People in Lebanon endured a series of wars such as the endemic war of 1976-1990 in the last decades. This war was characterized by intermittent and unpredictable bouts of violence that included street fighting, indiscriminant shelling of residential areas, sniping, kidnapping and torture, and massive displacement waves. These war events were likened to the episodes of a chronic disease as they were uncontrollable, unexpected when they flared and abated.1 Researchers have noted that pathologic stress syndromes such as post traumatic stress disorder (PTSD), which were closely identified in war veterans, were also experienced by individuals in the community.2,3 Adolescents are a vulnerable group in face of war adversities. A plethora of research exists describing mental health problems of children and adolescents in areas of armed conflict in the Middle East such as studies conducted in Lebanon,4-8 Iraq,9-12 Kuwait,13 Israel,14,15 and the Palestinian territories to name a few.16-20
Little is known about the effects of exposure to war trauma in people with sensory impairments. To harbor an impairment means to be presented with every day problems related to the impairment itself, in addition to coping with negative social response. Adolescents living with impairments are faced by social stigma, prejudices and discrimination.21 A social distance places them in social isolation from their able-bodied peers.22 Under conditions of extreme war stress, the question is whether people with impairments have indeed become more resilient than their able-bodied peers, and hence would fare better under stressful conditions.
Studies of PTSD among people with impairments in general are scanty. A national study in Afghanistan included persons with sensory and physical impairments and assessed their disabilities including disability in their social roles.23 Lower PTSD prevalence rates were noted among the disabled group of young adults sub-sample aged 15-34 years as compared to the able-bodied group (24.2% and 39.9% respectively). To our knowledge, no other similar studies were found. As such, this study was set up to answer the following questions: i) What is the frequency and what are the risk factors for exposure to severe traumatic events in adolescents with sensory impairments compared to their able-bodied peers? ii) Given exposure to severe traumatic events, how do these two groups compare regarding development of PTSD and what are their risk factors for PTSD inception?
Materials and Methods
Subjects and procedure
The study information was extracted from the study Mental Health of Adolescents with Sensory Disabilities in Times of War in Lebanon (Shaar KH, unpublished data). Data for that study were collected at the end of the Lebanese Civil War (1991-1992). All institutions that offered educational services to individuals with sensory impairments in three Administrative Sectors (Muhafazat) in Lebanon were identified, contacted and informed about the study (11 institutions). All adolescents aged 10 to 20 years enrolled in these schools (n=232) were invited to participate in the study. One institution in Mount Lebanon refused to cooperate. A total of 199 adolescents with impairments were included in the study for a response rate of 85.8%. Further, 166 adolescents with impairments agreed to participate in the study (response rate: 83.4%). For each institution that cared for adolescents with impairments, a neighborhood school similar to that institution on mode of tuition payment (private vs. state funded) was selected at random, and these schools were also contacted and informed about the study. An age (±3 years) and sex-matched able-bodied adolescent was selected from each school to constitute a comparison group for the disabled group. Data were collected in the school setting under the supervision of trained university students.
At the time of data collection, the author received the approval of the University Research Board, American University of Beirut, the Ministry of Education, and the respective schools that cared for persons with sensory disabilities. In addition, verbal consent was obtained from each participant after being informed of the study and its anonymous nature.
The study questionnaire included questions about disability characteristics, age, sex, father’s occupation, exposure to severe trauma, and PTSD. Disability characteristics were provided by teachers of the study subjects. Socio-demographic information was elicited by simple questions. Occupation of father was the basis for determining the family’s social class (SC) according to the British Registrar General’s Classification of Occupations.24 This classification was adapted earlier for use in Lebanon.25 In this classification, SC I is professional work, SC II is managerial work, SC III NM is skilled non-manual work, SC IIIM is skilled manual labor, SC IV is semi skilled labor and SC V is unskilled labor. Social class was also bracketed into two groups: a non-manual work group comprising social classes I, II, and IIINM, and a manual work group comprising classes IIIM, IV and V.
