Download Smith, P., Perrin, S., Yule, W., et al., 2002. War exposure among

The Impact of the 2009 Jazan War on Saudi Children, a community
retrospective Cohort Study
Abstract
Objectives: The study aims at nutritional, psychological, behavioral, family adjustment and
psychiatric assessment of Saudi children exposed to the 2009-2010 war in Jazan. Methods: The
study was conducted in July 2010, 6 months after the end of the Jazan war. One hundred eighty
six internally displaced children exposed to the war were assessed in Jazan and 157 unexposed
children were assessed in King Khaled Military City, Hafr Elbatin. Both groups were studied for
clinical and laboratory evidence of malnutrition, for psychological problems using the Child
Behavior Inventory, for behavioral problems using the Rutter Scale A2, for family adjustment
using the McMaster Family adjustment device and for psychiatric disorders. In the exposed
group the effect of different socioeconomic variables on the psychological outcome was also
studied. Results: The exposed children were well nourished. The exposed children had more
anxiety (P=0.044), better adaption (P=0.0000005), less aggression (P=0.025), less antisocial
behavior (P=0.014), better family adjustment (P=0.017) and less deviant behavior (P=0.007)
compared to the unexposed group. In the exposed children group, females had more anxiety
(P=0.0057) and males had more antisocial behavior (P=0.02). Older children had less deviant
behavior (P=0.0046), better adaption (P=0.0074) and better planful behavior (P=0.00013).
Children of elder mothers had better planful behavior (P=0.039). Children from bigger families
were less aggressive (P=0.049) and had less antisocial behavior (P=0.04). The exposed children
had more PTSD, generalized anxiety, nightmares and grief reaction than the unexposed group.
Conclusion: The nutritional support prevented malnutrition of children exposed to Jazan war.
Their anxiety is stress induced. Their higher adaption and lower antisocial behavior and better
family adjustment reflect effective adaptive mechanisms, possibly social. The socioeconomic
status affects the psychological outcome. Exposed children need education, psychological
screening and studies for their adaptive mechanisms.
Key words:
Jazan war, Children, malnutrition, psychological disorders, family adjustment
Introduction
War is a traumatic event that has its grave physical and psychological impact on the civilians due
to exposure to violence, stress, and loss of jobs, homes and properties. Displacement, internally
1
or externally, is also associated with changes in the structure of the society and a breakdown of
the existing protective networks such as the village chief and the elders in the village.
War aggravates poverty, which is the main cause of malnutrition. Children are affected with
malnutrition more than adults. Malnutrition has a long term impact on physical and mental
development.
Young age is a predisposing factor to the war induced psychiatric symptoms. In war, children are
more affected than adults by psychiatric symptoms. A study on children aged between 9 and 14
years in Balkan showed a high level of Post-traumatic stress disorder (PTSD) and grief
symptoms [1]. Other predisposing factors include; female sex [2, 3], disability [2, 3], chronic
health condition [4, 5], previous psychiatric disorders [4, 5], living alone or in small families [6],
high level of depressive symptoms in the mother [7] and high number of traumatic events [2, 7,
8]. The adjusted odds ratio of meeting PTSD symptom criteria for each additional traumatic
event was 1.43 [9].
The psychological impact of the war is due to trauma-related problems, changes in the financial
and living conditions and worry about the future. Following trauma, most children will have
some symptoms. Young children may show a fear of strangers or be scared to leave their parents.
They might also have sleep problems or bad dreams. Young children may also repeat themes of
the trauma in their play. They might go back to earlier habits like sucking their thumb. Very
young children may not show the same PTSD symptoms we see in adults. This may be because
many of the symptoms of PTSD require that the child be able to talk about what happened. Early
trauma affects the child's nervous system. The nervous system is shaped by the child's
experiences. Stress over a period of time can lead to changes in the parts of the brain that control
and manage feelings. That is to say, stress and trauma early in life can change the brain. This can
have long-term effects on physical, mental, and emotional growth. What's more, the impact of
early abuse often extends into later childhood, teen, and even adult years.
Coping strategies included religious and spiritual practices and family support in Afghanistan [2,
3], praying, talking, keeping busy and seeking the support of the family members in Chechyna
[10, 11] and active information search about the loved ones and social support in Israel [12].
