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Exposure to war trauma and PTSD
Thabet A.A., Consultant Child and Adolescent Psychiatrist & Senior Researcher
*Panos Vostanis, Professor of Child and Adolescent Psychiatry, University of Leicester, Greenwood Institute of Child Health, Westcotes House, Westcotes Drive, Leicester LE2 OQU, UK
* Correspondence
Purpose: Exposure to war trauma has been independently associated with posttraumatic stress (PTSD) and other emotional disorders in children and adults. The aim of this study was to establish the relationship between ongoing war traumatic experiences, PTSD and anxiety symptoms in children, accounting for their parents equivalent mental health responses.
Key words: War, trauma, parents, child, PTSD, anxiety Introduction
Children directly or indirectly exposed to war and conflict experience a variety of stressors, and develop both short-term and long-term post-traumatic stress reactions [4]. Common symptoms and reactions in the aftermath of a traumatic event include sadness, anger, fears, numbness, feeling jumpy or jittery, moodiness or irritability, change in appetite, difficulty in sleeping, nightmares, avoidance of situations that are reminders of the trauma, impairment of concentration, and guilt because of survival or lack of harm during the event [3, 38].
A number of studies have found a high prevalence of post-traumatic stress disorders (PTSD) among children exposed to war trauma, state-sponsored terrorism, or interpersonal violence. For example, a recent epidemiological study in countries exposed to widespread political trauma estimated that the prevalence of lifetime PTSD is 37% in Algeria, 28% in Cambodia, 16% in Ethiopia, and 18% in Gaza [7]. The latter area in the Middle East has been subject to several studies on children’s recollection of trauma experiences and their impact on their mental health. For example, the most common traumatic events reported by Palestinian children were, seeing victims’ pictures on television, and witnessing bombardment and shelling, with between one-third and half of the children in different samples fulfilling criteria for PTSD [25, 35]. They were also likely to present with high rates of anxiety or depressive disorders [34, 35]. Similar evidence on the impact of war trauma has been established for adults by a number of studies [7]. For example, in a study of Rwandans, 24.8% of adults met symptom criteria for PTSD [22]. In a cross-sectional survey of war survivors who had experienced war-related stressors (combat, torture, internal displacement, refugee experience, siege, and/or aerial bombardment) in former Yugoslavia, participants reported experiencing a mean of 12.6 war-related events, with 22% and 33% having current and lifetime posttraumatic stress disorder (PTSD), respectively, and 10% current major depression [5]. Some studies aimed to identify mediating factors in the association between war trauma and other disorders among children. PTSD rates were particularly prominent if children had been displaced from their community, for example during the conflicts in Croatia and Bosnia [2, 15]. Both the type and the amount of the exposure are important [15, 20]. Other risk factors associated with PTSD symptomatology include proximity to the zone of impact [19, 24], degree of life threat [20, 23], and underlying socioeconomic hardship [14]. The effect of parental and family variables has also been investigated. Children exposed to war conflict have been found to be protected by family cohesion [16, 17], positive home environment, and mothers’ perceptions of a functional family [42]. Previous studies have established an association between parents’ and children’s general psychopathology following war and political conflict [10, 26, 30]. This relationship can vary at different stages in the child’s development [41]. Recent studies have specifically examined the mechanisms underlying links in PTSD symptoms within families. Qouta et al. [25] suggested that the impact of maternal responses on children is different for the PTSD subscales of intrusion and avoidance. The aim of this study was to establish the relationship between exposure to trauma on parents’ and children’s PTSD and other anxiety symptoms; also, to investigate whether this relationship between trauma exposure and child psychopathology varies for different types of symptomatology. Methods Setting and Sample The Gaza Strip is a narrow elongated piece of land, bordering the Mediterranean Sea between Israel and Egypt, and covers 360 km2. It has high population density. About 17% of the population lives in the north of the Gaza Strip, 51% in the middle, and 32% in the south area. There is high unemployment, socioeconomic deprivation, family overcrowding, and short life expectancy. Nearly two-thirds of the population are refugees, with approximately 55% living in eight crowded refugee camps. The remainder lives in villages and towns. Since September 2005, the population of the Gaza Strip has been exposed to regular incursions and shelling, resulting in at least 200 deaths and many more injuries, in the last six months alone. The study population included 100 families living in areas exposed to shelling, in the north and east of the Gaza Strip. Families with two children aged from 9-18 years were included. A total number of 200 parents and 197 children agreed to take part in the study. Families were selected randomly from two villages, one camp, and one city. The selection was based on the closeness of the area to regular shelling, which was defined as households within visible distance of shelling (dust and pieces of shells). One street was selected in each area, and every other household that fulfilled the family selection criteria. In larger buildings, one flat from each floor was