Evaluation of Vicarious PTSD among Children of Sardasht Chemical Warfare Survivors 20 Years after Iran-Iraq War
Post-Traumatic Stress Disorders (PTSD) was reported before in 90% of chemical warfare survivors. Traumatic experiences could affect on the life of other family members, too. Clinical experiences and frequent observations demonstrated more psychological problems in families with a member affected by chemical agent. The aim of this study is to evaluate the frequency of vicarious PTSD among the children of Iraqi chemical attack survivors. In a descriptive, Cross-sectional study, we enrolled 286≥15 years old single children of chemical attacks survivors as case and also 242 ages and sex matched normal civilian from the same city, Sardasht as the control group. PTSD in both groups was assessed by applying Mississippi Questionnaire. Mississippi scale for PTSD among the children of the Sardasht chemical attack survivors was 128.88±13.92 and 108.34±22.7 in the control group (p<0.05). There was no significant difference in the Mississippi scale among different sex and age groups. This study demonstrated higher rates of PTSD among children of Sardasht chemical attack survivors compared with control group, suggesting the need to follow up and treat severe cases.
Received: July 21, 2010;
Accepted: September 25, 2010;
Published: October 14, 2010
After WW2, the most extensive chemical attacks ever occurred, in
violation of the Geneva Protocol 1952, Iraqi-Iran war occurred during 8 years.
UN fact finding team confirmed the use of mustard gas as well as nerve agents
against Iranian troops. According to Iranian government estimates, Iran sustained
approximately 387 chemical attacks (by rocket, air, or artillery) during 8 years
war (Cordesman, 1998). Iraq not only used chemical weapons
against Iranian military targets, but also frequently targeted residential areas,
especially along the border towns and villages. According to the statistics
of Bonyad-e Janbazan, there are at least 34000 chemical warfare victims (disabled)
recognized in Iran until now, (Tavallaie et al.,
2004) which takes almost 37 million USD annually to treat physical complications
of this huge population of victims.
Sardasht is a small Iranian city in northwestern Iran, with a 10 km distance
from the Iran-Iraq border, which exposed during the war to both high intensity
conventional warfare (60 times) and to chemical weapons. In June 1987, this
Kurdish town was bombarded with four 250 kg sulfur mustard warheads that exploded
in the center of town and approximately 4500 residents were exposed to it (Hashemian
et al., 2006).
There are several studies which evaluated the trauma-related mental health problems among veterans and war victims. But there is paucity of studies to evaluate Post-traumatic stress disorders in Chemical warfare victims.
Tavallaie et al. (2004) reported PTSD in 90%
of Iranian chemical warfare victims. Romano and King (2001)
demonstrated anxiety disorders in 57% of soldiers, exposed to chemical and biological
agents. Anxiety disorders reported to be more frequent in Iranian chemical warfare
victims in comparison with other disabled veterans (Haghdadi
and Parchami, 1993; Mohammadi and Noori, 1993).
High prevalence rates of symptoms of depression, anxiety and PTSD were seen
in the post-war Afghanistan (Cardozo et al., 2004;
Scholte et al., 2004). Others studies performed
in war zones such as Kosovo (Cardozo et al., 2004),
Bosnia (Mollica et al., 2007) and Northern Uganda
(Vinck et al., 2007) confirms these results.
De Jong et al. (2001) reported rate of PTSD symptoms
of 37% in Algeria, 28% in Cambodia, 18% in Gaza and 16% in Ethiopia. This study
demonstrated specific patterns of risk factors for PTSD in different settings
and countries (De-Jong et al., 2001).
Post-Traumatic Stress Disorder not only affects the quality of life of chemical
warfare victims, but also has a large influence on their families and environment
(Devilly, 2002). Evaluations shows more mental health
problems in the family members of disabled veterans (Radfar
et al., 2005), but yet the mental consequences of experiencing chemical
attack on the children of chemical warfare victims was not investigated before.
Vicarious trauma is also referred to as a secondary trauma. First, it was reported
in clinicians who worked with traumatized individuals, whether they worked with
victims of child maltreatment, domestic violence, victims of torture, or victims
of large-scale disasters (Sabin-Farrell and Turpin, 2003).
Secondary traumatic stress is defined as psychogenic reaction to a traumatic
experience of another one who is important for that person (Figley,
1998; Fullerton and Ursano, 1997). Symptoms of secondary
or vicarious trauma are extremely similar to the symptoms of directly affected
ones, including nightmares about the directly traumatized person, insomnia,
irritability, loss of emotions, fatigue and etc. (Figley,
1998). Physical symptoms include headache, ear problems, predisposition
to infectious diseases, alcohol, drugs and tobacco abuse (Bell,
2003; Koic et al., 2002).
Most of crises occurred around the world are human-made, such as wars, political
conflicts and etc. it is demonstrated that war have more negative effects on
children (Guha-Sapir and Van-Panhuis, 2003).
After WWÐ, it is suggested that children living with their parents were influenced to fewer amount by war, but this hypothesis rejected in 1990 decade, because later studies demonstrated more clear and precise sense of danger and reaction to that among children.