The province of Jazan lies in the south west of Saudi Arabia. It covers an area of 40,000 square
kilometer including some 5,000 villages and cities. The population number in Jazan is
approximately 1.2 million. Jazan is the poorest among the Saudi Arabia provinces .Saudi Arabia
was involved From November 2009 to January 2010 in a military conflict along its southern
border against Al Hotheieen, a religious group of Yemeni exteriors who were involved in a
military conflict with their own country. The 2009 Jazan war resulted in 73 deaths and 27 losses
among the Saudi population. Fifty thousand Saudi from 300 villages were internally displaced
for their safety or to create a 10 kilometer isolation zone at the south border of Saudi Arabia.
2
Saudi Arabia is a strong rich country with wide experience in supporting the war victims all over
the world through governmental and nongovernmental organizations. The Saudi government was
challenged to provide military protection & social support to its own people in the first military
conflict in the last decades. It started a wide protection and support program to the exposed and
internally displaced people during and after the war. The government provided free residence in
furnished houses or in refugees' camps equipped with 1600 tent, 18 school class and different
governmental facilities and a health center. Around 10,000 new homes were planned.
The study aims to assess the Saudi children exposed to the 2009-2010 war against Al Hotheieen
in Jazan for malnutrition, psychological disturbances and deviant behavior and to assess the
adjustment of their families, compared to children living in the King Khaled Military city and to
explore impact of different demographic and socioeconomic factors on the psychological
outcome of the exposed children. The results of the study will help to assess the outcome of the
supportive programs and to plan for future preventive intervention strategies, including action
research perspective and initiatives to deal with these effects and to prevent them in any future
conflict.
Methods
This observational study was conducted in July 2010, 6 months after the end of the 100 day
Jazan war. The study was conducted in Jazan province, at the Saudi Yemen border in the
southern area of Saudi Arabia and in the King Khaled Military City, Hafr el Batin. The study
was done by the cooperation between the Northern Area Armed Forces Hospital (NAAFH) staff
and the Jazan Military Hospital staff. The exposed group was internally displaced children after
the Jazan war to person’s camp in Ahad El Masarhah camp or to settlement housing in the Jazan
province. The unexposed group was children living in the KKMC. Children were excluded if
they were less than 5 years age or their father was not willing to give consent.
The study proposal was approved by the ethics committee of NAAFH. Considering the military
nature of the field of the study; Medical Services Division (MSD) of ministry of defense in Saudi
Arabia got permission from local civilian and the military authorities to conduct the study.
Father's consent for participation of his children and wife in the study was obtained. They were
allowed to hold consent for all or part of the study, e.g. to disclose their children’s names, their
income or to collect blood tests. None of the respondents were compensated for the interviews as
the cultural norm does not support material inducements for such activities.
Using Openepi software, the sample size based on the Kelsey equation to achieve a 95%
confidence level and 80% power using an exposed: unexposed ratio in the sample of 1:1, where
the percent of exposed with PTSD was 17 % [13] and an average of 6.6% in the general
population calculated as the mean of prevalence of (9.7%) in women [14] and (3.6%) in men
[15] was 150 exposed and 150 unexposed.
3
In this study all studied subjects were sponsored by their parents and were referred to as children.
Out of around 50,000 internally displaced people 186 exposed children were randomized to be
enrolled in the study. Out of around 100,000 people of the King khaled Military city at the Hafr
El Batin province at the western area of Saudi Arabia, 157 unexposed children were enrolled in
the study as a control group. Children of both groups were selected from a list of school students.
The subjects were invited with their parents to conduct the study in NAAFH and in the primary
health care clinic in Jazan where interviews, clinical assessment and blood sampling were done.
Children were interviewed in attendance of at least one of their parents. Data of each child was
recorded in a separate note book with a child specific serial number that is used to identify all
data collected for the same patient throughout the study. Data were then transferred to an excel
spread sheet.
A semi-structured questionnaire was used to collect demographic data, as name, age and sex,
social data about displacement status (Kept native house, displaced to a secure house, displaced
to camps or homeless) , education performance (regular at school or educational disturbance),
parental loss (maternal loss or paternal loss), the paternal work (civilian, military retired, military
in service, military in fighting services), parental education and number of siblings and family
members, economic data; as the father’s and mother’s income, the income per capita and
satisfaction about the income and Medical data on chronic illnesses.
For clinical assessment of malnutrition; body weight, height, mid arm circumference and triceps
skin fold thickness were recorded and the Body Mass Index (BMI) and percentile BMI were
calculated using the BMI_group_calculator_Metric excel software program. Laboratory
parameters of malnutrition included Hematological parameters (Hemoglobin concentration and
Hematocrit) and chemical parameters (serum albumin, cholesterol, iron, and iron saturation).
