Social adversities and anxiety disorders

Aim - To investigate the rate and nature of childhood anxiety symptoms and disorders, and their relationship to social adversities in a cultural sample not previously researched. Methods - A sample of 237 children of 9-13 years living in the Gaza strip was randomly selected in a school-based study. Children completed the Revised Manifest Anxiety Scale and teachers completed the Rutter Scale. Results - Children reported high rates of significant anxiety problems (21.5%) and teachers reported even higher rates of mental health problems (43.4%) that would justify a clinical assessment. Anxiety problems, particularly negative cognitions, increased with age and were significantly higher among females. Low socio-economic status was the strongest predictor of general mental health problems. Living in inner-city areas or camps, both common among refugees, was strongly associated with anxiety problems.

Conclusions - The rate and nature of anxiety disorders were similar to those established in western societies. Factors reflecting social adversity and lack of stability were also similarly involved. There may be more similarities in the presentation of mental health symptoms across cultures than previously believed, due to lack of cross-cultural research.

Social disadvantage is well established as a risk factor for the development and prognosis of child psychiatric disorders¹. Factors such as family size and overcrowding (at least four children), low social class, family disruption and breakdown, father’s employment (semi- or unskilled job), father’s criminality, and school disadvantage have predominantly been associated with conduct disorders^2-4. Most research has found increased prevalence of conduct disorders in inner-city deprived areas⁵. The identified socioeconomic risk factors are associated with poor child mental health outcome^6-7.

The association of anxiety (emotional) disorders with social adversity is less clear⁷. Epidemiological studies from the UK and North America have found prevalence rates between 6-9% for severe conditions, including separation anxiety disorders^8-9, and about 20% for anxiety symptom constellations⁵ in the general population. In contrast with conduct disorders, there is some effect of socioeconomic status on the development of anxiety disorders, but this does not appear to be as strongly predictive as parental illness and life events¹⁰.

So far, research findings are predominantly from western society populations¹¹. It is as yet unclear whether social adversity factors are similarly involved in the mechanisms underlying child psychopathology in cultures with different family and social structure. The aim of the study to investigate the relationship between social disadvantage and anxiety disorders among Palestinian children living in the Gaza Strip.

The study was performed in the Gaza strip, which had a population of 860,369 in 1995, excluding returnees from abroad after the peace process. The Gaza Strip has a high population density of 2,150 people per km², which is a psychosocial risk factor for child psychopathology. The total refugee population is 62.6%. About 55.1% live in eight crowded camps, and 44.9% live in villages and towns. Half of the population (50.8%) are younger than 15 years of age. In 1995, the annual infant birth rate was 49.4 per 1000 population, the infant mortality rate was between 26-50 per 1000 infants, and the general population death rate was 8 per 1000. Respiratory diseases and diarrhoea are major causes of infant morbidity and mortality. The annual increase of population growth in the Gaza Strip is 4.5%.

The sample of this study was selected at random from children of 9-13 years of age, attending twelve state schools in the five districts of the Gaza strip. Twenty children were randomly selected from each school. As this was a school-based survey, ethics approval was granted by the Ministry of Education and parents gave informed consent before children were approached. For each child the following scales were administered:

Rutter teacher scale^12-13: This is a widely used and standardised screening questionnaire for the detection of child mental health problems in different cultures. It consists of twenty-six items of child mental health problems, rated on a 0-2 scale (statements 'certainly applies', 'applies somewhat' or 'doesn't apply'). There are three subscales measuring conduct, emotional and hyperactivity problems. A total score of 9 or above has been found to predict the presence of mental health disorder. The Rutter scales have been translated and piloted in Arabic.

Revised Children's Manifest Anxiety Scale(RCMAS¹³): The RCMAS is a standardised 37-item self-report questionnaire for children of 6-19 years of age. It measures the presence or absence of anxiety-related symptoms (yes/no answers) in 28 anxiety items and 9 lie items. Factor analysis of the anxiety items has identified three factors: physiological, worry/oversensitivity and concentration¹⁴. A cut-off total score of 18 has been found to predict the presence of anxiety disorder¹⁵. This instrument was also translated into Arabic and was completed in the presence of a researcher, who clarified the items if necessary. Demographic data were collected on family structure and family size, area of residence, housing status/overcrowding, and parents= employment status.

