Background: Traumatic experiences and post-traumatic stress symptoms were assessed in Kurdish children in their native country and in exile. Method: 312 ...
Child and Adolescent Mental Health Volume 13, No. 4, 2008, pp. 193–197
doi: 10.1111/j.1475-3588.2008.00501.x
Traumatic Experiences and Post-traumatic Stress Symptoms in Kurdish Children in their Native Country and in Exile Abdulbaghi Ahmad, Anne-Liis von Knorring, & Viveka Sundelin-Wahlsten Department of Neuroscience, Uppsala University, SE-751 85 Uppsala, Sweden. E-mail: abdulbaghi.ahmad@bupinst. uu.se
Background: Traumatic experiences and post-traumatic stress symptoms were assessed in Kurdish children in their native country and in exile. Method: 312 randomly selected school-age children at two sites completed assessments of traumatic experiences and post-traumatic symptoms. Results: Although traumatic experiences showed more similarities than differences between the two samples, the PTSD frequencies and post-traumatic stress symptom scores were higher in Kurdistan than in exile. Living in exile showed negative correlation with PTSD frequencies and post-traumatic stress symptom scores. Conclusions: Living in exile seems to have trauma healing effect on children of Kurdistan. Keywords: Childhood; Kurdistan; PTSD; trauma
Introduction A number of researchers have detailed the presentation of post-traumatic symptoms in children (Ahmad & Sofi et al., 2000a; APA, 1994; McNally, 1993; Perry, 1998; Pynoos, 1990; Sundelin-Wahlsten, 1991; Terr, 1991). A group at high risk of experiencing post-traumatic symptoms are refugee children and a growing body of knowledge is beginning to emerge. In addition to the age and developmental level of the child, psychosocial support from their own social network and host country authorities are considered to be among the protecting factors (Hollifield et al., 2005; Schweitzer et al., 2006; Sundeline-Wahlsten, Ahmad, & von Knorring, 2001). Pre-migration childhood trauma has been associated with continuing PTSD in adult refugees (Marshall et al., 2005). However, dose-effect relationships between cumulative trauma and social functioning or health status were lacking in refugee adolescents (Mollica et al., 1997). Furthermore, the precarious socioeconomic status of the refugee families was not accompanied by an increase in the adolescentsÕ emotional and behavioural problems in the host country (Rousseau, Drapeau, & Platt, 2000). The first assessment of Kurdish childrenÕs psychological reactions to trauma was conducted in the aftermath of the first Gulf War in 1991 (Ahmad, 1992; Ahmad, Mohammad, & Ameen, 1998). The results showing the family bandsÕ protecting effect were confirmed in the subsequent studies of orphans (Ahmad & Mohamad, 1996) and survivors of the genocide operation ÔAnfalÕ in Iraqi Kurdistan (Ahmad & Sofi et al., 2000a). The ÔAnfalÕ was the name of a military operation which the Iraqi government applied on Iraqi Kurdistan in 1988 (Middle East Watch, 1993). More similarities than differences were found between Kurdish refugee
children and a comparable Swedish group matched for age, gender and equal trauma scores (SundelinWahlsten et al., 2001). This article presents the cross-sectional results from child interviews concerning the rates of traumatic experiences and post-traumatic stress reactions in two populations of Kurdish children: one in Iraqi Kurdistan and the other one in Sweden.
Method Participants Random samples of Kurdish children, aged 6–18, were drawn both from the general population in Duhok city in Iraqi Kurdistan and the general population in the Swedish city of Uppsala. Children with mental or physical disabilities that prevented them from taking part in the interviews were excluded. The Duhok sample. This was randomly selected from the computerised registers of the United NationsÕ (UN) World Food Programme (WFP), the only organisation with a register of the population of Duhok at the time of this study. Out of the 206 children identified as eligible, 201 (101 girls and 100 boys) participated, a completion rate of 97.6%. The childrenÕs and their familiesÕ experiences in Kurdistan were mostly related to man-made disasters. They had been exposed to the deportation programmes of the Iraqi government in the late 1970s, the military ÔAnfalÕ in 1988 (Ahmad & Sofi et al., 2000a; Middle East Watch, 1993), and the Mass-Escape Tragedy (MET) in March 1991 (Ahmad et al., 1998). The families returned only when the city had been included in the safe haven area under the United NationsÕ (UN) protection in June 1991.
