https://doi.org/10.15218/ejnm.2019.08 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Prevalence of Post-traumatic Stress Disorder and Potentially Traumatic Events among Adolescents in Erbil City ABSTRACT INTRODUCTION Children and teenagers are vulnerable for experiencing many forms of stressful events due to the rapid physiological and psychological changes happening during adolescent years. This vulnerability can increase among adolescents living in coun- tries facing crisis continuously. Trauma cre- ates a loss of faith that there may be any safety in this world, and it smashes a per- son’s innocence *1+.. Wars, political and religious violence, forced displacement and migration, human right abuses, Background and Objectives: Many children and teenagers throughout lifetime maybe ex- pose to extraordinary forms of stressful and traumatic events, particularly individuals who live in countries experiencing continuous conflicts such as Iraq. Approximately one-third of traumatized adolescents might develop symptoms of post-traumatic stress disorder. The current study aimed to evaluate the types of potentially traumatic events and prevalence of post-traumatic stress disorder among adolescents in Erbil city. Methods: A descriptive cross-sectional study was carried out at eleven public and private schools in Erbil City. The samples of the study were selected in three stages; the schools' selection, the class selection in the schools, and involvement of 300 students within the study. Data were collected from face-to-face interview of participants from 1st of March to 15th May 2018. Screening for post-traumatic stress disorder was done by using the post- traumatic stress disorder screening tool. The validity and reliability have been verified. Fre- quency, percentage, mean, standard deviation, chi-square, t-tests, and Fisher exact test was used for data analysis. Results: Majority of participants were Kurdish, from the host community; More than half of them were males and middle in the rank within their families while the most prevalent potentially traumatic events were identified to be emotional abuse and physical abuse. Such events include betrayal and disappointment, witnessing parents fighting with each other, witnessing direct physical torturing, and physical torture. Among traumatized ado- lescents it is predicted that about 41.7% have post-traumatic stress disorder. Conclusions: Post-traumatic stress disorder is prevalent among adolescent students and it differs in terms of gender and type of schools. Post-traumatic stress disorder was found to be the highest percentage among females compared to males, and within public schools compared to private schools. The most prevalent potentially traumatic events among ado- lescents were emotional and physical trauma. Key words: Adolescent, Child Maltreatment, Post-Traumatic Stress Disorders, Students, Schools. Raveen Ismael Abdullah; Department of Nursing, College of Nursing, University of Duhok , Duhok , Iraq. (Correspondence: raveenmayi@yahoo.com ) Norhan Zeki Shaker; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. 60 Erbil Journal of Nursing & Midwifery Received: 7/12/2018 Accepted: 15/1/2019 Published: 30/5/2019 mailto:Raveenmayi@rocketmail.com https://doi.org/10.15218/ejnm.2019.08 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article unemployment, and poverty have dam- aged Iraqi society, creating major public mental health crises *2+. .Post-Traumatic Stress Disorder (PTSD) can result from ex- posure to shocking trauma and is charac- terized by continual re-experiencing, avoid- ance/numbing, and hyper arousal, present for more than one month and associated with significant distress and/or functional impairment *3+.. Trauma during the child- hood period has been called as “the hidden epidemic’’ *1+. Many recover from trau- matic events and others may develop symptoms of post-traumatic stress disor- der *4+, especially after exposure to a range of traumatic events *5+, such as sexual and physical abuse, domestic and school vio- lence, medical trauma, car accidents, war and terrorism, suicides, and other trau- matic events *6+. Other individuals may de- velop PTSD after being exposed to Poten- tially Traumatic Events (PTEs) *7+. PTSD is a disabling disorder, in both the developed and the developing countries *8+ which can lead to chronic psychiatric morbidity and loss of normal daily life *9+. It has a lifelong impact on multiple aspects of functioning, including adaptive and interpersonal func- tioning, emotion regulation, cognition and memory, and neuroendocrine function *4+.The risk for PTSD among children relies upon on the nature of the trauma; the child's age and gender; and personal, fami- ly, and community factors *4+. Traumatic experiences may result from conflicts *10+ as supported by literature that shows that the rate of PTSD among youth in Iraq has