IMMIGRANT CHILDREN IN TURKEY'
O s m a n S a b u n c u o g lu , M . D . / M e r a l B e r k e m , M . D .
D e p a r t m e n t o f C h ild P s y c h ia try , S c h o o l o f M e d ic in e , M a r m a ra U n iv e rs ity , Is ta n b u l, T u rk e y .
A B S T R A C T
O b je c tiv e : T h e main purpose of this study is to a s s e s s the emotional state of Bosnian refugee and immigrant children in Istanbul/Turkey and to com pare the findings.
M e th o d s: T h e sub jects w ere given the Croatian version of the Child D epression Inventory (CD I) and Z ivcic's Mood S c a le , which consisted of 4 su b sc a le s: joy, fear, sa d n e ss and anger. Their parents also completed a Mood S c a le . A data questionnaire w a s used for the refugee sam ple to obtain information about the w ar experience. R e s u lt s : Mean CD I and Mood S c a le sco res were not elevated for both groups and no statistically significant difference w a s found. Refugee sam ple reports displayed higher correlations than the immigrant sam ple.
C o n c lu s io n : T h e results can be interpreted as the re fu g e e s h ave sp en t enough time to norm alize their w ar related emotions. Intergroup factors are important in the refugee sam ple.
K e y W o r d s : Children, R efugee, W ar, Traum a
IN T R O D U C T IO N
Shortly after the Dayton P e a ce Agreem ent, it w as estim ated that a total num ber of 6 8 6 ,5 3 3 B o sn ian s b ecam e refugees outside of former (*)
Yugoslavia in Europe. The number of Bosnian refugees in other countries of former Yugoslavia w as estimated a s 645,300 (1). Inside Bosnia- Herzegovina, the estimated number of displaced and w ar affected people w as 2,700,951 (2).
T h e s e num bers, being produced by the
genocidal act called "ethnic cleansing", denote the degree of violence directed against civilians.
Among the com plex ethnicity of p rew ar
Yugoslavia, Bosnian M uslims were the people who suffered most during the w ar. Th is issue should be kept in mind w hile considering psychiatric sequelae of w ar in survivors.
O 'Brien, in his wartime article, drew attention to the psychiatric co nseq uences of w ar in Bosnia. Refugee children, both internal and external, were referred a s a particularly at-risk group (3). The earliest study found high rates of depressive sym ptoms among local and refugee children exposed to war stre ss in Croatia (4). Sim ilarly, Kuterovac noted high sco re s of Impact of Event S cale for displaced children in Croatia(5). W eine a sse sse d Bosnian adolescents resettled in the U S and focused mostly on posttraumatic stress disorder (P T S D ), d e p re ssiv e d isord ers and trauma testim onies(6).
Prelim inary concerns for the effects of w ar on children arose mostly during World W ar 2 and were directed to those who w ere exposed to air bombings and evacuated from their homes to the countryside (7). In the following period, reports from conflict a re a s , su ch a s Middle E a s t,
(*) P re s e n te d a t th e 3 rd T u rk is h -G e rm a n P s y c h ia try C o n g re s s , B e rlin , G e rm a n y , 1998.
(A c c e p te d 12 F ebru ary, 20 02 ) M arm ara M e d ic a l J o u rn a l 2 0 0 2 ;1 5 (2 ):1 0 3 -10 7
Correspondance to: Osman Sabuncuoglu M.D, - Department of Child Psychiatry, School o f Medicine. Marmara University Hospital, Altunizade, Istanbul, Turkey
C am b od ia, Vietnam and North Ireland, accum ulated. Th e concept of traum a developed and w as applied to younger populations. The psychological co nseq u en ces of d isasters also becam e an important area of research within this context (8-10).
Immigrants are people who settled in Tu rkey not a s a c o n se q u e n ce of an arm ed conflict. Expecting better life conditions, people from all Balkan countries cam e to Tu rkey during the last century. H ow ever, a s arm ed co nflicts are frequent, it m ay so m e tim e s be difficult to distinguish w hich fa cto rs really operate in migrating.
The estimated number of all Bosnian refugees who cam e to Tu rkey during the w ar is nearly 25,000.
Th e purpose of this study is to a s s e s s the em otional state of two groups of B o sn ian
refug ees and im m igrant children and
adolescents In Turkey. It w a s hypothesised that the w ar exp erien ce, persecution b e cau se of
ethnic identity and ethnic cleansing will all
contribute negatively to the mental health of refugees com pared to immigrants. T h is is the first and only study in Turkey, addressing this issue.
M E T H O D
The refugee sam ple consisted of 10 fem ale and 9 male children and ad olescents aged 7 to 18 ye a rs (m ean: 13.73), staying in a refugee cam p in Istanbul; 16 of them with their fam ilies. Th e total population of the cam p w a s 205 and the number of children in this age group w as 20. The camp w as located in a governm ent building and one room w a s offered for each fam ily. Official permission and informed parental consent w as obtained, except for 3 unaccom panied subjects for whom cam p officers gave consent. One parent refused to participate.
