The Relationship Between Spirituality and Post-Traumatic Stress Symptoms in Syrian Adolescents in Jordan

Abstract

The civil war in Syria began in 2011 and escalated over years resulting in one of the largest humanitarian crises since the Second World War. Injury, loss, poverty, and immigration trapped the Syrian population in a diversity of psychological disorders, including post-traumatic stress disorder (PTSD). Spirituality has, on the other hand, been consistently reported as a resilient factor against developing mental disorders. Hence, spirituality or religiosity have been incorporated in clinical and psychotherapeutic practice for several mental disorders. We explored the association between spirituality and the development of PTSD symptoms among Syrian refugee adolescents in Jordanian schools. A sample of 418 Syrian adolescent students (age range between 12–16 years) from Jordanian schools in the northern part of the country were enrolled in the study after informing on study context and objectives. The study questionnaire included sample demographics, smoking status, PTSD checklist – Civilian Version (PCL-C), two spirituality-targeting questions, and trauma and loss history. `Almost half of participants (N = 196) showed moderate PTSD symptoms while around 30% (N = 124) had a severe level of PTSD symptoms. On the other hand, 3 out of four students perceived themselves as highly spiritual. The study resulted in a positive correlation between belief in God and God’s thankfulness. Furthermore, increased spirituality level did not appear to lower the risk of developing PTSD symptoms. Spiritual self-perception of Syrian refugee adolescents showed neither protective nor aggravating effect of on the occurrence of post-traumatic stress symptoms. Additional research and more accurate tools are needed to assess the potential impact of spiritual/religious values towards PTSD symptoms among adolescents.

Introduction

The Syrian crisis broke out in March 2011 as pro-democratic demonstrations, which escalated into one of the most devastating civil wars in modern history. With the conflict now in its eighth year, the number of refugees has soared to 5.6 million with a further 6.6 million Syrians internally displaced in what is now the largest refugee crisis since the Second World War (Omar, 2020).

Trauma, grief, loss, fear, homelessness, poverty, hopelessness, immigration and post-immigration living status are impacting a large portion of the Syrian population with mental disorders, which is alarming the international community for the acute and long-term consequences.

War’s psychological adverse effects and traumatic stress symptoms can persist for years or even decades (Fares et al., 2017). Multiple pieces of evidence showed that adverse mental health effects can go across generations (Roberts et al., 2012).

Post-traumatic Stress Disorder (PTSD) is a psychiatric disorder in individuals who have experienced or witnessed a traumatic event such as a natural disaster, a severe accident, a terrorist act, war/combat, rape, or other forms of violent personal assaults. PTSD symptoms include persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the traumatic event, numbing of general responsiveness as well as persistent symptoms of increased arousal (Parekh, 2017).

It has been found that the lifetime prevalence of PTSD among Syrian survivors is 35.4%, with a point prevalence of 27.2% (Kazour et al., 2017). A review on children refugees in Western countries reported an overall PTSD prevalence of 10% up to 46.8% after 1 year (Fazel et al., 2005). PTSD was also reported in 11 (26%) out of 42 children aged 0–6 years, and in 18 (33%) out of 54 children aged 7–14 years in a reception camp for Syrian refugees in Germany (Soykoek et al., 2017). Prevalence values of PTSD among Syrian children are similar to those for Yazidi children relocated to Turkey with a prevalence of 10.5% and 36% in two different studies, but lower than that of Palestinian children in war zone (PTSD prevalence of 56%) (Thabet et al., 2002), as well as lower compared with children exposed to a one-time natural disaster (e.g., Hurricane Katrina, 50% developed PTSD) (Scheeringa & Zeanah, 2008).

The risk of PTSD among Syrian refugees depends on the Syrian hometown, with refugees from Aleppo having significantly more PTSD than those coming from Homs (Kazour et al., 2017). Being from Damascus is also a strong indicator of more severe PTSD symptoms in children aged 8–15 year, in addition to other determinants like female gender, history of depression and anxiety, negative experiences, displacement, and daily warzone exposure (Perkins et al., 2018).