multiplied. Adolescents in Iraq have been exposed to different kinds of traumatic events during the last decade especially after the conflict of 2003*11+, but the fact is even ordinary people who experience common stressful events may develop PTSD *12+. People in Iraq have been more or less continually exposed to war for more than three decades *13+. Iraq and the Kurdistan region of Iraq have faced more difficulties and challenges since the influx of Syrian refugees which began in 2012 and Iraqi civil war against the Islamic State of Iraq and al-Sham (ISIS) in 2014 which resulted in thousands of internally dis- placed people *14+. This humanitarian cri- sis has created financial and political insta- bilities in the country *15+. Furthermore, the political violence as a factor for devel- oping psychological distresses among com- munity individuals has been taken in con- sideration *10+. It expected that adoles- cents in Kurdistan Region of Iraq along the ISIS war have been exposed to a variety of potentially traumatic events and violence such as physical violence ,emotional vio- lence, and domestic violence which result- ed from different types of crisis and inse- curities. Increase in the number of trau- matic events result in increase in PTSD prevalence *16+. Therefore, it is important to identify teenager’s psychological chal- lenges for forming a more healthy genera- tion of future adults. The current study aims to find the types of potentially trau- matic events, prevalence of post-traumatic stress disorder and PTSD association with adolescent’s sociodemographic character- istics in Erbil city. A descriptive cross-sectional study was carried out in a period from January to No- vember 2018 among adolescent students in Erbil city. The study samples were re- cruited through multiple stage of random sampling from the list of 260 mixed schools which have grade level of six to eleven (basic, high, and secondary schools) in Erbil city of the Iraqi Kurdistan Region. Eleven schools were selected after dividing schools into two strata: private schools and public schools. Two private schools and nine public schools were randomly se- lected from each stratum using a METHODS 61 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2019.08 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article tortured physically, witnessing parents fight with each other, being betrayed or disappointed, witness of physical torture, being affected by horror movies and indi- rect violence through television, experi- ence of unexpected death of someone close, witnessing suicide or homicide and experience of car accidents. The last part of questionnaire has been adopted from the Primary Care of Post-Traumatic Stress Disorder screening tool (PC-PTSD-5) for screening probable PTSD. A score of three or more out of a total of five questions about how traumatic event(s) has affected him/ her over the past month is consid- ered positive *18+. PC-PTSD-5 is based on the fifth edition of the Diagnostic and Sta- tistical Manual of mental disorders (DSM- 5) which was published in the May 2013 *19+. Data collection has been done throughout face-to-face interview by re- searcher and it took place in an isolated room inside the school building to create a safe, supportive, and non-threatening en- vironment for the participant. The validity of instruments has been verified for its ac- curacy, relevance, and clarity via a panel of experts. After conducting a pilot study on a sample of 30 adolescent students at one of the mixed basic schools the internal con- sistency and reliability was determined and measured via computation of Pearson product moment correlation and the r val- ue was (r = 0.8294). The collected data have been analyzed through using the sta- tistical package for social science (SPSS, Version 23). The socio-demographic char- acters described by frequency, percentage, mean, and standard deviation tests. While chi-square, fisher exact test, and Inde- pendent t-tests used for identifying the significance of association. The P value of ≤ less 0.05 used for determination of signifi- cance level. proportionate stratified random sampling where the total number of private mixed schools were 45 (17.3 %) and the total number of public mixed schools were 215 (82.6%) out of 260 schools. as researcher proportioned choosing sample fraction of 4% for both strata. The selected partici- pants from the eleven schools (high, sec- ondary, or basic schools) ranged from ages 11 to 17 years old (both sexes) from grades six to eleven. Using simple random sam- pling, 52 students were from private schools and 248 students were from public schools. Adolescent students from twelfth school grade level and those whose age less than 11 years or more than 17 years old were excluded from the study. Estima- tion of sample size in the current study was 303 adolescent students but