Children were influenced by crises depending on their age and developmental
state. Behavioral reactions, such as Post-traumatic stress disorder, or anti-social
behaviors are most common symptoms among children. During and after wars, direct
and indirect trauma affects on the coping ability of children (Najjarian
and Barati-Sade, 2000).
Children of veterans were more likely to show psychological disorders and PTSD.
The most common form of these disorders was ADHD (Fairbank
et al., 1993; Kalantari et al., 1993;
Rutter and Quinton, 1984). There are few studies worldwide
which investigated mental health consequences of exposure to chemical agents.
Some available articles disclosed post-traumatic stress disorder (PTSD) symptoms:
in a sample of World War Ð (WWÐ) veterans exposed to mustard gas, 50%
experienced partial or full lifetime PTSD nearly one third met the criteria
for full current PTSD 50 years after the exposure (Ford
et al., 2004; Jankowski et al., 2004;
Schnurr et al., 1996, 1997).
Another study about Mental disorders in people exposed to chemical agents focused
on 1995 Sarin terrorist attack in which More than 5,000 passengers on Tokyo
subway trains were injured with toxic chemicals including the nerve gas sarin
(Kawada et al., 2005). Seventeen percent of samples
met the criteria for PTSD 5 years after attack (Ohtani et
Vafaei and Seidy (2003) demonstrated more depression
among Iranian chemical warfare victims than other disabled victims of Iran-Iraq
war (which called Janbaz in Persian).
The aim of this study is to evaluate the secondary post-traumatic stress disorder
among children of victims of Iraqs chemical warfare against Iran almost
20 years after bombardment of Sardasht.
MATERIALS AND METHODS
In May 2008, in a descriptive Cross-sectional study, we enrolled 528 individuals in two categories: (1) 286≥15 years old single children of chemical attacks survivors as case and (2) 242 ages and sex matched normal civilian from the same city, Sardasht as the control group. We had measured the PTSD among the fathers (150 chemical victims as fathers of case group and 156 fathers of control group) too, to determine probable relationships of self-reported PTSD among war victims and their children.
In order to assign case subjects, all records related to Chemical attack victims who were available in Shahid and Isargaran Affairs Bonyad in Sardasht city were reviewed by the study group. There were 1336 recognized and registered chemical warfare victims in Sardasht. Children of the victims who met the inclusion criteria were enrolled. Our inclusion criteria included having father experienced Chemical warfare during Iran-Iraq war, having a family (including father, mother and at least one ≥15 years old single child), absence of chronic illness or malignancy in other family members, absence of other chemical warfare victims or disabled persons in the family and finally declaring consent to participate in the study. 176 families met the criteria to include in our study, among which 150 families (85.2% of target population) had accepted to participate in the study.
We assigned 156 families as the Control group. They were selected by systematic randomized sampling method from among population of the Sardasht city. The criteria of selecting control group were similar to the case group, excepting that the family father should have no evidenced exposure to chemical agents during the chemical warfare.
Measurement of outcomes: PTSD in both groups was assessed using Mississippi Questionnaire. The Mississippi Scale for Combat-Related PTSD is widely used in the assessment of post-traumatic stress disorders. We had measured the PTSD among the fathers (chemical victims) too, to determine probable relationships of self-reported PTSD among war victims and their children. The M-PTSD is a 39-item self-report measure that assesses combat-related PTSD in veteran populations. Items sample DSM Ø symptoms of PTSD and frequently observed associated features (substance abuse, suicidality and depression). Respondents were asked to rate how they feel about each item using 5-point, Likert-style response categories. Ten positively framed items were reversed, scored and then responses were summed to provide an index of PTSD symptom severity which can range from 39-195.
This Scale developed by Kean et al. (1988) and
revised by Norris and Perilla (1996). Norris
and Perilla (1996) High cross-language stability was demonstrated be Norris
before (Norris). The Persian version validated by Goodarzi
(2003) . for the Iranian population (2003) with a high internal consistency
(Cronbach α = 0.91). ). High internal consistency and cross-cultural validity
was noted by Goodarzi (2003). Up to 65 score determined
Mild, 65-130 determined Moderate and more than 130 score was considered as severe
self-reported PTSD. This instrument was selected because it had a combat-related
Statistical analysis: We used SPSS software ver11.5 to calculate measures of central tendency including Mean and Median and measures of dispersion such as standard deviation and variance in order to analysis the study groups. In order to test the hypothesis, we used parametric methods including Independent t-test, Variance analysis and Correlation test.
In this study we compared case group including 286 children of chemical warfare victims with control group including 242≥15 years old single population using Mississippi questionnaire. Similar Mississippi scores were compared among the fathers (150 chemical victims as fathers of case group and 156 fathers of control group) too.
Among 286 cases, 154 (53.8%) were 15-20 years old, 117 (40.9%) were 21-30 yrs old, 11 (3.8%) 31-40 years old and 2 subjects more than 40 years old. 157 (54.8%) persons were male and 127 (44.4%) were female. There was no significant relationship between Mississippi score and different age or sex groups (p≥0.05).
