Hair hormone data from Syrian refugee children: Perspectives from a two-year longitudinal study

For numerous issues of convenience and acceptability, hair hormone data have been increasingly incorporated in the field of war trauma and forced displacement, allowing retrospective examination of several biological metrics thought to covary with refugees' mental health. As a relatively new research method, however, there remain several complexities and uncertainties surrounding the use of hair hormones, from initial hair sampling to final statistical analysis, many of which are underappreciated in the extant literature, and restrict the potential utility of hair hormones. To promote awareness, we provide a narrative overview of our experiences collecting and analyzing hair hormone data in a large cohort of Syrian refugee children (n = 1594), across two sampling waves spaced 12 months apart. We highlight both the challenges faced, and the promising results obtained thus far, and draw comparisons to other prominent studies in this field. Recommendations are provided to future researchers, with emphasis on longitudinal study designs, thorough collection and reporting of hair-related variables, and careful adherence to current laboratory guidelines and practices.

Alone on the frontline: The first report of PTSD prevalence and risk in de-occupied Ukrainian villages

IMPORTANCE

The ongoing Russian invasion of Ukraine marks a critical juncture in a series of events posing severe threat to the health of Ukrainian citizens. While recent reports reveal higher rates of PTSD in Ukrainian refugees following Russia's invasion - data for Ukrainians remaining at the warfront is inherently difficult to access. A primarily elderly demographic, Ukrainians in previously Russian-occupied areas near the front (UPROANF) are at particular risk.

DESIGN

Data was sourced from screening questionnaires administered between March 2022 and July 2023 by mobile health clinics providing services to UPROANF.

SETTING

Previously occupied villages in Eastern and Southern Ukraine.

PARTICIPANTS

UPROANF attending clinics completed voluntary self-report surveys reporting demographics, prior health diagnoses, and PTSD symptom severity (n = 450; Meanage = 53.66; 72.0% female).

EXPOSURE

Participants were exposed to Russian occupation of Ukrainian villages.

MAIN OUTCOME AND MEASURES

The PTSD Checklist for the DSM-V (PCL-5) with recommended diagnostic threshold (i.e. 31) was utilized to assess PTSD prevalence and symptom severity. ANCOVA was used to examine hypothesized positive associations between (1) HTN and (2) loneliness and PTSD symptoms (cumulative and by symptom cluster).

RESULTS

Between 47.8% and 51.33% screened positive for PTSD. Though cumulative PTSD symptoms did not differ based on HTN diagnostic status, those with HTN reported significantly higher PTSD re-experiencing symptoms (b = 1.25, SE = 0.60, p = .046). Loneliness was significantly associated with more severe cumulative PTSD symptoms (b = 1.29, SE = 0.31, p < .001), re-experiencing (b = 0.47, SE = 0.12, p < .001), avoidance (b = .18, SE = 0.08, p = .038), and hypervigilance (b = 0.29, SE = 0.13, p = .036).

CONCLUSIONS AND RELEVANCE

PTSD prevalence was higher than other war-exposed populations. Findings highlight the urgent mental health burden among UPROANF, emphasizing the need for integrated care models addressing both trauma and physical health. Given the significance of loneliness as a risk factor, findings suggest the potential for group-based, mind-body interventions to holistically address the physical, mental, and social needs of this highly traumatized, underserved population.

Maternal Trauma and Psychopathology Symptoms Affect Refugee Children's Mental Health But Not Their Emotion Processing

Refugee children's development may be affected by their parents' war-related trauma exposure and psychopathology symptoms across a range of cognitive and affective domains, but the processes involved in this transmission are poorly understood. Here, we investigated the impact of refugee mothers' trauma exposure and mental health on their children's mental health and attention biases to emotional expressions. In our sample of 324 Syrian refugee mother-child dyads living in Jordan (children's Mage=6.32, SD = 1.18; 50% female), mothers reported on their symptoms of anxiety and depression, and on their children's internalising, externalising, and attention problems. A subset of mothers reported their trauma exposure (n = 133) and PTSD symptoms (n = 124). We examined emotion processing in the dyads using a standard dot-probe task measuring their attention allocation to facial expressions of anger and sadness. Maternal trauma and PTSD symptoms were linked to child internalising and attention problems, while maternal anxiety and depression symptoms were associated with child internalising, externalising, and attention problems. Mothers and children were hypervigilant towards expressions of anger, but surprisingly, mother and child biases were not correlated with each other. The attentional biases to emotional faces were also not linked to psychopathology risk in the dyads. Our findings highlight the importance of refugee mothers' trauma exposure and psychopathology on their children's wellbeing. The results also suggest a dissociation between the mechanisms underlying mental health and those involved in attention to emotional faces, and that intergenerational transmission of mental health problems might involve mechanisms other than attentional processes relating to emotional expressions.

The Scope and Distribution of Upper Extremity Nerve Injuries Associated With Combat-Related Extremity Limb Salvage

PURPOSE

Chronic pain and functional limitations secondary to nerve injuries are a major barrier to optimal recovery for patients following high-energy extremity trauma. Given the associated skeletal and soft tissue management challenges in the polytraumatized patient, concomitant nerve injuries may be overlooked or managed in delayed fashion. Whereas previous literature has reported rates of peripheral nerve injuries at <10% in the setting of high-energy extremity trauma, in our experience, the incidence of these injuries has been much higher. Thus, we sought to define the incidence, pain sequelae, and functional outcomes following upper extremity peripheral nerve injuries in the combat-related limb salvage population.

METHODS

We performed a retrospective review of all patients who underwent limb salvage procedures to include flap coverage for combat-related upper extremity trauma at a single institution between January 2011 and January 2020. We collected data on patient demographics; perioperative complications; location of nerve injuries; surgical interventions; chronic pain; and subjective, patient-reported functional limitations.