It is essential to differentiate spirituality and religiosity. Both Spirituality and religiosity concepts are based on mutual indicators like belief in, submission to, hope in, generosity of God or high powers, beside practicing prayers, rituals, and attending religious events individually or in social gathering at mosque, and churches. In our study, we used spirituality terminology as though we meant ideology (belief and thankfulness) rather than commitment to religious practice.

On the other hand, spirituality is defined as the subjective commitment to spiritual or religious beliefs; spirituality definitions are usually based on the meaning of transcendence beyond immediate accidents and circumstances, and other dimensions like the meaning of life, purpose, and peacefulness of life, comfort and strength in one’s beliefs, and others (Chandler et al., 1992; Miller & Thoresen, 2003; Peterman et al., 2002).

Spiritual well-being is conceptualized by two dimensions: the vertical dimension, which describes the sense of well-being with God or high powers, and the horizontal dimension, which refers to the sense of life meaning and satisfaction (Ellison, 1983). Lack of spirituality can interfere with interpersonal relationships, thus leading to psychological disturbance (Verghese, 2008). Several studies indicate less anxiety and depression among spiritual individuals (Koenig et al., 2001). Spirituality may facilitate the interpretation and assimilation of traumatic events because of social interaction (Ladd & McIntosh, 2008). Spirituality may aid in traumatic stress adjustment by providing an interpretive framework of traumatic events (McIntosh, 2009), whereas religiosity may adjust to traumatic events by religious social support achieved by attending religious ceremonies.

Recently, Spirituality and religiosity are considered to have potential preventive and therapeutic value against diversity of mental illnesses, like anxiety and depression. In this study, we intended to explore the effect of spirituality on Post-Traumatic stress symptoms (PTSS). Proving the adverse association between Spirituality and PTSS would boost the scientific tendency to move toward integration of Spiritual and religious values into therapeutic approaches and clinical psychotherapy. For example, Religious Cognitive Emotional Therapy (RCET) is an effective method in cognitive, humanistic, and psychologic therapy of patients suffering from identity crisis, anxiety, and depression (Rajaei, 2010).

Specifically, we tested the hypothesis that Syrian adolescent refugees with a higher level of spirituality are associated with lower risk of developing post-traumatic stress (PTS) symptoms when compared with those with lower spirituality levels.

Method

Participants and Procedure

Our study population included adolescent Syrian refugees within the age group of 12 to 17 years attending public middle and high school, regardless of their UNHCR registration status, in Ramtha. Ramtha is a district located in Northern Jordan at the Syrian-Jordanian border and has been one of the first areas to host Syrian migrants since 2011. The study team consisted of two physicians and four volunteer medical students. The team explored primary and secondary public schools where Syrian students were registered and attended afternoon classes after the regular morning hours designated for Jordanians. Four schools were selected randomly, two schools for males and two schools for females. Schools’ managers were met and agreed to support conducting the study. The study team prepared and performed an explanatory presentation to the students to encourage them to participate in the study. Five hundred students expressed interest in participating in the study, and consent forms were sent to their families; 52 students were excluded from the study because of their parents' refusal (or legal guardian). In addition, letters were sent to students’ parents (or legal guardians) to inform on the fact that reimbursement was not allocated for participating in the study. Thirty students did not attend to study place, and the residual 418 were enrolled in the study after getting complete, fully signed informed consents.

The study procedure started after collection of all consent forms, which lasted two weeks. The study team visited schools twice weekly in the afternoon shift, and participants were summoned at the beginning of studying hours and asked previously to attend to the computer lab.