selected (area of Beit Lahia). Families were included if they consisted of both parents, with one boy and one girl, aged between 9-18 years, and had been in the area for the last year. Families were approached until 100 agreed to participate. The data collection was carried out by three trained professionals, under the supervision of the first author. The data was collected during June 2006. Families were interviewed in their homes. One of the difficulties of this study was that, throughout the interviews, there was frequent shelling of the selected areas, for which reason the interviews had to be discontinued and repeated later. Measures Children ● The Gaza Traumatic Events Checklist was used, describing the most common traumatic experiences families could have faced in the Gaza Strip, including shelling of their area of residence. The checklist was revised from a version used in earlier research [34, 35], adapted for the nature of traumatic events occurring during the current period. ● The Children’s Revised Impact of Events Scale (CRIES-13) [12, 29] measured symptoms of post-traumatic stress disorder (PTSD). This included all 8 items of the original Impact of Events Scale, as well as 5 items derived from the arousal criteria in the DSM-IV classification [3]. Individual items were rated according to the frequency of their occurrence during the past week (none = 0, rarely = 1, sometimes = 3, a lot = 5) and in relation to a specific traumatic events written at the top of the scale. In this study the revised IES was translated from English to Arabic and back translated. A cut-off score of 30 and above has been found to indicate the likelihood of presence of PTSD [21]. A total score was provided, as well as subscales scores for intrusion, arousal and avoidance PTSD symptoms. ● The Revised Children’s Manifest Anxiety Scale (RCMAS) [27] is a standardised 37-item self-report questionnaire for children of 6-19 years of age (21) It measures the presence or absence of anxiety-related symptoms (‘yes’/‘no’ answers) in 28 anxiety items and 9 lie items. A cut-off total score of 19 has been found to predict the presence of anxiety disorder [28]. ● The Strengths and Difficulties Questionnaire (SDQ) [11] was completed by parents on their children’s behavioural and emotional functioning. This standardised questionnaire includes 25 items on a 0-2 scale. The 25 SDQ items are grouped in the scales of hyperactivity, emotional, conduct, and peer relationships problems, as well as a prosocial scale. A score is estimated for each scale and a total difficulties score for the four problem scales. The SDQ has previously been used in the Gaza child population by the research group [36]. Parents ● The Gaza Traumatic Checklist was also completed with parents. This included the same items as for children. ● The Posttraumatic Stress Disorder Checklist for parents contains 17 items adapted from the DSM-IV [3] PTSD symptom criteria. Respondents are asked to rate on a 5-point Likert scale (1 = not at all to 5 = extremely) the extent to which symptoms troubled them in the previous month. A total score was provided, as well as subscales scores for intrusion, arousal and avoidance PTSD symptoms. ● The Taylor’s Manifest Anxiety Scale (MAS) [32], which measures symptoms of chronic anxiety. We used the Arabic version [31] with 50 items rated as ‘yes’/‘no’. Scores can be classified as 0-26 (no anxiety), 27-32 (mild anxiety), 33-40 (severe anxiety), and 41 and above (very severe anxiety). The latter two categories were grouped together as indicating anxiety symptoms of clinical significance. Results Sociodemographic data The boys’ mean age was 12.8 years (SD = 2.5), and the girls’ mean age was 13.2 (SD = 2.51). Palestinian families consisted of large number of children, as 39 (19.5%) had 4 or less children, 92 families (46.0%) had 5-7 children, and 69 families (34.5%) had 8 or more children. Forty-eight children (24%) lived in the city, 102 (51%) lived in villages, and 50 children (25%) lived in refugee camps. The fathers’ mean age was 43.6 years (SD = 7.14), and mothers’ mean age was 39.48 years (SD = 6.83). The majority of families (130, or 65.0%) had a very low monthly income of less than $265, 27 families (13.5%) had an income of $271-560, and 43 families (21.5%) had a monthly income of more than $560. Traumatic events experienced by children The most frequently reported traumatic events were, watching mutilated bodies and wounded people on TV (98.5%), witnessing signs of shelling on the ground (94.9%), and hearing shelling of the area by artillery (92.9%) (Table 1). Children experienced a mean number of 8 traumatic events (SD = 2.55). Boys were more significantly exposed to trauma than girls (Mann-Whitney test: z=1.95, p=0.050). Children in high income families experienced significantly less traumatic events than the other two income groups (Kruskal-Wallis test, chi-square 9.18, df=2, p=0.010). There was no association between children’s age and exposure to trauma (Spearman rank correlation r=-0.071, p=0.32). Insert Table 1 about here
Children’s psychopathology and association with trauma exposure The mean scores on the mental health measures are presented in table 2. Children reported different reactions to traumatic events on the CRIES-13, the most common reactions being: insomnia (40.5%), exaggerated startle (39%), and trying to remove memories from their mind (39%). Considering the CRIES-13 cut-off score of 30 [29], 138 children out of 197 (70.1%) were likely to present with PTSD, or 69% of the boys and 71.1% of the girls. Insert Table 2 about here