RESULTS

A total of 45 patients underwent flap procedures on 49 upper extremities following combat-related trauma. All patients were male with a median age of 27 years, and 96% (n = 47) of injuries were sustained from a blast mechanism. Thirty-three of the 49 extremities (67%) sustained associated nerve injuries. The most commonly injured nerve was the ulnar (51%), followed by median (30%) and radial/posterior interosseous (19%). Of the 33 extremities with nerve injuries, 18 (55%) underwent surgical intervention. Nerve repair/reconstruction was the most common procedure (67%), followed by targeted muscle reinnervation (TMR, 17%). Chronic pain and functional limitation were common following nerve injury.

CONCLUSIONS

Upper extremity peripheral nerve injury is common following high-energy combat-related trauma with high rates of chronic pain and functional limitations. Surgeons performing limb salvage procedures to include flap coverage should anticipate associated peripheral nerve injuries and be prepared to repair or reconstruct the injured nerves, when feasible.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Enduring association between irritable bowel syndrome and war trauma during the Nicaragua civil war period: A population-based study

BACKGROUND

Psychosocial and physical trauma are known risk factors for irritable bowel syndrome (IBS), including in war veterans, whereas war exposure in civilians is unclear. Nicaragua experienced two wars, 1970-1990: The Sandinistas Revolution (1970s) and The Contra War (1980s). Our aim was to investigate the role of exposure to war trauma in the subsequent development of IBS in the context of an established health surveillance system (11000 households).

AIM

To investigate in a civilian population the relationship between exposure to war trauma and events and the subsequent development of IBS in the context of an established public health and demographic surveillance system in western Nicaragua.

METHODS

We conducted a nested population-based, cross-sectional study focused on functional gastrointestinal disorders based on Rome II criteria. 1617 adults were randomly selected. The Spanish Rome II Modular Questionnaire and Harvard Trauma Questionnaire were validated in Nicaragua. War exposure was assessed with 10 measures of direct and indirect war trauma and post-war effects. Multiple exposures were defined by ≥ 3 measures.

RESULTS

The prevalence of IBS was 15.2% [Female (F) 17.1%, Male (M) 12.0%], war exposure 19.3% (F 9.3%, M 36.7%), and post-traumatic stress disorder (PTSD) 5.6% (F 6.4%, M 4.3%). Significant associations with IBS in the civilian population were observed (adjusted by gender, age, socioeconomic status, education): physical and psychological abuse [adjusted odds ratio (aOR): 2.25; 95% confidence interval: 1.1-4.5], witnessed execution (aOR: 2.4; 1.1-5.2), family member death (aOR: 2.2; 1.2-4.2), and multiple exposures (aOR: 2.7; 1.4-5.1). PTSD was independently associated with IBS (aOR: 2.6; 1.2-5.7).

CONCLUSION

An enduring association was observed in the Nicaragua civilian population between specific civil war-related events and subsequent IBS. Civilian populations in regions with extended armed conflict may warrant provider education and targeted interventions for patients.

Transport over a flexible nail to treat a tibial defect caused by shelling injury: A case report of a 13-year-old child

INTRODUCTION

The care of tibial traumatic fractures brought on by shelling injuries is extremely difficult, as these fractures are frequently comminuted, leading to a bone defect, extensive soft tissue damage, and an increased risk of bacterial contamination.

CASE PRESENTATION

A 13-year-old male presented with trauma to the right leg following a shelling injury. He had a Gustilo IIIa open fracture with soft tissue destruction and a 7.5 cm bone loss in the distal region of the tibial shaft. Neurovascular exams were unremarkable. Primary treatment by external fixation, wound debridement, and simple suture closure was achieved. After the external fixator was removed, distraction osteogenesis was performed to deal with the bone loss. The surgical technique chosen was transport over a flexible intramedullary nail. By the end of both distraction and consolidation phases, the patient was healed with no complications, deformities, or length discrepancies.

DISCUSSION

The objective of treating tibial shelling wounds is to restore functionality and save the patient's life and limb. Neurovascular evaluation, early bone fixation, and wound care are the basic treatment. Many techniques of distraction osteogenesis can be used to restore bone loss. With lower external fixation time and complications, transport over a nail is an important one. However, using a rigid intramedullary nail in children is contraindicated, so a flexible one was used.

CONCLUSION

In this case report, we highlight the value of proper management of open leg fractures and the importance of restoring bone loss to improve the quality of life for war victims, particularly children.

Effect of daily stressors and collective efficacy on post-traumatic stress symptoms among internally displaced persons in post-war northern Sri Lanka

BACKGROUND

Daily stressors have been shown to mediate the relationship of war trauma and trauma-related distress among refugees and internally displaced persons exposed to war and conflict.

AIMS

To examine the extent to which the relationship between war-related trauma and mental distress was mediated by daily stressors and collective efficacy among internally displaced communities a decade after exposure to war.

METHOD

In a cross-sectional study, we recruited a random sample of residents in villages severely affected by conflict in five districts in the Northern Province of Sri Lanka. Measures of war trauma, daily stressors, collective efficacy and post-traumatic stress symptoms (PTSS) were examined. Statistical analyses of the mediating and moderating effects of daily stressors were conducted using regression based methods.

RESULTS

Daily stressors mediated the association of war trauma and PTSS, as both paths of the indirect effect, war trauma to daily stressors and daily stressors to PTSS, were significant. The predictive effect of war trauma on PTSS was positive and significant at moderate and high levels of daily stressors but not at low levels. Higher levels of neighbourhood informal social control, a component of collective efficacy, function as a protective factor to reduce effects of war trauma and daily stressors on mental distress in this population.

CONCLUSIONS

Daily stressors are an important mediator in the well-established relationship between war exposure and traumatic stress among internally displaced persons, even a decade after the conflict. Mental health and psychosocial support programmes that aim to address mental distress among war-affected communities could reduce daily stressors and enhance collective efficacy in this context.

