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. Author manuscript; available in PMC: 2020 Aug 10.
Published in final edited form as: Pediatr Blood Cancer. 2019 Apr 30;66(8):e27775. doi: 10.1002/pbc.27775

Posttraumatic stress in young children with cancer: risk factors and comparison to healthy peers

Rachel Tillery 1, Victoria W Willard 1, Alanna Long 1, Sean Phipps 1
PMCID: PMC7417025  NIHMSID: NIHMS1568221  PMID: 31038281

Abstract

Objective

The most commonly occurring childhood cancers are diagnosed during the preschool years, yet limited psycho-oncology research has focused on this developmental time period. The primary objective was to examine rates of posttraumatic stress symptoms (PTSS) in young children with cancer and compare these findings to children without history of serious illness (comparisons). The secondary aim was to examine risk and modifiable factors associated with PTSS.

Method

Ninety-seven caregivers of patients (n=50) and comparisons (n=47) aged 3–6 years completed diagnostic interviews for the assessment of PTSD. They also completed a survey measure of PTSS adapted from the Child Behavior Checklist (CBCL-PTSD), along with measures of their child’s temperament and their own current psychological functioning.

Results

On the CBCL-PTSD, no differences in PTSS were observed between children with cancer and comparisons, although many in both groups appeared at-risk, with approximately 34% of children with cancer and 27% of comparisons meeting threshold scores for probable PTSD. However, using a “gold-standard” clinical-interview assessment, only three children in the patient group and no children in the comparison group met diagnostic criteria for PTSD. Parental distress and child temperament were significantly associated with PTSS scores.

Conclusion

Findings indicate PTSD is relatively infrequent in children with cancer and survey measures may overestimate rates of PTSD in young children. However, other emotional or behavioral issues may be present. Ultimately, screening for potential emotional/behavioral concerns in young children with cancer is indicated, and interventions should continue to target caregiver distress.

Keywords: pediatric oncology, early childhood, posttraumatic stress, temperament, parental coping

Childhood cancer, though a serious, significant, and stressful event, is often experienced with remarkable resilience by patients, caregivers, and families of children with cancer;1 however, a small subset of children and families experience ongoing psychological distress.2 Posttraumatic stress (PTSS), or the symptoms that make-up the diagnosis of posttraumatic stress disorder (PTSD), has been a useful framework for understanding the ongoing psychological sequela for older children and adolescents diagnosed with cancer,3 yet few studies have focused on PTSS in younger children.4–7 This gap is likely due to methodological barriers, as popular data collection modalities (i.e., self-report) are not feasible with young children. This disparity in research is especially problematic, considering the psychological needs of a significant portion of the pediatric oncology population remains unknown.8 It is imperative we gain an understanding of the psychological impact of cancer on young patients, since the implications of distress during this sensitive developmental period can be long-lasting.9

The PTSS framework may prove useful for young children with cancer, as stressful medical procedures in conjunction with the young child’s limited cognitive, language, and coping abilities may foster problematic emotional outcomes.10 Since subjective experiences are difficult to reliably ascertain in young children, measurement of PTSS within this population has relied on caregiver report.10–13 In pediatric cancer specifically, one study of caregiver-reported behaviors of 48 infants, who ranged in age from 8–48 months, found nearly 18% were diagnosed with PTSD and 41% met partial criteria.5 This is markedly different from rates of PTSD in older children with cancer (1.6%14), which was also evaluated by caregiver reports of behavior. These findings warrant the need for further investigation of PTSS and PTSD in young children with cancer, including an examination of risk and modifiable factors, and an evaluation of how development within the cancer context may differ from children without a life threatening illness.

Bronfenbrenner’s bioecological model (Figure 1),15 which posits emotional and behavioral functioning as a combination of biological components and reciprocal interactions among nested systems (i.e. family environment, school environment, society, etc.), has been used as a framework for understanding psychosocial outcomes in children including PTSS16. When focusing on the individual child, the developmental literature has pointed to temperament as an indicator of psychological functioning.17 Temperament is defined as individual differences in attention, motor, emotional, and self-regulation that are believed to be relatively stable, biologically driven, and shaped by environmental influences.18 The construct of temperament is closely related to that of personality, and early childhood temperament may be viewed as a precursor to personality in later childhood or adulthood.19 In older children, personality has been linked to PTSS following stressful life events like pediatric cancer20,21, and may serve as an important risk factor for PTSS in young children.