PTSD was assessed by the Post Traumatic Stress Reaction Checklist for Children (PTSRC) devised by Macksoud et al.26 The PTSRC is designed as a structured interview schedule for children based on the DSM III-R diagnosis of PTSD.27 It measures PTSD symptoms in relation to one war trauma that he or she feel as the most disturbing for him or her, and measures PTSD symptoms in relation to that one trauma. The PTSDRC consists of 14 items that are rated on a dichotomous basis and that cover the three main domains of PTSD, namely i) experiencing the event, ii) avoidance and decreased involvement with the environment, and iii) increased state of alertness. Consequently, the DSMIII-R criteria for identifying a case of PTSD were used: i) exposure to a traumatic event, and ii) at least one symptom of re-experiencing the event, and iii) at least three symptoms of avoidance, and iv) at least two symptoms of increased arousal. A valid and reliable Arabic version of this scale was also devised by Macksoud et al.26
Simple frequency distributions about disability characteristics of the group with sensory impairments and selected socio-demographic characteristics of the two study groups were generated. The distribution of the two study groups by type of most severe event that they experienced was also generated. In a next step, cross-tabulations of the relationship of the study risk factors to exposure to traumatic events and to PTSD were generated. Risk factors were age (≥13 years vs. <13 years), sex (male vs. female), identity of head of household (father vs. other), social class of head of household (manual vs. non-manual), and region of residence (Greater Beirut vs. Mount Lebanon and vs. the city of Sidon). For the group with sensory impairments, type and severity of impairment (partial hearing vs. total hearing, and vs. partial vision, and vs. total vision impairments) were also included as risk factors. The third phase of the analysis was logistic regression analyses. Two dependent variables were investigated, namely, exposure to severe trauma and development of PTSD and for the two study groups. Stepwise logistic regression analyses were conducted in view of more than one risk factor significantly related to the outcome variable in the bivariate analyses. The logistic regressions tested whether variables that were significant when tested alone remained significantly related to the outcome variable when used simultaneously with other risk factors.
Description of the study groups
The majority of the group with sensory impairments had hearing impairments (77.3%), and 39.8% of these adolescents had a partial hearing impairment compared to partial visual impairment in 55.3% of adolescents with visual impairments. The mean age for the group with impairments was 13.9 years (SD=2.5), and 13.9 years for the able-bodied group (SD=2.1). Males constituted 39.8% of each study group. The head of household was the father in 87.9% of the group with impairments compared to 88.0% in the able-bodied group. Further, the group with impairments belonged predominantly to manual social classes (66.7%) as compared to 50.3% in the able-bodied group. As for geographical region, most of the study subjects attended schools in Mount Lebanon (57.8%), followed by Greater Beirut (38.0%), and the city of Sidon in South Lebanon (4.2%). In fact, this reflects the geographic distribution of institutions that cater for the educational needs for adolescents with impairments, their preponderance being in Mount Lebanon.28
Exposure to traumatic events
Exposure to severe traumatic events in the two study groups is presented in Table 1. For adolescents with sensory impairments, the most common traumatic events were close exposure to bombing and shelling, death of others, being injured, and other war events. For their able-bodied peers, bombing and shelling were the most prevalent, followed by war events, injury of others and destruction or theft of one’s own home. For respondents with sensory impairments, 24.1% reported exposure to a traumatic event that fit the PTSD stressor definition as compared to 69.9 among the able-bodied group (Table 1).
The distribution of PTSD sum score by exposure to severe trauma for the two study groups is are presented in a box plot in Figure 1. Severe trauma was categorized into four broad categories: death, injury to self or other, shelling, and other war events. For the disabled group, it is noted that similar median scores for PTSD are noted across all four categories of trauma. For the able-bodied group, higher median scores and are noted for shelling and other war events and a lower mean score is noted for injury to self or others. Noteworthy here is that other war events include events whose nature the subjects did not wish to disclose. Comparing the two groups on PTSD sum scores and trauma categories, it is noted that the able-bodied group reported more extreme scores for shelling and other war events.
The results of the stepwise logistic regression for the disabled group showed that exposure to a stressor event was significantly lower in those younger than 13 years (OR=0.28, CI=0.09-0.81), among individuals with total visual impairment (OR=8.57, CI=2.24-32.76), and among those whose household was not headed by their father (OR=4.83, CI=1.51-15.44) (Table 2). For their able-bodied peers, results of the stepwise logistic regression showed that this exposure was significantly less common among those whose household is not headed by their father (OR=0.23, CI=0.07-0.70). This exposure was also more common in those residing in Mount Lebanon (OR=4.33, CI=2.68-12.73), and less common is those residing in the city of Sidon (OR=0.11, CI=0.01-0.03) (Table 2).
Prevalence of and risk factors for post traumatic stress disorders
Of the 40 respondents with sensory impairments who reported exposure to traumatic events, 17.5% developed PTSD, yielding a prevalence of 4.2% in the total group of adolescents with impairments. One risk factor for PTSD in this exposed group was identified by the stepwise logistic regression, namely, belonging to the age group younger than 13 years (OR=11.25, CI=1.42-89.26) (Table 3). For able-bodied adolescents, 16.4% of those exposed to a traumatic event had PTSD, for a prevalence rate of 11.4% in this group. No risk factors were identified for PTSD among the able-bodied group (Table 3).