Computer labs were used as location for participating students to fill a 20 min questionnaire using iPads. Students who were not familiar with iPads were given 5 min to play with iPad before proceeding with the questionnaires. All study questionnaire blocks were translated into Arabic by an expert panel and afterward backtranslated for validation. Most of the students took around 20 min to fill the questionnaire as expected. Data were collected between February and April 2015.

Measures

Socio-demographics included gender, current age, age upon arrival to Jordan (all in years), and current family members number (living in the same house) (1–5 members, 6–10 members, 11 or more members), and smoking status (smoker, non-smoker). Moreover, the duration of refugee (in years) was also included in the study questionnaire, with a minimum value of zero if the duration was less than one year.

Students were asked two questions to detect their exposure to conflict-related trauma, included family member injury and/or death due to the war in Syria. These questions were to be answered with either yes or no: “Since the events took place in Syria, had you lost a family member to death due to the war?” and “Since the events took place in Syria, had a family member experienced a war-related injury?”. These two questions aim to detect the presence of direct exposure to loss and grief and witnessing any trauma of one or more family members.

Post-Traumatic Stress symptoms (PTSS) were assessed based on a version of the PTSD Checklist – Civilian Version (PCL-C; Weathers et al., 1991) (Table 1). The version used in the present study had a 4-point response scale, with options 1 (no), 2 (rarely), 3 (mostly), and 4 (always), compared to the 5-point scale on the original measure that ranged from 1 (not at all), 2 (a little bit), 3 (moderately), 4 (quite a bit) to 5 (extremely), as the third and fourth scales could not be applied due to translation difficulties (especially the meaning of moderately and quite a bit, which carry similar meanings in Arabic). In addition, as used questionnaires did not include the duration of symptoms, diagnosis of PTSD could not be verified by the inclusion of all diagnostic criteria of the disease.

Table 1.

Modified PTSD Checklist – Civilian Version (PCL-C; Weathers et al., 1991)

No	Response:	Not at all 1	Rarely 2	Mostly 3	Always 4
Intrusive Thoughts Symptom Cluster
1	Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
2	Repeated, disturbing dreams of a stressful experience from the past?
3	Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?
4	Feeling very upset when something reminded you of a stressful experience from the past?
5	Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?
Avoidance Symptom Cluster
6	Avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?
7	Avoid activities or situations because they remind you of a stressful experience from the past?
8	Trouble remembering important parts of a stressful experience from the past?
9	Loss of interest in things that you used to enjoy?
10	Feeling distant or cut off from other people?
11	Feeling emotionally numb or being unable to have loving feelings for those close to you?
12	Feeling as if your future will somehow be cut short?
Hyperarousal Symptom Cluster
13	Trouble falling or staying asleep?
14	Feeling irritable or having angry outbursts?
15	Having difficulty concentrating?
16	Being “super alert” or watchful on guard?
17	Feeling jumpy or easily startled?

PTSD symptoms severity was presented as PTSD score, calculated by the sum of results. In purpose to study each of PTSD diagnostic symptom blocks, Three sub-variables were created to express PTSD symptom clusters separately: Intrusive Thoughts, Avoidance Symptoms, and Hyperarousal symptoms. PTS symptoms score variable was created, and ranged from a score of 17 to 68. PTSD severity variable was created by dividing PTSD score into three grading categories using data-based categorization methodology: mild, moderate, and severe. PTSS severity variable was created by dividing PTSD score into three grading categories: mild, moderate, severe. Participants with a PTSS score of 19–33 were included in the mild PTSS group, moderate group scored 34–48, and severe group scored 49–61.

In addition to PTS symptoms variable categorization, the three PTSD blocks were studied separately in association with Spirituality.

Spirituality was assessed using two questions, measuring two previously studied dimensions of spirituality, “Belief”, and “Thankfulness”. The first question measured belief in God’s well, “do you think that all events that happened are God’s destiny and judgment.” The second question measured level of thankfulness,” do you thank God for all that happens.” Both questions had to be answered by choosing one of four scaled answers,”1- no, 2-rarely, 3- most of the time, 4-always”. The two variables were created to represent spirituality. The first variable was Spirituality score, calculated by the Sum of scores of spirituality scores (Belief and Thankfulness components). The second variable was a categorical variable recoded from the first variable to grade spirituality level among participating adolescents.