Petrification and Revitalization: The Role of Somatic Narration in Working Through A War Trauma

The author investigates bodily aspects of the defense organization in the treatment of a soldier suffering from a war traumatization. The patient reports two situations-a bomb attack and the subsequent confrontation with wounded comrades-that had a traumatizing impact. In the treatment process, a phase of stagnation is described before the shared attention is focused on the bodily perception of the patient. His petrified body feeling ("my body feels like concrete") was systematically examined in the therapeutic process then slowly transformed through shared perception, leading to a process of vitalizing reorganization. This method is called somatic narration. It reverses the defense processes of the encapsulated body engram. This capsule results from the threatening impact of a traumatic event, disorganizing the patient's body-self. This disorganization then is encapsulated through a process of petrification and avoidance of awareness. The therapeutic process is described in detail. The structure of the bodily unconscious is revealed. The process of reorganization of perception and memory is outlined.

Change in child mental health during the Ukraine war: evidence from a large sample of parents

The ongoing war in Ukraine is expected to negatively impact the mental health of the country's population. This study aims to provide a preliminary estimate of the degree of change in the mental health problems of Ukrainian children following Russia's invasion in February 2022, and to identify the sociodemographic and war-related risk factors associated with these changes. A nationwide, opportunistic sample of 1238 parents reported on a single randomly chosen child within their household as part of The Mental Health of Parents and Children in Ukraine Study. Data were collected between July 15th and September 5th, 2022. Participants completed modified versions of the Pediatric Symptom Checklist (PSC-17) which was adapted to capture change in the frequency of symptoms since the beginning of the war. Parents reported increases across all 17 indicators of internalizing, externalizing, and attention problems of the PSC-17. Increased problems were most pronounced within the internalizing domain, with 35% of parents reporting that their child worried more since the beginning of the war. A number of individual, parental, and war-related factors were associated with increases across the three domains. Exposure to war trauma, pre-existing mental health problems, and child age were among the strongest predictors of change. This survey provides preliminary evidence that the Russian war on Ukraine has led to an increase in common mental health problems among children in the general population. Further research is required to determine the extent and sequela of this increase, and to develop intervention strategies for those most in need.

War trauma and strategies for coping with stress among Ukrainian refugees staying in Poland

Objectives

The Russian military aggression against Ukraine resulted in a humanitarian crisis. There was a mass exodus of war refugees. More than 17 million people have left Ukraine since the war broke out. The refugees who came to Poland and other countries have experienced war trauma. The study aims to assess mental health of Ukrainian war refugees in Poland.

Population and methods

At the time of the study, that is, in April and May 2022, between 1,5 million and 2 million Ukrainian refugees were staying in Poland. They were mainly young women with their children. The CAWI (Computer-Assisted Web Interview) technique was used in the study. The research sample was selected using purposive sampling. The invitation to take part in the survey was posted on social media for Ukrainians in Poland, and also sent to the participants of a Polish as a Foreign Language course. The study utilizes the RHS-15 and a nominal scale measuring the strategies for coping with stress.

Results

The research sample consists of 737 respondents. The results of the screening tests indicate that depression, anxiety disorders and PTSD may be observed among 73% of respondents, whereas 66% of the respondents display psychological distress. The analyses have shown that higher levels of mental health disorders were observed among women and refugees who do not speak Polish. Younger respondents experienced a higher psychological distress. The results of the study also indicate that the refugees more often implemented problem-focused strategies. The analysis has shown that the respondents who followed active strategies scored the lowest on RHS-15. The emotion-focused strategies, such as praying, diverting attention by becoming involved in different activities or taking sedatives were not effective. The highest levels of disorders were present among the refugees who indicated resignation.

Conclusions

The collected observations indicate that the main problem which might hinder their adaptation could be mental health issues, which in turn impact the general deterioration of health and the quality of life.

Predictors of psychological risk and resilience among Syrian refugee children

OBJECTIVES

War-exposed refugee children are at elevated risk for mental health problems, but a notable proportion appear resilient. We aimed to investigate the proportion of Syrian refugee children who can be considered resilient, and applied a novel approach to identify factors predicting individual differences in mental health outcomes following war exposure.

METHODS

The sample included 1,528 war-exposed Syrian refugee children and their primary caregiver living in refugee settlements in Lebanon. Children were classed as having low symptoms (LS) if they scored below clinically validated cut-offs for post-traumatic stress disorder (PTSD), depression and externalising behaviour problems. Children scoring above any cut-off were classified as having high symptoms (HS). Each LS child was matched with one HS who reported similar war exposure, to test what differentiates children with similar exposures but different outcomes.

RESULTS

19.3% of the children met our resilience criteria and were considered LS. At the individual level, protective traits (e.g. self-esteem; OR = 1.51, 95% CI [1.25, 1.81]) predicted LS classification, while environmental sensitivity (OR = 0.69, 95% CI [0.59, 0.82]), poorer general health (OR = 0.71, 95% CI [0.58, 0.87]) and specific coping strategies (e.g. avoidance; OR = 0.90, 95% CI [0.85, 0.96]) predicted HS classification. Social/environmental predictors included perceived social support (OR = 1.23, 95% CI [1.02, 1.49]), loneliness and social isolation (OR = 0.85, 95% CI [0.80, 0.90]), child maltreatment (OR = 0.96, 95% CI [0.94, 0.97]), and caregiver mental and general health (e.g. caregiver depression; OR = 0.94, 95% CI [0.92, 0.97]).

CONCLUSIONS

Future research should take multiple dimensions of functioning into account when defining risk for mental health problems and consider the identified predictors as potential targets for interventions.

