Post-traumatic stress reactions in children of war
Abdel Aziz Mousa Thabet and Panos Vostanis

Abdel Aziz Mousa Thabet: Gaza Community Mental Health Programme, PO Box 1049, Gaza, Palestine

Panos Vostanis) : Senior Lecturer in Child and Adolescent Psychiatry, University of Birmingham, Parkview Clinic, Queensbridge Road, Moseley, Birmingham B13 8QE, United Kingdom, Tel: 0121 243 2035, Fax: 0121 243 2036

Running head: PTSD in war children

The aims of this study were to estimate the rate of posttraumatic stress reactions in Palestinian children who experienced war traumas, and to investigate the relationship between trauma-related factors and PTSD reactions. The sample consisted of 239 children of 6 to 11 years of age. Measures included the Rutter A2 (parent) and B2 (teacher) scales, the Gaza Traumatic Event Checklist and the Child Post Traumatic Stress Reaction Index. 174 children (72.8%) reported PTSD reactions of at least mild intensity, while 98 (41%) reported moderate/severe PTSD reactions. Caseness on the Rutter A2 scale was detected in 64 children (26.8%), which correlated well with detection of PTSD reactions, but not with teacher-detected caseness. The total number of experienced traumas was the best predictor of presence and severity of PTSD. Intervention programmes for post-war children need to be evaluated, taking into account developmental and cultural aspects, as well as characteristics of the communities involved.

Key words: posttraumatic stress, war, trauma, children

Abbreviations: PTSD: post-traumatic stress disorder; CPTSD-RI: Child Post-Traumatic Stress Reaction Index

 Introduction

In the last 15 years, there has been substantial research in the phenomenology and prevalence of post-traumatic stress disorders (PTSD) in at risk groups of children from different ethnic groups and cultures. The majority of studies refer to young people exposed to natural catastrophic events, such as floods (with prevalence of 37% at postflood and 7% at 17 years - Green et al., 1994), and hurricane disasters (short-term prevalence of 3 through 9%: Shannon, Lonigan, Finch and Taylor, 1994; Garrison et al., 1995). Also, following earthquakes, with rates varying from 37% to 91%, depending on the proximity (Pynoos et al., 1993). Other researchers investigated children who had been exposed to community violence. Pynoos, Frederick and Nader (1987) studied children who had been exposed to a sniper attack at school. Nearly 40% were found to have moderate to severe PTSD. Fourteen months later, Nader, Pynoos, Fairbanks and Frederick (1990) assessed the same children and reported that 74% of those most severely exposed in the playground still reported high levels of PTSD, whereas 19% of unexposed children reported any degree of PTSD. Epidemiological studies differ in their methodology and instruments used (screening, interviewing, two-stage procedure) and their sample size.

Materials and Methods

Sample

The Gaza strip is an elongated area that stretches along the Mediterranean sea, between Israel and Egypt, covering 360 km². It is divided into five districts: North Gaza, Gaza city, Mid-zone, Khan Younis and Rafah. In 1995, the Gaza Strip population was 860.369, excluding returnees from abroad after the peace process. The Gaza Strip has a high population density of 2.150 people per km², which is an index of environmental adversity. The total refugee population is 62.6%. About 55.1% live in eight crowded camps and the remaining 44.9% live outside the camps in rural (villages) and urban areas (towns). In 1995, 50.8% of the population were under 15 years of age, i.e. another risk factor for child psychopathology.

 In the first stage (Thabet, unpublished data), 981 children of 6-11 years were selected by stratified quasi randomisation from the 97 Elementary schools of the five districts, to be screened by teachers for behavioural and emotional problems using the Rutter B2 Scale (Rutter, 1967). The return rate of the questionnaires was very high (97%). The number of children screened according to the original sample was 959. The >caseness= rates (i.e. possible presence of any mental health disorder) were calculated using previously established cut-off scores of 9 (Rutter, Tizard and Whitmore, 1970). There were 422 children (44%) who scored positive and 537 (56%) who scored negative.