unfortunately three of them have dropped out from the study. The study sample size has been cal- culated through using n=Z 2P (1−P)/d for- mula *17+. Prior to data collection ethical approval was obtained from Ethical Com- mittee at the College of Nursing, Hawler Medical University, Erbil General Direc- torate of Education, and the consent of participated schools. Furthermore, the oral consent was taken from adolescent stu- dents for the participation in the study after confirmation of confidentiality, ano- nymity and participants self-determination by the researcher. Withdrawal from study was permitted whenever the person lost desire to answer questions or disclose. A reliable questionnaire format which con- sisted of three parts was used to collect data. The first part covered socio- demographic characteristics of adolescents such as school type, school grade level, age, gender, ordinal position in the family, nationality, type of residency, source of financial support, child labor. The second part assessed the potentially traumatic life events among adolescent students which included physical torture, threat to be 62 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2019.08 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Tables 1 shows that the mean± SD of the participant’s age was 14.02 ± 1.62, it also illustrates that the 92.7% of participants (278) were from the host community, 91.3% were Kurds (274). 140 (46.7%) were females and 160 (53.3%) were males. The highest percentage,76.7% of students were financially depended on their parents, and only 14.7% of adolescents were working for earning money. It also shows that 18.3% of adolescents who participated in the study were from grades eight and nine. *F: frequency, **%: percentage Figure 1 shows that the highest percent- age, 54.7% of participants were the middle children in their families. Figure 1: Ordinal position of adolescents in the family Figure 2 shows that the prevalence of PTSD among adolescents was estimated to be 41.7% of whom probably had PTSD. Figure 2: Prevalence of PTSD among ado- lescents’ students in Erbil city Table 2 illustrates the highest percentage, 56% of PTSD symptoms among adoles- cents was for “Tried hard not to think about the event(s) or went out of the way to avoid situations that reminded them of the event”, and the least prevalent symp- tom, 27.7%, was “Felt numb or detached from people, activities, or their surround- ings”. 63 Erbil Journal of Nursing & Midwifery RESULTS Table 1: Socio-demographic characteristics of adolescents. Characteristics n= 300 *F **% Age Mean± SD School grade level Six Seventh Eighth Ninth Tenth Eleventh 56 52 54 57 28 53 14.02±1.62 18.7 17.3 18.0 19.0 9.3 17.7 Gender Female Male 140 160 46.7 53.3 Ethnicity Kurdish Arabic Turkmen 274 25 1 91.33 8.33 0.33 Residency type Host community Internally displaced person 278 22 92.7 7.3 Financial support Parents Siblings Financially independent Others such as: grandfather, uncle ,and other1st degree relatives 230 13 44 13 76.7 4.3 14.7 4.3 Working Yes No 44 256 14.7 85.3 https://doi.org/10.15218/ejnm.2019.08 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Table3 shows that most prevalent potentially traumatic events among adolescents were: betrayal and dis- appointment (58%), witnessing parents fighting with each other (53.3%), and witnessing physical torturing directly (46.3%). Table 3: Prevalence of potentially traumatic events among study sample . 64 Erbil Journal of Nursing & Midwifery n=300 PTEs NO F % YES F % Physical torture 173 57.7 127 42.3 Threatens to be tortured physically 176 58.7 124 41.3 Witnessing parents fights with each other 140 46.7 160 53.3 Being betrayed or disappointed 126 42.0 174 58 Witness of physical torture 161 53.7 139 46.3 Forced migration or displacement 275 91.7 25 8.3 Experience car accident 240 80.0 60 20 Long-term illnesses and hospitalizations 271 90.3 29 9.7 Being affected by horror movies and indirect violence through TV 212 70.7 88 29.3 Been in war zone 257 85.7 43 14.3 Witnessing suicide or homicide 274 91.3 26 8.7 Experience of unexpected death of someone close 216 72.0 84 28 Witness of car accidents 256 85.3 44 14.7 Table 2: Post-traumatic stress disorder symptoms among adolescents n=300 In the past month have you.. Yes F (%) No F (%) Had a nightmare about the event(s) or thought about event(s) when you did not want to? 99(33) 201(67) Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event? 168(56) 132(44) Been constantly on guard, watchful, or easily startled? 138(46) 162(54) Felt numb or detached from people, activities, or your surroundings? 