Intensity of PTSD was evaluated by this questionnaire as well and demonstrated higher rates of severe cases in the case group compared with the control group (both children and fathers). The Mississippi total score in chemical victims (as case group fathers) was 123.06 and was higher than control group's Mississippi score (112.29) (p<0.001).
There was 5.5% severe cases (score≥130) and 93% moderate cases (65-130 scores) among children of chemical warfare victims and 2% severe and 70% moderate PTSD in the control group (Table 1).
29.6% of children of Iraqs chemical attack victims had high intensity penetrating memories, which exists in only 6.9% of controls. In the victims children group, 78% suffer severe and moderate problems in their personal relationship. This rate was 51.7% in the control group. Among victims children, 22.4% were severely and 71% were moderately unable to control emotional feelings. These rates are 25.2% and 26.4% in the control group. Lack of severe depression exists among 52.7% of chemical victims children, which was 39% in the control group (Table 2).
Total Mississippi scores of the chemical victims children group with
a mean score of 128.88±13.92 is significantly higher than the control
group with a mean score of 108.34±22.70. (p<0.05, T=5.42). Severe
penetrating memories were significantly higher in the case group compared with
the control group (35.32±6.18 compared to 28.77±7.67, p<0.05).
||Severity of PTSD according to the Mississippi score in case
and control groups (children)
||Comparing total mississippi score and its factors between
case and control groups (War victims)
||Comparing total mississippi score and its factors between
case and control groups (children)
||Distribution of post-traumatic stress disorder among children
of chemical warfare victims based on fathers Morbidity percentage
according to Bonyad-Janbazan Morbidity index
According to T-test, problems in personal relationship is significantly higher
among cases compared with controls (29.59±3.99 compared to 25.38±7.16,
p<0.05) (Table 3).
Inability to control emotional feelings was more frequent among cases than the controls (32.60±3.93 compared to 28.00±8.62, p<0.05). Lack of depression similar to other 3 factors of Mississippi Scale is higher in the cases (31.41±4.92) compared with the controls (26.17±9.31) (p<0.05) (Table 4).
Comparing the severity of PTSD based on revised Persian Mississippi scale, 5.5% of the children with parents affected by chemical agents had severe levels and 93% had moderate levels of Post-traumatic stress disorder, compared to 2 and 70% in the control group, respectively. All four PTSD criterias (Penetrating memories, Problem in personal relationships, inability in controlling emotional feelings and lack of depression) were high among chemical warfare victims. There was no significant difference between the score of Mississippi scale among different age or sex groups in our study.
In reviewing literature, no article had been published concerning PTSD among
children of chemical warfare victims. But there are some studies which show
more psychological disorders among children of veterans compared with the control
groups. In studies conducted by Kalantari et al.
(1993), Fairbank et al. (1993) and Rutter
and Quinton (1984), children of veterans were more likely to show psychological
disorders and PTSD. The most common form of these disorders was ADHD. A study
conducted by James CL revealed that teenagers with a parent affected mentally
(with essential emotional disorder or schizophrenia) showed more psychological
disorders than the others (Janes et al., 1983).
Radfar et al. (2005) conducted a study about
the children of veterans with mental disorders and concluded that their sense
of wellbeing was less than the children of veterans without any mental problem.
They justified high prevalence of psychiatric symptoms in their study group
to be due to the problems and stressors of fathers which not only affect the
veteran himself, but also his family (Radfar et al.,
2005). All these studies reveal the impact of parents with physical and
mental disorders on children which is consistent with our findings.
In the study conducted by Rutter and Quinton (1984)
and Earls (1976), Female children of war veterans were
more affected by PTSD than male children, yet our study revealed no significant
difference in Mississippi scores between different age and sex groups.
The town studied in this research has had some levels of other stressors, including natural disasters and unemployment. Unemployment of family superintendent could make mental and psychological problems by means of lowering socioeconomic status. But all mentioned stressors are equal for the case and control groups in our study.
Sardasht city is one of the main attacked cities and maybe stress level of its general population was high. In Iran, supportive and counseling services are more focus on chemical warfare victims and their children were neglected. Therefore, their children due to lower age need to more attention than others. PTSD such as other mental disorders can inherit as behavioral model between generations and we must more attention to control of PTSD for prevention of its transmission to next generation.
Our study had some limitations; firstly we designed our study on chemical warfare victims who lived in Sardasht city. Our results only can prediction power for these people and next studies must be done for other social, cultural and geographical distribution for covering other chemical warfare victims. Secondly, some of our couples did not feel the questionnaire honestly or did not answer to all of study questions against our request and unfortunately, we must exclude them from our study.
The authors would like to thank Behavioral Sciences Research Center, Baqiatallah University of Medical sciences, Students Research Committee of Urmia University of Medical Sciences and Janbazan Medical and Engineering Research Center for the grants provided for our study.
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