 In the second stage, 25% of children were randomly selected for collection of self-reported and parent-rated data, while maintaining the ratio between positive:negative cases=44%:56%. The sample of this study therefore consisted of 239 children (105 positive and 134 negative cases). There were 129 boys and 110 girls.The mean age of the sample was 8.9 years (6-11). According to place of residence, 42 came from north of Gaza Strip (17.6%), 103 from Gaza city (43.1%), 30 from the Middle area (12.6%), 41 from the Khan Younis area (17.2%), and 23 from the Rafah area (9.6%). The majority attended state schools (N=227, or 95%), while 12 attended private schools (5%).

Methods

Rutter Scale A2 for compleby parents - Rutter, Tizard and Whitmore, 1970. This widely used and standardised measure of behavioural and emotional problems in epidemiological research has been found to correlate well with clinical interviews and to distinguish clinical from non-clinical subjects, with a high degree of sensitivity and specificity for children of 6-13 years. Different cut-off scores have been established according to sex and ethnic origin (Elander and Rutter, 1996). The scale consists of 31 items measuring behavioural and emotional problems on a 0-2 scale. Children with a total score of 13 or more have been found to be potential >cases=, i.e. presenting with a possible mental health disorder.

 Rutter Scale B2 for completion by teachers - Rutter, 1967. This is the equivalent 26-item form for teachers. Children with a total score of 9 or more have been found to be potential cases. The Rutter Scales A2 and B2 were translated into Arabic, following meetings with teachers and piloting of the translated version.

Gaza Traumatic Event Checklist (Abu Hein et al., 1993). The initial checklist was developed by the research department of the Gaza Community Mental Health Programme and consisted of 17 items covering different types of traumatic events that a child may have been exposed to (tear gas, beating, witnessing beating, breaking limbs, imprisonment, siblings= imprisonment, injury, night raids, humiliation, and detention). The checklist can be completed by children of 6-16 years (>yes= or >no= statements). Traumatic experiences can be classified as >few= (less than 5 traumatic events), >frequent= (5-9 events), or >many= (10 or more - Summerfield, 1993). A revised version of the checklist was used in this study, with 21 items. These included different sensory types of exposure to traumatic experiences, i.e. auditory, visual, or olfactory experiences (Table 1).

 Child Post Traumatic Stress Reaction Index (CPTSD-RI: Pynoos et al., 1987). The CPTSD-RI is a 20-item self-report scale designed to assess post-traumatic stress reactions of children of 6-16 years following exposure to a broad range of traumatic events (Frederick, 1985). The scale has been found valid in detecting PTSD according to DSM-III-R criteria (American Psychiatric Association, 1987). Inter-rater reliability for this instrument when administered by a clinician has been reported to be high, with a Cohen kappa of 0.87 for inter-item agreement (Pynoos et al., 1987). Items are rated on a 0-4 scale. Scores were classified as >mild PTSD reaction= (total score of 12-24), >moderate= (25-39), >severe= (40-59), and >very severe= (above 60 - Goenjian et al., 1995). The CPTSD-RI was also translated into Arabic, following piloting.

Statistical analysis

Descriptive statistics were used to present the characteristics of the sample. Within-sample associations between continuous variables were tested by Spearman rank correlation test. The proportion of cases identified by different measures and informants were compared by McNemar non-parametric test for related samples. The associations of categorical (e.g. types of traumas) and continuous variables with presence of PTSD reactions or caseness on the Rutter scales were tested by series of stepwise forward regression analyses.

Results

The Rutter Scales

According to parent-completed Rutter A2 Scales (100% completion rate), 64 children (26.8%) exceeded the cut-off score of 13. The mean total score was 8.27 (SD 7.0), with items

frequency ranging from 0 to 32. The items most frequently rated as Acertainly applies@ (scale 2) were being restless (N=48, or 20.1%), irritable (N=33, or 13.8%), worrying (N=26, or 10.9%), and bed wetting more than once per week (N=25, or 10.5%). Somatising items were not rated very highly: 13 children (5.4%) were rated as having headaches and 6 children (2.5%) as having asthma (both on scale 2).

