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School of Public Health, Al Quads University, Gaza
Greenwood Institute of Child Health, University of Leicester, Leicester, UK
Correspondence: Professor Panos Vostanis, Department of Child and Adolescent Psychiatry, University of Leicester, Institute of Child Health, Westcotes House, Westcotes Drive, Leicester LE2 0QU, UK. Tel: +44 (0) 116 225 2885; fax: +44 (0)116 225 2881; e-mail: pv11{at}le.ac.uk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Aims To investigate the relationship between exposure to war trauma and behavioural and emotional problems among pre-school children.
Method A total of 309 children aged 3–6 years were selected from kindergartens in the Gaza Strip, and were assessed by parental reports in regard to their exposure to war trauma, using the Gaza Traumatic Checklist, and their behavioural and emotional problems, using the Behaviour Checklist (BCL) and the Strengths and Difficulties Questionnaire (SDQ).
Results Pre-school children were exposed to a wide range of traumatic events. The total number of traumatic events independently predicted total BCL and SDQ scores. Exposure to day raids and shelling of the children’s houses by tanks were significantly associated with total behavioural and emotional problems scores.
Conclusions Direct and non-direct exposure to war trauma increases the risk of behavioural and emotional problems among pre-school children, which may present as non-specific psychopathology.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Pre-school children were selected from ten kindergartens in a representative province (mid zone) zone) of the Gaza Strip, which contained one city, two villages and three refugee camps. Of the kindergartens, six were from the camps, three from the villages and one from Deir el-Balah City. These were considered representative, as they have the same socio-economic characteristics as other areas in the Gaza Strip. A description of the study was sent to the parents and written consent was obtained prior to the study. The data were collected by four clinicians (one psychiatrist and three psychologists) between December 2002 and February 2003. Parents were asked to complete the instruments (the Parent form of the Gaza Trauma Checklist, the Behaviour Checklist and the Strengths and Difficulties Questionnaire; see below) and supply information on their own socio-demographic characteristics. A sample of 310 children aged 3–6 years was selected from the registration books of the ten kindergartens; the parents of 309 children agreed to participate.
Measures
Gaza Traumatic Checklist – Parent Form
The initial version of the Gaza Traumatic Checklist – Parent Form
(Thabet & Vostanis, 1999)
was developed by the research department of the Gaza Community Mental Health
Programme and consisted of 17 items covering different types of traumatic
events that the child might have been exposed to. Owing to the changing nature
of the political conflict in the region, this checklist was subsequently
revised to include new items such as witnessing bombardment of homes by
helicopters, heavy artillery and tanks, and witnessing mutilated bodies on
television. The main carer completed the checklist (‘yes’ or
‘no’ statements). Parents were asked about the events their
children had experienced in the preceding 12 months. The checklist scores were
analysed as a total score, as well as a categorical variable (low traumatic
exposure for scores lower than 5, moderate exposure for scores 5–9 and
high exposure for scores of 10 and above;
Summerfield, 1993). We also
considered the exposure to specific traumatic events, i.e. the presence or
absence of each checklist item.
Strengths and Difficulties Questionnaire
The parents completed the Strengths and Difficulties Questionnaire (SDQ;
Goodman, 1997) version for
pre-school children, a standardised and widely used measure of behavioural and
emotional problems. Out of 25 items, 14 describe perceived difficulties, 10
perceived strengths and one is neutral (‘gets on better with adults than
other children’). Each perceived difficulties item is scored on a
0–2 scale (0, not true; 1, somewhat true; 2, certainly true). Each
perceived strengths item is reversely scored, i.e. 2, not true; 1, somewhat
true; 0, certainly true. The 25 SDQ items are grouped into five sub-scales:
hyperactivity, conduct, emotional, peer problems and prosocial behaviour (five
items per scale). A score is estimated for each scale (range 0–10) and a
total difficulties score for the four scales (excluding prosocial behaviour,
which was considered different from mental health difficulties), i.e. a range
of 0–40. The SDQ has been used in Arab children
(Thabet et al,
2000).
