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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. 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