Creation and application of war trauma treatment simulation software for first aid on the battlefield based on undeformed high-resolution sectional anatomical image (Chinese Visible Human dataset)

BACKGROUND

Effective first aid on the battlefield is vital to minimize deaths caused by war trauma and improve combat effectiveness. However, it is difficult for junior medical students, which have relatively poor human anatomy knowledge and first aid experience. Therefore, we aim to create a treatment simulation software for war trauma, and to explore its application for first aid training. METHODS : This study is a quantitative post-positivist study using a survey for data collection. First, high-resolution, thin-sectional anatomical images (Chinese Visible Human (CVH) dataset) were used to reconstruct three-dimensional (3D) wound models. Then, the simulation system and the corresponding interactive 3D-PDF, including 3D models, graphic explanation, and teaching videos, were built, and used for first aid training in army medical college. Finally, the interface, war trauma modules, and training effects were evaluated using a five-point Likert scale questionnaire. All measurements are represented as mean and standard deviations. Moreover, free text comments from questionnaires were collected and aggregated.

RESULTS

The simulation software and interactive 3D-PDF were established. This included pressure hemostasis of the vertex, face, head-shoulder, shoulder-arm, upper forearm, lower limb, foot, and punctures of the cricothyroid membrane, pneumothorax, and marrow cavity. Seventy-eight medical students participated in the training and completed the questionnaire, including 66 junior college students and 12 graduate students. The results indicated that they were highly satisfied with the software (score: 4.64 ± 0.56). The systems were user-friendly (score: 4.40 ± 0.61) and easy to operate (score: 4.49 ± 0.68). The 3D models, knowledge of hemostasis, and puncture were accurate (scores: 4.41 ± 0.67, and 4.53 ± 0.69) and easily adopted (scores: 4.54 ± 0.635, and 4.40 ± 0.648). They provided information about hemostasis and puncture (all scores > 4.40), except for cricothyroid membrane puncture (scores: 4.39 ± 0.61), improved the learning enthusiasm of medical students (score: 4.55 ± 0.549), and increased learning interest (score: 4.54 ± 0.57).

CONCLUSION

Our software can effectively help medical students master first aid skills including hemostasis, cricothyroid membrane and bone marrow puncture, and its anatomy. This may also be used for soldiers and national first aid training.

Connection between the COVID-19 pandemic, war trauma reminders, perceived stress, loneliness, and PTSD in Bosnia and Herzegovina

In order to gain a better understanding of what happens during the COVID-19 pandemic to those who were previously traumatized, this study investigated perceived stress and severity of PTSD symptoms during the COVID-19 pandemic in people who experienced the 1992-1995 war in Bosnia and Herzegovina. It was also examined how reminders of past trauma and loneliness instigated by the COVID-19 crisis relate to current stress and PTSD symptoms. The sample consisted of 123 participants (74.8% women). Participants responded to assessments of sociodemographic characteristics, exposure to COVID-related information, concerns over disease, severity of exposure to war, frequency and intensity of war trauma reminders, loneliness, stress, and severity of PTSD symptoms. Data was collected as part of the COVIDiSTRESS Global Survey. Results showed that in a population previously exposed to the effects of war, severity of PTSD symptoms was positively related to perceived stress, and loneliness during the pandemic significantly mediated this relationship. Intensity of exposure to war trauma reminders was associated with higher levels of PTSD symptom severity. Higher severity of PTSD symptoms was related to forced displacement during the war. Moreover, higher stress was related to increased concerns over disease. To conclude, those exposed to war may be more affected by the global COVID-19 pandemic and preventive measures that accompany it, while loneliness mediates the effects of PTSD and perceived stress in this population.

War trauma and infant motor, cognitive, and socioemotional development: Maternal mental health and dyadic interaction as explanatory processes

BACKGROUND

Taking care of infants in conditions of war is highly demanding and a few studies reveal the negative impact of war trauma on maternal and infant well-being. Yet, little is known regarding the influence of trauma on infant development and the potential explanatory mechanisms. First, the present study examines how mothers' prenatal exposure to traumatic war events is associated with infant cognitive, motor, and socioemotional development. Second, it analyses the mediating roles of maternal postpartum mental health problems, quality of dyadic mother-infant interaction, and earlier infant development (at six months) in the association between prenatal traumatic war events and infants' developmental skills at 18 months.

METHOD

This prospective three-wave study involved 502 Palestinian pregnant females in their first trimester during the 2014 Gaza War and participated at delivery (T1) and when the child was six (T2;N = 392) and eighteen (T3; N = 386) months of age. Mothers reported their exposure to traumatic war events (human and material losses, horrors, and threat to life) at T1 and T2, and researchers photo-documented the extent of destruction at T1. Mothers reported infants' language, fine- and gross-motor, and socioemotional skills at T2 and researchers tested infants' motor, cognitive-language and socioemotional skills using the Bayley Scales of Infant development (BSID-II) at T3. Mothers reported their mental health problems (symptoms of post-traumatic stress disorder [PTSD], depression and somatization) at T2 and T3 as well as dyadic interaction quality (the emotional availability self-report, [EA-SR] brief) at T2.

RESULTS

First, the structural equation model (SEM) on direct effects indicated, in contrast to our hypotheses, that maternal prenatal exposure to traumatic war events did not associate with infants' developmental skills at T2 and predicted higher level of developmental skills at T3. Second, as hypothesized, we found two negative underlying mechanisms (paths) between high exposure and low levels of motor, cognitive-language, and socioemotional skills at T3: (1) through increased maternal mental health problems at T2, which then were associated with problems at T3, and (2) through increased maternal mental health problems at T2, which then were associated with a low quality of mother-infant-interaction and low level of infant developmental skills at T2.

CONCLUSION

Improving maternal mental health and encouraging close and positive dyadic interaction can be critical for infant sensorimotor, cognitive, and socioemotional development in war conditions.

