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Role of childhood adversities and environmental sensitivity in the development of post-traumatic stress disorder in war-exposed Syrian refugee children and adolescents

  • Elie G. Karam (a1), John A. Fayyad (a2), Claudia Farhat (a3), Michael Pluess (a4), Youmna C. Haddad (a5), Caroline C. Tabet (a5), Lynn Farah (a6) and Ronald C. Kessler (a7)...

Increased post-traumatic stress disorder (PTSD) rates have been documented in children exposed to war. However, the contribution of childhood adversities and environmental sensitivity to children's responses to adversities and trauma are still far from settled.


To evaluate the relative roles of war, childhood adversities and sensitivity in the genesis of PTSD.


Data on childhood adversities and sensitivity was collected from 549 Syrian refugee children in Lebanon. PTSD symptoms were assessed using the PTSD Reaction Index.


Although childhood adversities, war events and sensitivity were all significantly related to PTSD in bivariate analyses, multivariate analyses showed that childhood adversities were the most important variable in predicting PTSD. The effect of war on PTSD was found to be dependent on the interplay between childhood adversities and sensitivity, and was most prominent in highly sensitive children with lower levels of adversities; in sensitive children experiencing high levels of adversities, the effects of war exposure on PTSD were less pronounced.


When considering the effects of war on PTSD in refugee children, it is important to take account of the presence of other adversities as well as of children's sensitivity. Sensitive children may be more vulnerable to the negative effects of war exposure, but only in contexts that are characterised by low childhood adversities.