According to a cut-off score of 19 or more on Revised Children’s Manifest Anxiety Scale, 35 children (33.9%) were rated as having anxiety symptoms of likely clinical significance. According to a SDQ cut-off score of 17 or above, 77 children (42.7%) were rated as having significant mental health morbidity by their parents. Children living in inner-city areas were rated significantly higher on total SDQ scores (broad mental health problems) – K Wallis test: chi-square=6.25, df=2, p=0.044). Children’s age was associated with only one psychopathology measure, i.e. inversely correlated with avoidance scores (r=-0.22, p=0.002). In a univariate linear regression analysis, exposure to traumatic events was significantly associated with PTSD symptoms (CRIES-13 scores): B=1.31, 95% CI=0.48-2.13, p=0.002. When this analysis was repeated separately for each PTSD subscale, the association remained significant for intrusion symptoms (B=1.11, p<0.001), avoidance (B=0.36, p=0.047), and arousal symptoms (B=0.86, p<0.001). When each traumatic event was entered as an independent variable in a multiple regression model, with total CRIES-13 scores as the dependent variable, no single traumatic event was significantly associated with PTSD symptoms. The number of experienced traumatic events was also associated with total anxiety (RCMAS) scores: B=0.53, 95% CI = 0.17-0.89, p=0.004. In contrast, trauma exposure was not associated with general mental health problems (SDQ total scores): B=0.070, 95% CI=-0.57 to 0.43. Traumatic events experienced by parents Parents reported similar frequencies of traumatic events to their children (Table 1). The most common traumatic events were, watching mutilated bodies and wounded people on TV (98.5%), witnessing the signs of shelling on the ground (95%), hearing the sonic sounds of the jetfighters (94%), and witnessing bombardment of other homes by airplanes and helicopters (93%). Parents reported a mean number of 8.5 traumatic events (SD = 1.68). As among children, parents in the high income group experienced less traumatic events than the other two income groups (K-Wallis test: chi-square=11.69, df=2, p=0.03). Parents and children’s ratings of exposure to trauma were significantly correlated (Spearman coefficient 0.25, p<0.001). Parents’ psychopathology and association with trauma exposure
Parents’ and children’s ratings of PTSD symptoms were significantly correlated for the intrusion (Spearman r=0.34, p<0.001) and arousal subscales (r=0.29, p<0.001), but not for the avoidance subscale (r=0.009, p=0.90), which explains the overall lack of association on total PTSD scores (r=0.10, p=0.15). Parents’ and children’s anxiety scores were also significantly correlated (r=0.30, p<0.001). In a univariate linear regression analysis, and unlike their children, trauma exposure was not associated with total PTSD scores in parents: B=0.72, 95% CI=-0.20 to 1.63, p=0.12). This was not the pattern for all PTSD subscales, when the analysis was repeated with each subscale score as the dependent variable. Trauma exposure was associated with intrusion symptoms (B=0.32, p=0.044), but not with avoidance (B=0.05, p=0.84) or arousal symptoms (B=0.24, p=0.20). When each traumatic event was entered as an independent variable in a multiple regression model, with total PTSD scores as the dependent variable, two events were significantly associated with parents’ PTSD symptoms:
The total number of experienced traumatic events was not associated with anxiety symptoms in parents (B=0.21, 95% CI=-0.34 to 0.75, p=0.45). Relationship between trauma exposure, parental and child psychopathology The association between trauma exposure and either PTSD or anxiety symptoms in children, was subsequently tested accounting for equivalent parents’ responses, in two multiple linear regression models. Children’s PTSD symptoms were predicted by both trauma exposure (B=1.36, 95% CI=0.54-2.17, p=0.001) and parents’ PTSD scores (B=0.18, 95% CI=0.038-0.33, p=0.014) (Table 3). Similarly, children’s anxiety symptoms were predicted by both trauma exposure (B=0.39, 95% CI=0.07-0.73, p=0.018), and parents’ anxiety scores (B=0.30, 95% CI=0.21-0.39, p<0.001). The addition of parents’ gender or the children’s age as a covariate did not alter the findings. Insert Table 3 about here
Discussion As with other types of acute and chronic trauma, exposure to war and political conflict has been found to independently impact on adults’ and children’s mental health, predominantly associated with internalising disorders such as PTSD, anxiety and depression. Studies in recent years also indicated the association between parental and child responses [26, 30], although little is known on the underlying mechanisms, i.e. whether these are the same as for other types of trauma [9], or whether different mechanisms operate for different types of psychopathology. This study explored further this relationship in relation to PTSD and anxiety symptoms among Palestinian exposed to shelling and other forms of military violence. One difference from previous studies was that exposure to trauma was ongoing during the data collection, rather data on mental health symptoms being collected after the cessation of conflict. This might be relevant to some of the findings, particularly those concerning parents’ responses. Exposure to war trauma was significantly associated with all measures of PTSD, including its three subscales, and with anxiety. The impact appeared related to the total number and severity of events, without any single event predicting PTSD symptoms. The lack of association with general mental health problems, predominantly of behavioural and social nature, as measured by the SDQ, was not surprising, as such generic measures usually reflect longstanding problems related to parenting, school or developmental difficulties, rather than acute trauma-induced distress [36, 39]. Both parents and children had experienced high rates of similar events, which indicate that children are affected directly by exposure to