depression, anxiety, and grief, as well as a report of the amount of their own exposure to war-related violence. Results showed that children reported high levels ...
Journal of Traumatic Stress, Vol. IS, No. 2, April 2002. pp. 147-156 (Q 2002)
War Exposure Among Children From Bosnia-Hercegovina: Psychological Adjustment in a Community Sample Patrick Smith,' ,4 Sean Perrin,l William Yule,' Berima Hacam: and Rune Stuvland3
As part of a United Nations Children's Fund (UNICEF) psychosocial programme during the war in Bosnia-Hercegovina, data were collected from a community sample of 2,976 children aged between 9 and 14years. Children completed standardized self-report measures of posttraumatic stress symptoms, depression, anxiety, and grief, as well as a report of the amount of their own exposure to war-related violence. Results showed that children reported high levels of posttraumatic stress symptoms and grief reactions. However, their self-reported levels of depression and anxiety were not raised. Levels of distress were related to children's amount and type of exposure. Girls reported more distress than boys, but there were few meaningful age effects within the age band studied. Results are discussed in the context of service development for children in war. KEY WORDS: PTSD;children; war.
Although children have been caught up in wars in one way or another for centuries, the study of the psychological effects o f war on children is a relatively recent phenomenon. Modem research dates from World War I1 when most reports emphasizedchildren's resilience (e.g., Vernon, 1941). However, more recent research, using standardized assessment tools, has shown that, at the very least, a substantial minority of children is adversely psychologically affected by exposure to war and political violence (see Cairns, 1996).Over the last decade, efforts have been made to delineate more closely the specific psychological sequelae for children of having survived war.
A number of studies, from various war zones in differing cultures, have reported high rates of posttraumatic stress disorder (PTSD) in children exposed to the stresses of war. Saigh (1991) found that 27% of a large group of Lebanese children who had been exposed to bombings and terror attacks met criteria for PTSD. After the genocide in Rwanda, Gupta, Dyregrov, Gjestad, and Mukanoheli (1996) found that up to 79% of Rwandese children were at risk for developing PTSD. Thabet and Vostanis (1999) showed that 41% of Palestinian children from Gaza reported moderate to severe PTSD reactions. In the early stages of the war in former Yugoslavia, up to 74% of Croatian children were at risk for developing PTSD (Kuterovac, Dyregrov, & Stuvland, 1994). Posttraumatic stress reactions have also been reported in refugee children from Cambodia (Kinzie, Sack, Angell, & Clark, 1989; Kinzie, Sack, Angell, Manson. & Rath, 1986), with up to 50% of adolescents meeting criteria for PTSD some 5 years after their exposure to war atrocities. Broadly similar rates have been found in other refugee groups from Cambodia (Realmuto et al., 1992) and Central America (Arroyo & Eth, 1985).
'Department of Psychology. Institute of Psychiatry. Camberwell. London. United Kingdom. 2Psihosocijalni Program, Mile Budaka 98a, 88 OOO Mostar, BosniaHercegovina. 3Center for Crisis Psychology Oslo, Kr. Augustsgt. 12, N-0164 Oslo, Noway. 4T0whom correspondence should be addressed at Department of Psychology, Institute of Psychiatry, De Crespigny park, Denmark Hill, Camberwell.London SE5 8AF. United Kingdom;e-mail: p.smith@iop. kcl.ac.uk.