Daily dietary intake was assessed by 24 hours diets recall and calculation of daily protein and
carbohydrate intake using dietary tables.
Three instruments were used for psychological & behavioral assessment of the studied children.
The translation of the instruments was considered adequate as it was used in a study that was
published in the Adolescent Psychiatry and Mental Health journal in 2008 [13]. The
psychological and behavior assessment was conducted by two research teams who had previous
experience in interviewing people for social science/mental health research. At the preliminary
stage of the study, the psychiatrist from NAAFH ensured uniform understanding and harmonic
ratings by the research assistants in both teams. The interview lasted an average of 30 minutes
for each case, the relaxed atmosphere during the session and the manner in which the subjects
had been approached, made the exercise acceptable to the subjects.
4
The Child Behavior Inventory (CBI) [13] was used to assess the psychopathological status in the
study group. The questionnaire was completed by interviewing mothers of children below 10
years of age, while children aged 10–16 years were interviewed face-to-face. The scale was
designed to assess children's anxiety, depression and behavioral symptomatology following
experience of traumatic events of war. The English version has 43 questions. Each question is
scored on a four-alternative, forced-choice format, ranging from 0 = never, through, 1 = rarely
and 2 = sometimes, to 3 = always. The measure has been translated into Arabic, and has been
adapted for use in Lebanon and Kuwait [13] The Kuwaiti version has 42 items. Before its use in
Kuwait, the CBI was pilot-tested to assess the meaning and relevance of the questionnaire items
for Kuwaiti children. [13] The items are grouped into five domains; three mental health
symptoms (aggression, depression, anxiety) and two adaptational outcomes (prosocial and
planful behavior). Each domain is represented by a set of questions that inquire about the child's
behavior six months prior to the assessment. Aggression contains 9 items scored (0-27) that
include, for example, gets angry easily, verbally aggressive, physically aggressive towards others
and destroys his/her or other people’s things. Depression contains 9 items scored (0-27) that
include, for example, appears sad or unhappy and his/her distance from love and care. Anxiety
contains 6 items scored (0-18) that include, for example, jumpy, indicates that he/she is
frightened that something bad will happen to him/her and reacts with fear to things or situations
that do not usually scare other children. High scores for the mental health items indicate
pathology.
Prosocial behavior contains 9 items scored (0-27) that include for example, helpful towards other
children, helpful towards adults, shows concern, or care for others. Planful behavior contains 9
items scored (0-27) that include for example, takes the lead in initiating activities, plans and
thinks ahead, skillful in solving problems. High scores of adaptional scores indicate positive
adaptation.
Rutter Scale A-2-parent's version [13] was used to assess behavioral problems. Only children
aged 6 – 16 years were assessed, as recommended by the scale founders. This scale, which is a
slightly modified version of the original form A, consists of 31 statements concerning the child's
behavior. The mother rated the extent to which the statement is applied to the child. The scale is
divided into 3 subscales; health problems, habits and statements on behavior. Health problems
subscale contains 8 items scored form 0-16 that includes for example, headache, stomach-ache,
wets bed, temper tantrums, truants from school. Habits subscale includes 5 items scored from 010 that includes for example, stammers/stutters, steals things, eating problems, etc. Statements
on behavior subscale include 18 items, scored from 0-36 that includes for example, restless,
destroys own or others' belongings, fights with others, has twitches, mannerisms or tics, sucks
thumb or finger, disobedient, tells lies, bullies other children. The most prominent behavioral
problems that can be extracted from these 18 statements are neurotic and antisocial subscales.
Tears on arrival at school, sleep problems, worried and fearful are scored for a neurotic subscale.
5
Steals things, destroys own or others' belongings, disobedient, tell lies, bullies other children are
scored for the antisocial subscale. Each item is scored on a scale of 0, 1 or 2. The subscale scores
are computed by adding the ratings for each item. The cut point for a deviant behavior is 13 or
more.Higher scores indicate pathology. The Arabic version of the above questionnaires
(produced by back-translation), has been used by previous workers in the Kuwaiti and
neighboring Arab populations, and the contents were found to be relevant to the respective
constructs and easily understood by Arabs [7,8]. These instruments are not meant to be
diagnostic of the various underlying constructs, but give indication of severity of probable
problems in the respective domains.
