Journal of Neonatology & Clinical Pediatrics Category: Clinical Type: Research Article

Risk Factors for Post-Traumatic Stress Disorder among Young Syrian Refugee Children in Jordan

Mohamed Sellouti1*, Hariri El Mehdi2, Jaouad Nguadi3 and Aomar Agadr1
1 Department Of Pediatrics, Mohammed V Military Teaching Hospital, Rabat, Morocco
2 Department Of Pedodontics, Mohammed V Military Teaching Hospital, Rabat, Morocco
3 Department Of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco

*Corresponding Author(s):
Mohamed Sellouti
Department Of Pediatrics, Mohammed V Military Teaching Hospital, Rabat, Morocco
Tel:+212 660627466,
Email:msellouti@gmail.com

Received Date: Aug 05, 2020
Accepted Date: Aug 10, 2020
Published Date: Aug 18, 2020

Abstract

Background 

Although millions of the world’s children, who account for most of the world’s refugees, there are few studies which investigate mental wellbeing of young children living in the camps of Syrian refugees in Zaatari. 

Methods 

A prospective, descriptive study was conducted at Moroccan military medical-surgical field hospital in Syrian refugee camp in Zaatari over a 3 month period from January 1st, 2015 till Mars 31st 2015. The sample in this study is comprised 200 syriens children 3 to 6 years of age, lived in Daraa in the south of syria and exposed to daily war-related trauma. Mothers were interviewed using the following instruments: Arabic version of the PTSD questionnaire and Spence Children’s Anxiety Scale. 

Results 

PTSD was diagnosed in 42% of war-exposed children (n=82). This prevalence was higher in young female compared with males (P=0.001). Children with PTSD exhibited multiple posttraumatic symptoms and substantial developmental regression. Children with PTSD have more pronounced psychological and behavioral problems (r=0.29; P < 0.001) compared to the children without PTSD. 

Conclusion 

Young children exposed to wartime trauma are a risk of developing a severe posttraumatic profile and more psychological and behavioral problems, which highlights the need to establish programs for this children to enhance refugee children’s mental health.

INTRODUCTION

Syrian war which in its ninth year now is an armed conflict in progress. It begins in the context of the Arab Spring with predominantly peaceful demonstrations in favor of democracy against the regime, syrien citizens have been exposed to extraordinary physical, psychological and emotional challenges. 

Due to these challenges, the majority of syrien face and may suffer from varying aspects of a range of psychological disorders; but children, due to the neurological system, are even more sensitive and susceptible to shocks. 

Overpowering evidence exists that refugees have an increased prevalence of mental disorders, including Post-Traumatic Stress Disorder (PTSD), depression and anxiety [1]. Child and adolescent refugees, who account for more than half of the world’s refugees, have a higher prevalence of mental disorders than children and adolescents who are not refugees [2]. Impaired psychological health in refugee children and adolescents can be largely attributed to war experiences, stresses in transition such as detention, postmigration stressors and acculturation difculties [3]. 

Many studies showed high rates of PTSD and depression among young children of concentration camps [4]. Studies conducted in Palestine, Lebanon, Iraq and Syria have shown increased rates of Post-Traumatic Stress Disorder (PTSD), depression, anxiety disorders and enuresis among refugee minors [5-8]. 

It is now well established from a variety of studies that traumatic events related to war had a negative impact on individual well-being in all ages, especially children [9]. 

The aim of this study is to understand the effect of war and related traumatic events on the psychological well-being of child survivors. We also aimed to investigate the relationship between war trauma, anxiety and PTSD among preschool children.

METHODS

Participants and procedure 

A prospective, descriptive study was conducted at Moroccan military medical-surgical field hospital in syrian refugee camp in Zaatari over a 3 month period from January 1st, 2015 till March 31st, 2015. 

Zaatari is a refugee camp in Jordan, located some kilometers south of the border with Syria. It is the world’s largest camp for Syrian refugees. It was first opened on July 2012 to host Syrians fleeing the violence in the ongoing Syrian Civil War that erupted in March 2011. The camp sheltered 78,357 refugees from Syria in October 2018, of whom nearly 20% were under five years old. 