trauma, rather than merely through adults’ recollection. Unlike earlier studies, the most common traumatic event in recent research with this population [33], has been watching mutilated bodies on television. This finding indicates the major effect of media on families and their children, as Palestinian families spend increasing time watching news and other programmes about the conflict, without alternative leisure or other activities. The pattern of parents’ and children’s emotional responses was somewhat different, i.e. trauma exposure was particularly associated with PTSD intrusion symptoms. Specific events, namely witnessing firing of their home by tanks and heavy artillery, and bombardment by aircrafts and helicopters, were found to have a specific impact on parents. In an earlier study, Laor et al. [17] found that families’ responses to a missile attack were explained by destruction of their house and displacement, rather than by mere distance from the missile impact. The nature of the traumatic events might have been implicated in the different mechanisms of affecting parents during this conflict. Qouta et al. [25] particularly highlighted the sudden and non-predictable violence that characterises the conflict in the Gaza Strip, i.e. shelling, bombardment and incursions; being prevented from helping wounded family members; and burying their dead with dignity and according to their religious rules. Although beyond the remit of this design, intrusion symptoms such as fears and nightmares might develop early as an acute response among people being in a continuous state of ‘high alert’, while avoidance symptoms might develop later, or in response to different types of traumatic situations. Like the Quota et al. study [25], this data was also collected during the conflict, which is different from most previous studies in the aftermath of military activities. In this conflict, the distinction between ‘primary’ and ‘secondary’ traumatisation may thus be less relevant than in other types of trauma exposure [6]. The rates of PTSD and anxiety symptoms among parents and children were of sufficient severity to require assessment and intervention. Parents’ and children’s scores were significantly correlated for PTSD intrusion and arousal (but not for avoidance), as well as for anxiety symptoms. Overall, parental responses were found to contribute to children’s PTSD and anxiety presentations. Previous studies established a stronger impact of maternal responses on younger (pre-school) children [16, 41]. Although we did not find age differences in this study, the sample was much older (9-18 years) than the previous cohorts. This study has a number of limitations. A longitudinal component may have helped understand better the changes in psychopathology among children and their parents, in relation to changes in trauma exposure. The inclusion of potentially mediating factors such as parenting ability, family functioning, support networks, coping strategies, and cultural perceptions of trauma or mental health [18], could also improve the understanding of such mechanisms. Involving parents in the assessment and intervention is important in promoting consistent strategies, responses to external adversities, and relative stability within the immediate family group, while avoiding if at all possible separation with their children [4]. This level of family input is not realistic for specialist mental health services in circumstances of widespread conflict [13], but could form the objective of non-governmental organisations (NGOs), as part of universal or targeted initiatives during and after the crisis. Families can be involved at different levels of phased psychosocial programmes, which aim at minimal disruption of protective factors, re-establishment of remaining protective factors, and provision of compensatory supports [1]. Group psychoeducational programmes are a cost-effective mean of reaching a large number of families by a limited number of staff. More focused interventions are also emerging and appear promising such as multi-family groups, combining education, support and therapeutic tasks [40]. Dybdahl [8] described and evaluated a psychosocial intervention for mothers following the war in Bosnia, whose aim was to promote young children’s development and well-being through parental involvement, support and education. Particular importance was attributed to the mother-child interaction during the healing process. Positive outcomes were established in several aspects of functioning, namely mothers’ mental health, children’s weight gain and psychosocial functioning. As such programmes inevitably target resettled populations, or the local community after termination of the acute conflict, when a considerable degree of safety and stability has been achieved, there is lack of evidence or consensus on whether and how to respond during external conflict, particularly when this is longstanding and there is no migration or significant population movement (such as the case of families in the Gaza Strip and the West Bank). In a previous trial during the same conflict, we found no significant difference in the impact of a relatively inactive group debriefing crisis intervention for children, compared to group education on post traumatic symptoms, or no intervention [37]. One potential explanation for this finding was the non-involvement of parents in the intervention, who may have maintained children’s emotional distress. This should be addressed by future studies. Acknowledgements We are grateful to the team who collected the data under shelling and enormous difficulties. Also, our many thanks to families and children who participated in this study, for their openness in sharing such difficult issues.
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