The purpose of this study was to investigate level of exposure to severe stressor events and subsequent development of PTSD among adolescents with sensory impairments and their able-bodied peers. This study also attempted to identify risk factors for exposure to these events and also for developing PTSD.
A major strength of this study is the pioneer investigation of the effect of political violence on adolescents with sensory disabilities, and the inclusion of all sensorially disabled adolescents in three geographical regions of the country. Limitations of this study include the fact that the group of adolescents with sensory impairments in this study may represent a select group who attended schools that cater for their needs as compared to a large segment of disabled people who did not have such an opportunity.29,30 Further, the PTSDRC scale was not used before with sensorially impaired subjects. However, there is reason to believe that the very simple wording of this scale that was devised for use with children made it appropriate for use in this study. Noteworthy is the fact that the institutions covered by the study catered only for adolescents with sensorial disabilities and not for adolescents with mixed disabilities such as having both a visual and a hearing disability or having a mental and a sensorial disability. Further, the cross-sectional design of the current study precluded any causal inference regarding the relationship between exposure to war events and its risk factors as well as relationships between PTSD and its risk factors.
Four main findings were noted in this study. The first showed that adolescents with sensory impairments reported lower exposure to severe traumas that qualify as PTSD stressors (24.1% vs. 69.90% in the able-bodied group). Results of studies of Lebanese adolescents in schools for the same time period reported prevalence rates of exposure to PTSD war stressors that ranged from 31.5% to 42.9%.4,31 Reasons for a lower exposure to war trauma point to the social distance that is kept from people with disabilities minimizes their interaction with their non disabled peers.22 Implicit also is the fact that in times of shelling, kidnapping and fighting, it is hard for visually disabled people to find their way around and are thus housebound. Able-bodied adolescents, on the other hand took an active part in war activities. Anecdotal evidence during data collection for this study showed that the able-bodied group was more likely to participate in war activities such as fighting or patrolling their neighborhoods while the group of disabled adolescents led a more sheltered life style. A pattern of active involvement and direct exposure to the armed conflict was also noted by Macksoud et al.31 in their investigation of the war experiences of Lebanese adolescents.
The second main finding was that rates of PTSD after exposure to trauma were similar in the two study groups (17.5% and 16.4% in the disabled and able-bodied groups respectively). These PTSD rates were elevated when compared to rates among adolescents in peaceful countries such as the neighboring Oman (0.5%) and the U.S. (8.0%).32,33 Further, in this study, the prevalence of PTSD in the total sample was 4.2% in the group with disability and 11.4% in the able-bodied group. Lower PTSD rates in disabled adolescents were due to a lower exposure to trauma rather than a higher level of resilience as was hypothesized earlier. Other PTSD rates noted in another study of adolescents in schools in Lebanon, using the same DSMIII criteria and for the same time period were 46.7% in those exposed to war trauma and 14.7% in the total sample (4).
The third main finding showed different risk factors for exposure to trauma in the two study groups. For individuals with sensory impairments, older age, severe visual impairment, and loss of father as head of household, were related to severe trauma exposure. Older age may signify more years of exposure to war.31 The father as head of household in a paternally oriented culture such as that of Lebanon is important in providing security and stability to the family. The loss of this figurehead for adolescents with disabilities may invoke feelings of vulnerability in a society known for its aversion to dealing with people with disabilities.22 For the able-bodied group, loss of father as head of household made the able-bodied adolescents more responsible for the family. In the able-bodied group, living in Mount Lebanon was also related to higher trauma exposure, an expected finding as severe bouts of fighting at the end of the Lebanese civil war occurred in these areas.
The fourth main finding was that among the study group, older age groups reported higher exposure levels to PTSD stressor events while younger age groups were at a higher risk of developing PTSD, which is in line with findings of other researchers.31,34 The vulnerability of younger age groups to effects of severe stress may be explained by the fact that young children lack the cognitive abilities available to adults, and this limits their repertoire of adaptive responses and coping capabilities.34
In conclusion, results of this study showed lower exposure rates to severe trauma and similar PTSD rates in adolescents with sensory impairments when compared to their able-bodied peers. The investigated risk factors operated largely by predicting trauma exposure rather than development of PTSD. Disability has not made adolescents with impairments more resilient, but forced them into a more sheltered lifestyle.