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Although the posttraumatic stress framework has proved useful in conceptualizingchildren’s psychological reactions to war, the effects of the sorts of massive and repeated exposure to traumatic events that occur during war will be broader still. Other reactions have received relatively little attention, but there is evidence for increased rates of depression among Lebanese (Saigh, 1991). Iraqi (Dyregrov & Raundalen, 1992), Croatian (Zivcic, 1993). and Cambodian children (Kinzie et al., 1989) who survived war. Increased levels of anxiety were also reported by Saigh (1991) among his series of Lebanese children; and by Kinzie et al. (1989) in Cambodian refugee youth. Findings are mixed, however. A seminal early study by Ziv and Israel (1973) found that the anxiety levels of Israeli kibbutzim children who had been exposed to recent shelling did not differ from those of children who had not been so exposed. Last, although many children are bereaved during war, grief reactions have been little studied. Following the Gulf War, Dyregrov and Raundalen (1992) found that, among a range of other symptoms, Iraqi children who had witnessed the bombing of a shelter that resulted in the deaths of 750 people showed significant and lasting signs of grief. Nader, Pynoos, Fairbanks, Al-ajeel, and Al-Asfour (1993) also assessed grief reactions in Kuwaiti children and youth (aged 8-21 years) after the Gulf War, finding that 98% of the sample reported at least one symptom of grief. In addition to examining the prevalence of PTSD and other disorders, recent research has moved toward investigating risk factors, and the focus has been on the amount of children’s exposure. In contrast to peacetime disasters, stressors during war are generally multiple, diverse, chronic, and repeated, including the violent death of a parent, witnessing the killing of close family members, separation and displacement,terror attacks, and bombardment and shelling (Macksoud, Dyregrov, & Raundalen, 1993). Several studies have reported a significant relationship between the amount of these kinds of war experiences and subsequentreactions (Chimienti,Nasr, & Khalifehi, 1989; Gupta et al., 1996; Kuterovac et al., 1994; Mghir, Freed, Raskin, & Katon, 1995;Naderet al., 1993).Along with evidence of a relatively straightforward relationshipbetween amount of exposure (i.e.. counting the number of experiences) and outcome (usually in terms of PTSD but also with respect to depression and grief), there is emergingevidence that the type of trauma is important. After the Gulf War, Dyregrov and Raundalen (1992) found that exposure to dead bodies and body parts was the best predictor of intrusion symptoms of PTSD. These authors suggest that exposure to very strong sensory impressions (e.g., smelling burning bodies and hearing screams for help) may result in more severe re-experiencing. In Rwanda, Gupta et al.
Smith, Perrin, Yule, Hacam, and Stuvland (1996) found that the best exposure predictor of child outcome was a (perceived) direct life threat. This is in line with work from elsewhere (e.g.. Carlson & Rosser-Hogan, 1994, with adult Pol Pot survivors; and Nader et al., 1993, with Kuwaiti children), suggesting that threat to survival may be related to posttraumatic stress symptoms across different cultures. Not surprisingly,given the difficulties of working in war zones, the methodology varies considerably between studies. Some are limited by small sample sizes, or assessment of only clinic-basedcases, making generalizability difficult. Some use only nonstandard questionnairesor semistructured interviews, making comparison with other groups difficult. Some have assessed children exposed to multiple trauma, some to a single massive trauma, and others to trauma experienced up to 5 years previously. The present study seeks to expand on previous work by utilizing an epidemiological community sample, by using a broad range of standardized measures, and by assessing the amount of children’s exposure. The work reported here was part of a United Nations Children’s Fund (UNICEF) psychosocial rehabilitation program for children in Mostar, Bosnia-Hercegovina, and was carried out in order to identify vulnerable children and to guide service planning (Hacam, Smith, Yule, & Pemn, 1998). Mostar, a fifteenth century town with a prewar population of around 1OO,OOO, saw some of the worst fighting in the recent wars in Bosnia-Hercegovina. During 1992-94, the Bosnian Muslims in the Eastern part of town were besieged for 9 months, cut off from any international military or humanitarian aid. During the long siege, including a bitter winter, many families in East Mostar lived in basements to shelter from artillery and sniper fire. It is estimated that more than 100,OOO shells landed in the town during the war, that over half of the buildings on the Eastern side of town were damaged or destroyed, and that more than 1,500 civilians were killed (UNICEF, 1994). After two years of war, the Washington Agreementbrought an end to fightingbetween the Bosnian Muslims and Croats. Tension in Mostar remained high however, and the town was politically and physically divided, with no freedom of movement from dne side of town to the other, armed checkpoints separating the two populations, and continued forced expulsion of Muslims from their homes. In the municipalities surrounding Mostar, there was intermittent and escalating fighting between Serbian and Bosnian government forces until the Dayton agreement was signed at the end of 1995. Current data were collected at the beginning of 1996 (2 years after the signing of the Washington Agreement, which brought a semblance of peace to the area) as an integral part of a service-oriented project, in
War and Adjustment in Children order to identify vulnerable children and to guide service planning. The aims of this study were to investigate the levels of posttraumatic stress reactions, depression and anxiety reactions, and grief in children from Bosnia-Hercegovina; and to investigate the relationship between exposure and this broad range of psychological outcomes. It was predicted that (1) exposure would be high; (2) self-reports of distress of PTSD, depression, anxiety, and grief reactions would be high; and (3) levels of distress would be significantly associated with levels of exposure.
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Materiuls Bosnian language versions of English language measures were used. Final versions of all measures were obtained through translation and blind back translation (Bracken & Barona, 1991).A professionaltranslatortranslated from English to Bosnian. An independent translator translated back from Bosnian to English, blind to the original version. Discrepancies were checked by a child psychologist whose first language is English (PS); and a final version was arrived at through consultation with a bilingual Bosnian child psychologist (BH).