Behaviour Checklist
The Behaviour Checklist (BCL; Richman
& McGuire, 1986) is a standardised measure of behavioural
problems specifically designed for pre-school children. It is completed by the
parent, who selects which behavioural description out of three or four choices
best fits the child over the previous 4 weeks. A score of 0 indicates the
behaviour is absent, a score of 1 indicates it is sometimes present or present
to a mild degree, and a score of 2 that it occurs frequently or to a marked
degree. A total BCL score is estimated. Unlike the SDQ, the BCL has been less
frequently used in other cultures, but has previously been applied in Iranian
pre-school children during war (Kalantari
et al, 1990).
Statistical analysis
Descriptive statistics were used to present the characteristics of the
sample. The non-parametric Mann–Whitney U test and
Kruskal–Wallis test analysed the differences between groups for
continuous variables that were not normally distributed. The nature of this
association was tested out by a linear regression model, with trauma scores as
the independent variable and SDQ or BCL total scores as the dependent
variable. Data were analysed using the Statistical Package for the Social
Sciences, SPSS version 11.0 for Windows.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Exposure to traumatic events
The pre-school children were exposed to the full range of traumatic events
on the Gaza Traumatic Checklist (Table
1). Frequencies were based on 308 completed questionnaires. The
average child experienced three traumatic events (range 0–15). According
to the previous classification of the checklist, 237 children (valid frequency
78.5%, because of missing data) were reported to have had low exposure to
trauma, 52 (16.8%) had medium exposure and 13 (4.3%) had high exposure to
trauma. Because of the small number in the latter category, medium and high
exposures were grouped together in a new category for subsequent analysis.
Witnessing mutilated bodies and wounded people on television was the most
common traumatic event (n=282; 91.6%). Witnessing the bombardment of
other people’s houses by aeroplanes and helicopters (n=158;
51.3%) and witnessing the firing by tanks and heavy artillery at
neighbours’ houses (n=86; 27.9%) were also common. The beating
(n=9; 2.9%) or killing (n=9; 2.9%) of a close relative was
the least common. There was no gender difference for the number of traumatic
events (z=–0.28, P=0.78). The Gaza Traumatic Checklist
scores were significantly higher among children from urban kindergartens
(Kruskal–Wallis test, 
2=14.5, P=0.001). This
possibly reflected the repeated incursions by military forces into the city
during the period of the study.
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Pre-school children’s psychopathology
The frequency of BCL items reported as occurring frequently in children
living in the Gaza Strip can be compared with findings in children from a
British sample (Richman et al,
1982) (Table 2). Although the study designs were not identical, there were interesting
differences in the frequencies of certain problems. Children in the Gaza Strip
demonstrated significantly increased frequencies of faddy eating, difficulty
in going to bed, sleeping with their parents, poor concentration,
attention-seeking, dependency, temper tantrums, worries and fears. The mean
BCL score (12.6) was higher than the mean BCL score (8.9%) of Iranian
pre-school children whose fathers had been killed during an earlier war
(Kalantari et al,
1990). Although there have been several studies on the SDQ norms
for older children, there has been limited research with pre-school children,
for which reason it was not possible to provide a similar comparison for the
SDQ. There was only one significant difference in respect to gender, with boys
scoring higher on the SDQ hyperactivity sub-scale (Mann–Whitney test:
z=–2.01, P=0.04). There was no significant difference
between boys and girls on total SDQ scores (z= –0.83;
P=0.40) or BCL scores (Z= –1.65; P=0.09).
Children from inner-city areas were rated statistically higher on SDQ
emotional problems (Kruskal–Wallis test, 2=15.2,
P<0.001), prosocial behaviour (2=6.12,
P=0.04), peer problems (2=24.3, P<0.001)
and total SDQ scores (2=24.0, P<0.001). There was
no significant difference according to area of residence on SDQ hyperactivity
problem (2=4.24, P=0.12) and SDQ conduct problem
scores (2=0.94, P=0.63), or on the BCL total scores
(2=2.35, P=0.31). The association between BCL and SDQ
scores was low, although it did reach statistical significance (Spearman rank
correlation R=0.14, P=0.02).
