Original ArticlesPost traumatic stress disorder reactions in children of war: a longitudinal study
Introduction
THE HIGH PREVALENCE of posttraumatic stress disorders (PTSD) in children traumatized by exposure to community violence or war trauma is well established. Previous research has investigated the course and prognosis of PTSD and other mental health disorders, particularly in young populations who experienced natural disasters. Most studies have found a gradual improvement of posttraumatic symptoms, but with a high risk of relapse (American Association of Child and Adolescent Psychiatry Official Action, 1998). Children’s prognosis has often been mediated by the degree of exposure to trauma and its impact on parents (e.g., Swenson et al 1996, Winje and Ulvik 1998). Longitudinal studies have followed-up children who had been exposed to violence, usually within the school environment. A gradual decrease of PTSD symptoms following a sniper attack was demonstrated by Nader, Pynoos, Fairbanks, and Frederick (1990) at 1–6- and 14-month assessments.
More recent research has addressed the short-term impact of war on children, often within refugee populations. In a series of studies of Cambodian refugees, Savin, Sack, Clarke, Meas, and Richart (1996) found PTSD to persist over time, although the intensity of symptoms dropped. There was marked decrease in depression. Full PTSD was associated with experience of earlier war trauma, while development of depression was more related to recent stressors.
Macksoud and Aber (1996) found PTSD rates of 43% in Lebanese children up to 10 years after exposure to war trauma. Among displaced Kurdish children in Iraq following the Gulf war, all had PTSD symptoms and 20% had PTSD, with significant improvement when they returned to their home regions (Ahmad, 1992). Israeli pre-school children, who had also been displaced during the Gulf war and exposed to scud missile attacks, had high stress symptoms in the first 6 months (Laor et al., 1997). Children’s stress levels subsequently decreased, but persisted in their mothers. Servan-Schreiber, Le Lin, and Birmaher (1998) reported a 30% rate of PTSD reactions in Tibetan refugee children in India. These findings are obviously based on different ethnic groups, as well as different types of traumatic experiences.
The aim of this study was to investigate the outcome of PTSD reactions in Palestinian children who had experienced longstanding military conflict throughout their childhood. The children of this study had been brought up during the military conflict in the area between 1987 and 1993, that is, until the peace process was initiated by the Middle East Oslo agreement. They were selected and assessed for the first time 6 months after the start of the peace process. The hypothesis was that continuing PTSD reactions would be best predicted by the degree of initial trauma.
Section snippets
Sample
The Gaza strip in the Middle East has a general population of 860,000 in an area of 360 km2. There are several socio-economic adversity factors (Thabet & Vostanis, 1998) which have been repeatedly associated with child psychopathology, such as overcrowding (population density of 2,150 people per km2), 62.6% of the population living in refugee camps, a proportionately large young population (51% of the general population are under the age of 15 years, with an annual growth of 6%), and high rate
Results
There was a trend of improvement according to parent ratings of “caseness” (Rutter A2 Scales) from 26.9% (N = 63) at the initial assessment to 20.9% (N = 49) at follow-up, although this did not reach a statistically significant level (McNemar non parametric test for paired observations: χ2 = 2.91, p = .08 Table 1). In contrast, children above the cut-off score on the Teacher Rutter B2 Scales significantly decreased from 43.6% (N = 102) to 31.8% (N = 74)—McNemar test: χ2 = 9.85, p = .0017. The
Discussion
This longitudinal study found a decrease in rates and severity of PTSD reactions in a sample of children who had experienced earlier war trauma. Continuing PTSD symptoms were predicted by the amount of traumatic experiences, which confirmed the main hypothesis of the study. At the time of follow-up, there was peace in the region, although socioeconomic adversities remained, particularly for children living in refugee camps. One characteristic of this population was its geographical stability,
Acknowledgements
The authors are grateful to all families and teachers who participated in this project. We wish to thank Professor R. Pynoos and Professor M. Rutter for their permission and support in using the CPTSD-RI and the Rutter Scales, respectively, as well as Dr. Saeed Haque for advice on the statistical analysis.
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