The McMaster Family Assessment Device (FAD) [17] was used to assess the family adjustment.
The standard guidelines for using the questionnaire, recommend its administration in face-to-face
interview to children who were over 12 years of age. In this study, the questionnaire was difficult
to understand even for these old children, one of the parents in all the interviewed children,
irrespective their age. This is a screening instrument to identify problem areas in the most simple
and efficient manner. It is based on the assumption that family functioning is much more related
to transactional and systematic properties of the family system than to intra-psychic
characteristics of individual family members. It was designed to avoid genuine differences in
view, where the family may not be perceived in the same way by observers with different points
of view. The 53 items are statements a person could make about his/her family. Each family
member rates his/her agreement with how well an item describes the family by selecting among
the four response options: strongly agree, agree, disagree and strongly disagree. Higher scores
indicate unhealthy family adjustment. The McMaster FAD is made up of seven subscales which
measure the individual's perception of how well the family is adjusted in the Problem Solving,
Communication, Family Roles, Affective Responsiveness, Affective Involvement, Behavior
Control and General Functioning domains. The subscale labels are indicative of their underlying
constructs. For example, problem solving refers to the family's ability to resolve issues which
threaten their integrity and functional capacity. Communication refers to the exchange of
information among members. The dimension, Roles, focuses on whether the family has
established patterns of behavior for handling a set of family functions, including provision of
resources, nurturance and support [17]. In view of the absence of standard cut-off scores, it is
recommended that abnormal test scores should be judged by the group mean plus one standard
deviation.
Participants were psychiatrically evaluated. Diagnosis was put according to the diagnostic
criteria of the diagnostic and statistical manual of mental disorders –IV-RT (American
psychiatric association). Assessment involved open questions that allowed the child to express
his experience in exposure to violence (the child will explain whether he was terrified from
violence due to hearing terrorizing sounds as firing sound or shouts or cries, seeing violent sights
6
or if he was exposed to any threat), whether the child was physically involved in violence or
exposed to physical injury or to psychological trauma due to loss of a family member, loss of
housing.
In this study, the primary endpoints were objective, they included clinical and the laboratory
nutritional parameters, scores of the psychological tests and the psychiatric diagnosis. The coded
data were transferred to an excel spread sheet then to SPSS spread sheet. Data were statistically
analyzed. Descriptive statistics were used to summarize the data. Frequencies (number of
subjects studied or number of tests done) and relative frequencies (percentages) were used when
appropriate. For comparing means of a continuous data in the two study groups, independent
samples t-test was performed. For comparing categorical data, Chi square (χ2) test was
performed. Yates correction was used instead when the expected frequency is less than 5. A
probability value (ρ value) less than 0.05 was considered statistically significant. All statistical
calculations were carried out using computer programs Microsoft Excel version 7 (Microsoft
Corporation, NY, USA) and SPSS (Statistical Package for the Social Science; SPSS Inc, Chicago
IL, USA) statistical program. Calculations of BMI and percentile BMI was done by Group BMI
Calculator, Metric, v1.0 by CDC
Results
Demographic and socioeconomic data were analyzed. The Jazan group included 186 children
with a male: female ratio of 1.6:1 and age ranged from 5 - 16 years, with a mean of 12.43 years
(SD = 2.78) and the King khaled Military city group included 157 children with a male: female
ratio of 1.1:1 and age ranged from 5 - 17 years, with a mean of 10.14 years (SD = 2.96) There
was no significant difference in the sex (P = 0.132) or in the mean age of the studied groups. The
exposed children had significantly bigger families, higher number of siblings and higher total
family members (P< 0.05) compared to the unexposed children. One of the studied exposed
families was 35 members, including the father, his 4 wives and their children.
The unexposed children had significantly better paternal and maternal employment and
satisfaction with their income (P = 0). The income per capita was below 1120 Saudi Riyal (SR)
in 46 out of the 52 exposed children (88.5%) and 55 out of the 92 unexposed children (59.7%)
(P = 0.0003) (Risk Ratio = 1.48) (95% CI 1.219 - 1.797). Thirty seven out of 105 fathers of the
exposed children claimed to be jobless compared to none of the unexposed children.