The mean total score on the Rutter teacher scale was 10.5 (range 0-43). Teachers reported worrying (N=52, or 21.8%), restlessness (N=52, or 21.8%), fearfulness (N=37, or 15.5%), and poor concentration (N=36, or 15.1%) as the most frequent items on scale 2. Ten children (4.2%) had aches on the same scale. Detection of caseness for any mental health disorder by parents and teachers differed significantly (McNemar test: x²=17.2, p<0.0005). There was no significant sex difference on the rates of caseness according to either parent or teacher scales. Demographic data and instrument scores are presented in Table 2 for both positive and negative subjects on the teacher Rutter A2 scales, according to which this sample was selected.

Traumatic experiences (Gaza Traumatic Events Checklist)

Children were exposed to a wide range of traumatic experiences. Of the 21 possible exposures, the average child endorsed an average of 4 (median: 3, mode: 0, range 0-15). The frequency of reported items is presented in Table 1. Significantly more boys than girls had witnessed breaking limbs of close friend (x²=5.6, p=0.02) and demolition of their house (x²=6.1, p=0.01). The number of traumas experienced was significantly correlated with children=s age (Spearman rank correlation coefficient R=0.28, p<0.0005), i.e. older children had experienced more traumatic events.

Post-traumatic stress disorder reactions

Overall, 174 children (72.8%) reported posttraumatic stress reactions of at least mild severity: 76 (31.8%) reported mild reactions, 85 (35.6%) moderate, and 13 (5.4%) severe PTSD reactions. The mean CPTSD-RI score was 19.9 (SD=12.9, range 0-46). The most frequently reported symptoms were, thoughts and fear related to the trauma, anhedonia, impaired concentration, and avoidance of situations that reminded of the trauma (Table 3). There was no significant sex difference on the rates of PTSD reactions or total PTSD scores. There was significant difference on the ratings of only one PTSD symptom (event identified as traumatic), which was rated higher by boys (Mann-Whitney U test z=1.9, p=0.05).

Discussion

This study found high rates of posttraumatic stress reactions in children of primary school age, who had experienced war. According to children=s reports, 73.2% reported PTSD reactions of at least mild severity, whilst 39% reported moderate to severe reactions. A limitation was the absence of assessment of global functioning or a clinical interview in addition to the CPTSD-RI, in order to establish whether children met all criteria for a post-traumatic stress disorder. Although a number of studies have used the CPTSD-RI and the classification of its total scores into >mild, moderate, severe and very severe= reactions (e.g. Nader et al., 1993; Shawet al., 1995), the clinical implications of the scoring sysremain unclear. Goenjian et al. (1995) found that the >severe= categories correctly identified 78% of subjects who met DSM-III-R criteria for PTSD. However, if the CPTSD-RI was used for screening purposes, children of at least >moderate= severity should also be included. About 27.5% of children were potential cases of mental health disorder according to parental ratings on the Rutter A2 scale, a rate similar to other deprived urban populations.

Children who lived north of Gaza city, an area of refugee camps, were more likely to experience PTSD. The refugee population may reflect mediating adversities such as relocation and disruption of school life or peer relationships. It could also reflect higher exposure to life events such as house demolition (Qouta, Punamaki and El Sarraj, 1997). The previous finding of dose-effect relationship between cumulative trauma and PTSD symptoms (e.g. Mollica, Poole, Son, Murray and Tor, 1997) was replicated in this population. The research was carried out following the peace accord. In a longitudinal study of Palestinian children living in the Gaza strip, Quota, Punamaki and El Sarraj (1995b) found that their level of neuroticism was significantly lower after the peace treaty than before. Earlier exposure to traumatic experiences and non-acceptance of the treaty (continuing political activity and non-participation in peace treaty festivities) predicted increased neuroticism and low self-esteem.

