain the high
prevalence of traumatic symptoms in this sample. The type of disaster might also explain
such an impact; human-made disasters have more negative consequences than natural
disaster because ‘‘they symbolize human callousness and carelessness’’ (Norris et al., 2002,
p. 244).
The present results suggest that individual pre-trauma factors may be particularly
important for understanding reactions to traumatic events. Females reported more
traumatic symptoms and internalizing problems, which is consistent with the results of a
recent meta-analysis (Tolin & Foa, 2006). In line with previous findings, it appears that
preexisting anxiety (neuroticism) increases the severity of PTSD symptoms (Ickovics et al.,
2006; Norris et al., 2002). Adolescents with neurotic tendencies may be more prone to
extreme subjective appraisal of threat during a traumatic event. Findings on coping are also
consistent with the literature showing that avoidant, passive coping is associated with
negative mental health outcomes (Compas et al., 2001; Liverant, Hofmann, & Litz, 2004).
It should be noted that in the present study, coping was conceptualized as a trait, that is, we
assessed the preferable way of dealing with common adverse life events. The way in which
adolescents deal with this specific event might be even more important in predicting the
severity and chronicity of distress.
Indicators of physical and emotional proximity explained little variance in distress 2 years
later. Although regression analyses failed to support proximity as a significant predictor of
distress, it is worth noting that physical proximity to the disaster correlated negatively with
experienced distress. A possible reason for this unexpected finding is that these adolescents
received most support and attention after the disaster, which is in line with previous
384 M. Deković et al.

findings showing that the scope of disaster exposure is related to the amount of help
received, as such, those with more expose to the disaster received more assistance (Kaniasty
& Norris, 1995). In a study on the effects of an earthquake in China, similar findings have
been reported: the group that experienced lower level of exposure, but received less support
after disaster, reported lower levels of well-being 9 months after the earthquake than the
group who had more exposure, but received more assistance (Wang et al., 2000). It must be
pointed out, however, that in the present study the items to assess adolescents’ experiences
during and after the disaster were rationally derived specifically for this study, as it is often
the case in studies of specific disasters (Kubany et al., 2000), and no information is available
regarding its validity. Still, these findings suggest that the relationship between exposure and
postdisaster symptomatology is not a simple one and calls for careful examination of the
role that support received after disaster can play in this relationship.
The received support was a significant predictor of traumatic symptoms and internalizing
problems, that is, adolescents who received more support following disaster, reported less
distress 2 years later. The patterns of findings for traumatic symptoms and internalizing
problems were quite similar, supporting the notion of co-occurrence and similarity between
these two constructs (Pynoos, Steinberg, & Piacentini, 1999). This is probably due to the
fact that severe trauma exposure is often associated with loss of significant others, which is
in turn related to grief and depressive symptoms.
Some limitations of the present study are worth mentioning. First, as is characteristic of
many studies in this field, the sample size is relatively small, and the generalizability of the
findings is further limited because of the specific event and population studied. Second, the
lack of pre-event assessment and correlational, retrospective nature of the study prevent any
conclusions regarding the direction of effects. Although we assumed that individual
characteristics and social support affect traumatic response, the reverse could also be true.
That is, the time elapsed and the current level of distress may influence perceptions of self
(personality and coping style) and of relationships (received social support). Third, all data
have been obtained exclusively by means of self-report. Given the studied variables,
adolescents self-report is the most valid and logical choice. Parents typically under-report
both PTSD-related symptoms (McDermott & Palmer, 1999) and internalizing symptoms
compared with adolescent self-report (Verhulst & Van der Ende, 1992). This might be
especially pronounced in a disaster context; adolescents may try to hide their distress in
order not to upset their parents. Similarly, social support as experienced by an individual
appears to bear a stronger relationship with well-being than objective measures of support
(Bal et al., 2003). Thus, we had good reasons for relying on adolescent self-report, but still,
the role of shared method variance must be considered in accounting for the associations
among the variables.
Notwithstanding these limitations, the present findings suggest that individual char-
acteristics have the greatest prognostic value and support the importance of early
assessment of personality and coping responses among those exposed to a traumatic event.
A second implication is that one of the ways to prevent negative effects of traumatic events
is to ensure that adolescents receive enough support. However, in a context of community
disaster, victimization is shared and it is likely that those who should provide support are
victims as well. Research has shown that social and community resources tend to
deteriorate after a disaster (Kaniasty & Norris, 1995; Norris & Kaniasty, 1996). In
addition, responding to the distress of traumatized adolescents requires a high skill of
balancing adolescents’ need for comfort and support on the one hand, and stimulating their
normative developmental need for autonomy and independence on the other hand.
 Traumatic symptoms 385

Nevertheless, of the assessed factors, social support is the only one that can be influenced
after a disaster has occurred. Therefore, efforts should be made to identify the ways in
which the primary social environment can help prevent the negative consequences of a
traumatic experience.

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