Cases were recruited at the time of the pediatric consultation of during the study period. It was planned to reach all of the children between ages 3 to 6. Mothers of the selected children received a written form to sign explaining the study purpose and stressing that the data will be kept with the researchers for scientific research and their confidentiality and that of their children, was ensured. The mothers were interviewed by nurses inside the hospital with interview lasting 30 minutes. Research documents were sent to parents by
teachers. We excluded eight forms because of missing data. 

Instruments

General demographic questionnaire: Designed for the purpose of this study which included general demographic data: Gender, age, number of siblings, area of residence and monthly family income. 

Child PTSD Symptoms Scale (CPSS) : Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that may result from a strong emotional reaction to an extraordinarily stressful event [10]. The scale measures the frequency of symptoms of stress disorders, addressing how often a child has suffered from a particular
symptom over the past two weeks prior to the date of data collection. Using a 4-point scale ranging from 0 = not at all to 3 = five or more times a week, mothers rated the frequency with which the child demonstrated each of the 17 items, corresponding to the DSM-IV PTSD symptoms. Respondents rate the frequency of occurrence of 17 items, which results in a scale ranging from 0 to 68 (the higher the score, the more severe are the symptoms of PTSD) [11]. 

Spence Children’s Anxiety Scale (SCAS): A specialized version of the test (The Preschool Anxiety Scale) was adapted from the Spence Children's Anxiety Scale (SCAS) by Spence [12]. The Arabic version of the scale was used in the current study consisted of a list of 28 items that describe anxiety in preschool children. The preschool SCAS has a maximum score of 112, with the following items: Generalized anxiety [1,4,8,13], social anxiety [2,5,11,14-16], separation anxiety [6,12,17-19], obsessive-compulsive disorder [3,9,20-22] and personal injury fear [7,10,23-27]. The parent should answer all the items as well as she/he can, even if some do not seem to apply to her/his child. Each question on the test addresses the frequency of certain anxiety symptoms, measured on a 0-3 scale from "never", "sometimes", "often" to "always".

STATISTICAL ANALYSIS

Statistical analyses were performed using SPSS version. The χ2 test was used for the comparison of the proportions. Multivariate analysis using binary logistic regression was used to determine factors associated with moderate to severe PTSD. P < 0.05 was considered statistically significant.

RESULTS

Characteristics of the sample 

A total of 200 young syrien refugee were included in the main analysis of this study s (20% males and 80% females). Age of participants ranged from 3 to 6 years with a mean (SD) of 3.5 (1.5). The length of stay in Jordan was 13-24 years for 50% of children. Almost all cases were living with their parents, while four children were separated from their parents and were living with their relatives. Table 1 shows the socio-demographic characteristics of Syrian children. 

Characteristics

Number

Percentage

Age (years)

3-4

75

37.5

5-6

125

62.5

Gender

Boys

40

20

Girls

160

80

Sibling

   

4 and less

60

30

5-7

78

39

8 and more

62

31

Family monthly income (dollar)

Less than 200

64

32

200-300

90

45

300 and more

46

23

length of stay in jordan (month)

3-6

38

29

7-12

43

21

13-24

119

50

Having relatives in Jordan

Yes

99

49.5

Non

101

50.5

Fathers education

Primary school

49

24.5

High school

100

50

University

51

25.5

Mothers education

Primary school

93

46.5

High school

79

39.5

University

28

14

Table 1: Demographic and clinical characteristics of the young children.

Prevalence of PTSD 

Results showed that n=84 children (42%) had moderate to severe PTSD. The rate was significantly higher among females compared with males (45.6% vs. 27.5%). The severity of posttraumatic stress disorder among males and females is shown in tab II. The prevalence of moderate to severe PTSD disorder among young Syrian children according to gender and other variables is shown in table 2. Significant differences in total PSTD and subscales according to number of siblings, Mothers’ education, Total family income were found. 