Ó 2008 Association for Child and Adolescent Mental Health. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
194
Abdulbaghi Ahmad et al.
During the period of the study, people lived mainly on UN WFP support thus making the standard of living essentially comparable for all subjects. The fathers of 157 children (78.1%) and the mothers of 10 children (5.0%) worked outside their homes. While 88.1% of the children lived in two-parent families, 10.9% had lost their father, 77.3% of them in combat. Three children had lost their mothers, two owing to illness and one having been killed for reasons unknown. The Uppsala sample. The names of Kurdish children were obtained from child-care centres, school health care, and the two Kurdish societies in the city. Only 111 (65.3%) of the 170 eligible children completed the interviews. Of the 59 non-participants, 42 did not respond to the invitation letters, 12 refused to take part, and 5 did not complete the interviews. An analysis revealed no significant differences between participants and non-participants regarding age, gender and contact with child and adolescent psychiatry. The Kurdish families in Uppsala originally came as refugees from the Kurdistan parts of Turkey, Iran, Iraq, Syria, and Lebanon. Thirty-two children were born in Sweden (31.4%) with the mean number of years spent in Sweden being 7.9 years. Significant differences were found between the Duhok and Uppsala samples regarding parental education and maternal working status (Table 1).
Instruments Harvard-Uppsala Trauma Questionnaire for Children (HUTQ-C). This instrument was developed from the Harvard Trauma Questionnaire (HTQ) (Mollica et al., 1992). In addition to the 17 adult-related events in the first part of the original instrument, 12 child-related traumatic events were added. For each traumatic event the child was asked whether she/he had experienced, witnessed, or heard of the event, and what age the child had been when confronted with the event. One score was given for every reported event. If the trauma occurred more than three times during the same year, or when the trauma continued for a period of time
Table 1. Subject characteristics
Age, years 6–12 13–18 Gender Girls Boys Household constellation Two parent family Father working Mother working Father absent Mother absent Standard of living Mother low education Father low education
Duhok (n = 201)
Uppsala (n = 111)
n (Means / %)*
n (Means / %)*
201 (13.0) 90 (44.8) 111 (55.2)
111 (11.6) 66 (59.5) 45 (40.5)
101 (50.2) 100 (49.8)
65 (58.6) 46 (41.4)
177 157 10 22 3 201 191 153
(88.1) (78.1) (5.1)** (10.9) (1.5) (5.1) (96.5)** (85.5)**
n = Number of observations. *p < .01, **p < .001
86 87 29 17 3 111 35 46
(77.5) (85.3) (27.1) (16.7) (2.9) (5.4) (32.7) (51.7)
exceeding one year, it was given three scores. The sum of the experienced, witnessed, and heard scores determined the trauma level. In order to study the influence of trauma type on PTSD diagnosis the child was asked to indicate the most distressing event. The PTSD criteria were assessed against the reported type of event as criterion A of the PTSD diagnosis according to DSM-IV (APA, 1994). The HUTQ-C has been used in different child populations, translated to the Kurdish language in Kurdistan and to the Swedish language in Sweden (Ahmad & Sofi et al., 2000a, Sundelin-Wahlsten et al., 2001). Family map (Genogram). A modified family map was used to collect demographic data (Ahmad & Sofi et al., 2000a). The following independent variables on each family member were obtained: age, gender, marital status, education, profession, chronic disease(s), current medication, separation(s), death(s), disappearance(s), absence(s), family structure and properties, living situation, and time spent in exile. Post-traumatic Stress Symptoms for Children (PTSS-C). This instrument was developed as a simple, cultureadjusted, semi-structured interview both to diagnose PTSD and to identify other stress symptoms in children (Ahmad, 1992). The scale consists of 30 questions dichotomised into yes or no responses scored 1 and 0 respectively. The first 17 items covering the diagnostic criteria for PTSD (re-experiencing 1–5, avoidance 6–12, and hyperarousal 13–17) were used in the analysis in this study (APA, 1994). The maximum scores for re-experiencing, avoidance, and hyper-arousal are 5, 7 and 5, respectively, with the sub-scales being summed to produce a total symptom score. The psychometric properties of the PTSS-C have been assessed in previous research (Ahmad & Sundelin-Wahlsten et al., 2000b). This instrument has been used with several populations in Kurdistan, Kurdish children in Sweden, and Swedish children. The PTSS-C yielded satisfactory internal consistency, high interrater reliability, and excellent validity on cross-validation with the Child Post-traumatic Stress Disorder Reaction Index (CPTSD-RI) (Frederick, Pynoos, & Nader, 1992), and the Diagnostic Interview for Children and Adolescents (DICA) according to the DSM-IV (Reich, 2000).