Forty two of the studied exposed children were displaced to camps and 76 to temporary secure
houses while all the unexposed children were living in their native permanent houses. The
number of rooms (or tents) per capita in the exposed group (0.46 rooms per capita) was
significantly lower than the unexposed group. Table 1 shows a comparison between the housing
conditions in both groups, using the chi square test. It shows that the unexposed children had
7
significantly better housing conditions (as sanitary drainage, room painting, presence of land line
telephone and DSL lines) and better relation to the neighbors compared to the exposed group.
Table 1: Housing Conditions in the 2 studied groups
Exposed Unexposed
Total number Significance (P)
Sanitary
No
27
4
31
drain
Yes
92
143
235 0
Total number
119
147
266
Painted
No
32
1
33
rooms
Yes
86
146
232 0
Total number
118
147
265
Good
relation with
neighbors
Housing
telephone
Housing
DSL
Private Car
Near main
road
Income
satisfactory
No
Yes
Total number
No
Yes
Total number
No
Yes
Total number
No
Yes
Total number
No
Yes
Total number
No
Yes
Total number
4
109
113
113
2
115
115
0
115
44
70
114
52
41
93
62
32
94
0
147
147
31
114
145
78
67
145
41
106
147
85
57
142
23
112
135
4
256
260
144
116
260
193
67
260
85
176
261
137
98
235
85
144
229
0.035
0
0
0.038
0.337
0
The school performance in the 2 studied groups was compared using a chi-square test. Table 2
shows that the unexposed children achieved higher education grade and higher school
performance than the unexposed children.
Table 2: School performance in the 2 studied groups
Exposed
8
Unexposed
Total
number
Significance
(P)
School
grade
School
performance
Not educated
Primary school graduate
Intermediate school graduate
Secondary school graduate
University
Total number
Bad
Good
Excellent
delayed
Total number
22
71
22
13
1
129
12
61
28
7
108
8
104
29
9
0
150
3
80
57
1
141
30
175
51
0.008
22
1
279
15
141
0.00
85
8
249
As shown in table 3; a comparison of the socioeconomic difference in the families using the Chi
square test revealed that the difference in the military rank between the exposed and the
unexposed military fathers was not significant. Fathers and mothers of the exposed children have
a significantly lower education level and mothers of the exposed children had significantly lower
employment.
Table 3: Comparison of the socioeconomic difference in the families in the 2 groups
Parents
alive
Father job
Father
education
None
One only
Both of them
Total number
Not working
Civilian
Military retired
Military not fighter
Military fighter
Irregular job
Total number
Not educated
Primary school graduate
Secondary school graduate
Intermediate school
graduate
Exposed Unexposed Total
Significance
Group
Group
number
1
0
1
15
0
15
0.0
100
147
246
116
147
263
37
0
37
25
21
46
15
28
43
3
52
55 0.0
0
48
48
25
0
25
105
149
254
27
2
29
21
16
37
3
42
45 0.0
13
9
55
68
University graduate
Total number
2
66
7
122
9
188
Soldier
Noncommissioned officers
Officer
Total number
Not educated
Primary school graduate
Intermediate school
graduate
Secondary school graduate
Diploma
University graduate
Total number
not working
employee
Total number
16
1
0
17
40
3
89
12
2
103
19
28
105
13 0.64
2
120
59
31
2
1
1
0
47
44
1
45
25
28
13
12
125
92
29
121
27 0.0
29
14
12
172
136
30 0.00035
166
Father rank
Mother
education
Mother job
Table 4 Comparison of the nutritional outcome using the t test revealed no significant difference
in the mean caloric intake between the 2 groups and a significantly higher mean protein intake in
the exposed group compared to the unexposed group. There was no significant difference in the
biochemical parameters of malnutrition (Serum Albumin, cholesterol, Serum Iron and Iron
saturation), in the hematological parameters of malnutrition (HB and Hematocrit) or in the
percentile body mass index between the 2 studied groups.