Future orientation of youth with a history of war trauma: a qualitative study in the African context

Adolescence is an important developmental period for social relationships, identity formation and future planning. Traumatic experiences, such as war and persecution, may interfere with optimal development, including the future orientation of adolescents. The present study examines how young adult war survivors construct, make sense of, and narrate their future goals, plans, and expectations. The participants were 13 Liberian 25-35-year old male and female refugees living in Ghana. This qualitative study is based on semi-structured interviews with prompting questions. By applying a phenomenological approach the interview transcripts were categorized into themes and subthemes about future orientations. Results revealed three main themes, two of them desired a positive future orientation, indicating optimism and determination to improve one's own life and to contribute to a flourishing nation and to peacebuilding. The third theme illustrated a failure to reconstruct war-shattered lives and involved pessimistic views of the future. The results are discussed in relation to peacebuilding and the developmental challenges of young adults as war survivors.

The role of maternal attachment in mental health and dyadic relationships in war trauma

Background

Infant care is a demanding task in dangerous war conditions, but research on the wellbeing of mother-infant dyads is mainly available in peaceful conditions. Knowledge on protective versus risking processes is especially vital for tailoring effective help, and the present study proposes the maternal attachment style to play an important role in dangerous war conditions.

Objective

The study analyses, first, how various traumatic war events, such as losses, horrors and life-threat, are associated with maternal mental health and dyadic mother-infant interaction quality, indicated by maternal emotional availability (EA). Second, it tests a hypothesis that maternal insecure attachment risks and secure attachment protects good mental health and optimal EA from negative impacts of traumatic war events.

Method

The prospective three-wave study involved 502 Palestinian mothers, who were pregnant during the 2014 War on Gaza, and participated at delivery (T1), and when the infant was seven (T2; N = 392) and eighteen (T3; N = 386) months. Mothers reported about war events at T1 and T2 (death and losses, witnessing horrors and life-threat), and posttraumatic stress disorder (PTSD) and depression symptoms at T2 and T3. Dyadic interaction quality was assessed by mother-perceived emotional availability (EA) scale at T2 and T3, and attachment styles by mothers’ self-reports at T3.

Results

Death and losses, witnessing horrors, and life-threat were all associated with a high level of maternal PTSD, but only at T2, whereas death and losses were associated with her depressive symptoms both at T2 and T3. Witnessing horrors was associated with a low close and positive and a high distant and negative emotional availability at T2 and T3. As hypothesized, maternal avoidant attachment was associated with a low level of close and positive EA in general, and especially when the dyads were exposed to a high level of traumatic war events, thus indicating a risking function. Against the hypothesis, secure attachment did not show any protective function on emotional availability, while, unexpectedly, maternal preoccupied attachment was associated with close and positive emotional availability, when dyads were exposed to a high level of traumatic war events.

Conclusion

Mothering in conditions of war and military violence is an overwhelmingly demanding task, and mother-infant dyads need legal, social, and psychological assistance. Knowledge and reflection of unique responses and meanings of different attachment styles would be fruitful in tailoring effective help.

What doesn't kill you makes you feel older: lifespan adversity and its association with subjective age among former prisoners of war

Background: Subjective age (SA) is an indicator of aging that has been empirically associated with health impediments and hindered longevity. Studies show that adverse life events may result in relatively older SA, but have not addressed the differential contribution of life events across the lifespan and the course of posttraumatic psychopathology on the SA of aging survivors of extreme trauma. Objective: Filling this gap, the current study explored the differential contribution of (1) adverse experiences in various life-stages and (2) trajectories of posttraumatic stress disorder (PTSD) to the prediction of SA in a sample of former prisoners-of-war as they enter old age. Method: A cohort of Israeli former prisoners-of-war of the 1973 Yom Kippur War (N = 103) was assessed at four points throughout four decades after the war. A linear hierarchical regression was utilized to assess the contribution of negative life events during childhood, participation in other wars, combat exposure, suffering in captivity, life events since the war and the trajectories of PTSD for predicting SA 42-years post-repatriation. Results: Lifespan adversity explained 50% of the variance in SA, with trajectories of PTSD making the largest contribution, followed by life events since the war. Negative life events in childhood added to the explained variance only when PTSD trajectories were accounted for. Exposure to combat, participation in additional wars and the severity of specific experiences during captivity did not reach significance, though the latter marginally contributed to the explained variance (p = .069). Conclusions: This study demonstrates the importance of considering the prolongation of posttraumatic psychopathology together with life adversities and their differential implications when addressing SA after extreme trauma. The findings suggest that early life adversity may be a latent factor that increases vulnerability to posttraumatic premature aging processes.

Long-term psychological distress of Bosnian war survivors: an 11-year follow-up of former displaced persons, returnees, and stayers

BACKGROUND

Research on the long-term mental health consequences of war and displacement among civilians who live in post-conflict countries is rare. The aim of this study was to examine the developmental trajectories and predictors of general psychological distress in three samples of Bosnian war survivors over an 11-year period.

METHODS

In 1998/99, about three years after the war in Bosnia and Herzegovina, a representative sample of 299 adult Sarajevo citizens was examined in three subsamples: individuals who had stayed in Sarajevo throughout the siege, individuals who had been internally displaced, and refugees who had returned. Of the 138 study participants who could be located 11 years later, 100 were re-assessed (71%) using the Brief Symptom Inventory.

RESULTS

Over time, psychological symptoms and general psychological distress decreased in those survivors who had stayed and increased in returnees. Former displaced persons did not show any significant changes. After controlling for other factors, cumulative trauma exposure before and during the war predicted general psychological distress at baseline. Eleven years later, higher trauma exposure during and after the war, returnee status, and more current stressors were all associated with higher levels of general psychological distress.

CONCLUSIONS

Levels of psychological symptoms remained high in three subsamples of Bosnian war survivors. The differential symptom trajectories may correspond to distinct war experiences and contemporary stressors. Still, the cumulative effect of war traumata on mental distress persisted more than a decade after war and displacement, although the influence of current stressors seemed to increase over time.

Mental health in Syrian children with a focus on post-traumatic stress: a cross-sectional study from Syrian schools

PURPOSE

Studies show that conflict can negatively affect psychological health. The Syrian crisis is 8 years old and yet little is known about the impact of the conflict on the well-being of Syrians who remain. This gap was addressed by conducting an empirical study on the mental health burden of Syrian children in two areas of the country.

