emotional reactions of children to war stress in croatia

Emotional Reactions of Children to War Stress in Croatia

IVANKA ZlVcic, M.A.

Abstract. Objective: The main purpose of the research was to assess the emotional reaction of childrenexposed to different levels of war stress in Croatia. Method: Four hundred eighty children completed the Croatianversion of the Child Depression Inventory (COl) and the Mood Scale. Their parents and teachers also completedthe analogue Mood Scale. Results: Both groups, refugees and local children, showed more depressive symptomson the COl in comparison with the children of the same age assessed before the war in Croatia. Displaced childrenmanifested more negative. emotions (especially sadness and fear) than did their local peers, based on self-report aswell as parents' and teachers' reports. Poor correlations were found between the children's self-report and theirparents' and teachers' report on the Mood Scale. Conclusions: The war stress had a negative impact on theemotional functioning of all children, especially the refugees. The findings of parents' and teachers' knowledgeabout their children's mood, more obvious in the group of displaced children, deserve special attention because ofthe increased risk for the children. It is recommended that we consider working with the parents, not just children,in promoting children's mental health during times of stress. J. Am. Acad. Child Adolesc. Psychiatry, 1993, 32,4:709-713. Key Words: children, refugees, war stress, emotions.

The war in Croatia, especially the refugee situation, hasnecessarily had a very negative impact on family structure.Usually children are affected the most, because· they oftenare separated from one or both parents. The war is extremelystressful to children as it is sudden, unexpected, unpredict­able, dramatic, and affects many people at the same time.Beyond this, separation from people close to them and espe­cially the death of a parent becomes an important additionalstress for children.

According to UNICEF, the ratio of soldiers to civilians(especially women and children) killed in armed conflictshas shifted during the twentieth century from 9: 1 in the earlydecades (e.g., World War I) to 1:9 in recent conflicts, e.g.,Lebanon (Garbarino et aI., 1991). This has been true in thewar in Croatia. In the first 6 months of the war, 46 childrendied and 302 were wounded (Hirsl-Hecej and Fattorini,1992), and this is not the final number of child victims, asthe war continues at the time of the writing of this article.The number of displaced children and refugees exceeds100,000. Many, including the youngest, have been separatedfrom their parents. For example, 35% of first grade pupilswere displaced without their mothers (Dzepina et aI., 1992).

Each child had his or her own way of reacting to the newwar situation, depending on the level of emotional securityfelt before the war, conditions exposed to during the war,and own individual manner of coping with stress. Researchon children evacuated in England during World War IIshowed that 25% to 50% of them developed various symp­toms (Garmezy, 1988). Frederick (1985) found that childrenexposed to different catastrophes have developed similarpost-traumatic stress disorders (PTSD).

Accepted March 11, 1993.Ivanka Zivcic is with the Department of Psychology, Faculty of

Education, University ofRijeka, 51000 Rijeka, J. Brusica 1, Croatia,telephone 38-51-446-692, fax 38-51-446-611.

0890-8567/93/3204-0709$03.0010© 1993 by the American Acad-emy of Child and Adolescent Psychiatry.

J. Am. Acad. Child Adolesc. Psychiatry, 32:4, July 1993

Children's reactions depend on proximity and intensityof exposure to danger, so that direct exposure to violencehas a stronger influence than violence at a distance (Pynooset aI., 1987). Almost 80% of children who have been ex­posed to the immediate danger of being shot develop post­traumatic stress symptoms (Pynoos et aI., 1987). Sometimes,the symptoms of post-traumatic stress disorder may developmuch later after the real danger is no longer present. Kinzieet aI. (1986, 1989) have found a high incidence of PTSDand depression in children traumatized by war, with persis­tence at follow-up.