Table 4: Comparison of the nutritional parameters between the 2 groups
Exposed Group
Unexposed Group
Num
Number
Means
±SD
ber
Means
±SD
Serum Albumin
63
40.97
5.21
52
40.46
2.64
Serum Iron
63
13.25
5.80
51
12.31
5.54
Iron saturation
63
61.68 11.47
52
61.77
8.74
HB
152
12.71
1.30
55
12.90
1.24
Hematocrit
152
38.78
3.91
55
37.70
3.47
Serum Cholesterol
157
4.02
0.89
54
4.03
0.70
BMI Percentile
116
44.58 34.61
41
35.04 34.62
10
Signific
ance
0.52520
0.38175
0.96434
0.33731
0.07172
0.95081
0.13109
calculator
None of the studied children were exposed to physical injury. CBI was used to study 131
exposed children and 142 unexposed children. The mean outcome of the CBI score was
compared using the t test. The examined exposed children had a significantly higher anxiety
subscale (P = 0.044), non-significant higher depression subscales (P = 0.065), and significantly
lower aggression subscale (P = 0.025). The difference in the sum of these 3 subscales, namely
the mental health score was not significant (P = 0.582). High scores for the mental health items
indicate pathology
The exposed children had a significantly higher prosocial subscale (P = 0.0002) and planful
behavior (P = 0) and significantly higher sum of both subscales, namely the adaptional scale (P =
0.0000005). High scores of adaptional scores indicate positive adaptation.
Rutter Scale A-2 was used to study 113 exposed children and 92 unexposed children. The number of
children with deviant behavior was compared in the 2 studied groups, using the chi- square test.
As shown in table 5, the number of children with deviant behavior was significantly higher in the
unexposed group. The risk ratio for a deviant behavior was 0.8518 (95% CI 0.3771 - 0.8968).
Table 5 : Outcome of the Rutter Scale A2 for the exposed and unexposed groups using the chisquare test
Normal behavior
 Neurotic
 Antisocial
 Equivocal
Deviant behavior (≥13)
Total number Examined
Exposed Group
88
15
8
2
25 (22.1%)
113
Unexposed Group
57
18
13
4
35 (38%)
92
Significance
(P)
0.007
Seventy seven families of exposed children and 67 families of unexposed children were studied by the
FAD. The mean of the score of the FAD test in both groups was compared using the t test. It
shows that the studied exposed children’s families had a significantly better general functioning
and better 6 out of 7 McMaster family adjustment subscales compared to the studied unexposed
families.
Table 6 : Outcome of the FAD test for the exposed and unexposed groups
Exposed (n = 77)
Unexposed (n=67)
11
Significance
Problem Solving
Communication
Roles
Affective Responsiveness
Affective Involvement
Behavioral Control
General Functioning
Means
11.30
13.52
18.23
13.04
16.00
18.29
27.06
SD
6.22
7.01
8.82
5.88
8.20
7.15
13.50
Means
17.01
18.46
22.25
14.78
17.36
22.72
32.85
SD
2.64
3.25
3.88
3.40
4.72
3.71
5.01
(P)
0.0
0.0
0.00074
0.03513
0.23435
0.00001
0.00117
Table 7 shows a comparison between the psychic outcomes in the 2 studied groups using a chisquare test. The number of exposed children who fulfilled the criteria to diagnose post-traumatic
stress disorder (PTSD), generalized anxiety, grief reaction and night mares was significantly
higher than the number of the unexposed group. Major depression and nocturnal enuresis were
detected in a higher percentage of the exposed children but the difference not significant.
Table 7: The Psychiatric outcome in the 2 studied groups
Exposed Group
Normal
48
37.8%
Post-traumatic stress disorder (PTSD) 17
13%
Major depression
10
7.8%
Generalized anxiety
20
15.6%
Grief reaction
8
6.3%
Night mares
19
15%
Nocturnal enuresis
5
4%
Total number examined
127
100%
Unexposed Group
94
83.1%
2
1.7%
5
4.4%
3
2.6%
2
1.8%
5
4.4%
2
1.8%
113
100%
P
0.0003
0.1434
0.00058
0.044
0.0032
0.1774
The exposed children were further analyzed for the impact of different socioeconomic factors.
Using the t test to compare the mean score of different CBI subscales revealed that females had
higher mean CBI anxiety subscale score than males (P = 0.0057). Males had more antisocial
behavior than the females (P = 0.02). Older children had less deviant behavior (P = 0.0046),
better adaption (P = 0.0074) and better planful behavior (P = 0.00013). Children of elder mothers
had better planful behavior (P = 0.039). Children from bigger families were less aggressive (P =
0.049) and had less antisocial behavior (P = 0.04).
Table 8, a comparison between the outcome of the psychological and behavioral tests according
to the income, in both the exposed and unexposed children using the t test shows that in the
exposed children, there was no significant difference in the CBI scores between those above and
12
below the poverty line as revealed by the t test. In the Unexposed children, those below the
poverty line had significantly higher anxiety subscale (more anxiety) and significantly higher
prosocial subscale (better adaption).