Statistical Analysis

Analysis of collected data was conducted using Statistical Package for Social Sciences (SPSS).

As first step, frequency analysis and cross-tabulations were used to present the demographics of the study population and other specific variables. Further, in order to display PTSS and Spirituality scores of the study sample, with range, mean (M) ± standard deviation (SD) were calculated. Finally, the spirituality score variable was computed by summation of belief and thankfulness variables.

The afore-mentioned study sample variables were additionally recoded into new graded variables, and results were displayed in numbers and percentages.

Finally, association between numerical variables (Belief score, Thankfulness score, PTS score, Spirituality score), and between categorical variables (PTSD Symptoms, Spirituality, Trauma History) was assessed using correlation and cross-tabulations respectively.

P-value of less than 0.05 was considered significant for all statistical tests, with confidence interval of 95%.

Results

Participants' age range was 12–17 with a sample mean age of 14.89 (SD =  ± 1.34) years. Around half (51.2%) of participants were between 14 and 15 years old. Age at arrival to Jordan ranged from 10 to16 years with a mean of 13.04 (SD =  ± 1.51) years. Duration of refugee status ranged from 0 to 4 years, with a mean of 1.83 (SD =  ± 0.82) years. Twenty students were smokers (4.8% of participants), split equally between males and females.

Out of the total 418, 284 (67.9%) were living with a family of 6–10 members, 74 (17.7%) with 1–5 members’ family, and 60 (14.4%) with more than 11 members family. Witnessing both injury and loss of family member(s) was reported by 56 students (13.4%) while 152 (36.4%) reported history of either family member injury or loss, and the remaining reported neither injury nor loss history of a family member.

Table 2 shows the mean scores of the adolescents for each PTSD symptom in the modified checklist. Repeated disturbing memories, thoughts, or images of a stressful experience from the past, and loss of interest in the usually joyful things, were the most debilitating symptoms for the participants.

Table 2.

Mean and Standard Deviation of individual PTSS based on four-point Likert scale modified version of PTSD Checklist – Civilian Version

PTSD Symptoms	Mean	SD
Intrusive Thoughts Symptom Cluster
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?	3.09	0.885
Repeated, disturbing dreams of a stressful experience from the past?	2.29	1.006
Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?	2.33	1.036
Feeling very upset when something reminded you of a stressful experience from the past?	2.95	1.019
Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?	2.12	1.125
Avoidance Symptom Cluster
Avoid thinking about or talking about a stressful experience from the past, or avoid having feelings related to it?	2.67	1.096
Avoid activities or situations because they remind you of a stressful experience from the past?	2.45	1.017
Trouble remembering important parts of a stressful experience from the past?	2.26	1.037
Loss of interest in things that you used to enjoy?	3.05	1.116
Feeling distant or cut off from other people?	2.29	1.084
Feeling emotionally numb or being unable to have loving feelings for those close to you?	2.22	1.103
Feeling as if your future will somehow be cut short?	2.33	1.217
Hyperarousal Symptom Cluster
Trouble falling or staying asleep?	2.32	1.141
Feeling irritable or having angry outbursts?	2.27	1.076
Having difficulty concentrating?	2.41	1.037
Being “super alert” or watchful on guard?	2.95	1.100
Feeling jumpy or easily startled?	2.00	0.992

Based on the two spirituality questions used in our questionnaire, the positive correlation was as follows: Students with high belief in God’s destiny and judgment are more thankful for God (P value = 0.001) (Table 3). Correlation between both variables was tested using Pearson’s correlation coefficient. None of the students answered both questions with (no) indicating that the non-spiritual group was not constructed in the study.