Figure 1.

Figure 1.

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Bronfenbrenner’s Ecological Model depicting nested influences on the child.

Bronfenbrenner’s bioecological model15 also points to other systems that may explain psychological adjustment to pediatric cancer, such as the family microsystem. In older pediatric oncology populations, children are more likely to experience PTSS related to their cancer experience if family member distress is also present.22 Limited research in young children has suggested that parental distress following diagnosis can have lasting implications on cognitive and psychosocial functioning.23 For preschool-aged children, parental psychological adjustment may play an even more salient role in predicting the emotional adjustment of this age-group, and is a modifiable factor that warrants further investigation.

Of the few studies examining the psychological implications of pediatric cancer during early childhood, available findings indicate young children may not experience the same levels of psychological resilience as older children diagnosed with cancer.5 These findings warrant replication, and would benefit from the inclusion of a comparison sample of young children unaffected by serious illnesses (comparisons). This would allow for isolation of developmental and psychological implications of pediatric cancer (apart from normative childhood stressors) during this developmental stage. We hypothesized that PTSS (i.e., symptoms characterizing PTSD) and PTSD (the clinical diagnosis) will be higher in young children with cancer than in comparisons. As a secondary aim, we used Bronfenbrenner’s framework15 to examine the influence of individual differences (temperament) and family microsystem factors (caregiver distress) on PTSS/PTSD. We hypothesized that temperament and caregiver distress would be linked to PTSS in young children. Demographic factors were included but these aims were largely exploratory.

METHODS

Procedures

Young children with cancer (ages 3 to 6 years) were recruited from outpatient clinics at a St. Jude Children’s Research Hospital for participation in a larger longitudinal study. Participants were part of a young child cohort, and included if the child was: (a) between 3 to 6 years of age, (b) at least one-month from diagnosis, (c) did not have any significant cognitive or sensory deficits, and (d) a parent/legal guardian was willing to participate and could speak/read English. A total of 50 caregivers were consented to participate and completed all study measures, while 16 participants declined or failed to show for the scheduled assessment (participation rate 75.7%). Participants and nonparticipants did not differ statistically by age, gender, race/ethnicity, diagnostic category, or categorized time since diagnosis.

Comparison participants were included if they (a) did not have a history of chronic or life threatening illness (caregiver report), (b) did not have any significant cognitive or sensory deficits (caregiver report), and (c) a caregiver was willing to participate, provide consent, and could speak/read English. Comparison participants were recruited in a two-part process from daycare centers, preschool, and kindergarten classrooms from a three-state area surrounding the hospital. In the first step, permission slips were distributed through the institutions, with returned permission slips including information on child age, gender, race/ethnicity, and caregiver education and occupation. The returned data were used to create a pool of potential control participants, who were subsequently contacted, based on demographic match, using a frequency matching approach. Of 56 contacted, 47 (83.9%) consented and completed all study measures. All study procedures were approved by the hospital’s Institutional Review Board.

Caregivers in the study (patient and comparison) met with trained psychology staff at the hospital’s outpatient psychology clinic. Caregivers were asked to evaluate their child’s most stressful life event and to complete measures related to their own and their child’s psychological adjustment. Caregivers (86% mothers, see Table 1) also participated in a semi-structured interview with trained study staff (e.g., experienced research assistants, advanced graduate students, psychology fellows) in which they were asked to report on their child’s PTSS in relation to a selected stressful life event.

TABLE 1.

Demographic Information

Patient Group n = 50 Control Group n = 47
Sex
   % Female 46 45
   % Male 54 55
Age
   Mean (SD) 4.48 (1.11) 4.66 (1.03)
   Range 3–6 3–6
Race
   % Caucasian 72 81
   % African American 18 15
   % Other 10 4
Parent Type
   % Mom 80.0 92.0
   % Dad 14.0 6.0
   % Other 6.0 2.0
Socioeconomic Status Score
   Mean (SD) 38.90 (14.09) 48.57 (11.96)
   Range 9–66 19–66
   Diagnosis
   % Acute Lymphoblastic Leukemia 30.0 --
   % Other Leukemia 4.0 --
   % Hodgkin’s & Non-Hodgkin’s Lymphoma 6.0 --
   % Solid Tumor 42.0 --
   % Brain Tumor 18.0 --
   % Healthy Comparison -- 100.0
Age at Diagnosis
   Mean (SD) 2.15 (1.43) --
Years Since Diagnosis
   Mean (SD) 2.36 (1.30) --
Treatment Intensity
   Mean (SD) 2.52 (1.02) --
   Range 1–4 --
On Therapy
   % Yes 50.0% --
Relapse
   %Yes 18% --
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Participants

Demographic and medical information are presented in Table 1. Participants were on average 4.57 years of age (SD=1.07). Approximately 55% of child participants were male, and caregivers were predominately mothers (mother=86%, fathers= 10%, other=4%) and White (White=76%, Black=17%, Other=7%).