Table 8: Comparison between the outcome of the psychological and behavioral tests according
to the income, in both the exposed and unexposed children.
Exposed
Unexposed
Below
Above
Signif Below
Above
Signifi
poverty line poverty line
icance poverty line
poverty line cance
(n=45)
(n=6)
(n=56)
(n=30)
Mea SD
Mea SD
Means SD Mea SD
ns
ns
ns
1) Mental score 23.8 9.8
24.3 6.9
0.88
22
10.5 19.4 8.2
0.2
a) Depression
subscale
8.9
4.7
11.7 4.8
0.23
7
4.8
5.9
3.5
0.23
b) Aggression
subscale
5.6
4.8
4.9
2.8
0.62
6
5.2
6.4
5.3
0.73
c) Anxiety
subscale
9.3
3.3
7.8
3.5
0.36
9
4.1
7
3.4
0.018
2) Adaptional
score(max 54)
45.3 8.6
38.3 10.6
38.3
42
10
37.2 11.9 0.65
a) Prosocial
subscale
23.3 4.5
20
6.5
0.27
23
5.2
19.1 6.7
0.008
b) Planful
behavior
21
4.6
18.3 4.6
0.23
18
7
18
6.2
1
Discussion:
The study was conducted in Saudi Arabia. The study group was the displaced children in Jazan
who were exposed to the 2009 Jazan war and the control group was unexposed children in a
military city. There was socioeconomic discrepancy between the 2 studied groups. The exposed
children were members of families of relatively big size and lower socioeconomic status. In
Saudi Arabia, the poverty line is 1120 SR without the expenses of the residence [18], 1.5 million
Saudi (15%) are below the poverty line. Jazan, with its limited natural resources, is among the
poorest provinces in Saudi Arabia. [16] The lower socioeconomic status of people in Jazan was
exaggerated by the impact of the war due to the loss of the jobs and properties.
The better nutritional outcome in Jazan children, inspite of the lower socioeconomic status, was
explained by the generous financial and nutritional supportive programs that included 3 free
13
meals daily and provided the same caloric and better protein supply compared to unsupported
children from higher socioeconomic standards families. The success of the nutritional support
program in preventing malnutrition and improving the nutritional status may suggest the
implementation of a similar national program to directly supervise and support the nutrition of
the children.
In this study, the psychological tests revealed that the exposed children were less aggressive than
the exposed children. The children exposed to the Jazan war did not develop aggressive behavior
probably as they were not directly involved in the military procedures, which were carried out by
the professional military staff, and were not exposed to physical injury due to the military
operations. In children who were directly involved in a military conflict, as the Palestinian
children, after the second intifada, 46% of the children showed aggressive behavior. Aggression
of the unexposed children may be related to the style of life as playing video games, more access
to the internet. As stated by 34% of the Palestinian children, violence in the TV was the main
influence for aggression. More studies are needed to assess the effect of the style of life on the
aggressive behavior in the unexposed male children in the military city, Hafr El batin. This
study revealed that children from bigger families were less aggressive. The lower family size
may be a confounding factor for higher aggression in the exposed children.
The study revealed high anxiety subscale in the studied exposed children, which goes with
studies that reported that symptoms of anxiety in Afghanistan in 72.2% of respondents in one
study [2] and in 52.8% of respondents in another study [3].
This study has not shown a significantly higher depressive score or a significantly higher
incidence of major depression in the studied exposed children compared to the unexposed
children, whereas other studies reported symptoms of depression in Afghanistan in 67.7% of
respondents in one study [2] and in 38.5% of respondents in another study [3] in 55% in
Cambodia [5] varied from 16.3% to 41.9% in 4 different communities studied in Lebanon [21].
The absence of significant higher depression score and the presence of higher adaption, lower
antisocial behavior, less deviant behavior and the better family adjustment in the Jazan children
may reflect effective social adaptive mechanisms as stronger family bonds and troop values of
the native inhabitants of Jazan, compared to the urban less stable inhabitants of the military city.