Variable

No to moderate

PTSD

Moderate to severe PTSD

P value

N % N %

Age(Years)

3-4

46

61.3

29

38.7

0.0001

5-6

38

30.4

87

69.6

 

Gender

Male

11

27.5

29

72.5

0.038

Female

73

45.6

87

54.4

 

Family monthly income

Less than 200

14

21.9

50

78.1

0.0001

200-300

40

44.4

50

55.6

 

300 and more

30

65.2

16

34.8

 

Length of stay in Jordan (month)

3-6

32

84.2

6

15.8

0.0001

7-12

28

65.1

15

34.9

 

13-24

24

20.2

95

79.8

 

Having relatives in Jordan

Non

29

28.7

72

71.3

0.0001

Yes

55

55.6

44

44.4

 

Sibling

4 and less

30

50

30

50

0.0001

5-7

42

53.8

36

46.2

 

8 and more

12

19.4

50

80.6

 

Fathers education

Primary school

18

36.7

31

63.3

0.57

High school

42

42

58

58

 

University

24

47.1

27

52.9

 

Mothers education

Primary school

24

25.8

69

74.2

0.0001

High school

45

57

34

43

 

University

15

53.6

13

46.4

 

Table 2: Prevalence of PTSD among young children.

Risk factors associated with PTSD 

Table 3 shows the results of the multiple logistic regression analysis of factors associated with PTSD disorder among young syrian refugees. Compared with male Syrian adolescents, female adolescents were significantly more likely to have moderate to severe PTSD (OR=1.31). The prevalence differ significantly between children according to their family size and housing status (8 and more). 

Variable

Number =200

 OR (IC 95%)

 P value

Age (years)

3-4

5-6

 

75

125

 

 

2.86 (1.25-6.51)

 

 

0.012

Family monthly income (dollars)

Less than 200

200-300

300 and more

 

64

90

46

 

3.08 (0.84-11.25)

3.27 (1.11-9.56)

 

0.077

0.088

0.03

Length of stay in Jordan (month)

3-6

7-12

13-24

 

38

43

119

 

 

0.032 (0.01-0.107)

0.15 (0.062-0.39)

 

 

0.0001

0.0001

Sibling

4 and less

5-7

8 and more

 

60

78

62

 

 

0.49 (0.15-1.60)

0.29 (0.08-0.96)

 

 

0.24

0.04

Having relatives in Jordan

Yes

Non

 

99

101

 

0.33 (0.14-0.77)

 

0.011

Gender

Male

Female

 

40

160

 

1.31 (1.09-3.9)

 

0.34

Table 3: Multivariate analysis of factors associated with PTSD among Young children Syrian refugees according to the Child Post-traumatic Stress Disorder Symptom Scale.

Relationship between PTSD and anxiety 

Pearson correlation test was conducted to find the association between PTSD and anxiety. Results showed that there was significant association between total traumatic events reported by children and total anxiety (r=0.29, p=0.0001).

DISCUSSION

While the numbers of young children around the world growing up in the wake of armed conflict appear to increase each decade, very little is known about the psychological functioning and mental health illnesses, of young children exposed to war-related trauma over a lengthy period. This study examines the relationship between war trauma, anxiety and PTSD on a large sample of children exposed to war and investigates risk factors facing Syrian refugee kids in Jordan. 

The results showed that 42% reported mild to moderate and 58% reported moderate to severe PTSD. Several other studies also reported high rates of PTSD and depression among Palestinian in the Gaza Strip [23], adolescent during Lebanon civil wars [13] and Syrian refugee schoolchildren living in a German camp [14]. On the other hand, this prevalence was higher compared with that among Syrian adolescent refugees residing in Turkey or other countries. We can not generalise our fndings to all refugee children because of the sample selection. 

Females children compared with males, were more likely to have moderate to severe PTSD. Such findings were inconsistent with previous studies of older children, which suggested that boys were more traumatized than girls [17]. Females are generally more exposed to physical or sexual trauma during wars or conflicts and the psychological impact of such trauma is much more upon females than males, especially in conservative eastern communities. However, traumatic events may influence girls and boys in different ways, The male children move freely and go here and there, but female children connected to their mothers and stay at home [24]. 