Procedures This study was carried out in two stages between 1996 and 1999. The Kurdish children in Uppsala were interviewed during 1996, 1997 and 1998, while the interviews in Duhok were postponed to 1999 due to local circumstances in Kurdistan. The study was approved by the Ethics Committee of the Faculty of Medicine at the Uppsala University in Sweden. . The names and addresses of the selected children were obtained from the relevant organisations. An invitation letter (in Kurdish) was sent to the child and a separate one to the carer. Written and informed consents were obtained both from the child and the primary carer. Wherever possible children and parents/carers were interviewed simultaneously, but separately and in private. When two parents were available, one of them was interviewed according to their choice.
Trauma and PTSD in Kurdistanian Children
Interviewers Four interviewers, two women and two men, received one week of training before starting the study. Each interviewer in Kurdistan videotaped 30 interviews for the purpose of quality control and to assess inter-rater reliability. Each videotaped interview was rated by the other three interviewers. Three ratersÕ scores were available on 28 interviews. The average intra-class correlation was .99 with a 95% coefficient interval of .98; .99.
Data analysis Statistical analysis was performed using SPSS. To examine group differences, a t-test was used for continuous variables and v2-test for categorical variables. Correlation between variables was estimated by Pearson Correlation Coefficient. Inter-rater reliability was estimated by the average measure intra-class correlation for the total scores.
Results Children in Duhok reported a significantly higher trauma level than the Kurdish children in Uppsala (means 24.3 ± 20.3 vs. 10.7 ± 6.7, t(310) = 6.8, p < .001), with significant differences between the two samples being found in nine of the 30 traumatic events (Table 2). No significant correlation was found between trauma level and PTSD frequencies in the Duhok sample, while in Uppsala the corresponding correlation was significant, although low (r = .17 and .25, p = .013 and p < .01, respectively). In the Duhok sample, boys reported maltreatment (v2 = 36.3, p < .001) and forced isolation (v 2 = 34.9, p < .001) significantly more than girls. No gender differences were found in the Uppsala sample. Regarding the age differences, the teenagers in the Duhok sample reported higher frequencies of natural disaster (61.0%, p < .001), being close to death (36.9%, p < .01), war experience (31.0%, p < .001), lack of food (22.4%, p < .001), murder of a family member (21.4%, p < .01), and lack of shelter (13.8%, p < .01) than the younger children, i.e., ages 6–12 years. In the Uppsala sample, the age differences only appeared in distressing hospital experiences which were reported significantly more by teenagers (31.9%, p < .001). Common for both samples, death of a family member and accidents were identified as the most distressing events that led to a PTSD diagnosis (17.8% and 12.6% in the Duhok sample and 12.5% and 12.5% in the Uppsala sample, respectively). Kurdish children in Duhok reported significantly higher rates of PTSD and post-traumatic stress symptoms than those in Uppsala (Table 3). The differences between the two samples were significant both in girls and boys, and in both younger children and teenagers. Girls in Duhok exhibited significantly higher posttraumatic stress symptom scores than boys as assessed by the total PTSS-C scores, t(795) = 5.7, p < .001, avoidance, t(795) = 5.0, p < .001, and hyper-arousal, t(795) = 3.7, p < .001. No gender differences were found in the Uppsala sample.