Among the most typical reactions of elementary schoolchildren, to be expected in the first few months after severestress, are: separation difficulties, loss or increase of appe­tite, sleep disturbances and nightmares, loss of interest inschool, concentration and memory difficulties, irritability,specific fears, problems in communication with peers, andpsychosomatic complaints (Lystad, 1984; Solomon, 1988;Yule, 1989). Terr (1991) has described other emotions be­side the fear that is ubiquitous to childhood trauma. Theseare an absence of feeling, a sense of rage, and unremittingsadness. Because they found no reports of children showingamnesia, "psychic numbing," or intrusive flashbacks of theevent, Garmezy and Rutter (1985) argued that there was noneed for a specific diagnostic category for stress reactions inchildren parallel to the diagnostic category of post-traumaticstress disorder in adults. However, others (Yule and Wil­liams, 1990) have found that children report very high levelsof distressing, recurrent intrusive thoughts. It seems thatsome of the typical reactions found in PTSD in adults arenot necessarily found in children, although other symptomsmay be signs of reactions to trauma (Terr, 1991). Otherdiagnoses besides PTSD often found among children ex­posed to war stress include adjustment disorders and majordepression.

The present research is primarily focused on the emo­tional reaction of children exposed to different levels of warstress in Croatia. Depressive symptoms and the frequency

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ZIVCIC

of the four basic emotions (joy, anger, fear, and sadness)were measured in two groups of children, refugees and localchildren. It was predicted that displaced children wouldmanifest more depressive symptoms as well as higher nega­tive moods in comparison with local children (those affectedby the war but not displaced).

As there is common agreement that parents offer thestrongest protection and support for children in situations ofextreme stress, it was of special interest to examine howmuch parents knew about their children's moods. We triedto answer this question by correlating children's self-reportsand parents' reports on their children's recent moods.

Method

Subjects

Two groups of children (total 480) were studied. Onegroup consisted of 160 refugee children displaced from thewar zones in the northeastern and southern parts of Croatiaduring 1991. There were 78 boys and 82 girls, average age11.58 years (median 11.75 years, range 8.58 to 14.92 years).The children were placed in hotels and other facilities nearRijeka, a Croatian city not affected by the war. The majorityof the children were placed with their mothers, others withgrandparents, aunts, or older brothers and sisters. Amongthem was one girl who had no one from her village and whoheard nothing about the rest of her family for months. Theaverage length of time of displacement from home was5.3 months (median = 6, range 1 to 9 months). Beforedisplacement, most of the children had stayed in areas di­rectly affected by the war devastation for an average lengthof 2.9 months (median = 3 months, range 0 to 8 months),which means they had experienced one or more extremelystressful events such as prolonged bombing, living in a shel­ter for days, devastation of their homes, and people aroundthem injured and killed. Thirty percent of these children hadexperienced death and 8% the loss of a close relative; 45%of their fathers were at the front.

The second group consisted of 320 local Rijeka children(170 boys and 150 girls). Their age averaged 11.83 years(median = 11.75, range 8.5 to 15.08 years). The question­naire, completed by their parents, found that 30% of fatherswere mobilized, 11 % had experienced death in the family,and 9% had accepted refugees in their homes.

The children from both groups attended the same school,but displaced children formed separate classes with theteachers who were also refugees.

The third group of children consisted of 158 children,regular students of another school in the city.

All three groups were matched by age, gender, and par­ents' educational level.

Measures and Procedure

The study of the first two groups of children was con­ducted during the winter of 1992. The children were as­sessed in the school during regular school hours.

Both groups ofchildren completed the Croatian version ofthe Child Depression Inventory (CD!) developed by Kovacs(1981). It is a 27-item inventory, each item examines theintensity of a depressive symptom on a three-point scale.The total result reflects the manifestations of depressivesymptoms, with a possible range from 0 to 54. Internalconsistency (Cronbach's ex) in the sample of displaced chil­dren is r = 0.83, and in the sample of local children r =0.84.

Children also completed the Emotion Scale, which wasdeveloped in Croatia for the purpose of this research. Itconsists of the four subscales, each representing one of thefour basic emotions (joy, anger, fear, and sadness). Eachsubscale has four items. The children were asked to estimatethe frequency of each mood state in the past 2 weeks on athree-point scale (0 = almost never, 1 = sometimes, 2 =very often). The possible range on each subscale is 0 to 8points. Internal consistency (Cronbach's ex) for each sub­scale on each sample is presented in Table 1. Some coeffi­cients are low, owing to the brevity of the scale.