Although we investigated the extent of trauma and its impact on PTSD, other possible mediating variables, such as family functioning, adult perceptions of trauma or perceived parenting (Elizur and Kaffman, 1983; Laor et al., 1997; Punamaki, Qouta and El Sarraj, 1997), and their interaction with trauma, were not accounted for in this study. Secondary adversities such as school and social network disruption are also important. For example, Farhood et al. (1993) found that Lebanese family members were confident that they could rely on social support to deal with problems of various natures during the war. A high level of social support, family cohesiveness and family communication has been found to protect children by mediating the effect of war trauma (Ziv and Israeli, 1973; Cohen and Dotan, 1976; Figley, 1983).

Despite the war, there was relative stability in our population to enable them to continue to attend school, which could thus form the basis for detection of children most at risk and intervention (Yule, 1992, 1994). General screening instruments with high sensitivity and specificity such as the Strengths and Difficulties Questionnaire, which has since extended the Rutter scales used in this study (Goodman, 1997), would be appropriate. As mentioned above, the use of specific instruments, such as the CPTSD-RI, for screening purposes is less well established, in which case a cut-off score indicative of >low to moderate= severity could be adopted.

As there was a substantial proportion of cases undetected by teachers, screening methods should also involve children and parents. The significant difference on rates of cases detected by parents and teachers could be related to the nature and presentation of mental health problems (situation-specific) or lack of awareness by teachers (Kent, Vostanis and Feehan, 1995). Discrepancy between teacher and parent reports has been previously found on different child mental health symptoms and disorders, particularly emotional problems such as those characterising this sample (Kolko and Kazdin, 1993). Compliance with such programmes is likely to be high in close communities, as demonstrated by the participation rate in this study. Goenjian et al. (1995) suggested a realistic and cost-effective method of screening, i.e. periodic monitoring of secondary adversities that may have a cumulative risk effect, and precipitate new-onset disorders.

A >cultural= hypothesis on the phenomenology of mental health and PTSD symptoms was not supported. For example, children did not present predominantly with somatising or behavioural problems. High rates of cognitive and emotional PTSD symptoms were reported. Previous research with victims of war trauma has supported the validity of PTSD >beyond the barriers of culture and language= (Sack, Seeley and Clarke, 1997). In another epidemiological study by the authors with a different and older sample of Palestinian children of 9-13 years of age (Thabet and Vostanis, in press), children reported high rates of significant anxiety problems (21.5%) and similar phenomenology to western populations. Anxiety symptoms were associated with socio-economic deprivation, while the higher prevalence rates among females was explained by the 12-13 year-old children of that sample (in contrast with the younger sample of the present study).

Future research could address cultural variations by studying the perceived impact of the trauma and the children=s >meaning= of it among different cultures. Eisenbruch (1991) proposed an interesting concept of >cultural bereavement=, which includes the refugees= picture - what the trauma meant to them; their cultural ways of signaling distress; and their cultural strategies for overcoming it. At the same time, certain coping mechanisms and protective factors appear to be independent of culture and societal structure. In a review of the psychological effects of war on children, Jensen and Shaw (1993) put forward a positive message on the development of coping skills due to children=s >cognitive immaturity, plasticity and innate adaptive capacities, which can protect from trauma in low-to-moderate war time settings=.

The development and evaluation of treatment interventions for post-war child populations, where >natural community groupings exist= (Yule, 1994), can be school- and group-based. Galante and Foa (1986) demonstrated the effectiveness of school-based group treatment for at risk children following earthquake in Italy (seven hourly sessions for one week). Brief cognitive-behavioural treatment that aimed at improving children=s locus of control and self-esteem has also been described (Baker, 1990). Parents should be involved in these programmes as far as possible.

Acknowledgements

The authors are grateful to all families and teachers who participated. Also, the Palestinian Ministries of Health and Education, and the Mental Health Services staff for their help and co-operation. We wish to thank Professor Sir Michael Rutter and Professor Robert Pynoos for their permission and advice on the translation of the Rutter Scales and the CPTSD-RI respectively, and to Dr Zyad Abdeen and Dr Saeed Haque for the statistical help.

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