195
Table 2. Frequencies of traumatic experiences in numbers (n) and %, according to the Harvard-Uppsala Trauma Questionnaire (HUTQ-C) in the study Duhok (n = 201)
Road accident (+) School accident (+) Leisure time accident (+) Technical accident (+) Natural disaster (+) Serious injury Robbery (+) Maltreatment (+) Bullying (+) Hostage (+) Kidnapping Imprisonment Lost Forced isolation Forced separation Lack of food and water Lack of shelter War experience Family member mobilised to war Torture Sexual abuse Close to death Forced medical treatment (+) Distressing hospital experience (+) Ill, no access to treatment Murder of a family member Murder of stranger Unnatural death Brainwashing Others
Uppsala (n = 111)
n
%
n
%
41 43 32 68 78 78 38 113 33 2 2 8 50 23 9 31 19 52 41 4 0 54 57 27 25 32 9 17 1 46
20.4 21.4 15.9 33.8* 38.8** 38.8 18.9 56.2** 16.4* 1.0** 1.0 4.0 24.9 11.4 4.5 15.4 9.5 25.9 20.4 2.0 0** 26.9 28.4** 13.4 12.4 15.9* 4.5 8.5 0.5 22.9*
22 26 26 17 14 40 18 35 36 12 1 11 27 10 7 9 7 36 22 5 9 24 7 18 7 6 2 6 3 10
19.8 23.4 23.4 15.3 12.6 36.0 16.2 31.5 32.4 10.8 0.9 9.9 24.3 9.0 6.3 8.1 6.3 32.4 19.8 4.5 8.1 21.6 6.3 16.2 6.3 5.4 1.8 5.4 2.7 9.0
*p < .01, **p < .001, (+) = added item to the HUTQ-C.
Table 3. The Means and Standard Deviations (SD) of Post-traumatic Stress Symptom Scores, and the Frequencies of Post-traumatic Stress Disorder (PTSD) in numbers (N) and %
Duhok (N = 201)
Total PTSD- score re-experiencing avoidance hyper-arousal PTSD diagnosis, N, %
Uppsala (N = 111)
Mean
SD
Mean
SD
6.7** 1.5** 3.2** 1.5** 65
2.9 1.0 1.3 1.3 32.3**
2.4 0.6 1.0 0.7 8
2.8 0.8 1.3 1.3 7.2
*p < .01, **p < .001
Both in Duhok (v2 = 13.8, p < .001,) and Uppsala (v = 7.9, p < .01), the PTSD frequencies were significantly higher among teenagers than younger children. Children born in Kurdistan showed significantly higher PTSD frequencies, v2 = 13.1, p < .001, and higher scores in all PTSS-C scales, p < .001, than those born in Sweden. Finally, a negative linear correlation was found between number of years living in Sweden and PTSD frequencies, total PTSS-C score, re-experiencing, avoidance, and hyper-arousal. 2
196
Abdulbaghi Ahmad et al.
