Post-traumatic Stress Disorder in Libyan Children after War: Case Series
Tahar A. Suliman*, Mahmud A. Kaddura**, Sabah A. Gomati***
*Dept. of Forensic Medicine & Toxicology, Faculty of Medicine, Zawia-Libya.
**Dept. of Forensic Medicine & Toxicology, Faculty of Medicine, Benghazi-Libya
***Medico-legal expert at Benghazi Medico-Legal Centre (BMLC)
()
Abstract
Background: Libyan children have suffered from the war during liberation of the country. Mental health in the population, especially children, can be affected by wars. Elimination disorders; secondary nocturnal enuresis and secondary encopresis are known to happen in children after exposure to a stress situation such as domestic violence and motor vehicle accidents. In this situation War is the cause of PTSD in children. Presentations of PTSD in children can be different from those in adults.
Objective: To describe a series of children in whom secondary nocturnal enuresis and secondary involuntary encopresis occurred after exposure to war during the liberation of Libya.
Methods and Results: Sex male children, four of them were brought to our clinic for evaluation of secondary nocturnal enuresis and other two for secondary involuntary encopresis.
Review of past history revealed that all children were completely normal and their elimination problems started after the war. All of them had normal hematological, urine, and Ultrasonographic studies.
Conclusions: Libyan children need further researches for the evaluation of PTSD among them. The elimination disorders; secondary nocturnal enuresis and secondary involuntary encopresis can occur as a part of PTSD in children.
Backgound
The diagnosis of posttraumatic stress disorder (PTSD) was not introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its third publication, in 1980. The DSM-IVTR has made some modifications, which have attempted to compensate for the difference in symptom presentation in children and adolescents.1 There are no sufficient epidemiological studies of the prevalence of PTSD among children in the general population. The studies in United States have indicated that around 3-6% of high school students have PTSD as a result of domestic violence.2 There are only few studies about prevalence of PTSD following wars. Macksoud and Aber found PTSD rates of 43% in Lebanese children up to 10 years after exposure to war trauma.3 Ahmad & Mohamad found that among displaced Kurdish children in Iraq following the Gulf war, all had PTSD symptoms and 20% had PTSD.4 Servan-Schreiber , Le Lin, and Birmaher reported a 30% rate of PTSD reactions in Tibetan refugee children in India.5 Attanayake et al. systematically reviewed existing literature to identify studies on prevalence of post-traumatic stress disorder, anxiety, depression and psychosis among children exposed to armed conflict. They found that PSTD is the primary outcome ranging from 4.5 to 89.3%, with an overall pooled estimate of 47%.6
A recent study in Libya showed that PTSD prevalence in populations exposed to a high level of political terror and traumatic events was estimated at 12.4% and was 19.8% for severe depression. 7
Case Descriptions
Case 1
An 8-year-old boy presented with secondary nocturnal enuresis that had been started 4 months after the beginning of the war. He had been having nightmares and nocturnal enuretic episodes nearly every night. His parents reported that he had been fully toilet-trained by age 2 years. Complete physical and neurological examinations were normal. Renal tests and urinalysis revealed no abnormalities. Child had improved with psychotherapy.
Case 2
A 10-year-old was brought by parents as he started to have nocturnal enuresis after 3 months from the start of war. He started to have nightmares. The child was dry at the age of 2 years. Physical and neurological examinations were normal, as were renal tests, ultrasonography, urinalysis and cultures. Child has improved with psychotherapy.
Case 3
An 11-year-old boy presented with complaints of sleep disturbances, abdominal pain and episodes of enuresis every night. He had been completely dry at night since age 2 years. Physical examination was normal as well as urinalysis, cultures and abdominal ultrasonography. Child improved with psychotherapy.
Case 4
A 14-year-old boy presented with complaint of nocturnal enuresis. The symptoms had begun 4 months earlier. He had enuretic episodes every night, though he had been fully toilet trained by age 3 years. Physical and neurological examinations were normal. All investigations were normal. Child was improved after starting a course of antidepressant therapy using imipramine.