The age group of 5-6 year are more PTSD symptom than the other ages. Studies showed that children under age six rarely possess the verbal ability to relay symptomology associated with previous PTSD diagnostic criteria. Such findings consistent with study data being analyzed which showed that very young children cannot describe traumatic events because their cognitive abilities to appraise the meaning of the traumatic events are not as developed as those of older children. We think that the accumulation of long-lasting traumatic events such as living in a war-torn area, resilience capacities of every person may break down that make it hard to observe unique reactions [15,20,21,25]. 

This study showed that young children with eight siblings or more were more likely to have moderate to severe PTSD symptoms. Such findings were consistent with a study which found that children who lived with many siblings were more likely to meet the criteria for PTSD diagnostic [18]. 

Having a less educated father was also a predicting factor for more emotional problems in children. Similar fndings were also reported which emphasized the importance of psychosocial well-being of parents on the mental wellbeing of their kids [16]. Fathers with a higher education level may have better-coping strategies or may be more successful in maintaining a supportive milieu that might be protective for their children [26]. 

Our study showed that there were significant differnces in total PSTD according to family monthly income. Total PTSD was more in families with monthly income less than 200 Dollars. The families with high income satisfied positively with different types of traumatic events, because they were able to secure the basic life, but the families with low income have intensified problems in addition to traumatic problems. The current study consistent with the results of Thabet et al that found children coming from families with incomes of less than 300 dollars/month, living in a city, whose parents had less than elementary education were found to suffer more frequently from PTSD [19]. 

Our results showed that there was significant correlation between total traumatic events reported by children and total anxiety and with total PTSD, which was also consistent with most of the studies conducted on children in Gaza and other areas [22,27].

CONCLUSION

This study pointed out high prevalence rates of emotional and behavioural problems among young Syrian, years afer resettlement in Jordan. Results also showed high exposure rates to severe traumatic events during the war. Despite high rates of psychological problems that may diminish their social functioning, none of the children was able to reach mental health care services due to several barriers. We think that mental health of refugee children is a public health crisis that requires the collaboration of international community and policymakers to support mental health providers in undeveloped countries.

LIMITATIONS

It is required to acknowledge several limitations of our study. Mothers were not sufficient for accurately assessing the psychological disorders of their children. Psychological assessment of children requires multiple informants and careful observation of the child. Another limitation of this study was the absence of a suitable control group of unaffected children.

CONFLICT OF INTEREST STATEMENT

The authors disclosure no conflict of interests.

INFORMED CONSENT

Informed consent was obtained from all the parents participated in the study.