Samples of the mood descriptions in the Mood Scale(Children Self-Report): happiness-happy, cheerful, in agood mood, pleased, or satisfied; anger-angry, as you aregoing to scream at somebody or hit something, quarrelsome,enraged; fear-scared, afraid, fearful, worried; sadness­sad, unhappy, depressed, downhearted.

The correlations between the subscales on the Mood Scale(Children's Self-Report) are presented in Table 2. The corre­lations are modest, but all reached the significant level be­cause of the large sample size.

It could have been expected that the correlation betweensadness and joy would be highly negative. Even if all nega­tive emotions are highly correlated, they still present qualita­tively different moods and might correlate differently withsome other variables included in the broader research. Themoderately high correlation between the sadness and fearsubscale could be additionally explained by the specificsituation that children are facing (sadness about losses andfear about unclear future). Most authors dealing with themeasurement of emotions consider the existence of certaindiscrete emotional dimensions and suggest separate sub­scales for each basic emotion (Izard, 1982; Plutchik, 1980).

TABLE 1. Internal Consistencies (Cronbach's a) on the Emotion Scale

J. Am. Acad. Child Ado/esc. Psychiatry, 32:4, July 1993

Refugee Children Local Children

Parent Teacher Self ParentSubscale Self

Joy 0.76Anger 0.67Fear 0.55Sadness 0.75

710

0.840.770.680.75

0.760.810.700.67

0.790.740.670.70

0.830.770.710.64

Teacher

0.870.850.820.74

EMQTIONAL REACTIONS TO WAR

TABLE 2. Correlations between the Subscales on the Mood Scale(Children's Self-Report)

8,-------------------,7

TABLE 3. Results on the Child Depression Inventory

Group Mean SD N

Refugee children 11.28 6.63 160Local children 10.77 6.63 320Children assessed

before the war 9.57 5.33 158

Joy Anger Fear Sadness

_ Refugees _ Local children

FIG. 1. Emotion sca1e---children self-report.

u0.61*0.17*0.33*

-0.23*-0.37*-0.55*

* p < 0.001

JoyAngerFearSadness

Parents and teachers also completed the analogue MoodScale estimating the children's recent moods, based on theirobservations about children in the past 2 weeks. Samples ofthe mood descriptions in the Mood Scale (parent and teacherreport): happiness-in a good mood, happy, satisfied, cheer­ful; anger-angry, aggressive, irritated, quarrelsome; fear­fearful, scared, worried, afraid; sadness-depressed, sad,unhappy, tearful.. Par~nts also completed the questionnaire about the nega­

tIve hfe events that children experienced in the past 6months. This was done in the small groups in the dormitorieswhere they were placed.. The third group of children completed only Child Depres­

SIOn Inventory, as part of the research on developing theCroatian version of Kovacs' cm done during 1991.

Results

The results on the Child Depression Inventory (Table 3)suggest no difference in depressive symptoms between thetwo groups of children, assessed during the war, t(478) =0.79; P = 0.429).

Comparison of these results with the data obtained withchildren of the same age before the war shows that bothgroups had significantly more depressive symptoms, t(3l8)= 0.254, P = 0.012 for the group ofrefugees, and t(46l) =2.10; p = 0.036 for the group of local children.

The results on the Emotion Scale are presented in Figure1 (children self-report), Figure 2 (parent-report), and Figure3 (teacher-report). e

There was a difference between the two groups on three s

o~ the four e~otions, based on the children's self-reports. u

DIsplaced chIldren manifested less joy, t(479) = 2.99, P =0.003, but more fear, t(477) = 6.69, p < 0.001, and sadness,t(477) = 6.93, p < 0.001, although there was no differencein the manifestation of anger.

Parent reports (Fig. 2) suggested a significant differenceon all four emotions, p < 0.001 for joy, fear, and sadness,and p = 0.018 for anger, indicating more joy, less anger,less fear, and less sadness in the group of local children.Teacher reports (Fig. 3) differed two groups in the same

l. Am. Acad. Child Adolesc. Psychiatry, 32:4, July 1993

direction, but only in the manifestation of joy, t(443) =6.14, P < 0.001, and not for sadness, fear, and anger.