Demographic data are presented in Table 1. Twenty children were selected from each of the twelve schools, or 240 children, 237 of whom agreed to take part (98.7%). Their mean age was 10.8 years. The great majority (N=228, or 96.2%) lived with both parents, and had at least three siblings (N=217, or 91.6%). Only one child had lived in care, and only twelve mothers were in employment.

The most frequently teacher-rated abnormal behaviours (i.e. rated as >certainly applying=) were, bullying (11%), lying (10.5%), disobedience (10.5%), and fighting (6%). The most frequent emotional items were, worries (17.3%), fears (11.8%), and feeling miserable (5.9%). The most frequent hyperactivity items were, restlessness (16.0%), poor concentration (12.2%), and being squirmy (11.4%). Significant school absence related to anxiety was reported in 21 children (8.9%), and truancy related to behaviour problems in 6 children (2.5%). A high number of children (N=104, or 43.4%) exceeded the cut-off point of 9, which indicates the potential presence of significant mental health problems. Males had higher scores on the hyperactivity subscale than females (Mann-Whitney U test: z=2.07, p=0.04). Low socioeconomic status (i.e. the father being unemployed or unskilled worker) was the sociodemographic variable that best predicted the presence of mental health problems in children (caseness, i.e. Rutter scales score of 9 or above) in a forward stepwise logistic regression (B=0.38, SE=0.13, p=0.004). This variable also best predicted the total conduct subscale score (linear regression: B=1.01, 95%CI 0.34-1.68, p=0.003). The total teacher-rated emotional subscale score was best predicted by the age of the child (i.e. increased with age: B=0.67, 95%CI 0.02-1.32, p=0.04).

The detailed self-reported anxiety items (Revised Children=s Manifest Anxiety Scale) are presented in Table 2. Fifty-one children (21.5%) scored above the cut-off score for anxiety disorders. Females reported significantly higher total anxiety scores (mean scores 8.2 and 6.5 respectively; Mann-Whitney U test: z=2.44, p=0.015) and were significantly more likely to have scores above the cut-off (x²=3.9, DF=1, p=0.047). Also, females scosignificantly higher than males on most anxiety items, particularly: >having trouble making up my mind= (Mann-Whitney U test: z=2.9, p=0.003), >getting nervous when things do not go the right way= (z=2.2, p=0.03), >others do things easier than me= (z=2.2, p=0.03), >worrying about what parents will say= (z=2.1, p=0.03), >feeling that others do not like the way I do things= (z=2.3, p=0.02), sickness (z=3.3, p=0.001), >impaired concentration= (z=2.0, p=0.04), and >often worrying about something bad happening= (z=3.3, p=0.001).

Children with possible anxiety disorders were more likely to be living in an inner-city area or camps (x²=9.2, DF=2, p=0.01). Older age (B=0.33, SE=0.12, p=0.01) and living in inner city or camps (B=0.59, SE=0.3, p=0.05) were the strongest predictors of anxiety disorders in a logistic regression. Teacher-rated conduct and hyperactivity scores were strongly correlated (r=0.76, p<0.0005).

In order to investigate the potential change of anxiety symptoms with age, we compared the youngest (N=62 nine-year-olds) with the oldest (N=26 thirteen-year-olds) group of the sample on all anxiety items (Mann-Whitney U test). Older children scored significantly higher on 7 anxiety symptoms, mainly related to cognitions.

This study on the prevalence of anxiety symptoms and disorders among children living in the Gaza strip found a similar pattern with previous epidemiological research from western societies. There were high rates of anxiety disorders and school-related mental health problems. In a previous community survey in the United States using the RCMAS, Kashani and Orvaschel¹⁶ found the same prevalence rate (21%) of anxiety disorders, which included separation anxiety, phobic and overanxious disorders. This study also identified similar frequencies of symptoms, such as worries and nightmares, to the American study.