METHODS

492 children between 8 and 15 years were randomly selected from schools in Damascus and Latakia. The incidence of psychological disorder symptoms was measured using self-report screening instruments, the Children's Revised Impact of Event Scale (CRIES-8) and the Revised Children's Anxiety and Depression Scale (RCADS-25). Simultaneously, sociodemographic and traumatic event information was collected. Binary logistic regression was used to identify factors that influence the development of post-traumatic stress disorder (PTSD) symptoms.

RESULTS

In our sample, 50.2% of students were internally displaced and 32.1% reported a negative experience. 60.5% of those tested had at least one probable psychological disorder with PTSD the most common (35.1%), followed by depression (32.0%), and anxiety (29.5%). Binary logistic regression indicated that PTSD symptoms were predicted by: living in Damascus [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.51-3.69], being female (1.54, 1.02-2.34), having depression and anxiety (2.55, 1.48-4.40), and the negative experiences; displacement and daily warzone exposure (1.84, 1.02-3.30 and 2.67, 1.08-6.60).

CONCLUSIONS

Syrian children are experiencing traumatic events and war-associated daily stresses that are hugely impacting psychological well-being. Our data offer guidance for mental health providers regarding risk factors and highlights the use of the school system to reach suffering children.

Displaced Syrian children's reported physical and mental wellbeing

BACKGROUND

Surviving a warzone inflicts harmful consequences on the physical health and the psychosocial wellbeing of children. This study aimed at exploring the physical and psychosocial perceived state of health of displaced Syrian refugee children in Jordan.

METHODS

A cross-sectional explorative design was applied. Structured questionnaires were used to collect data through face-to-face interviews with 250 Syrian refugee children. Descriptive and inferential statistics were used.

RESULTS

Children had fair levels of physical health; their health concerns were minor. Psychosocially, 25% (n = 63) suffered from loneliness and 24% (n = 59) reported feeling depressed. The majority of children (>60%) had low rates of somatic pain. Age had a negative correlation with hyperactivity (r = -.14, p = .034); gender differences were found in anger expression and anger trait (p < .05).

CONCLUSIONS

The results in this study highlight a number of physical and psychosocial health concerns among refugee children. The health needs of displaced Syrian children need to be addressed using comprehensive assessment and care. Our findings documented the physical and psychosocial health needs of the displaced Syrian children in Jordan and addressed areas of focus to guide health promotion interventions and community health efforts for them.

Post-conflict struggles as networks of problems: A network analysis of trauma, daily stressors and psychological distress among Sri Lankan war survivors

A growing body of literature indicates that the mental distress experienced by survivors of war is a function of both experienced trauma and stressful life events. However, the majority of these studies are limited in that they 1) employ models of psychological distress that emphasize underlying latent constructs and do not allow researchers to examine the unique associations between particular symptoms and various stressors; and 2) use one or more measures that were not developed for that particular context and thus may exclude key traumas, stressful life events and symptoms of psychopathology. The current study addresses both these limitations by 1) using a novel conceptual model, network analysis, which assumes that symptoms covary with each other not because they stem from a latent construct, but rather because they represent meaningful relationships between the symptoms; and 2) employing a locally developed measure of experienced trauma, stressful life problems and symptoms of psychopathology. Over the course of 2009-2011, 337 survivors of the Sri Lankan civil war were administered the Penn-RESIST-Peradeniya War Problems Questionnaire (PRPWPQ). Network analysis revealed that symptoms of psychopathology, problems pertaining to lack of basic needs, and social problems were central to the network relative to experienced trauma and other types of problems. After controlling for shared associations, social problems in particular were the most central, significantly more so than traumatic events and family problems. Several particular traumatic events, stressful life events and symptoms of psychopathology that were central to the network were also identified. Discussion emphasizes the utility of such network models to researchers and practitioners determining how to spend limited resources in the most impactful way possible.

"We must cooperate with one another against the Enemy": Agency and activism in school-aged children as protective factors against ongoing war trauma and political violence in the Gaza Strip

This exploratory qualitative study investigated self-perceived risk and protection factors that may reinforce the ability of children living in refugee camps on the Gaza Strip to adjust to a traumatic and risky life context characterized by loss and dispossession. The sample comprised 200 Palestinian children recruited at primary schools in four refugee camps in the Gaza Strip following the Israeli military operation "Pillar of Defence" in 2012. Thematic content analysis was applied to written materials and narratives produced by the children. Environment, friends, emotions, family, play, self, sociality, health, school, and spirituality were the dimensions that emerged from the narrative texts. Palestinian children's psychological adaptability and ability to reposition themselves along the continuum between ease and disease is underpinned by constant political agency and activism - a dimension that guides sense-making activities in a traumatizing environment marked by continuous uncertainty, loss and bereavement. We therefore recommend a politically-informed focus, both when assessing children and when designing intervention for them in contexts of chronic political violence and war.

The protective role of maternal posttraumatic growth and cognitive trauma processing among Palestinian mothers and infants

War survivors use multiple cognitive and emotional processes to protect their mental health from the negative impacts of trauma. Because mothers and infants may be especially vulnerable to trauma in conditions of war, it is urgent to determine which cognitive and emotional processes are effective for preventing negative trauma impacts." This study examined whether mothers' high posttraumatic growth (PTG) and positive posttraumatic cognitions (PTC) protected (a) their own mental health and (b) their infants' stress regulation and sensorimotor and language development from the effects of war trauma. The participants were 511 Palestinian mothers and their infants living in the Gaza strip. The mothers were interviewed in their second trimester of pregnancy (T1) as well as when the infant was four months (T2) and twelve months (T3). Mothers reported posttraumatic growth (PTG; Tedeschi & Calhoun, 1996) at T1 and posttraumatic cognitions (PTCI; Foa et al., 1999) at T2. They also reported their exposure to traumatic war events both at T1 and T3 and described their mental health conditions (e.g., PTSD and/or depressive and dissociation symptoms) at T3. The Infant Behaviour Questionnaire (IBQ) was used to measure infants' stress regulation at T2 and sensorimotor and language development at T3. The results, based on regression analyses with interaction terms between trauma and PTG, showed that high levels of traumatic war events were not associated with high levels of PTSD, depressive, or dissociation symptoms among mothers showing high levels of PTG. This suggests that PTG may protect maternal mental health from the effects of trauma. In turn, positive maternal PTCs appeared to protect the infants' stress regulation from the effects of war trauma. The study concludes by discussing ways to develop and implement preventive interventions for mother-infant dyads in war conditions.

