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.
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.
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 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.
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).
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].
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.
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.
The authors disclosure no conflict of interests.
Informed consent was obtained from all the parents participated in the study.
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.