Declaration of interest


Corresponding author
Correspondence: Elie G. Karam, Department of Psychiatry and Clinical Psychology, St Georges Hospital University Medical Center, Youssef Soursok Street, 2nd floor, office number 208, 209, PO Box 166378, Beirut Achrafieh 1100-2807 Lebanon, Beirut, Lebanon. Email:
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1Thabet, AA, Vostanis, P. Posttraumatic stress reactions in children of war. J Child Psychol Psychiatry 1999; 40: 385–91.
2Cloitre, M, Stolbach, BC, Herman, JL, Kolk, BVD, Pynoos, R, Wang, J, et al. A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity. J Trauma Stress 2009; 22: 399408.
3Gustafsson, PE, Nilsson, D, Svedin, CG. Polytraumatization and psychological symptoms in children and adolescents. Eur Child Adolesc Psychiatry 2009; 18: 274–83.
4Copeland, WE, Keeler, G, Angold, A, Costello, EJ. Traumatic events and posttraumatic stress in childhood. Arch Gen Psychiatry 2007; 64: 577–84.
5Karam, E, Mneimneh, Z, Karam, AN, Fayyad, J, Nasser, S, Chatterji, S, et al. Prevalence and treatment of mental disorders in Lebanon: a national epidemiological survey. Lancet 2006; 367: 1000–6.
6Itani, L, Haddad, YC, Fayyad, J, Karam, A, Karam, E. Childhood adversities and traumata in Lebanon: a national study. Clin Pract Epidemiol Ment Health 2014; 10: 116–25.
7Schiff, M, Pat-Horenczyk, R, Benbenishty, R, Brom, D, Baum, N, Astor, RA. High school students’ posttraumatic symptoms, substance abuse and involvement in violence in the aftermath of war. Soc Sci Med 2012; 75: 1321–8.
8Dubow, EF, Huesmann, LR, Boxer, P, Landau, S, Dvir, S, Shikaki, K, et al. Exposure to political conflict and violence and post-traumatic stress in middle east youth: protective factors. J Clin. Child Adoles Psychol 2012; 41: 402–16.
9Catani, C, Schauer, E, Neuner, F. Beyond individual war trauma: domestic violence against children in Afghanistan and Sri Lanka. J Marital Fam Ther 2008; 34: 165–76.
10Okello, J, De Schryver, M, Musisi, S, Broekaert, E, Derluyn, I. Differential roles of childhood adversities and stressful war experiences in the development of mental health symptoms in post-war adolescents in northern Uganda. BMC Psychiatry 2014; 14: 260.
11Zuckerman, M. Vulnerability to Psychopathology: A Biosocial Model. American Psychological Association. 1999.
12Monroe, SM, Simons, AD. Diathesis-stress theories in the context of life-stress research: implications for the depressive disorders. Psychol Bull 1991; 110: 406–25.
13Belsky, J, Pluess, M. Beyond diathesis stress: differential susceptibility to environmental influences. Psychol Bull 2009; 135: 885908.
14Pluess, M, Assary, E, Lionetti, F, Lester, KJ, Krapohl, E, Aron, E, et al. Environmental sensitivity in children: development of the highly sensitive child scale and identification of sensitivity groups. Dev Psychol 2018; 54: 5170.
15Pluess, M, Boniwell, I. Sensory-Processing Sensitivity predicts treatment response to a school-based depression prevention program: evidence of Vantage Sensitivity. Pers Individ Dif 2015; 82: 40–5.
16Nocentini, A, Menesini, E, Pluess, M. The personality trait of environmental sensitivity predicts children's positive response to school-based anti-bullying intervention. Clin Psychol Sci 2018: 6: 848–59.
17Slagt, M, Dubas, JS, van Aken, MAG, Ellis, BJ, Dekovic, M. Sensory processing sensitivity as a marker of differential susceptibility to parenting. Dev Psychol 2018; 54: 543–58.
18Betancourt, TS, Khan, KT. The mental health of children affected by armed conflict: protective processes and pathways to resilience. Int Rev Psychiatry 2008; 20: 317–28.
19Bronfenbrenner, U. The Ecology of Human Development. Harvard University Press, 1979.
20Pynoos, R, Rodriguez, N, Steinberg, A, Stuber, M, Frederick, C. UCLA PTSD Index for DSM-IV. UCLA Trauma Psychiatry Program, 1998.
21Thabet, AA, Abed, Y, Vostanis, P. Comorbidity of PTSD and depression among refugee children during war conflict. J Child Psychol Psychiatry 2004; 45: 533–42.
22Miller, T, El-Masri, M, Allodi, F, Qouta, S. Emotional and behavioural problems and trauma exposure of school-age Palestinian children in Gaza: some preliminary findings. Med Confl Surviv 1999; 15: 368–78.
23Nader, KO, Pynoos, RS, Fairbanks, LA, Al-Ajeel, M, Al-Asfour, A. A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis. Br J Clin Psychol 1993; 32: 407–16.
24Runyan, DK, Dunne, MP, Zolotor, AJ, Madrid, B, Jain, D, Gerbaka, B, et al. The development and piloting of the ISPCAN Child Abuse Screening Tool-Parent version (ICAST-P). Child Abuse Negl 2009; 33: 826–32.
25Kessler, RC, Ustun, TB. The World Mental Health (WMH) survey initiative version of the WHOCIDI. Int J Methods Psychiatr Res 2004; 13: 95121.
26Rutter, M. Resilience as a dynamic concept. Dev Psychopathol 2012; 24: 335–44.
27Weems, CF, Pina, AA, Costa, NM, Watts, SE, Taylor, LK, Cannon, MF. Predisaster trait anxiety and negative affect predict posttraumatic stress in youths after hurricane Katrina. J Consult Clin Psychol 2007; 75: 154–9.
28Jakšić, N, Brajković, L, Ivezić, E, Topić, R, Jakovljević, M. The role of personality traits in posttraumatic stress disorder (PTSD). Psychiatr Danub 2012; 24: 256266.
29North, CS, Abbacchi, A, Cloninger, CR. Personality and posttraumatic stress disorder among directly exposed survivors of the Oklahoma City bombing. Compr Psychiatry 2012; 53: 18.
30Pynoos, RS, Frederick, C, Nader, K, Arroyo, W, Steinberg, A, Eth, S, et al. Life threat and posttraumatic stress in school-age children. Arch Gen Psychiatry 1987; 44: 1057–63.
31Laor, N, Wolmer, L, Cohen, DJ. Mothers’ functioning and children's symptoms 5 years after a SCUD missile attack. Am J Psychiatry 2001; 158: 1020–6.
32Wolmer, L, Laor, N, Dedeoglu, C, Siev, J, Yazgan, Y. Teacher-mediated intervention after disaster: a controlled three-year follow-up of children's functioning. J Child Psychol Psychiatry 2005; 46: 11611168.
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Role of childhood adversities and environmental sensitivity in the development of post-traumatic stress disorder in war-exposed Syrian refugee children and adolescents

  • Elie G. Karam (a1), John A. Fayyad (a2), Claudia Farhat (a3), Michael Pluess (a4), Youmna C. Haddad (a5), Caroline C. Tabet (a5), Lynn Farah (a6) and Ronald C. Kessler (a7)...
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