Discussion This is the first cross-sectional study of traumatic experiences and post-traumatic stress symptoms reported by Kurdish children in two urban communitybased populations. Although more similarities than differences were found, the children in Iraqi Kurdistan showed significantly higher frequency of PTSD than those in Exile in Sweden. There is however a question as to the comparability of the two samples considering the significant differences in the parental education levels and the heterogeneity of the sample in exile having 31% of the children born in Sweden. Both in Kurdistan and Sweden, an increase in the frequency of PTSD was correlated with low parental education and low parental working rates. No significant correlation was found between the trauma level and PTSD frequencies in the sample in Kurdistan. Although the corresponding correlations in the exile sample were significant, they also proved to be low. These findings do not support the suggestion that trauma level was associated with the development of PTSD in these two samples. Trauma type did not correlate to PTSD diagnoses, either. Birth in Sweden and number of years spent in Sweden correlated negatively with childrenÕs post-traumatic symptom scores. Despite the stressors of uprooting and cultural changes, Kurdish children seem to have undergone a healing process during their stay in Sweden. These findings support the results of a comparison between Kurdistan children and a Swedish group (Sundelin-Wahlsten et al., 2001). The differences in parental education level between the two samples are significant with more educated parents among Kurdish families in Uppsala than in Duhok. This might be explained by socioeconomic differences with Sweden having more opportunities for education and more encouraging systems for women to work outside the home than in Kurdistan. Another explanation might be inherent in the differences of family characteristics between the families who leave their native country to seek asylum in a new country and those who stay. However, these factors have not been possible to investigate in this study. There were age-related differences in trauma reports with younger children in both samples reporting lower trauma levels than teenagers. Being younger is likely to result in children having less experience of traumatic events. Although non-significant, a trend related to age was found between the two samples (p = .014), indicating higher rates in older children in Kurdistan than Sweden . This may also have influenced the differences in the trauma levels between these two samples. The PTSD prevalence of 32.3% in the children in Kurdistan and 7.2% in the Kurdish children in Sweden is similar to the results of our previous studies (Ahmad & Mohamad, 1996; Ahmad & Sundelin-Wahlsten et al., 2000b; Sundelin-Wahlsten et al., 2001). Also, the higher PTSD frequencies and post-traumatic stress symptom scores among the girls and teenagers than among the boys and younger children (aged 6–12 years) in this study support the findings from previous research with child interviews, while parents reported the opposite. These findings emphasise the importance of interviewing children about their problems instead of asking the parents.
Clinical implications The results of this study provide some insights into the characteristics of childhood trauma and associated psychopathology among children of Kurdish background. The findings have significant clinical implications for both prevention and intervention programmes targeted at this population, both in Kurdistan and abroad. The rapid social transition in Kurdistan and the lack of child mental health services poses practical difficulties in providing clinical services to diagnose trauma-related disorders in childhood and also to prevent adulthood psychopathology. In Sweden as well as in many other western countries, the Kurdish refugees compose a substantial part of the immigrants. The results of this study can provide significant information about the traumatic experiences of the refugee children to the health care systems which can inform health planning and clinical management. The results also support the clinical assumption in a previous study that refugee childrenÕs residence in the host country might have a healing effect on their psychopathology (Sundelin-Wahlsten et al., 2001).
Limitations Several limiting factors are inherent in this study. Although the same methods were used at both sites strict comparison of the two samples is questionable because the sample in Kurdistan was not strictly matched with that in Sweden. In addition, Kurdish children in Sweden came from different parts of Kurdistan which is divided between Iran, Iraq, Syria and Turkey, while the sample in Kurdistan only included children from Iraqi Kurdistan. This might further weaken the comparison, because of the expected influence of the dominating Persian, Arabic, and Turkish cultures on the Kurdish families coming from these countries to Sweden. Secondly the relatively high degree of non-participation in the sample in Sweden further limits it being representative. Therefore, the findings of this study do not necessarily apply to all Kurdish children, neither in Sweden nor in Kurdistan. The findings of this study warrant further replication in other settings. The analyses only concern cross-sectional data, which further limit the conclusions. Further research is needed to assess other types of disorders as well as post-traumatic psychopathology among immigrants compared with the same ethnic group in the country of origin.
Acknowledgements The Swedish International Development Cooperation Agency (SIDA) financially supported this study. The assistance of the statistical expert Hans Arinell is specially acknowledged.