Measures

The Child Behavior Checklist-PTSD scale (CBCL-PTSD) was used as an evaluation of PTSD and behavioral dysregulation.24 This scale includes 15 items from the CBCL that are used as a screener for posttraumatic symptomatology. Caregivers respond on a 3-point scale to indicate the frequency of the symptom (e.g., “Defiant,” “Sudden changes in mood or feelings,” “Clings to adult or is too dependent.”). This scale correlates (r=.66) with the number of PTSD symptoms endorsed in diagnostic interviews.11 A cutoff score of 9 was established to indicate a probable PTSD diagnosis.11 Internal reliability for the present data was adequate (α=.77).

Child Posttraumatic Stress

The Posttraumatic Stress Disorder Semi-Structured Interview and Observational Record for Infants and Young Children (PTSD-IYC) is an interview designed for caregivers of infants and children age 18 months to 6 years.12 The interview evaluates Criterion A (exposure to threatened injury, death, or violence), Criterion B (intrusion), Criterion C (avoidance/numbing), and Criterion D (alterations in thoughts/mood) of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV PTSD) diagnosis25 and provides a categorical diagnosis. The wording for five of the seventeen DSM-IV symptoms has been modified to be more developmentally sensitive and behaviorally anchored.12 An alternative scoring algorithm13 was used, in which A2 criteria is not specifically required and only one avoidance/numbing symptom (Cluster C) is required rather than three. This algorithm is consistent with the DSM-526 criteria for PTSD children under 6. All interviews were recorded and subsequently scored by at least two raters. Across all rater dyads, level of absolute agreement was 97% for both A1 criteria, and full criteria for PTSD. When raters disagreed, a third rater was used and scoring decisions made by consensus.

Child Temperament

The Children’s Behavior Questionnaire, Short form (CBQ)27 is a caregiver-reported questionnaire that assesses temperament of 3–7 year old children. This 36-item measure has three subscales: Surgency (high impulsivity, pleasure- and novelty-seeking, and activity level), Negative Affectivity (high lability, reactivity, and negative emotion), and Effortful Control (ability to refrain from a behavior, maintain attention, and resist distraction). Reliability in the current sample was adequate for negative affectivity (α=.73), and effortful control (α=.79), and was marginal for surgency (α=.66).

Caregiver Distress

The Brief Symptom Inventory (BSI)28 was completed by caregivers as an assessment of global distress. The BSI is a 53-item scale that yields nine subscales of psychological functioning (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism). A Global Severity Index (GSI) score is calculated by averaging across the subscale scores. The GSI was used in the present study and obtained adequate reliability (α=.95).

Caregiver Posttraumatic Stress

Impact of Events Scale, Revised (IES-R)29 is a 22-item measure of PTSS symptoms based on DSM-IV criteria. Caregivers report on their experience within the past 7 days associated with the event self-identified as the most traumatic in their lives. It has adequate internal reliability and test–retest reliability.29 In the present study, the sum of all the items was used as a total indicator of the distress associated with the event identified as most traumatic by the caregivers. This measure also evidenced adequate internal consistency (α=.94).

Treatment Intensity

Treatment intensity was scored using the Intensity of Treatment Rating Scale 2.0 (ITR-2).30 The ITR-2 uses information regarding diagnosis, stage or risk level, and treatment modality to produce an overall treatment intensity rating with 4 levels, ranging from least intensive to most intensive, with interrater reliability reported at .87.30

Prior Mental Health

Caregivers reported on whether or not their child received prior mental health services, and if so, the types of mental health services received. Mental health services were categorized into two broad categories: consult/therapy services (n=12, 12.4%) and cognitive/academic testing (n=12, 12.4%). The majority of children participating in the study received neither service (n=73, 75.3%).