Preparing the Field for Feasibility Testing of a Parenting Intervention for War-Affected Mothers in Northern Uganda

In this article, we discuss the successful implementation of an adapted evidence-based parenting intervention for families affected by two decades of war in Northern Uganda. The adaptation and adoption of such interventions to support mental health and family functioning is widely endorsed by prevention scientists and considered a priority in global mental health. The preparation and early adoption phases of engaging with a highly vulnerable community affected by war trauma are documented in this paper along with a discussion of the steps taken to adapt a parenting intervention for cultural and contextual fit. This study is a component of an overall program of research aimed at reducing the long-term negative effects of war on parenting practices and childhood outcomes, which have considerable implications for preventing mental, neurological, and substance-use disorders. The processes described here cover a 4-year period culminating in the implementation of the nine-session Enhancing Family Connection intervention piloted with a group of 14 mothers. The lessons in cultural adaptation have been valuable and the feasibility results promising for further testing the intervention.

Can functional emotion regulation protect children's mental health from war trauma? A Palestinian study

Effective emotion regulation (ER) is expected to protect mental health in traumatic stress. We first analysed the protective (moderator) function of different ER strategies and the associations between ER and mental health. Second, we tested gender differences in the protective function of ER and the associations between ER strategies and mental health. Participants were 482 Palestinian children (girls 49.4%; 10-13 years, M = 11.29, SD = .68) whose ER was assessed by the Emotion Regulation Questionnaire and mental health by post-traumatic stress (Children's Impact Event Scale), depressive, and psychological distress (Strengths and Difficulties Questionnaire) symptoms, and by psychosocial well-being (Mental Health Continuum-Short Form). War trauma involved 42 events. Results showed, first, that none of the ER strategies could protect a child's mental health from negative impact of war trauma, but self-focused ER was associated with low depressive symptoms, and other-facilitated ER with high psychological well-being. However, controlling of emotions formed a comprehensive risk for children's mental health. Second, gender differences were found in the protective role of ER, as self-focused and distractive ER formed a vulnerability among boys. The results are discussed in the context of emotional and regulative demands of war and life-threat.

Family systems approach to attachment relations, war trauma, and mental health among Palestinian children and parents

Background: Trauma affects the family unit as a whole; however, most existing research uses individual or, at most, dyadic approaches to analyse families with histories of trauma. Objective: This study aims to identify potentially distinct family types according to attachment, parenting, and sibling relations, to analyse how these family types differ with respect to war trauma, and to explore how children's mental health and cognitive processing differ across these family types. Method: Participants included Palestinian mothers and fathers (N = 325) and their children (one per family; 49.4% girls; 10-13 years old; mean ± SD age = 11.35 ± 0.57 years) after the Gaza War of 2008-2009. Both parents reported their exposure to war trauma, secure attachment availability, and parenting practices, as well as the target child's internalizing and externalizing symptoms [Strengths and Difficulties Questionnaire (SDQ)]. Children reported their symptoms of post-traumatic stress disorder (on the Children's Revised Impact Event Scale), depression (Birleson), and SDQ, as well as their post-traumatic cognitions (Children's Post Traumatic Cognitions Inventory). Results: A cluster analysis identified four family types. The largest type reflected secure attachment and optimal relationships (security and positive family relationships, 36.2%, n = 102), and the smallest exhibited insecurity and problematic relationships (insecurity and negative family relationships, 15.6%; n = 44). Further, families with discrepant experiences (23.0%; n = 65) and moderate security and neutral relationships (25.2%; n = 71) emerged. The insecurity and negative relationships family type showed higher levels of war trauma; internalizing, externalizing, and depressive symptoms among children; and dysfunctional post-traumatic cognitions than other family types. Conclusion: The family systems approach to mental health is warranted in war conditions, and therapeutic interventions for children should, thus, also involve parents and siblings. Knowledge of unique family attachment patterns is fruitful for tailoring therapeutic treatments and preventive interventions for war-affected children and families.

Facilitating mental health screening of war-torn populations using mobile applications

BACKGROUND

War-torn populations are often hard to screen for mental health disorders. Classical data collection approaches, such as paper-based, online, or SMS-operated, are either infeasible or lack accuracy due to a variety of challenges associated with dynamics and consequences of war.

METHODS

In this paper, we introduce a novel approach for accurate and fast screening using free open-source software, Open Data Kit (ODK) mobile application. This approach was developed by the Palestine Children's Relief Fund (PCRF) to assess the mental health symptoms of 986 Palestinian children (age 6-18) in the aftermath of Israel's Operation Protective Edge (OPE) in 2014. The organization developed assessment questionnaires and trained local field workers on the use of the mobile application, and on recruiting and interviewing war victims.

RESULTS

War-affected children were found to suffer from several alarming symptoms associated with post-traumatic stress disorder (PTSD), depression, and somatic symptoms. Children with highest number of psychological symptoms were referred for further evaluation and treatment.

CONCLUSIONS

The use of ODK mobile technologies facilitated efficient screening of affected children in war zones. The offline data collection capability was crucial for handling the difficult conditions associated with war-torn areas, enabling timely intervention for urgent cases. Further applications of the novel mobile technology are to be explored.