References Ahmad, A. (1992). Symptoms of post-traumatic stress disorder among displaced Kurdish children in Iraq; victims of a manmade disaster after the Gulf war. Nordic Journal of Psychiatry, 4, 315–319. Ahmad, A., Mohammad, H., & Ameen, N. (1998). A 26-month follow-up of posttraumatic stress symptoms in children after
Trauma and PTSD in Kurdistanian Children Mass-Escape Tragedy in Iraqi Kurdistan. Nordic Journal of Psychiatry, 52, 357–366. Ahmad, A., & Mohamad, K. (1996). The socioemotional development of orphans in orphanages and traditional foster care in Iraqi Kurdistan. Child Abuse and Neglect, 20, 1164–1173. Ahmad, A., Sofi, M. A., Sundelin-Wahlsten, V., & von Knorring, A.-L. (2000a). Posttraumatic stress disorder in children after the military operation ÔAnfalÕ in Iraqi Kurdistan. European Child Adolescent Psychiatry, 9, 235–243. Ahmad, A., Sundelin-Wahlsten, V., Sofi, M. A., Qahar, J. A., & von Knorring, A.-L. (2000b). Reliability and validity of a child-specific cross-cultural instrument for assessing posttraumatic stress disorder. European Child Adolescent Psychiatry, 9, 285–294. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders. 4th edition (DSM-4). Washington, DC: APA. Frederick, C., Pynoos, R. S., & Nader, K. (1992). Child Post Traumatic Stress Disorder Reaction Index (CPTS-RI). Available from Robert Pynoos, MD, Trauma Psychiatry Service, UCLA, 300 UCLA Medical Plaza, Los Angeles, CA 900246968. Hollifield, M., Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. The Lancet, 365, 1309–1314. McNally, R. J. (1993). Stressors that produce posttraumatic stress disorder in Children. In: R. T. Davidson & B. E. Foa (Eds.) Posttraumatic stress disorder, DSM-IV and beyond (pp. 57–74). Washington DC: APA. Marshall, G. N., Schell, T. L., Elliott, M. N., Berthold, S. M., & Chun, C. A. (2005). Mental health of Cambodian refugees 2 decades after resettlement in the United States. Journal of the American Medical Association, 294, 571–579. Middle East Watch (1993). Genocide in Iraq: The Anfal campaign against the Kurds. New York: Middle East Watch. Mollica, R. F., Caspi-Yavin, Y., Bollini, P., Truong, T., & Lavelle, J. (1992). The Harvard trauma questionnaires;
197
validating a cross cultural instrument for measuring torture, trauma and posttraumatic stress disorder in Indochinese refugees. The Journal of Nervous and Mental Disease, 180, 111–116. Mollica, R. F., Poole, C., Son, L., Murray, C. C., & Tor, S. (1997). Effects of war trauma on Cambodian refugee adolescentsÕ functional health and mental health status. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1098–1106. Perry, B. (1998). Homeostasis, stress, trauma, and adaptation, a neurodevelopmental view of childhood trauma. Child and Adolescent Psychiatric Clinics of North America, 7, 33–51. Pynoos, R. S., (1990). Posttraumatic stress disorder in children and adolescents. In: B. Grafinkel, B. Carlsson & E. Weller, (Eds.), Psychiatric disorders in children (pp. 48–63). Philadelphia: WB Saunders. Reich, W. (2000). Diagnostic Interview for Children and Adolescents (DICA). Journal of the American Academy of Child and Adolescent Psychiatry, 39, 59–66. Rousseau, C., Drapeau, A., & Platt, R. (2000). Living conditions and emotional profiles of Cambodian, Central American, and Quebecois youth. Canadian Journal of Psychiatry, 45, 905–911. Schweitzer, R., Melville, F., Steel, Z., & Lacherez, P. (2006). Trauma, post-migration living difficulties, and social support as predictors of psychological adjustment in resettled Sudanese refugees. Australian and New Zealand Journal of Psychiatry, 40, 179–188. Sundelin-Wahlsten, V. (1991). Development and survival: A study of children at risk living in adverse psychosocial milieu. Doctoral Dissertation. Department of Education, Stockholm University. Edsbruk: Akademitryck AB. Sundelin-Wahlsten, V., Ahmad, A., & von Knorring, A.-L. (2001). Traumatic experience and posttraumatic stress reactions in children from Kurdistan and Sweden. Acta Paediatrica, 90, 563–568. Terr, L. C. (1991). Childhood trauma. American Journal of Psychiatry, 148, 10–19.