It was of special interest to check agreement betweenthe children's self-reports and their parents' and teachers'reports. Data presented in Table 4 showed moderately lowcorrelations. Poor internal consistency of some subscales(e.g., fear) might be one of the factors that also contributedto the low correlations. However, the correlations between~hildren's self-reports and their parents' reports were higherIII the group of local children. In this group, they reached0.001 level of significance for all four emotions. In the groupof refugees the correlations were lower, with the nonsignifi­cant agreement between self and parent report for anger.The comparison of children's self-reports and their teachers'reports showed a similar trend. In the group of local children,a~l.four correlat~ons were significant, whereas the only sig­mficant correlation found in the group of refugees was forthe estimation of sadness.

Discussion

The absence of a significant difference between the twogroups on the Child Depression Inventory was comparablewith the findings of some other authors (Lipovsky, 1991,Protacio-Marcelino, 1989). Investigating the consequences

6.-----------'--------

_ Refugees _ Local children

FIG. 2. Emotion scale-parent report.

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ZIVCIC

TABLE 4. Correlations between Children Self-Report, Parent-Report and Teacher-Report on the Emotion Scale

Emotion Refugee Children Local Children

Subscale r (Self/Parent) r (Self/Teacher) r (Self/Parent) r (Self/Teacher)

Joy 0.18* 0.06 0.23*** 0.19**Anger 0.06 0.10 0.30*** 0.26***Fear 0.19* 0.13 0.18*** 0.19**Sadness 0.19* 0.27** 0.20*** 0.16**

* p < 0.05, ** p < 0.01, *** P < 0.001.

8r--------------------,7

of the large earthquake in which many children suffered lifethreat, loss of their home or property, etc., Lipovsky (1991)did not find a higher rate of depressive symptoms amongthe children (based on their self-report on the CDI), and theparents' reports about their children's behavior problemsdid not suggest any clinically significant difficulties. Theauthor argued that the instruments commonly used in as­sessing child psychopathology were not sensitive enoughfor the effects of the traumatic experiences.

Comparing children displaced to Canada from politi­cal torture in Chile and Argentina with children in othercountries, investigators did not find any difference in themanifestation of psychopathological symptoms (Protacio­Marcelino, 1989). The authors think the presence of a closeperson (parent or grandparent) provides enough emotionalsupport and protection for the child.

The difference between the present results on the CDI inwar-affected children and the data collected on the same­aged children before the war could be explained by thenegative influence of the war stress on all children. Even ifthere was a common assumption that the children livingoutside the endangered zones were not exposed to the nega­tive effects of the war stress, the difference found in thisstudy was in line with the observations of our local childrenwho have been affected by the war, even if indirectly(through the mass-media, listening to the stories of otherpeople who experienced severe trauma, by their parents'reactions, etc.).

The results of the Emotion Scale (Fig. 1) confirmed thedifferences between the two groups. As expected, the groupof refugees manifested more negative emotions, primarily

_ RefugeeB _ Local children

FIG. 3. Emotion scale-teacher report.

fear (due to real or anticipated dangers) and sadness (stimu­lated by experienced losses), and less positive mood (joy).Even if the group of local children was exposed to a certaindegree of war stress, it was obvious the refugees had experi­enced much more intense stress before displacement.

Both groups of children reported more negative emotionsthan did their parents and teachers, which is comparable toother findings in the literature (Yule, 1989; Ines and Sacco,1992). Summing up several studies investigating the conse­quence of traumatic experiences on the life of children,Yule (1989) found a consensus that teachers report lesspsychopathology among child survivors than do parents, andthat both report far less than do the children themselves. Thefindings in the present study confirmed his conclusions,with the exception of a nonsignificant difference betweenchildren's self-report and their parents' report about themanifestation of anger in the group of refugees. It is under­standable that children themselves have the best knowledgeof their internal feelings and report more intensive moodsthan do others who can only observe their external reactions.Because the parents spend more time with the children thando their teachers, especially the group of refugees, theymay be able tb notice more emotional symptoms than theteachers. It is also possible that children manifest more nega­tive emotions when alone with their stressed mothers thanwhen among their peers in the school.