Peritraumatic dissociation predicts posttraumatic stress disorder symptoms via dysfunctional trauma-related memory among war-affected children

Background: Among adults there is strong evidence about peritraumatic dissociation (PD) predicting posttraumatic stress disorder (PTSD), yet evidence among children is very limited. It has been suggested that disturbances in memory functioning might explain the association between PD and PTSD, but this has not yet been empirically tested. Objective: We aimed to test the hypotheses that greater PD would be associated with more posttraumatic stress disorder (PTSD) symptoms, and that some of this association would be mediated by disorganized and non-verbal memories about the traumatic event. Method: The sample included 197 Palestinian children (10-12-years) living in the Gaza Strip, participating in the aftermath of the 2008/9 war. Self-report questionnaires were used to measure PD (Peritraumatic Dissociative Experiences Questionnaire) three months post-war, as well as trauma-related memory (Trauma Memory Quality Questionnaire) and PTSD symptoms (Children's Revised Impact of Event Scale) six months later. Exposure to war trauma was assessed by a checklist. Structural equation modelling was used to examine direct and indirect paths from PD to posttraumatic PTSS, controlling for number of traumatic war events. Results: Structural equation modelling results showed that greater self-reported PD predicted higher levels of PTSS nine months post-war, and that a significant part, but not all, of this relationship was mediated via the quality of trauma-related memories. Conclusions: This study provided empirical evidence that, among war-affected children, greater PD during traumatic events is linked with higher levels of PTSD symptoms several months later, even when accounting for their personal exposure to war trauma. Further, the study supported the idea that the detrimental effects of dissociation during a traumatic event may be due to dysfunctional memories characterized by disorganization and lack of access to verbal and coherence. Further tests of these hypotheses with larger samples and more points of measurement are called for.

Effectiveness of psychosocial intervention enhancing resilience among war-affected children and the moderating role of family factors

The study examines, first, the effectiveness of a psychosocial intervention based on Teaching Recovery Techniques (TRT) to increase resiliency among Palestinian children, exposed to a major trauma of war. Second, it analyses the role of family factors (maternal attachment and family atmosphere) as moderating the intervention impacts on resilience. School classes in Gaza were randomized into intervention (N=242) and control (N=240) groups. The percentage of girls (49.4%) and boys (50.6%) were equal, and the child age was 10-13 years in both groups. Children reported positive indicators of their mental health (prosocial behaviour and psychosocial well-being) at baseline (T1), post-intervention (T2) and at a six-month follow-up (T3). At T1 they accounted their exposure to war trauma. Mothers reported about their willingness to serve as an attachment figure, and the child reported about the family atmosphere. Resilience was conceptualized as a presence of positive indications of mental health despite trauma exposure. Against our hypothesis, the intervention did not increase the level of resilience statistically significantly, nor was the effect of the intervention moderated by maternal attachment responses or family atmosphere.

Mineralocorticoid receptor and heat shock protein expression levels in peripheral lymphocytes from war trauma-exposed men with and without PTSD

Alterations in the number and functional status of mineralocorticoid (MR) and glucocorticoid receptors (GR) may contribute to vulnerability to posttraumatic stress disorder (PTSD). Corticosteroid receptors are chaperoned by heat shock proteins Hsp90 and Hsp70. We examined relations between corticosteroid receptor and heat shock protein expression levels, and related them with war trauma exposure, PTSD and resilience to PTSD. Relative levels of MR, Hsp90 and Hsp70 were determined by immunoblotting in lymphocytes from war trauma-exposed men with current PTSD (current PTSD group, n=113), with life-time PTSD (life-time PTSD group, n=61) and without PTSD (trauma control group, n=88), and from non-traumatized healthy controls (healthy control group, n=85). Between-group differences in MR, Hsp90 and Hsp70 levels and in MR/GR ratio were not observed. The level of MR was correlated with both Hsp90 and Hsp70 levels in trauma control and healthy control groups. On the other hand, GR level was correlated only with Hsp90 level, and this correlation was evident in current PTSD and trauma control groups. In conclusion, PTSD and exposure to trauma are not related to changes in lymphocyte MR, Hsp90 or Hsp70 levels, but may be associated with disturbances in corticosteroid receptors interaction with heat shock proteins.

The impact of group counseling on depression, post-traumatic stress and function outcomes: a prospective comparison study in the Peter C. Alderman trauma clinics in northern Uganda

BACKGROUND

The effectiveness of group interventions for adults with mental distress in post-conflict settings is less clear in sub-Saharan Africa.

AIM

To assess the impact of group counseling intervention on depression, post-traumatic stress and function outcomes among adults attending the Peter C. Alderman Foundation (PCAF) trauma clinics in northern Uganda.

METHODS

631 War affected adults were enrolled into PCAF trauma clinics. Using a quasi-experimental design, assessments were conducted at baseline, at 3 and 6 months following initiation of care. Multivariate longitudinal regression models were used to determine change in depression, post-traumatic stress and function scores over time among group counseling participants and non-participants.

RESULTS

In comparison to non-participants, participants had faster reduction in depression scores during the 6-month follow-up period [β=-1.84, 95%CI (-3.38 to -0.30), p=0.019] and faster reduction in post-traumatic stress scores during the 3-month follow-up period [β=-2.14, 95%CI (-4.21 to -0.10), p=0.042]. At 3-month follow up, participants who attended two or more sessions had faster increase in function scores [β=3.51, 95%CI (0.61-6.40), p=0.018] than participants who attended only one session.

LIMITATIONS

Selection bias due to the use of non-random samples. Substantial attrition rates and small sample sizes may have resulted in insufficient statistical power to determine meaningful differences.

CONCLUSION

The group counseling intervention offered in the PCAF clinics may have considerable mental health benefits over time. There is need for more research to structure, standardize and test the efficacy of this intervention using a randomized controlled trial.