Analyses

T-test and chi-square analyses were performed to examine group differences among demographic variables. Next, frequency statistics were examined separately by group to evaluate the rate of young children who met the threshold for probable PTSD using the CBCL-PTSD. The same analyses were also performed using the PTSD-IYC interview for each symptom criteria (A, B, C, and D). Next, a one-way analysis of variance (ANOVA) was performed to examine differences among predictor variables between the patient and comparison groups. A regression analysis was then conducted for the patient group only to determine if medical factors (i.e., treatment intensity, time since diagnosis, age at diagnosis, and relapse) predicted PTSS. Finally, a regression analysis was performed to determine which risk and modifiable factors were associated with PTSS in young children. Since PTSS could be experienced despite not meeting full criteria for PTSD, the CBCL-PTSD was used as the dependent variable in order to allow for a spectrum of responses. Step 1 included demographic variables and group status (patient or comparison). Step 2 comprised assessments of caregiver distress and child temperament. Step 3 encompassed interactions between group status and step 2 variables. Variables were centered prior to analyses.

RESULTS

Preliminary Analyses

Participants with cancer did not differ from healthy controls on age (t(95)=−.83, p=.81), sex (χ2[1,N=97]=.17, p=.90), ethnicity (χ2[2,N=97]=4.92, p=.09), or types of mental health services received (χ2[2,N=97]=1.50, p=.47). However, healthy comparisons evidenced slightly higher SES scores (M=48.57, SD=11.96), as assessed by the Barratt Simplified Measure of Social Status31, than youth with cancer (M=38.90, SD=14.09; t(95)=−3.64, p<.001). As such, SES was included as a covariate in analyses.

Rates of PTSD Symptoms and PTSD

CBCL-PTSD Questionnaire

On the CBCL-PTSD, mean scores did not differ between cancer and comparison groups (Table 2). Using the recommended cutoff score of 9, 34% of young children in the patient group (n=17) met criteria for probable PTSD, while in the comparison group, 27% (n=13) of children met this threshold. This difference was not statistically significant (χ2 [1, N=97] =.46, p=.50).

TABLE 2.

Mean Differences for Primary Study Variables

Patient Group n = 50 M(SD) Control Group n = 47 M(SD) F
Child Behavior Checklist-Posttraumatic Stress Scale 6.24 (4.29) 4.96 (3.31) 2.79
Child Temperament: Surgency 51.30 (9.24) 55.13 (9.18) 4.13*
Child Temperament: Negative Affect 49.15 (11.64) 49.91 (9.46) .12
Child Temperament: Effortful Control 60.64 (10.17) 61.01 (11.36) .03
Parent Distress: Global Severity Index 53.92 (11.02) 53.04 (10.18) .17
Parent Posttraumatic Stress Symptoms 25.69 (18.81) 21.17(18.36) 1.43
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Note.

*

p<.05

Structured Interviews

For patient participants, three children (6%) met the PTSD-IYC criteria for PTSD. In terms of meeting cluster criterion, 94% of caregivers (n=47) reported their young child met criteria A. Only three caregivers (6%) did not identify cancer as their child’s most stressful life event, and these children also did not meet the threshold for Criteria A. Forty percent (n=20) met criterion B, 16% (n=8) met Criterion C standards, and 6% (n=3) met criterion D. In the comparison group, no child met the PTSD-IYC criteria for PTSD. Approximately, 72% met criterion A, 51% (n=24) met criterion B, 17% (n=8) met Criterion C standards, and 2% (n=1) met criterion D.

Rates of PTSD did not statistically differ between the two groups (χ2 [1,N=97]=2.91, p=.08). However, significant differences emerged in rates of meeting symptom cluster criterion. Based on caregiver reports, young children in the cancer group were more likely to meet Criterion A (χ2[1, N=97]=8.97, p=.01), whereas comparison children were more likely to meet Criterion B (χ2[1, N=97]=11.92, p=.003). There were no differences in threshold rates for Criterion C (χ2[1, N=97]=.95, p=.62) or D (χ2[1, N=97]=2.02, p=.36).

