Abstract
In an earlier issue of Word of Mouth, I discussed what speech-language pathologists (SLPs) need to know about children who have experienced adverse childhood experiences (ACEs). The majority of the work on ACEs has focused on children in Western cultures who have experienced ACEs within their families, and more recently, within their communities. Such studies have shown that brain development is disrupted in children who have experienced strong, frequent, and/or prolonged adversity—such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship—without adequate adult support. These children are at increased risk for stress-related disease and cognitive and language impairments throughout their life span. A large number of children around the world are experiencing post-traumatic stress disorder (PTSD) related to forced migration due to war, famine, and natural disasters. Countries in Western Europe, Canada, and the United States are attempting to cope with an influx of forced migrants. Because of the effects of trauma on development, refugee children are likely to experience a higher incidence of developmental difficulties. SLPs should be alert to this increased risk for disabilities in refugee children and not be quick to assume that difficulties are simply due to learning a second language or adjusting to a new culture. Ideally, SLPs are part of a team evaluating and planning for refugee children.
Researchers know that children do not all respond to ACEs and trauma to the same extent. Genetic factors influence children’s response to stress. Some genetic alleles are more sensitive to the environment, positive or negative (Belsky & van IJzendoorn, 2017). Children react in different ways to environmental experiences. Pluess and colleagues (2018) proposed that children have differing sensitivities to the environment. Some are like dandelions. They grow and thrive in any type of environment; they adapt to any situation. Others are like orchids. They are highly sensitive to the environment. They require supportive, nurturing conditions, and a regular routine to thrive. And still other children are like tulips—they fall between high and low sensitivity. Children with alleles that are more influenced by environmental factors are more negatively affected by trauma and exhibit less resilience. Children with different sensitivities to trauma are likely to require different supports and interventions.
The purpose of this study was to evaluate the relative roles of war, childhood adversities, and sensitivity in the genesis of PTSD. The participants in this study were 549 Syrian refugee students between ages 7 and 17 years enrolled in schools in Lebanon.
Assessments
PTSD symptoms were assessed using the PTSD Reaction Index (PTSD-RI) for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994), which includes a total of 20 post-traumatic stress symptom items rated on a scale of 0 to 4. Scores were classified as mild PTSD reaction (total score 12–24), moderate (25–39), severe (40–59), and very severe (above 60). Sample items included the following: I have thoughts like “I am bad.” I am on the lookout for danger or things that I am afraid of. When something reminds me of what happened, I get very upset, afraid, or sad. I have trouble going to sleep, wake up often, or have trouble getting back to sleep. I have trouble remembering important parts of what happened.
War exposure was measured with a checklist of 25 items with a corresponding score of 1 for every war item children experienced. War items ranged from being unable to leave home because of bullets and bombings to witnessing people getting tortured and/or dying.
The childhood adversities measure was composed of 29 items from the ISPCAN Child Abuse Screening Tools (ICAST) as well as a list of adversities created based on focus group discussions with mothers, and two additional items related to childhood neglect. Adversities were collected with the following responses: never (score of 0), sometimes in the past year (score of 1), always in the past year (score of 2), and not in the past year, but happened in the past. For the last item, researchers gave a score between 0 and 2 based on responses to other items that happened during the past year.
Sensitivity was measured using the Highly Sensitive Child Questionnaire (HSC) which includes a total of 12 items each rated on a scale of 0 to 6 (0, do not agree; 3, agree moderately; 6, totally agree) and reflects three factors: (a) the ease of excitation factor that reflects being easily overwhelmed, (b) low sensory threshold that captures unpleasant sensory arousal, and (c) aesthetic sensitivity that measures sensitivity to aesthetic aspects of the environment. Based on the distribution of sensitivity, three levels were created by dividing its distribution into low, middle, and high sensitivity. Some items are as follows: I find it unpleasant to have a lot going on at once. Some music can make me really happy. Loud noises make me feel uncomfortable. I am annoyed when people try to get me to do too many things at once. I notice it when small things have changed in my environment. I get nervous when I have to do a lot in little time.
Results
PTSD-RI scores: 50.7% of children reported no post-traumatic reactions, 31.5% mild, 14.3% moderate, and 3.5% severe.
War events: A total of 69.4% of the participants experienced at least one type of war event, with 25.7% reporting 1–3 war events and 43.7% reporting ≥ 4 war events.
Childhood adversities: 31.3% of students reported no childhood adversity, 32.8% reported 1–3, and 35.7% reported more than 4.
The number of war events increased with the number of childhood adversities. There was a significant relationship between the number of war events and number of childhood adversities.
At low and middle levels of childhood adversity, the effect of war exposure on PTSD was stronger with increasing sensitivity. In contrast, at high levels of childhood adversity, the relationship of war exposure remained equally strong across all levels of sensitivity.
Discussion
The effects of war on PTSD were strongest in children with high sensitivity and low childhood adversities and weakest in children with low sensitivity and low childhood adversities but at a similar moderate level, regardless of sensitivity differences, when childhood adversities were high. This suggests that sensitivity is an important moderator of the negative effects of war, but only in a developmental context that is relatively free of other chronic adverse conditions such as an unsupportive family environment. The researchers suggest that sensitive refugee children who have not been exposed to other adversities are more vulnerable to the effects of war, possibly because these children have been more sheltered from other adversities. Sensitive children exposed to significant childhood adversities, on the contrary, may have developed coping strategies over time, which make them slightly less vulnerable to the development of PTSD.
Okello and colleagues (2014) also found that in a sample of adolescents in Uganda, for those with lower levels of childhood adversities, stressful war experiences were more strongly related to PTSD than in adolescents with higher levels of childhood adversities. Parent–child attachment has also been shown to mediate effects of war trauma in Ugandan (Okello et al., 2014) and Palestinian (Punamäki et al., 2018) children. Children who had more secure attachments with caregivers were less affected by war trauma than those with insecure attachments.
Personnel charged with providing services to refugee children must be aware that children’s response to trauma cannot be determine by measures of the types or severity of traumas alone. Consideration must also be given to the quality of attachments children have experienced with caregivers and to their sensitivity to environmental factors that is related to their genetic characteristics. Therefore, a single intervention strategy may not be effective for all children. Although there are no studies to date that have investigated refugee children’s response to interventions to reduce the effects of war and migration trauma, there has been a study to investigate how children with differing sensitivities responded to interventions to reduce the mental health effects of victimization from bullying. Nocentini et al. (2018) reported on an intervention that significantly reduced bullying behaviors and mental health outcomes. They noted that the intervention significantly reduced bullying behaviors and mental health outcomes across the whole sample, but that highly sensitive boys seemed particularly responsive to the beneficial effects of the intervention on victimization and internalizing symptoms. Highly sensitive boys were twice as responsive to the beneficial effects of the interventions as children with low sensitivities. Low-sensitivity boys did not benefit from the intervention in relation to victimization and internalizing symptoms. Medium-sensitive and high-sensitive girls were also more likely to report reduced levels of victimization when in the treatment group than low-sensitive girls. A possible explanation for the victimization findings is that highly sensitive children are more likely to be (or perceived as being) victimized and therefore also more positively affected by a treatment-induced reduction of bullying behavior in the school context. The limited research available on this topic indicates that highly sensitive children are more likely to suffer the multiple effects of trauma, and they may also be more responsive to interventions to treat the effects.