This study identified the effect of some demographic and socioeconomic risk factors on the
psychopathological, behavioral and family adjustment as an outcome of interest in the exposed
children. Although the study showed that the unexposed children with a lower income had more
anxiety and had better adaption, yet it failed to show any effect of poverty on the
psychopathological outcome in the exposed children. Gorst-Unsworth (1998) reported that
planned, integrated rehabilitation programs and attention to social support and family reunion
14
may alleviate some of the most important factors in producing psychological morbidity in Iraqi
refugees.[22] The study revealed that children from bigger families were less aggressive and
had less antisocial behavior. This finding is compatible with finding of Salama et al., (2000),
who reported that those who were living alone or in small families were more prone to
psychiatric morbidity, which reflects a protective role of intra-family relation in big families. The
study showed that paternal age and the site of displacement, whether in camps or in temporary
houses, had no correlation with the psychological, behavioral or family adjustment outcomes,
which indicates that the selection of the future temporary settlement should be decided according
to other financial and safety factors.
This study identified more anxiety in the exposed females compared to the exposed males, which
reflects more vulnerability of females to anxiety. Anon (2013) reported that “The lifetime rate of
diagnosis of anxiety disorders is higher in women, with 33% experiencing an anxiety disorder in
their lifetime, as compared with 22% of men. Experts believe this difference arises from a
combination of hormonal fluctuations, brain chemistry and upbringing.” [19] Lewinsohn, et al.
(1998) studied Gender differences in anxiety in a large sample of adolescents and reported “a
preponderance of females among current and recovered anxiety disorder cases, but not among
those who had never experienced an anxiety disorder”. They also reported that “female
preponderance emerges early in life, and retrospective data indicate that at age 6, females are
already twice as likely to have experienced an anxiety disorder as are males [20]
The study revealed that males had more antisocial behavior than the females. Children of elder
mothers had better planful behavior. Young children had more deviant behavior, less planful
behavior and an overall less adaption. Young mothers had less planful behavior. These risk
factors has to be considered during assessment of children exposed to the stress of war and
during planning for the psychological support programs that has be tailored according to the
vulnerability of each demographic and socioeconomic subgroup.
This study showed that the exposed children had more PTSD, generalized anxiety, nightmares
and grief reaction but not major depression or nocturnal enuresis. The percentage of children
with PTSD exposed to the war (13%) was lower than that observed in other studies. PTSD was
observed in 17.1% of Kosovar Albanians (95% CI 13.2%-21%) and in 15% in Cambodia [5].
Moderate PTSD was observed in 15.6% of Palestinians [21] Severe PTSD requiring intervention
was observed in 49.2% of the Palestinians [21] and in 20.4% of respondents in Afghanistan in
one study [2] and in 42% of respondents in another study [3]. The relatively lower percentage of
the PTSD reported in this study may be explained by exposure of Jazan children to a short
duration of stress of few months, less stressful events, considering the relative weakness of the
enemy, whereas the conflict in Palestine and in Afghanistan was more aggressive and extended
for 50 years in Palestine and 30 years in Srilanka. Higher rates of symptoms are associated with
15
the higher number of traumatic events [2, 7, 8]. The adjusted odds ratio of meeting PTSD
symptom criteria for each additional traumatic event was 1.43 [9]. This study was a retrospective
cohort study that provided a baseline evaluation and lacks a Long term follow up. In other
studies Long term consequences were observed and a high level of psychiatric symptoms were
reported 10 years after the conflict in Cambodia [23]. Three years follow up of 27 Cambodian
who were severely traumatized at the age 8-12 years showed that PTSD was still highly
prevalent (48%) and that depression was present in 41% of cases [24]. This indicates that long
term consequences of a short conflict cannot be ruled out. The internally displaced children
included in this study received effective socioeconomic and nutritional support but unfortunately
the psychological, behavioral and psychiatric influences of the war on children were overlooked.
The military hospital of Jazan has part-time psychiatrists, no psychologist and no PTSD clinics.
In this study all the children did not receive any prior psychological or psychiatric assessment or
support compared to 70% of the Palestinians who did not receive this service [25]. This lack of
psychological services may contribute in the higher incidence of psychiatric disorders as PTSD
and higher incidence of psychiatric disorders as anxiety.
It is recommended to establish PTSD clinics in areas of military conflict to provide
psychological screening for PTSD in children exposed to war, provide initial assessment and
support of detected cases and follow up for long term consequences. It is recommended also to
study different risk and protective demographic and socioeconomic factors and to consider its
effects when dealing with children exposed to stress of war.
Conflict of interest
The research topic was proposed by the Military Service Division (MSD), Saudi Arabia. The
research was sponsored by NAAFH, which is a military nonprofit organization that provided
logistic facilities through its Continuous Medical Education (CME) department. NAAFH did not
interfere with data collection or its processing. Three out of the four authors were working for
the MSD.
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