Anxiety problems significantly increased with age, particularly among females. Although >physiological= symptoms of anxiety were highly reported (insomnia, nightmares, sweating), children also experienced a substantial amount of negative cognitions related to poor self-image and self-esteem. Social cognitions, such as self-awareness, shame and guilt, first develop in middle childhood (7-8 years). Between 9-12 years, children can distinguish between conflicting emotions, and between others= accidental and intentional behaviours. Internal psychological factors are increasingly perceived as causal to the child=s behaviour. During adolescence, social cognitions are enhanced further, together with the development of belief systems, hypothetical and abstract thinking, and self-evaluation of their thought process. This explains the increase of anxiety-related cognitions with age, which is consistent with previous findings¹⁶, and has implications for treatment interventions, particularly cognitive-behavioural therapy¹⁷.

The findings did not support the commonly held belief that anxiety and other mental health symptoms are predominantly expressed through somatising symptoms in non-western cultures and societies. This view may be due to lack of systematic epidemiological research on cross-cultural issues. Studies on phenomenology indicate that child mental health symptoms do not differ significantly across cultures and that culture-specific mental health disorders are rare¹⁸.

Social adversity factors were implicated in the development of anxiety and other mental health problems, even within a society with extended family and community networks. As in earlier UK-based research^3-4, factors involved were lower socioeconomic status (reflected by the father=s employment status) and living in inner-city areas. A mediating factor involved could be the social instability of refugee families within this population, who lived in urban areas and camps. In contrast, the social support system of families from rural areas has not been disrupted despite the war, and this may have acted as a protective factor for the children. In a study among Croatian children during the war, Zivcic¹⁹ found significantly higher depressive and phobic symptoms in displaced (refugee) than in local children in stable social conditions. In contrast with studies from western countries, large family size (overcrowding) was not found to be associated with child mental health problem. In Arabic families, a large number of children is culturally determined rather than an index of adversity or deprivation.

The experience of traumas by children in war zones is often directly related to the development of anxiety symptoms such as fear and nightmares. In a prevalence study of post-traumatic stress disorders (PTSD) reactions from another young population living in the same area, the authors found PTSD reactions of at least mild severity in 73% of children of 6-11 years, while 39% of the children reported moderate to severe PTSD reactions (Thabet & Vostanis, submitted for publication). Other studies with children of war have found similar associations between trauma and psychopathology. Ahmad²⁰ established PTSD in about 25% of displaced Kurdish children, and Weine et al²¹ found similar rates in Bosnian adolescents who had moved to America during the war. Nader et al²² established moderate to severe posttraumatic stress reactions in 70% of Kwaiti children following the Gulf war.

Limitations of the study need to be acknowledged, particularly the lack of diagnostic interview and corroborative information from the parents. Research instruments used in cross-cultural research need further development, as little is known on potential cultural influences on how children interpret certain questions²³. Future research also needs to address the potential impact of family and social beliefs and perceptions of child mental health problems. Child mental health services in developing countries are often best integrated with existing primary child health care services¹⁸. Treatment intervention programmes need to be developed and evaluated for traumatised children.

We are grateful to all children and teachers who participated in the study. Also, to Dr Saeed Haque for the statistical advice.

1 Pearce J. Child health surveillance for psychiatric disorder. Arch Dis Child 1993;69:394-398.

2 Rutter M. Why are London children so disturbed? Proc Roy Soc Med 1973;66: 53-57.

3 Rutter M, Yule B, Quinton D, Rowland O, Yule W, Berger M. Attainment and adjustment in two geographical areas: III. Some factors accounting for area differences. Br J Psychiatry 1975;126:520-533.

4 Kolvin I, Miller F, Scott D, Gatzanis S, Fleeting M. Continuities of deprivation? The Newcastle 1000 family study. Aldershot: Avebury, 1991.

5 Rutter M. Isle of Wight revisited: twenty-five years of child psychiatric epidemiology. J Am Acad Child Adolesc Psychiatry 1989;28:633-653.

