Post-traumatic stress disorder and its associated factors among school-going children exposed to the tsunami disaster in Malaysia
Key findings
46% of children aged 10–12 showed PTSD symptoms six months after the tsunami, with 3.7% experiencing severe PTSD.
Children with low social support were 2.3 times more likely to develop PTSD symptoms.
Children who experienced the death of someone close to them were 3.7 times more likely to develop PTSD.
Re-experiencing symptoms were the most common, affecting 91.8% of children with PTSD.
Background
Post-traumatic stress disorder is a psychiatric condition that can develop in anyone — including children — who experiences a severely traumatic event. Research consistently shows that individuals exposed to more severe forms of trauma tend to develop higher levels of PTSD symptoms. Children are considered particularly vulnerable because their cognitive and emotional coping mechanisms are still developing.
On 26 December 2004, a massive undersea earthquake off the coast of Sumatra triggered a tsunami that devastated coastal areas across Southeast Asia. In Malaysia, the northwestern coastline was hardest hit, with fishing villages in states such as Kedah and Penang sustaining significant damage. While Malaysia’s death toll was far lower than that of Indonesia, Sri Lanka, or Thailand, the communities directly affected — many of them small, rural, and economically vulnerable — experienced profound disruption to their lives.
Children in these communities were exposed to terrifying scenes: sudden flooding, destruction of homes and schools, injuries and deaths of family members and neighbours. Yet at the time of this study, very little research had examined the psychological impact of the tsunami on Malaysian children specifically. Understanding how these children were affected — and what factors made some more vulnerable than others — is essential for planning mental health responses to future disasters in the region.
Study design and methods
This cross-sectional study was conducted six months after the tsunami disaster in a rural area of Malaysia that was directly affected by the tsunami waves. The researchers recruited 219 children aged 10 to 12 years from the affected community.
PTSD symptoms were assessed using the Child Posttraumatic Stress Disorder – Reaction Index (CPTSD-RI), a validated screening instrument specifically designed for children. The tool was administered as a self-completed questionnaire by the affected children themselves. The CPTSD-RI measures symptoms across three core PTSD domains: re-experiencing (intrusive memories, flashbacks, nightmares), numbing and avoidance (emotional withdrawal, avoiding reminders of the event), and hyperarousal (heightened startle response, difficulty sleeping, irritability).
In addition to PTSD screening, the researchers collected data on potential associated factors including demographics, level of social support, degree of exposure to the disaster, and whether the child had experienced the death of someone close to them.
Results
PTSD prevalence
Almost half of the children studied — 46% — showed symptoms of PTSD six months after the tsunami. The severity breakdown revealed that the majority of affected children fell into the mild category, but a meaningful proportion experienced moderate to severe symptoms.
| PTSD severity level | Percentage of children |
|---|---|
| No PTSD symptoms | 54.0% |
| Mild PTSD | 31.1% |
| Moderate PTSD | 11.4% |
| Severe PTSD | 3.7% |
| Very severe PTSD | 0% |
Symptom patterns
Among children who showed PTSD symptoms, the three core symptom clusters presented at markedly different rates. Re-experiencing symptoms — such as intrusive memories of the tsunami, flashbacks, and distressing dreams — were by far the most common, affecting 91.8% of symptomatic children. This is consistent with broader PTSD research showing that re-experiencing is typically the earliest and most prevalent symptom cluster in trauma-exposed children.
Hyperarousal symptoms were the second most common, present in 49.3% of children. These symptoms include being easily startled, difficulty concentrating, irritability, and disturbed sleep. Numbing and avoidance symptoms, which include emotional withdrawal and deliberate avoidance of anything that reminds the child of the traumatic event, were found in 28.3% of children.
| Symptom cluster | Prevalence among affected children |
|---|---|
| Re-experiencing (flashbacks, nightmares, intrusive memories) | 91.8% |
| Hyperarousal (startled, difficulty sleeping, irritability) | 49.3% |
| Numbing/avoidance (emotional withdrawal, avoiding reminders) | 28.3% |
Risk factors
Two factors emerged as significant predictors of PTSD in the multivariate analysis. Children with low social support had 2.3 times the odds of developing PTSD symptoms compared to those with adequate social support (adjusted OR = 2.3, 95% CI: 1.3–4.2). Children who experienced the death of someone close to them — a family member, friend, or neighbour — had 3.7 times the odds of PTSD (adjusted OR = 3.7, 95% CI: 1.2–11.5).
The finding that social support is a protective factor against childhood PTSD has direct implications for disaster response. Ensuring that children have access to family, community, and school-based support networks in the aftermath of a disaster may significantly reduce their risk of developing lasting psychological harm.
Implications
This study demonstrates that Malaysian children are at substantial risk of developing PTSD following a natural disaster, with nearly half showing symptoms within six months of the tsunami. The research highlights two actionable findings for disaster preparedness and response planning.
First, the strong protective effect of social support suggests that post-disaster interventions should prioritise maintaining and strengthening children’s connections to family, peers, teachers, and community structures. Isolating children — through displacement, school closures, or separation from caregivers — may inadvertently increase their vulnerability to psychological harm.
Second, children who have lost someone close to them require targeted psychological support. Bereavement in the context of a traumatic event creates a compounded burden that generic disaster relief may not adequately address. School-based screening programmes using validated tools like the CPTSD-RI could help identify at-risk children early and connect them with appropriate mental health services.
The authors recommend longitudinal follow-up studies to determine whether these PTSD symptoms persist, resolve, or evolve over time — a question particularly important for informing the duration and nature of post-disaster mental health support for children.
Study context and limitations
This study focused on a single rural community in Malaysia affected by the 2004 tsunami. While the findings are consistent with international research on post-disaster PTSD in children, the results may not be directly generalisable to urban populations or to children exposed to different types of natural disasters such as floods, earthquakes, or landslides.
The cross-sectional design captured a snapshot at six months post-disaster but cannot establish whether the observed symptoms persisted, worsened, or improved over time. The use of a self-administered questionnaire among children aged 10–12 may also introduce some measurement variability, though the CPTSD-RI is a well-validated instrument for this age group.
Despite these limitations, the study provides valuable data on a topic that was previously under-researched in the Malaysian context, and its findings align with the broader body of evidence on childhood PTSD following natural disasters across Southeast Asia.