Predictors of PTSD Symptoms

Prior to examining predictors of PTSS, a one-way ANOVA was performed to examine mean differences in predictor variables across study groups. Caregivers of the comparison group were more likely to endorse behaviors associated with surgency (high impulsivity, pleasure- and novelty-seeking, and activity level; cancer group, M= 51.30, SD=9.24, comparison group, M=55.13, SD=9.18, F [1, 95] =4.13, p=.04). No differences emerged on the other temperament variables (Table 2). Regarding caregiver predictors of children’s PTSS, caregiver PTSS (F [1, 96)] = 1.43, p = .24) and global distress (BSI; (F [1, 96)] = .17, p = .69) were consistent across both groups and within population norms (Table 2). Prior to examining determinants of PTSS across the entire sample, a regression analysis was performed within the cancer group to examine medical factors. Results revealed that neither age at diagnosis (β=−.03, p=.90), time since diagnosis (β=−.18, p=.42), treatment intensity (β=.03, p=.87), on/off treatment status (β=.08, p=.63), nor relapse status (β=−.12, p=.53) were significant predictors of PTSS.

Regression analyses were performed across the entire sample to examine predictors of PTSS using the CBCL-PTSD (Table 3). Notably, group status (cancer vs. comparison) was not a significant predictor of PTSS; neither were age, gender, or socioeconomic status. Caregiver global distress was associated with their child’s PTSS (β=.35, p=.003); however caregiver PTSS were not linked to child PTSS (β=.03, p=.77). Child temperament was also associated with PTSS with negative affectivity positively predicting PTSS (β=.38, p<.001). Interactions between group status and caregiver distress and group status and child temperament were not significant.

TABLE 3.

Regression analysis predicting posttraumatic stress symptoms (CBCL-PTSD) in young children with cancer and healthy comparisons.

β ΔR2
Step 1 .03
 Age −.03
 Sex −.03
 SES Strata .10
 Group Status (0=patient, 1=control) −.08
Step 2 .34***
 Parent Distress .35**
 Parent PTSS .03
 Surgency −.08
 Negative Affect .38***
 Effortful Control −.06
Step 3 .03
 Parent Distress X Group .10
 Parent PTSS X Group −.02
 Surgency X Group −.15
 Negative Affect X Group −.02
 Effortful Control X Group .08
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Note.

*

p < .05

**

p < .01

***

p < .001

PTSS= posttraumatic stress symptoms.

DISCUSSION

The extant literature examining the psychological implications of pediatric cancer has highlighted the overall resilience of older pediatric patients and their family members.1 Findings from the present research somewhat mirror studies with older children,14 and were in contrast to our first hypothesis that rates of PTSD would be higher than comparisons. Generally, rates of PTSS and PTSD were consistent across pediatric cancer patients and comparisons, with few exceptions noted below.

For the screener tool (CBCL-PTSD), rates of probable PTSD were elevated for both groups (34% for cancer group, 27% for the comparison group). In contrast, only about 6% of children in the entire sample met diagnostic criteria for PTSD when using “gold-standard” clinical-interview assessments. In addition to rates of PTSD being low, rates of probable PTSD (evaluated using the CBCL-PTSD) and the rates of PTSD (evaluated by the IYC-PTSD) were not statistically different between preschoolers with cancer and comparisons. This research suggests remarkable resilience of young children encountering stressful life events, including pediatric cancer.

While research on other childhood traumas has shown similar rates of PTSD using the CBCL-PTSD (30–35%), sensitivity and specificity were limited. 32,33 Discrepancies between the rates of probable PTSD and those meeting diagnostic criteria for PTSD may be explained by the recommended cutoff of 9 on the CBCL-PTSD measure. This value may overestimate the rates of PTSD.

This discrepancy may also be a function of the assessment, as the items on the CBCL-PTSD (e.g., “Defiant,” “Sudden changes in mood or feelings,”) may be more reflective of behavioral dysregulation, rather than specific to PTSD.33 This is further supported by elevated rates of criterion B symptoms (re-experiencing) from the clinical interview as this criterion captures emotional distress and physical reactivity. Further, findings are similar to those in a study of young children with acute lymphoblastic leukemia, which documented increased emotional and behavioral difficulties.7 Taken together, it appears a spectrum of behavioral and emotional issues may be present for both groups that are not best captured by a diagnosis of PTSD, and examining emotional regulation issues more broadly will be fruitful to explore with this population.

