Understanding Social Influences on Child PTSD Among Afghan Refugee Families Affected by Trauma

在低收入和中等收入国家（LMICs）受战争影响地区长大的儿童由于地区冲突、住房不安全、贫困和社区暴力更容易受到创伤暴露（Hofman et al., 2005）。在这样的高逆境环境中，可获得的基层心理服务极其有限，儿童社会环境的成员，主要是父母和同伴，可能是他们在创伤事件后的主要支持来源（Saxena et al., 2007）。大量研究发现，大多数暴露于急性创伤事件的儿童将父母视为其情感支持的主要来源（Dixon等人，2016），并且关于创伤经历和相关情绪的亲子对话很常见（Alisic等人，2017）。父母创伤后应激障碍在受战争影响的家庭中也很普遍，并且越来越多的人认识到父母创伤后应激障碍可能会影响儿童的应对策略和恢复，因为父母的养育方式会影响儿童的应对策略和恢复（Williamson等人，2017）。此外，同伴支持和高质量的友谊对于保护受战争影响的儿童的心理健康也很重要（Peltonen et al., 2010）。文献表明，消极的同伴关系可能介导战争相关创伤和创伤后应激之间的关联（Diab et al., 2018）。相比之下，同伴支持可以促进儿童的心理健康，帮助他们克服与创伤经历相关的负面结果。总之，虽然社会支持已被确定为对低风险高收入社区儿童创伤后应激障碍的关键影响因素，但在低收入和中等收入国家受冲突影响的脆弱家庭中，人们对这一点知之甚少，这些家庭的儿童可能面临多重创伤。由于阿富汗长达41年的战争，阿富汗难民遭受了集体和代际创伤，甚至在重新安置几年后也是如此（Roozbeh et al., 2018）。本研究包括对伊朗阿富汗难民儿童创伤后应激障碍和创伤后恢复轨迹相关的照顾者和同伴因素的调查。目的与方法探讨难民儿童及其照顾者对创伤和感知社会支持的看法。研究创伤相关方面的照顾者和同伴支持作为创伤后儿童创伤后应激障碍症状的预测因素，以及症状随时间的变化。通过父母的反应，探索从照顾者创伤和创伤后应激障碍到儿童症状的途径。第一阶段：目标1将通过对生活在伊朗两个省的6至17岁暴露于创伤的儿童及其主要照顾者进行定性访谈来探讨。访谈将探讨难民照顾者对他们孩子的创伤后应激障碍的看法，父母的支持，孩子对同伴支持的看法，应对策略，以及创伤后支持的理想方式。第二阶段：目标2和3将通过对伊朗两个省的阿富汗儿童及其照顾者进行前瞻性纵向研究来实现，阿富汗难民家庭在这两个省面临更多困难。我们的目标是通过哈米非政府组织在呼罗珊的办事处招募儿童和他们的主要照顾者，呼罗珊是新抵达的寻求庇护者的主要过境点之一。潜在的应用重新安置在高收入国家和低收入中国家的难民的生活质量之间存在巨大差距。虽然全球85%的难民都居住在中低收入国家（UNHCR, 2020），但我们对儿童创伤后应激障碍的社会影响的大部分知识来自高收入国家社区。本研究将对我们对中低收入国家创伤暴露难民家庭创伤后应激障碍的理论认识作出重大贡献。至关重要的是，将重点放在难以接触和研究不足的极高风险群体上，将产生与公共政策和新干预方法的制定高度相关的新数据。

Context of the ResearchChildren growing up in war-affected regions in low- and middle-income countries (LMICs) are more susceptible to trauma exposure due to regional conflict, housing insecurity, poverty, and community violence (Hofman et al., 2005). In such high-adversity contexts, ground-level accessible psychological services are extremely limited and members of children's social environment, predominantly parents and peers, are likely to be their key source of support following traumatic events (Saxena et al., 2007).A large body of research has found that a majority of children exposed to acute traumatic events identify parents as their principal source of emotional support (Dixon et al., 2016), and that parent-child conversations about traumatic experiences and associated emotions are common (Alisic et al., 2017). Parental PTSD is also prevalent among war-affected families, and there is increasing recognition that parental PTSD may influence children's coping strategies and recovery due to impacts on parenting styles (Williamson et al., 2017). Moreover, peer support and good-quality friendships are also important to protect children's mental health in war-affected contexts (Peltonen et al., 2010). The literature suggests negative peer relations may mediate associations between war-related trauma and posttraumatic stress (Diab et al., 2018). In contrast, peer support can promote children's mental health and help them overcome negative outcomes associated with traumatic experiences.In sum, whereas social support has been established as a key influence on child PTSD in low risk, HICs communities, much less is known about this among vulnerable families in LMIC, conflict-affected contexts where children are likely to be exposed to multiple traumas. As a result of 41 years of war in Afghanistan, Afghan refugees have suffered collective and intergenerational trauma, even several years after resettlement (Roozbeh et al., 2018). This research comprises an investigation of caregiver and peer factors in relation child PTSD and trajectories of posttrauma recovery among Afghan refugees in Iran.Objectives and Methods1. To explore perspectives of refugee children and their caregivers on trauma and perceived social support.2. To examine trauma related aspects of caregiver and peer support as predictors of initial child PTSD symptoms posttrauama, and symptom change over time.3. To explore pathways from caregiver trauma and PTSD to child symptoms, through parental responding.Phase one:Objective 1 will be explored via qualitative interviews with trauma-exposed children, aged 6 to 17, and their primary caregivers living in two provinces of Iran. The interviews will explore refugee caregivers' perceptions of their child's PTSD, parental support, child's perspective on peer support, coping strategies, and ideal ways of support following trauma.Phase two:Objectives 2 and 3 will be met through a prospective longitudinal study of Afghan children and their caregivers in two provinces of Iran, where Afghan refugee families face additional difficulties. We aim to recruit children and their primary caregivers via HAMI NGO offices in Khorasan, one of the main board crossing points for newly arrived asylum seekers.Potential ApplicationsThere is a huge gap between the quality of life for refugees resettled in HICs and those in the LMICs. While 85% of refugees worldwide are hosted in LMICs (UNHCR, 2020), most of our knowledge of social influences on child PTSD comes from HIC communities. This study will make a substantial contribution to our theoretical understanding of PTSD among trauma-exposed refugee families in LMICs. Crucially, the focus on hard-to-reach and understudied groups at extremely high risk will generate new data highly relevant to the development of public policy and novel intervention approaches.