Table 3.

Correlative Relationship between Spirituality score, Post traumatic Stress score, Age, Age at refugee, and duration of refugee

		Belief In God	Thankfulness to God	Spirituality Score	PTSS Score	Age	Age at Arrival to Jordan	Duration of Refugee
Belief In God	Pearson	1	0.108*	0.805**	0.079	-0.003	0.008	-0.026
	Significance		0.028	0.000	0.109	0.943	0.864	0.593
Thankfulness to God	Pearson	0.108*	1	0.676**	0.018	-0.002	-0.041	0.069
	Significance	0.028		0.000	0.710	0.975	0.403	0.161
Spirituality Score	Pearson	0.805**	0.676**	1	0.069	-0.004	-0.018	0.022
	Significance	0.000	0.000		0.159	0.943	0.710	0.660
PTSS Score	Pearson	0.079	0.018	0.069	1	0.195**	0.139**	0.074
	Significance	0.109	0.710	0.159		0.000	0.005	0.129
Age	Pearson	-0.003	-0.002	-0.004	0.195**	1	0.823**	0.095
	Significance	0.943	0.975	0.943	0.000		0.000	0.052
Age at Arrival to Jordan	Pearson	0.008	-0.041	-0.018	0.139**	0.823**	1	-0.480**
	Significance	0.864	0.403	0.710	0.005	0.000		0.000
Duration of Refugee	Pearson	-0.026	0.069	0.022	0.074	0.095	-0.480**	1
	Significance	0.593	0.161	0.660	0.129	0.052	0.000

*Correlation is significant at the 0.05 level (2-tailed)

**Correlation is significant at the 0.01 level (2-tailed)

The sum of scores of both spirituality questions was used to create a new variable to measure spirituality. The spirituality variable categorized the study sample into three groups: low spirituality, moderate spirituality, and high spirituality, using dependent cutoff points (Table 3).

The first two groups included a significant lower percentage of high spirituality compared with the third group. Sixty students (14.3%) were low spiritual, 52 students (12.4%) were moderately spiritual, while the majority (N = 306;73.2%) were considered as high spiritual.

Because of the considerable difference in percentages between high spiritual category and the other two (low and moderate spiritual groups), low and moderate spiritual categories were merged into one category (low-moderate spirituality) (Table 4). The two-groups spirituality variable was used in further analysis.

Table 4.

Spirituality Level categorization and results

Spirituality Score	Spirituality Level	Number of students	Percent
1–3	Low	60	14.4
5	Moderate	52	12.4
6	High	306	73.2

Mild PTSD symptoms category included 98 students (23.4%). The majority of students, 196 (46.9%), had moderate PTSD symptoms, while 124 (29.7%) had a severe level of PTSD symptoms.

Independent sample t-test was used to detect association between spirituality grade and PTS score. The association was not statistically significant (p value = 0.16). The level of spirituality appeared to have no significant effect with grade of PTSD. Besides, Spirituality level did not appear to have significant impact on the severity of PTSS (Table 4).

Each of the two spirituality questions scores were taken separately, and their correlation with PTSD score resulted in no significant correlations: P values of 0.05 and 0.37 for PTSD correlation with belief score (first question) and thankfulness score (second question), respectively. No significant association was detected for the relationship spirituality and total PTSS score (p = 0.16) as well as for PTSD domains individually: intrusive thoughts (p = 0.06), hyperarousal symptoms (p = 0.5), and avoidance (p = 0.4). Positive correlation was found between PTSS score and age, and age at arrival to Jordan. Family injury/loss was not found to be associated with spiritual level (p = 0.91) or PTSS severity (p = 0.53) Table 5.

Table 5.