6 Kolvin I, Miller F, Fleeting M, Kolvin P. Social and parenting factors affecting criminal-offence rates. Br J Psychiatry 1988;152:80-90.

7 Velez C, Johnson J, Cohen P. A longitudinal analysis of selected risk factors for childhood psychopathology. J Am Acad Child Adolesc Psychiatry 1989;28:861- 864.

8 Bowen R, Offord D, Boyle M. The prevalence of overanxious disorder and separation anxiety disorder: results from the Ontario Child Health Study. J Am Acad Child Adolesc Psychiatry 1990;29:753-758.

13 Reynolds C. Concurrent Validity of What I Think and Feel: the Revised Children's Manifest Anxiety Scale. J Consult Clin Psychol 1980;48:774-775.

14 Reynolds C, Paget K. Factor analysis of the Revised Children=s Manifest Scale for blacks, whites, males and females with a national normative sample. J Consult Clin Psychol 1981;49:352-359.

15 Montgomery LE, Finch AJ. Validity of two measures of anxiety in children. J Abn Child Psychol 1974;12:293-297.

16 Kashani JH, Orvaschel H. A community study of anxiety in children and adolescents. Am J Psychiatry 1990;147:313-318.

17 Vostanis P, Harrington R. Cognitive-behavioural treatment of depressive disorder in child psychiatric patients. European Child & Adolescent Psychiatry 1994;3:111-123.

18 Nikapota A. Child psychiatry in developing countries. Br J Psychiatry 1991;158:743-751.

19 Zivcic I. Emotional reactions of children to war stress in Croatia. J Am Acad Child Adolesc Psychiatry 1993;32:709-713..

20 Ahmed A. Symptoms of posttraumatic stress disorder among displaced Kurdish children in Iraq: victims of a man-made disaster after the Gulf war. Nord Journal of Psychiatry 1992;46:314-319.

21 Weine S, Becker D, McGlashan T, Vojvoda D, Hartman S, Robbins J. Adolescent survivors of >ethnic cleansing= on the first year in America. J Am Acad Child Adolesc Psychiatry 1995;34:1153-1159.

22 Nader K, Pynoos R, Fairbanks L, Al-Ajeel M, Al-Asfour A. A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis. Br J Clin Psychol 1993;32:407-416.

Age	Mean: 10.8 (minimum 9 - maximum 13)
Sex	Male: 122 (51.5%) Female: 115 (48.5%)
Family status	Both parents: 228 (96.2%) Single mother: 7 (3%) Single father: 2 (0.8%)
Father’s employment	Unemployed: 63 (27.4%) Unskilled worker: 42 (18.3%) Civil servant: 48 (20.9%) Professional: 31 (13.4%) Other: 46 (20%)
Area of residence	Urban: 166 (70%) Rural: 44 (18.6%) Camps: 27 (11.4%)

Item/symptom	N	(%)
My hands feel sweaty I have bad dreams I get nervous when things do not go the wright way for me Others seem to do things easier than I can It is hard to get to sleep at night My feelings get hurt easily when I am fussed at I get >mad= easily I worry about what is going to happen I have trouble making up my mind I am afraid of a lot of things My feelings get hurt easily Other children are happier than I Often I have trouble getting my breath I worry about what other people think about me I wake up scared some of the time I worry about what my parents will say to me I worry when I go to bed at night I am nervous I often worry about something bad happening to me I wiggle in my seat a lot I feel alone even when there are people with me It is hard to keep my mind on my school work I worry a lot of the time I feel someone will tell me I do things the wrong way I feel that others do not like the way I do things Often I feel sick in my stomach A lot of people are against me I am tired a lot	107 99 90 84 80 79 76 75 75 71 71 66 62 58 57 54 52 51 51 50 47 47 46 46 40 40 33 17	45.1% 41.8% 38.0% 35.4% 33.8% 33.3% 32.1% 31.6% 31.6% 30.0% 30.0% 27.8% 26.2% 24.5% 24.1% 22.8% 21.9% 21.5% 21.5% 21.1% 19.8% 19.8% 19.4% 19.4% 16.9% 16.9% 13.9% 7.2%