The immigrant sam ple consisted of 11 fem ale and 13 male children and adolescents aged 11 to 17 ye a rs (m ean: 13.83). B o sn ian s who had migrated to T u rk e y before the w ar w ere contacted through the local health center. Th ey were living in the district of Istanbul where people
from the B a lkan s had settled in large num bers. T h e y had been in Tu rkey for 8 to 14 ye a rs. All of them had relatives in B o sn ia. Th e y w ere all asked for informed consent.
A questionnaire in Bosnian w a s prepared by the research team including dem ographic and war- related information. T h e questionnaire w a s not given to the immigrants a s it included m any items about the w ar experience.
M e a s u r e s a n d P r o c e d u r e
Th e refugee subjects w ere individually a sse s se d in a separate room at the cam p provided by the officers. Th eir parents w ere requested to wait outside the room, with the door open. Th e subjects w ere instructed about the procedure in B osnian. A sim ilar procedure w a s applied to the immigrants after they had been invited for the study at the local health care centers.
The subjects w ere given the Croatian version of the Child Depression Inventory (C D I) and Z ivc ic’s Mood S c a le which had been developed and used for the first time in Z ivcic's original study to a s s e s s the im pact of w ar on children (4 ). Perm ission for the use Mood S c a le s and the Croatian version of CD I w a s obtained from Zivcic who at the sam e time provided the sc a le s. Th e CD I co nsists of 27 depression-related items which are scored on a 0-, 1-, or 2-point sc ale . Th e total score of CD I m ay range from 0 to 54 which represents the intensity of the d ep ressive sym ptom s for the last two w e e k s. Th e Turkish version of CD I w a s utilized w hen needed by the immigrant subjects. T h e Mood S c a le co n sists of four su b sc a le s with four items for each basic emotion; joy, anger, fear, sa d n e ss. E a ch item d escrib es a different mood state and the subjects are asked to report how they exp erience it for the last two w eeks on a 3-point sc a le (0=almost never, 1=som etim es, 2=very often). Accordingly, the total score of each su b scale m ay range from 0 to 8.
Th e parents w ere also requested to com plete a Mood S c a le with regard to their observations about their children over the past two w e e k s. All the m easu res w ere translated from Croatian into Turkish for evaluation purposes.
T h e im m igrant sa m p le w a s a ssiste d for com prehension problem s in the sc a le s.
S P S S com puterized statistical package (S P S S 6.1) w a s used to a n a lyse the findings.
RESULTS
Th e questionnaire revealed that, the refugee children w ere all m em bers of middle or low socioeconom ic status fam ilies. All but four had been living in cities in B o sn ia. T h e y had been in Turkey for 2 .5 to 3.5 y e a rs at the time of the stud y. 3 su b je c ts w e re u n acco m p an ied , 2 su b je cts w ere a cco m p a n ie d with only their mothers and the rest of the sam p le s w ere with both of their parents. O ne of the subjects' parents w ere of different ethnic backgrounds. 4 of the parents w ere in the Bosnian Arm y where 3 others had been discharged before. O ne of the subjects' father had been killed during the war.
All the refugee subjects had experienced bodily injury either within their fam ilies or extended fam ilies. O ne of the subjects had been wounded physically during the w ar. Th e questionnaire also
revealed that all of the subjects had no known physical or mental health problem before the war. Th e CD I revealed a mean depressive level of
11.57 (S D : 5.96) for the refugee sam ple. The mean level on the CDI for the immigrant sam ple w as 9.13 (S D : 5.41). Two groups were not different statistically.
The results of the Mood S cale are presented as Table I, Table II, Figure 1 and Figure 2.
Th e mean levels of basic emotions do not differ statistically in the Mood S c a le . The frequency of intergroup correlations are higher in the refugee sam ple than the immigrant sam ple.
D IS C U S S IO N
The small sam ple size is a limitation of the study, making statistical com parisons with previous studies difficult. Flowever, W eine et al. conducted a study even with a sm aller sam ple (6). Data from different co untries can contribute to generalise knowledge about the psychology of refugee status, even if they are sm all.