Relationship between spirituality grade and PTSD symptoms severity in study sample

			PTSS Severity
			Mild	Moderate	Severe
Spirituality Level	Low-Moderate	Number	24	62	26
		% of Low-Moderate	21.4%	55.4%	23.2%
	High	Number	74	134	98
		% of High	24.2%	43.8%	32.0%

Discussion

Scientific evidence of association between Post Traumatic Stress Disorder and Symptoms, and Spiritual ideology has become a major topic in recent modern literature. Our study among Syrian refugee adolescents showed that belief in God’s will and destiny and God thankfulness are not associated with PTS symptomatology, suggesting that belief and thankfulness do not enhance refugee youth’s resilience against developing PTS symptoms.

The study population under investigation here was unique. They were exposed to war-related trauma for a short period with different levels. Additionally, it is expected that adolescents are not yet spiritually mature or cannot understand the meaning of depending and relying on any higher power: compared with adults, adolescents might not be able to achieve the spiritual depth that can enable them to integrate spirituality with their mentality and social life. Mechanism and duration of war-related trauma and trauma severity more reliable measuring instruments could increase accuracy.

Conversely, exposure to war-related trauma and loss could predispose to spiritual injury or damage the previous spiritual context and believes of adolescents (Smith-macdonald et al., 2018). Moreover, attention should be paid to war-related trauma and loss sequelae and the subconscious impact on adolescents’ perspectives, which may disrupt their responding and participation in research.

It is also important to raise the point that the participating students could be biased in answering the spirituality questions with a tendency to imply higher spirituality. Children and adolescents might also be anxious about indicating no or weak belief and thankfulness due to cultural aspects such as unacceptance within the high religious Syrian community.

The ideology of children, including principles, general life beliefs, and personal ideas, is a critical factor when comparing our results to others (Khamis, 2012). This is especially true as the literature lacks studies that assessed the effect of spirituality/religiosity on vulnerable populations' mental health status such as refugees. As well, limited studies investigated refugee youth and the effect of spirituality/religiosity on their PTSD symptoms.

A very similar study, conducted in Gaza strip and south Lebanon with the enrollment of 600 adolescents aged 12–16 years, religiosity was neither related to PTSD nor to Ideology, but was presented as relieving factor against Depression and Anxiety disorders (Khamis, 2012). Despite using different items under religiosity context, study results were highly supportive to our results.

In one study conducted in Norway that enrolled a sample of female Eritrean refugees aged 18–60 year exposed to multiple kinds of physical and psychological traumas showed that all participants highlighted the importance of hope and religious beliefs in helping them to overcome post-traumatic symptoms and begin new life (Abraham et al., 2018). This study contradicted our findings; however, it was conducted in western culture, for a higher age group, and was within a well-established refugee resettlement program. The duration of exposure in our study was short and is not comparable to refugees living in Western cultures where resettlement programs are established.

When considering other studies, it is critical to consider noticeable differences in sample characteristics (age and gender), religion, culture, race, education level, tools used, and types of trauma. Our results were consistent with previous works in literature not conducted among refugees. For example, in the United States of America, no significant direct effect of spiritual struggling on developing PTSD symptoms was found among undergraduate university students (Wortmann & Park, 2012).

An Israeli study sampled Israeli soldiers after Gaza war to investigate the association between self-efficacy and traumatic stress severity using religiosity as a moderator. Religious soldiers appeared to carry higher post-traumatic scores than the non-religious soldier group. High self-efficacy was associated with less traumatic scores among religious groups, but not among non-religious groups (Oren & Smadar, 2016). The study results support our findings on two modules: absence of direct association between religiosity and traumatic stress symptoms and a moderator between self-efficacy and traumatic stress score (Oren & Smadar, 2016). This study encourages using spirituality/religiosity as moderators or buffering variables during studying PTS scores and other related variables. Although the study sample was a military group, which would be remarkably different from adolescent refugees, they might share similar war-related injuries and/or traumatic scenes.

Spirituality indicated lower Post Traumatic Stress Disorder (PTSD) among low-moderate military groups but not in high military group in a similar study. Furthermore, lowest suicidality was found among medium spirituality groups compared with both low and high spiritual groups (Hourani et al., 2012).