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Relationship between traumatic events and SDQ and BCL scores
The number of traumatic events was entered as the independent variable in a
univariate linear regression, with total SDQ score as the dependent variable,
and was found to have a significant predictive value (P=0.006,
Table 3). The regression
analyses were repeated, with the dependent variable being each of the SDQ
sub-scale scores, or the BCL score. Exposure to trauma was found to predict
SDQ hyperactivity problem scores (P=0.032), SDQ peer problem scores
(P=0.013), and BCL scores (P=0.003). When age and gender
were entered as covariates, these were not found to have a moderating effect
on total SDQ or BCL scores, which continued to be predicted by the total
trauma scores: for total SDQ scores, B=0.29 (95% CI 0.07–0.51),
P=0.011; for total BCL scores, B=0.36 (95% CI 0.13–0.58),
P=0.002.
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When exposure to traumatic events was dichotomised as low or high, and entered as the independent variable in linear regression models, high exposure was associated with total SDQ and BCL scores: for total SDQ scores; B=2.16 (95% CI 0.69–3.63), P=0.004; for total BCL scores, B=1.82 (95% CI 0.34–3.29), P=0.016.
Impact of specific traumatic events
The relationship between individual events and behavioural scores was found
to differ according to the scales used, which might have reflected differences
between the two scales (SDQ and BCL), hence the low correlation
(R=0.14) between them.
When children were compared on BCL scores according to exposure to each traumatic event, they significantly differed on two items of the Gaza Traumatic Checklist (both had higher BCL scores if exposed to that event, according to Mann–Whitney U test): exposure to day raids (z= –3.36, P=0.001) and witnessing a neighbour’s house being shelled by tanks (z= –2.33, P=0.020). The same analysis was repeated with total SDQ scores, i.e. according to exposure to each traumatic event. Exposure to night raids (z=–3.77, P<0.001), day raids (z=3.36, P=0.001), witnessing the shelling of their house by tanks (z=–2.88, P=0.004), witnessing the arrest of a close relative (z=–3.16, P=0.002) and witnessing the beating of a family friend (z=–2.04, P=0.041) were all associated with significant increase in total SDQ scores.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Exposure to trauma and psychopathology in pre-school children
Inevitably, there has been less attention on younger pre-school children,
possibly for a variety of reasons. Psychiatric disorders in this age-group
have a relatively non-specific behavioural or emotional presentation, because
of children’s different articulation of distress or conceptualisation of
traumatic events, which are reflected by measures largely relying on
parents’ reports. The findings of this study indicate that military
violence affects children irrespective of their age, albeit in different ways.
Pre-school children in the Gaza Strip were exposed to a wide range of
traumatic events. The majority had seen events on television, with just over
half witnessing the bombardment of homes from the air. A smaller but
significant number had witnessed the beating, shooting or killing of a
neighbour or member of the family. In this study, the total number of
experienced traumatic events was associated with raised scores on both the BCL
and the SDQ. There was also support for a ‘dose effect’
(Allwood et al, 2002),
with high levels of exposure to trauma related to more severe behavioural and
emotional symptoms.
Overall, the findings are consistent with those of previous studies in this age-group in areas of war. For example, Zahr (1996), in a study on the effect of war on the behaviour of Lebanese pre-school children, found significantly more problems in children aged 3–6 years exposed to heavy shelling over a 2-year period than in a control group living without this threat. Both the exposed and the control groups had behavioural problems scores significantly higher than American norms that could be explained by cultural differences on child-rearing. After Scud missile attacks, displaced Israeli pre-school children demonstrated increased externalising symptoms, including aggression, hyperactivity and oppositional behaviour, together with stress symptoms, compared with non-displaced children. These were strongly correlated to material symptoms (Laor et al, 1996).