Case 5
A 6- year-old boy presented with secondary involuntary encopresis. The child had normal bowel habits before the conflict. He started to have involuntary encopresis 5 months after the start of war. Physical and neurological examinations were normal. All investigations were normal. Child is having improvement with psychological support.
Case 6
A 13-year-old boy presenred with secondary encopresis, fear episodes, sleep disturbances. The child was completely normal before the war. He sarted to control his bowel at the age 3 years. These complaints started 4 months after the beginning of the conflict. Physical and neurological examinations as well as investigations were normal. Improvement started after antidepressant therapy with imipramine.
Discussion
Libyan revolution broke out on February 17 in Benghazi and then swept all Libyan cities. Zawia city is one of the first rebellious cities since the beginning of the revolution. The town suffered to be freed on August 20 after heavy fighting. As a result of this fighting, Zawia has many martyrs and prisoners and missing persons.
As expected after war, psychological problems, especially among children began to appear for which intensive efforts are needed to deal with this problem. All children in this series are living in Zawia city. Zawia city is the third city in Libya after Tripoli and Benghazi, with a population about 300,000 citizens.
The effects of war on mental health of the population, especially children, is one of the most important war-related problems.
In this case series, a group of children have been brought to the clinic by their parents with the complaints of secondary nocturnal enuresis or secondary involuntary encopresis. This finding is an indication to conduct more survey researches on the mental health of Libyan children.
The finding confirms that PTSD symptomatology among children and adolescents differs from that in adults. Presence of regression behavior as symptoms of PTSD in children emphasizes the demands to revise criteria for the diagnosis of PTSD in children, and thus confirms the findings of other studies.9,10
Conclusion
Further studies must be conducted among Libyan children for the evaluation of possible postwar mental changes.
Secondary nocturnal enuresis and secondary involuntary encopresis may present as a component of PTSD in children after war.
Current criteria of DSM-IV TR for the diagnosis of PTSD among children focus on reexperiencing, avoidance and hyperarousal cannot fully capture PTSD symptoms that are displayed in children.
References
1) American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC
2) Cuffe SP. Addy CL. Garrison CZ (1998): Prevalence of PTSD in a community sample of older adolescents. J Am Acad Child Adolesc Psychiatry. 37:147–154
3) Macksoud, M., & Aber, J. (1996). The war experience and psychosocial development of children in Lebanon. Child Development, 67, 70–88.
4) Ahmad, A., & Mohamad, K. (1996). The socio-emotional development of orphans in orphanages and traditional foster care in Iraqi Kurdistan. Child Abuse & Neglect, 20(12), 1161-1173.
5) Servan-Schreiber, D., Le Lin, B., & Birmaher, B. (1998). Prevalence of posttraumatic stress disorder and major depressive disorder in Tibetan refugee children. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 874–879.
6) Attanayake V, McKay R, Joffers M, Singh S, Burkle F, Mills E (2009): Prevalence of mental disorders among children exposed to war: a systematic review of 7,920 children. Med Confl Surviv Jan-Mar;25(1):4-19
7) Charlson F., Steel Z., Degenhardt L.,Chey T, Silove D., MarnaneC, Whiteford H. (2012): Predicting the Impact of the 2011 Conflict in Libya on Population Mental Health: PTSD and Depression Prevalence and Mental Health Service Requirements. PLoS One; 7(7)
8) Fritz G, Rockney R. et al (2004): Practice Parameter for the Assessment and Treatment of Children and Adolescents with Enuresis. Psychiatry,43(12):1540–50
9) Perrin, S., Smith, P. & Yule, W. (2000). Practitioner Review: The Assessment of post-traumatic stress disorder in children and adolescents. Journal of Child Psychology and Psychiatry, 41(3): 277-289.
10) Armsworth, MW & Holaday, M. (1993). Effects of Psychological Trauma on Children and Adolescents. Journal of Counseling & Development, 72: 49-56.
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