83(27.7) 217(72.3) Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused? 122 (40.7) 178(59.3) https://doi.org/10.15218/ejnm.2019.08 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article According to Table 4 shows that, the mean age of those who had PTSD was 14 and there was no significant association found between PTSD and age,while a very highly significance in association between type of school and PTSD 119 (48%) of participants from public schools and 6 (11.5%) of participants from private schools have the likelihood of having PTSD. Results indicate there is a highly significant association between gender and PTSD (p-value is less than 0.0001). PTSD prevalence among fe- males 80 (64%) is higher than in males 45 (36%). The likelihood of having PTSD was 111 ( 88.8%) among host community ado- lescents; 78 (62.4%) among adolescents who receive their financial support from parents; 59 (47.2%) among the middle chil- dren in families; and 93(74.4%) among those adolescents who work for gaining their daily life income. 65 Erbil Journal of Nursing & Midwifery Table 4: Association between PTSD and socio-demographic characteristics of adolescent students’ Socio-demographic characteristics PTSD Positive F (%) Negative F (%) P-value Age Mean± SD Type of school Private school Public schools School grade level Six Seventh Eighth Ninth Tenth Eleventh 14.13±1.598 6 (11.5) 119 (48) 17 (14.2) 20 (16.7) 22 (18.3) 27 (22.5) 13 (10.8) 21 (17.5) 13.95±1.639 46 (88.5) 129 (52) 11 (7.2) 34 (22.2) 33 (21.6) 28 (18.3) 15 (9.8) 32 (20.9) 0.498 NS <0.0001* VHS 0.341 NS Gender Female Male 80 (64) 45 (36) 60 (34.3) 115 (65.7) <0.0001 VHS Ordinal position in family First born child Middle child Youngest child Only child 28 (22.4) 59 (47.2) 35 (28) 3 (2.4) 40 (22.9) 105 (60) 25 (14.3) 5 (2.9) 0.028 S Residency type Host community Internally displaced person 111 (88.8) 14 (11.2) 167 (95.4) 8 (4.6) 0.030 S financial support Parents Siblings Financially independent Others 78 (62.4) 10 (8) 32 (25.6) 5 (4) 152 (86.9) 3 (1.7) 12 (6.9) 8 (4.6) <0.0001 VHS Working Yes No 93 (74.4) 32 (25.6) 163 (93.1) 12 (6.9) <0.0001 VHS *The chi-squared test was performed for all statistical analyses. NS: non-significant, VHS: very high signifi- cant, S: significant https://doi.org/10.15218/ejnm.2019.08 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article other. Exposure to child physical abuse and parents’ domestic violence lead to PTSD *23+. It is difficult to sort out the research conducted on child maltreatment because various forms of maltreatment do not oc- cur in isolation for example, physical mal- treatment and emotional maltreatment often happened together *25+. Regarding sociodemographic characteristics and PTSD prevalence, a very significant association was found between type of school and gender. Almost half of participants from public schools present the likelihood of having PTSD, , In previous studies researchers have emphasized that adoles- cents attending private schools not only utilize more effective strategies to cope with problems, they also utilized emotion- oriented strategies that were based on their relationships with others such as seeking out support from spiritual groups, talking with friends or identifying profes- sional help *26+. Public schools adolescents are mostly from families with low econom- ic status and from poor sectors of the com- munity. Adolescent public school popula- tion size is relatively larger compared to private schools, thus creating a barrier for receiving adequate support and attention from school officials and family members. Children who have greater social support are less likely to develop PTSD than those without such support *25+. The highest percentages of those who have the likeli- hood of PTSD in current study were fe- males. Findings from literature review sup- ported the current study results which em- phasized that girls are two to three times are likely to develop PTSD compared with boys *25+, but the results disagreed with a study conducted in a sample of school chil- dren of 122 girls and 165 boys in Kabul, Afghanistan which found 26% prevalence of probable PTSD in boys compare to 14% in girls *28+. All human beings starting from childhood might go through many different shockable life events, and difficulties until reaching to adulthood. Exposure to such events might increase internal fears and create insecurities and if the impacts of traumatic events remain with person for long durations without support to cope with the aftermath of traumatic events, it may ultimately lead to psychological prob- lems. The current descriptive cross- sectional study which was carried out at eleven public and private schools in Erbil city and has demonstrated that the majori- ty of adolescents in this study may have probable PTSD. The majority of adolescents expressed avoidance symptoms, and the least prevalent symptom was numbness and detachment from people, activities, or their surroundings. The current results were consistent to a 2017 study of 251 chil- dren from 3 summer camps ages 6 to 16 years in Palestine regarding PTSD symp- toms which presented an intrusion mean of 