The finding of a generally poor agreement between chil­dren's self-reports and their parents' reports on the EmotionScale in the group of refugees is especially important. It isnot surprising, however, considering that the parents in thisgroup also were exposed to a series of very intensive stres­sors and, consequently, had a diminished capacity for under­standing their children's problems. We should be aware thatthe larger size of the sample of local children might havecontributed to higher correlation.

In their study of the effects of a disastrous blizzard and aflood, researchers (Lyons, 1989) compared parental ratingsof specific child behavior reported after the event with rat­ings done by the parents before the disaster. They found thatparents identified more behavior problems after the event,but when asked their subjective impression of the impactthe disaster had on their child, all parents denied their child'sbehavior had been affected. It was suggested that such appar­ent insensitivity on the part of the adults may stem from theadults' own conflicts about their inability to protect the childfrom the event that occurred.

The same explanation could be applied to the presentdata, particularly in view of the fact that the mothers of

SADtlESSF'eARANGeAJOY

e

u

B

712 J. Am. Acad. Child Adolesc. Psychiatry, 32:4, July 1993

displaced children were faced with many problems of theirown (fear and worry about their husbands and other familymembers left in endangered zones, coping with differentlosses, uncertainty about the future). Despite a generalagreement that the presence of a close person represents thestrongest protective factor from the negative consequenceof the stress for the child, it could be questioned how muchmothers, who have so many problems themselves, are ableto help their children cope with an extremely stressful situa­tion and whether they are an additional stressor the childrenface.

Parents' preoccupation with their own problems mightlessen the child's readiness to discuss feelings and worrieswith them. Yule (1989) found that many children, afterexperiencing life-threatening disasters, did not want to talkabout their feelings with their parents "so as not to upsetthe adults," leaving parents unaware of the details of theirsuffering, although they could see the child was in difficulty.He also recorded a great sense of frustration between manyparents and children. Thus, children were left alone to copewith their own negative feelings that they often could neitherunderstand nor accept. Adults noticed and reacted to themonly when they manifested inadequate or disturbing behav­ior.

Trusting a close adult is a very important source of sup­port for a child. Being aware that parents were not able toprotect him or her reinforces the traumatic experience of achild exposed to the terror of the war. For that reason, it isimportant that a close adult shows an example of competentcoping and demonstrates self-control in stressful situations.

The findings of this study also showed that teachers wereno better aware of the children's emotions than were theparents, especially in the group of displaced children (Table4). Considering they were refugees themselves and facedtheir own problems, the explanation similar to that for theparents could be applied to the teachers.

During the elementary school years, a child is in a periodof intensive development of self-concept (Arnold, 1990).An extreme stress, as well as the resulting feeling of help­lessness, has a harmful effect on the perception of personalcompetence. The effect is even greater if the child sees thatthe adults are not able to lessen his or her fear and protecthim or her. Arnold argues that direct observation of thehelplessness of adults slows down the identification processof a child.

It generally is believed that the best predictor of positiveoutcomes for the child who survives an intensive stress isthe ability of the important adults around him, primarilyparents, to cope with the traumatic event (Lyons, 1989).Keeping that in mind, it seems necessary to include theparents in the work on protecting the mental health of chil­dren surviving severe trauma. Additional investigation ofthe effects of the war trauma on children should include thepossible role of mothers' emotional stability and copingstyle on children.

The findings presented here offer some suggestions forpreventive and therapeutic work. It is clear we should notneglect work with significant adults, primarily parents and

J. Am. Acad. Child Adolesc. Psychiatry, 32:4, July 1993

EMOTIONAL REACTIONS TO WAR

teachers. Helping parents deal with practical problems theyface in a new situation (the organization of their life undernew circumstances for which they have not been prepared)might enable them to be more available to their children.Most parents have almost nothing to do, which potentiatestheir feeling of uselessness, worthlessness, and helplessness.Finding ways of including them in useful work might en­courage better feelings about themselves, a basic prerequi­site for the capacity to help their children feel better aboutthemselves.

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