Methods War Trauma Questionnaire (WTQ; Macksoud, 1992)
Sample The study was designed as a community epidemiological screening. Participants were children from the Bosnian government-held municipality areas in and around Mostar. Children were invited to participate if they attended one of the 10 primary schools in Mostar city and the surrounding areas; they were in Grades 3-8 (aged 914 years) on 31st January 1996; and informed consent was given by their parents. According to school records, there were an estimated 3,877 children between the ages of 9 and 14 years in the municipality, roughly evenly divided between the city and surrounding areas. In general, return rates were good to excellent, ranging from 53 to 94% across the 10 schools, with an overall return rate of 84% ( N = 3,243). Of these children, 258 were not within the sample age range and so these children were excluded from the study. The sample therefore comprised 2,976 children between the ages of 9 and 14 years (M = 12.11 years, SD = 1.69).of whom 1,453(49%) were boys and 1,509 (5 1%) were girls (for 14 children, gender was not recorded). Most children (73%) were born in Mostar and most (98%) were identified as Muslim. The majority of children (84%) lived at home with both parents, and most of them (89%) also had one or more sibling living at home.
Procedure Data collection was via schools. Teachers were trained to administer the questionnaires by class. Teachers were given letters asking for informed consent from parents, and these were given to every child in the relevant grade. One week later, the questionnaireswere delivered to schoolsand administeredby class, except to those children whose parents had refused. Questionnaires were collected from schools on the same day.
Originally developed by Macksoud ( 1992) for use in Lebanon, this scale was adapted for use throughout Bosnia-Hercegovina by UNICEF (1993). It includes 28 yeslno questions about events the child may have witnessed during the war. The total score (range 0-28) therefore gives an indication of the child’s level of traumatic exposure. The first part of the WTQ elicits demographic information. Revised Impact of Event Scale (RIES; Dyregrov & Yule, 1995): 13 Items
The RIES was adapted from the Impact of Event Scale of Horowitz, Wilner, and Alvarez (1979). It is a self-report scale designed to measure symptoms of intrusion (four items), avoidance (four items), and arousal (five items). A score of 2 17 on the eight items relating to intrusion and avoidancehas been found to be an efficient cutoff for PTSD (Dyregrov & Yule, 1995). Using this cutoff, the scale works efficiently at discriminating cases, misclassifying only 10%. In order to assess the third symptom cluster of PTSD-increased physiological arousal-five new items were added. Each item was presented in question form because clinic piloting had suggested that this was easier for children to respond to than a statement format. Each question was answered on a 4-point scale (Not at all, Rarely, Sometimes, Often), scored 0, 1,3,5 with no reversed items. The total score thus ranges from 0 to 65 on this 13-item scale. Birleson Depression Self-Rating Scale (DSRS; Birleson, 1981)
This widely used scale was developed as a clinical instrument to assess the extent of depressive feelings of children and adolescents. It comprises 18 items, scored on
Smith, Perrin, Yule, Hacam, and Stuvland a 3-point scale (Most = 0, Sometimes = 1, Never = 2), with 8 items reversed for scoring. Good internal consistency has been reported (Birleson, 1981). and the scale is efficient at discriminating depressed from nondepressed children with a cutoff score of between 13 (Asamow & Carlson, 1985) and 15 (Birleson, Hudson, Buchanan, & Wolff, 1987).
items working poorly, and children may have been confused by the phrasing of these items. The Lie scale was therefore not used in any analyses. The internal reliability of the 9-item BGS was moderate, with a KuderRichardson statistic of .63.
Analysis Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978) The RCMAS is designedto measure generalizednonspecific anxiety in children. The scale comprises 37 true/ false items: 28 anxiety items and 9 Lie (or social conformity) scale items. Items have good face validity and the scale has shown good internal consistency (James, Reynolds, & Dunbar, 1994). Concurrent validity indicators are good, with a correlation of .85 with the A-Trait scale of the State Trait Anxiety Inventory for Children (Spielberger, Gorsuch, Luschene, Vagg, & Jacobs, 1973) reported by Reynolds (1980).
Analysis was carried out using the Statistical Package for Social Sciences (SPSS, 1993). For all measures, data were counted as missing if more than 25% of scale items were missing. Missing data were then excluded. Where fewer than 25% scale items were missing, missing items were scored zero, and data included. Descriptive statistics for the main outcome measures were obtained. The relationship of these outcome measures to age, gender, and level of exposure was then examined using Pearson correlations and multiple regression models. For significance testing, p-values were set conservatively to