8.98 and an avoidance symptoms sub- scale mean of 9.49 *20+. The results of an- other study prioritized social avoidance as one of the most common symptoms *21+. The current study also indicated that PTSD is prevalent and the results were very close to a study in Erbil during 2016 which showed the prevalence of PTSD among 570 participants aged between 15 and 64 years was 39.6% *22+. It’s also consistent to PTSD prevalence of several other studies includ- ing studies in Mosul which suggested that, 37% of children have mental disorders, and 10.5% have PTSD; in Baghdad which re- vealed that, 47% of primary school children reported exposure to a major traumatic event, 14% had PTSD *2+ and the most po- tentially traumatic lifetime event among adolescents are betrayal/disappointment and witnessing parents fighting with each 66 Erbil Journal of Nursing & Midwifery DISCUSSION https://doi.org/10.15218/ejnm.2019.08 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article events were emotional and physical trau- ma. Besides exposure and/or witness of traumatic events, there are many factors that interfere with probability of PTSD. It was concluded that there is an association with increased PTSD prevalence with fac- tors such as the type of school, gender, ordinal position, residency type, source of financial support, and child labor. The authors have no conflict of interest. *1+ Margolies L, read PD~ 3 min. Understanding the Effects of Trauma: Post-traumatic Stress Disorder (PTSD) *online+. Psych Central. 2016 .Available from: https:// psychcentral.com/lib/understanding-the- effects-of-trauma-post-traumatic-stress- disorder-ptsd/ *2+ AlObaidi A. Psychological Trauma: Experi- ence from Iraq. Journal of Trauma and Treatment. 2013 Nov 20;2(1):1–2. *3+ Suliman S, Kaminer D, Seedat S, Stein D. As- sessing post-traumatic stress disorder in South African adolescents: using the child and adolescent trauma survey (CATS) as a screening tool. Annals of General Psychiatry. 2005 Jan 31;4(1):2. *4+ Gerson R, Rappaport N. Traumatic Stress and Posttraumatic Stress Disorder in Youth: Recent Research Findings on Clinical Impact, Assessment, and Treatment. Journal Adoles- cent Health. 2013 Feb 1;52(2):137–43. *5+ Calitz FJW, Jongh D, J N, Horn A, Nel ML, Joubert G. Children and adolescents treated for post-traumatic stress disorder at the Free State Psychiatric Complex. South Afri- can Journal of Psychiatry. 2014 Mar;20(1):15 –20. *6+ American Psychological Association. Chil- dren and Trauma: Update for Mental Health Professionals *online+. http://www.apa.org. 2008 *cited 2018 Jul 26+. Available from: http://www.apa.org/pi/families/resources/ children-trauma-update.aspx A significant association was found be- tween PTSD and types of residency as the majority of those who have PTSD were from host community. This implies that de- spite of not being in war zone directly PTSD is prevalent among vulnerable groups si- lently *25+. Current study also concluded that almost half of those adolescents who receive money from parents they have PTSD and there is very highly significant association between PTSD and financial source. Those who work to earn money have a greater likelihood of having PTSD as environment of work for such age furthers the pressure on the adolescent population. This study also demonstrated that more than half of adolescents who receive their financial support from parents have likeli- hood of having PTSD. This may be a result of the recent economic crisis in Iraq which has created conflicts within families; no similar studies were found to support this. More than half of the adolescents who work for gaining their daily life income are likely to have PTSD which is supported from literature review findings that the there was a statistically significant associa- tion between PTSD and working during school and association between age and PTSD was also statistically significant. Al- most half of the adolescents who are the middle child in current study probably have PTSD which is contrary with a finding of another study which revealed that 49.2% of the PTSD children were the first-born in their families *27+. The current study concluded that PTSD is prevalent among adolescent students in Erbil city despite of not going through war directly. Each of participants had a lifetime exposure to at least one of the types of po- tentially traumatic events assessed, and the most prevalent potentially traumatic 67 Erbil Journal of Nursing & Midwifery CONCLUSIONS REFERENCES CONFLICTS OF INTEREST https://doi.org/10.15218/ejnm.2019.08 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article *17+ Lancaster CL, Teeters JB, Gros DF, Back SE. Posttraumatic Stress Disorder: Overview of Evidence-Based Assessment and Treatment. Journal of Clinical Medicine*Internet+. 2016 Nov 22 *cited 2018 Aug 28+;5(11). 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