The current findings are in contrast to the Graf et al5 paper, which documented nearly 18% of young children with cancer met diagnostic criteria for PTSD using the same interview method. Differences between the two studies may be attributed to higher rates of maternal PTSD (~42%) in the Graf et al. study.5 Differences in time since diagnosis may also explain discrepancies in caregivers’ distress and subsequently reduced PTSS symptoms in children. Nevertheless, this finding is consistent with previous research with caregivers of older children that included a comparison group.34,35 Finally, it is possible differences may be attributed to the slightly younger sample of participants included in the Graf and colleagues5 study, though our findings do not seem to support age as an indicator of PTSS.

A secondary aim was to examine risk and modifiable factors associated with PTSS using the Bronfenbrenner bioecological model.15 At the individual level, health status and interactions among health status and other predictors were not indicative of child PTSS, reiterating that health status alone is not a risk factor for PTSS. D At the individual level, child temperament was the only factor indicative of PTSS in preschoolers, with negative affectivity associated with increased PTSS. This finding, in conjunction with previous research,20 provides support that some dispositional characteristics leave children more vulnerable to develop PTSS/distress in the face of adversity. At the family systems level, caregiver psychological distress was associated with PTSS in young children, which is consistent with the extant literature in pediatric oncology populations22, and highlights the importance of supporting the broader family system during a child’s illness. Interestingly, caregivers’ own PTSS were not related to child PTSS. Though this finding appears surprising, previous research has found caregiver’s reports of their child’s PTSS was not related to their own PTSS in a population of older youth with cancer.36

Study Limitations and Future Directions

The present results should be considered in light of several limitations. First, child psychological distress was only evaluated using PTSS as an outcome. Findings from this research indicate this outcome is limited, as a spectrum of emotional/behavioral problems may be present and not best captured by the PTSS/PTSD diagnosis. Assessments using broader indicators of emotional/behavioral functioning is likely indicated. Second, the cross-sectional design of the study allows for static conclusions about children’s emotional adjustment. For the advancement of this area of research, it will be imperative that we examine the developmental course of social, emotional, and behavioral problems, particularly those that may be unique to pediatric cancer. Third, the small sample of fathers limited our understanding of how caregiver adjustment may impact the child’s emotional functioning. Increasingly, literature has documented the unique role of fathers’ adjustment to the pediatric cancer experience and the implications it has on the child’s overall wellbeing.37 Finally, measures were only collected from a single informant, raising concerns for inflated associations among study variables. Though this remains a concern for this study and research on children <8 years of age more broadly, it is important to note that previous research found consistency between caregiver reports of child’s distress and youth’s reports of their own distress among pediatric cancer patients.36

Clinical Implications

The literature base on the psychosocial adjustment of preschoolers with cancer remains small, thus it is crucial future research continues to investigate these issues. Consistent with the Standards of Psychosocial Care for children and caregivers of children with cancer,38 early psychosocial assessments are critical to mitigating potential psychological functioning difficulties associated with cancer treatment. Parent- proxies serve as the best substitute for young children, and including assessments of child temperament (e.g., CBQ) in screening batteries in conjunction with established screening tools (e.g., Pediatric Assessment Tool39), may enhance our ability to detect young children who may be at-risk for emotional adjustment issues during and after the cancer journey. Established standards also indicate the need to provide early and ongoing support for caregivers,40 and the present findings provide additional justification for this need to not only enhance caregiver quality of life outcomes but to assist in the management of child emotional distress. In particular, problem-solving interventions may provide an effective and feasible approach to mitigating caregiver distress.41,42

Conclusion

This research adds to the emerging literature on psychological adjustment in young children with cancer. Findings indicate PTSD is relatively low in children with cancer, however, other emotional or behavioral issues may be present. As survivorship rates continue to rise, investigating cognitive, emotional, and behavioral outcomes will be essential, including risk and modifiable factors associated with the wellbeing of young children diagnosed with cancer.

Acknowledgments

This research is Supported in part by NIH R01 CA136782, and by the American Lebanese-Syrian Associated Charities (ALSAC)

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviation Key

PTSD

Posttraumatic stress disorder

PTSS

Posttraumatic stress symptoms

CBCL-PTSD

Child Behavior Checklist-Posttraumatic Stress Disorder

PTSD-IYC

Posttraumatic Stress Disorder Semi-Structured Interview and Observational Record for Infants and Young Children

CBQ

The Children’s Behavior Questionnaire

BSI

Brief Symptom Inventory

IES-R

Impact of Events Scale, Revised

ANOVA

Analysis of variance

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