In another Israeli study enrolling targeted forcedly relocated civilians, no correlation was found between PTSD and religiosity or religious support. However, among very religious people, high religious support predicted lower PTSD, while among the moderately religious, high religious support predicted higher PTSD (Oren & Possick, 2009). Berg in 2011 studied the relationship between spiritual distress, PTSD, and depression in Vietnam veterans (Berg, 2011) using spiritual injury as variable (Spiritual injury variable being the inverse value of spirituality). Spiritual injury consisted of the following sub-variables: scale measures guilt, anger or resentment, sadness/grief, lack of meaning, feeling God/life has treated one unfairly, religious doubt, and fear of death. An inverse relationship was observed between spiritual injury and PTSD (Berg, 2011).

A combination of spirituality (commitment to belief in God) and religiosity (ritual practice) could add more to the study as the two concepts can have a synergistic effect on mental health. Religiosity predicts less mental illness and lesser cognitive intrusion. On the other hand, Spirituality alone predicted higher levels of cognitive intrusion and more decline in cognitive intrusion severity over time (McIntosh et al., 2011).

Higher PTSD scores associated with older age and older age at arrival to Jordan can be explained by increased years of trauma exposure in Syria (pre-immigration) and Jordan (post-immigration). The level of exposure to family injury and/or loss was not graded in the study questionnaire. Therefore, spirituality and PTS symptoms were studied in relation to occurrence but not to the level of family injury and/or loss exposure. It is critical to differentiate grading not only by family injury and/or loss, but also by trauma exposure, spirituality/religiosity, and PTS severity (Hourani et al., 2012).

Additional research on spirituality/religiosity using adapted and validated spirituality/ religiosity measuring tools is recommended especially when studying children refugees (with specific attention on their spiritual conceptualization and perception). Additionally, we recommend the presence of a control group for comparative purposes to aim at a more concrete measure of the effect of spirituality on the psychological resilience.

Finally, resilience of war injured communities, especially children and adolescents, should be studied in a comprehensive way. It is important to provide multiple medical, social, psychological, and spiritual support through well studied approaches as early as possible to detect, mitigate and prevent further deterioration of mental health condition. For example, mental health promotion to enhance access to psychologists and psychiatric care, constructing perceived family and social support, and fostering positive spiritual values and religious practices, would provide more impactful effect in tackling traumatic stresses and mental consequences of wars.

Conclusion

Our study results do not support any significant effect (neither protective nor aggravating) of spiritual self-perception of Syrian refugee adolescents on the occurrence of post-traumatic stress symptoms. History of injury of a family member was found to have no impact on spiritual self-perception. Similarly, it did not worsen PTS symptoms of adolescents in comparison with those with no history of injury of a family member.

Limitations

Due to a sample of non-participating eligible adolescents (legal guardians refused participation), this study is subjected to selection bias. Moreover, the study approach allowed for enrolling of students only with non-inclusion of non-student children and adolescents. Response bias is a main limitation in our study as the interviewees would tend to answer both spirituality questions positively in line with culturally accepted believes.

Another limitation is the narrow scope of spirituality that was measured in the study. In this regard, we recommend increasing the number and accuracy of

indicators measuring the spirituality and religious participation (e.g., belief in destiny and afterlife, surrender to God, attending prayers and ceremonies, religious charity participation, religious social gatherings).

Additional limitations include the fact that the impact of other traumas on a child's resiliency was not explored as well as the fact that correlational studies tend to be much weaker than using ANOVA or Multiple regression analysis as the later is better able to identify and partial out/in confounding variables.

Finally, we have to highlight the use of the PTSD Checklist – Civilian Version instead of other tools like the Trauma Symptom Checklist and the arbitrary dichotomization of our dependent variables not supported by previous research.

Declarations

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.