T a b l e I: P e a rs o n c o rre la tio n s w ith in th e s u b s c a le s o f M oo d S c a le s in re fu g e e c h ild re n (S e lf-re p o rt a n d P a re n t-re p o rt) Child joy Child anger Child fear Child sadness Parent joy 'Parent
anger Parenttear sadnessParent Child-Joy 1.0000 Child-anger -.2026 1.0000 Child- fear -.0293 .5840 • 1.0000 Child-sadness -.3827 .4967 .7030 ’ 1.0000 Parent-joy .4121 -.2855 -.0235 -.2391 1.0000 Parent-anger -.1750 .3081 .2575 .3807 -.3591 1.0000 Parent- tear -.2648 .2599 .3958 .5525 • -.2913 .6669 • 1.0000 Parent-sadness -.4481 .3051 .4568 .5986 * -.4761 .6237 • .5880 * 1.0000 "P < 0.05
T a b l e II: P e a rs o n c o rre la tio n s w ith in th e s u b s c a le s of M o o d S c a le s in im m ig ra n t c h ild re n (S e lf-re p o rt a n d P a re n t-re p o rt) Child
joy
Child
anger Childfear
Child sadness Parent joy Parent anger Parent (ear Parent sadness Child-joy 1.0000 Child-anger -.5074 * 1.0000 Child- tear -.2322 .6115 ‘ 1.0000 Child-sadness -.5055 • .6234 ‘ .4494 1.0000 Parent-joy .2741 -.1600 -.0530 -.0126 1.0000 Parent-anger .2461 .1087 .1567 -.2488 -.2621 1.0000 Parent- fear -.0525 .3239 .2634 .4197 .1418 -.0196 1.0000 Parent-sadness -.2201 .0138 .0033 .0959 -.0965 .1629 -.1791 1.0000 ‘ P < 0.05
The refugee sam ple disp lays frequent Intragroup correlations, a finding which may be explained by group p ro c e ss, living together and sharing feeling s. Ongoing refugee statu s m ay have resulted in being much more sensitive to others’ fee lin g s. P aren t-repo rts had no intragroup correlations in the immigrant sam ple. S a d n e ss in the Mood S c a le , is significantly correlated ( P < 0.05 ) in self-report and parent-report, indicating that parents can perceive it better in the refugee sam ple.
A s pointed out above, the results on the CD I
indicate no sig n ifican t d e p re ssiv e effect.
However, they should be interpreted with caution a s clinical interviews do not exist in our study design.
At the time of the study, the refugees had been living in Tu rkey for 3 ye a rs, which may have helped to overcom e w ar related feelings. It may explain why refugees and immigrants do not differ in co m parison. In a B o sn ian refugee sam ple, boys w ere found to be more capable of recovery than girls, which indicate a gender effect (11) but w e have not noted such a difference. W hen the sym ptom s of P T S D are considered, notable d e cre a se s w ere observed 1- year after resettlem ent (12) and also it w as
pointed out that they may be transient, not part of an enduring p sych o p ath o lo g y (1 3 ). T h e s e findings are consistent with our study.
Terr defined all childhood traum as a s originating from outside and d e scrib e d four resultant c h a ra c te ristic s a s visu a lize d or oth erw ise
rep eated ly p e rce ive d m e m o rie s, repetitive
behavior, traum a-specific fe a rs and changed attitudes (14). S h e also divided childhood trauma into two b a sic ty p e s; T y p e 1 trau m a from unanticipated single events with full, detailed m em ories, om ens, m isperceptions and Typ e 2 traum a from long-standing external events with denial and numbing, self-hypnosis, dissociation and rage. C ro sso ve r conditions w ere also noted. However, in evaluating p ostdisaster resp o n ses, it w a s sug g ested that a broader definition of posttraumatic states should be considered such a s anxiety and d epression, rather than only sym ptom s that are part of P T S D diagnosis (10). A s the Vietnam W ar and the B o sn ia conflict have sim ilar ch aracteristics, it m ay be worthwhile to review the studies on the mental health problems of V ietnam ese refugee children and adolescents. Tsoi found that the V ie tnam ese children who had been exposed to unpleasant w ar exp erien ces w ere more likely to display fear of being hurt than those children who had not been exp ose d , although all the children appeared relatively unaffected (1 5 ). Considering previous reports of
In cre ase d p sy ch ia tric morbidity of the
V ietnam ese children abroad, Tso i pointed out the significance of "country of first asylum ". Felsm an reported high levels of depression and anxiety from V ietnam ese refugee youth and noted the im portance of the p h a s e s of resettlem ent, m ethodological problem s and cro ss-cu ltu ra l influences (16).
Turkey is a sp ecial country for the Bosnian refugees, not only b ecau se of historical ties but also b ecau se of the p resence of their relatives who had com e to Turkey long ago. T h e y w ere all welcom ed warm ly and placed mostly in their relatives’ surroundings. Our refugee su b jects, on the other hand, had very limited reso u rces of this kind. Despite the fact that difficult psychosocial situation In exile has been considered a s an independant risk factor (17), it is apparent that, it did not contribute to significant psychopathology in the refugee sam ple.
Our findings reflect the chronic course of their traum atic exp erien ces, even though the impact of traumatization via m edia is neglected. Studies about how traum atization occurs indicated that this m ay originate from direct e xp e rie n ce , o b servatio n , and verb al m ediation (1 8 ,1 9 ). H ow ever, indifference to m edia new s about Bo snia w a s well observed among our refugee subjects.
An exam ple of em pirical research is presented here, a s considered in O 'Brien's article, which
helps a s s e s s , also ra is e s and m aintains
a w are n e ss of the specific problem s of refugee children (3). Although the w ar in Bo snia received co n sid e ra b le attention in T u rk e y , re se a rc h studies rem ained limited, probably due to the cross-cultural nature of the problem. Therefore, further studies are needed to reach a conclusion about the resultant psychological effects.
A C K N O W L E D G E M E N T S
The authors would like to thank Ivanka Zivcic and A zra Bihorac for their contributions.
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