REFERENCES

  1. Steel Z, Chey T, Silove D, Marnane C, Bryant RA, et al. (2009) Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass con?ict and displacement: A systematic review and meta-analysis. JAMA 302: 537-549.
  2. Bronstein I, Montgomery P (2011) Psychological distress in refugee children: A systematic review. Clin Child Family Psychol Rev 14: 44-56.
  3. Fazel M, Reed RV, Panter-Brick C, Stein A (2012) Mental health of displaced and refugee children resettled in high-income countries: Risk and protective factors. Lancet 379: 266-282.
  4. Kinzie JD, Sack WH, Angell RH, Manson S, Rath B (1986) The psychiatric e?ects of massive trauma on Cambodian children: I. The children. J Am Acad Child Adolesc Psychiatry 25: 370-376.
  5. Tabet AAM, Tawahina A, el Sarraj E, Vostanis P (2008) Exposure to war trauma and PTSD among parents and children in the Gaza strip. Eur Child Adolesc Psychiatry 17: 191-199.
  6. Farhood L, Dimassi H, Lehtinen T (2006) Exposure to war-related traumatic events, prevalence of PTSD, and general psychiatric morbidity in a civilian population from Southern Lebanon. J Transcult Nurs 17: 333-340.
  7. Ahmad A (2008) Posttraumatic stress among children in Kurdistan. Acta Paediatr 97: 884-888.
  8. Ibrahim H, Hassan CQ (2017) Post-traumatic stress disorder symptoms resulting from torture and other traumatic events among Syrian Kurdish refugees in Kurdistan Region, Iraq. Front Psychol 8: 241.
  9. Miller KE, Jordans MJ (2016) Determinants of Children’s Mental Health in War-Torn Settings: Translating Research Into Action. Curr Psychiatry Rep 18: 1-6.
  10. King, Daniel W, Leskin, Gregory A, King, et al. (1998) Confirmatory factor analysis of the clinician-administered PTSD scale: Evidence for the dimensionality of posttraumatic stress disorder. Psychological Assessment 10: 90-96.
  11. In order to be able to use the CPSS in the Yemeni context, two translators (Arabic/English) with a background in psychology translated the questionnaire into Arabic and - for control reasons - back into English.
  12. Spence SH, Rapee R (1999) Preschool anxiety scale (parent report). Brisbane, Australia: University of Queensland.
  13. Shaar K (2013) Post-traumatic stress disorder in adolescents in Lebanon as wars gained in ferocity: A systematic review. J Public Health Res 2: 17.
  14. Soykoek S, Mall V, Nehring I, Henningsen P, Aberl S (2017) Post-traumatic stress disorder in Syrian children of a German refugee camp. Lancet 389: 903-904.
  15. Pynoos R (1990) PTSD in children and adolescent. In: Garfinkle B, Carlson G, Weller B (Eds.). Psychiatric Disorders in Children and Adolescents. Pg no: 48-63.
  16. Yal?n ?S, Uzel BT, Öztürk M, Gözaçanlar Ö, Yörük GÜ, et al. (2017) Immigration-related mental health disorders in refugees 5-18 years old living in Turkey. Neuropsychiatr Dis Treat 13: 2813-2821.
  17. Thabet AA, Karim K, Vostanis P (2006) Trauma exposure in pre-school children in a war zone. Br J Psychiatry 188: 154-158.
  18. Franz L, Angold A, Copeland W, Costello EJ, Goodman NT, et al. (2013) Preschool Anxiety Disorders in Pediatric Primary Care: Prevalence and Comorbidity, Child Adolesc Psychiatry 52: 1294-1303.
  19. Dawas M, Thabet AA (2017) The relationship between traumatic experience, posttraumatic stress disorder, resilience, and posttraumatic growth among adolescents in Gaza Strip. Glob J Intellect Dev Disabil 5: 2017.
  20. Dyregrov A, Yule W (2006) A review of PTSD in children. Child Adolesc Ment Health 11: 76-184.
  21. Green BL, Grace M, Vary MG, Kramer T, Gleser GC, et al. (1994) Children of disaster in the second decade: A 17-year follow-up of Buffalo Creek survivors. J Am Acad Child Adolesc Psychiatry 33: 71-79.
  22. Edwards SL, Rapee RM, Kennedy S (2010) A prospective examination of risk for anxiety symptoms in preschool aged children. J Child Psychol Psychiatry 51: 313-321.
  23. Neria Y, Bravova M, Halper JM (2010) Trauma and PTSD among civilians in the Middle East. PTSD Res Quart 21: 1-8.
  24. Kolltveit S, Lange?Nielsen II, Tabet AAM, Dyregrov A, Pallesen S, et al. (2012) Risk factors for PTSD, anxiety and depression among adolescents in Gaza. J Trauma Stress 25: 164-170.
  25. El Bedour S, Bensel R, Maruyama GM (1993) Children at risk: psychological coping with war and conflict. Int J Ment Health 22: 33-52.
  26. Eruyar S, Maltby J, Vostanis P (2018) Mental health problems of Syrian refugee children: The role of parental factors. Eur Child Adolesc Psychiatry 27:401-409.
  27. Thabet AA, Ashraf AK, Vostanis P (2014) Prevalence of depression and anxiety in preschool children and Palestinian mothers' mental health. Arab J Psychiatry 25: 61-70.

Copyright: © 2020  Mohamed Sellouti, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

© 2021, Copyrights Herald Scholarly Open Access. All Rights Reserved!