Presentation of psychopathology in pre-school children
In contrast with older children, who often present with post-traumatic
stress and depressive disorders, pre-school children may respond through
increased non-specific behavioural problems and symptoms of underlying
anxiety, such as those reported by parents in this study. The high prevalence
rates of certain symptoms, for example the increased frequency of temper
tantrums, fears, overactivity, attention-seeking and poor concentration might
be associated with the exposure to trauma, although such relationships require
more in-depth study. Owing to the lack of standardisation of the BCL in this
culture, children’s high rates of sleeping with their parents or their
dependency on them could have a cultural basis, although both these behaviours
have also been reported in a study of Lebanese pre-school children
(Zahr, 1996). The symptoms for
hyperactivity were raised in both the BCL and SDQ measures and significantly
increased for boys, which is consistent with Western population studies.
Cultural issues in the interpretation of the findings
Although the impact of trauma on children’s mental health has been
replicated across cultures, there are also differences in the perceptions of
traumatic events and how these are processed
(Seedat et al, 2004).
These may be particularly important in the younger age-group, as they can be
mediated by cultural norms of parenting. In a previous study
(Thabet et al, 2000)
we found substantially different perceptions of concepts such as emotional
overprotection and separation anxiety among Palestinian mothers, compared with
mothers from Western countries. In this study, hyperactivity scores were
significantly predicted by exposure to trauma. These symptoms, as well as
conduct problems, require further validation in this population. This
obviously raises issues on the cross-cultural standardisation of instruments
for pre-school children and their reliance on adult reports, which are
discussed in the next section.
Limitations
The low agreement between the two instruments (SDQ and BCL) may be
explained as reflecting different construction, the relatively limited overlap
of items or differential application across cultures. The SDQ has been
validated in this culture and age-group, but there were some questions as to
the validity of emotional items (Thabet
et al, 2000). The BCL has been standardised as a
screening instrument, with some cross-validation in non-Western cultures
(Richman & McGuire, 1986;
Pavuluri et al,
1995). As there has been no previous study comparing these two
widely used measures in different cultural groups of pre-school children, the
cross-cultural validity of these instruments should be investigated further.
However, despite these potential limitations, the total scores on both scales
were significantly predicted by exposure to trauma.
We also need to acknowledge a limitation common to epidemiological research with pre-school children, i.e. the over-reliance on adult reports. Children of this age are less cognitively able to provide direct information, but the completion of measures by their parents poses some methodological difficulties. Parents can never be completely accurate about their child’s exposure to the various traumas, and their own experiences and perception of the conflict may influence their responses (Green et al, 1991). The more severely affected parents could have thus reported a higher number of traumas. Reports from kindergarten teachers or direct assessment methods designed for pre-school children would have added to the value of the findings.
This study did not investigate the moderating and mediating effect of other factors, which may have been associated with children recruited from different backgrounds. Qouta et al (2003) recently demonstrated that maternal symptoms of post-traumatic stress disorder (PTSD) were important determinants of their child’s PTSD. This factor, together with family functioning and parenting style, was not accounted for in this study. Earlier studies have noted that levels of social support, family cohesiveness and communication could mediate the consequences of war (Cohen & Dotan, 1976; Laor et al, 1996; Zahr, 1996). Post-traumatic symptoms in displaced children have been correlated with their mothers’ avoidant symptoms, with the authors suggesting that maternal capacity to cope with stress is an important protective mechanism (Laor et al, 1997). Future research should involve the psychiatric assessment of primary carers in parallel with that of the children, which would enable a better understanding of the impact of political conflict on parents and children, and the interaction between these three variables. In addition, studies on the underlying protective and risk mechanisms should include potentially confounding variables such as extended family and social support networks, coping strategies, and other secondary losses and life events. Finally, more in-depth research should measure the impact of the number and severity of exposure to different types of trauma, rather than exposure to the count of traumatic events.
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Clinical Implications and Limitations |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
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Received for publication March 25, 2004. Revision received March 10, 2005. Accepted for publication March 14, 2005.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Psychiatric Bulletin | Advances in Psychiatric Treatment | All RCPsych Journals |
