Researching Public Law and Public Policy in the Public Interest

Preliminary Research on Evidence of Psychological Trauma in the International Realm

Legal Memorandum on Trauma, Schools and Poverty

Preliminary Research on Evidence of Psychological Trauma in the International Realm


By Kaitlyn Maltese, CLiME Research Associate, Rutgers Law School

February 2017

This paper is available for download below.


This paper is the fourth in a series of legal memos presented as part of the Center on Law in Metropolitan Equity's (CLiME) participation in the Trauma, Schools, and Poverty project.  To view the previous installments visit the website at


Question Presented

What is the evidence of childhood psychological trauma in the international realm?


The most common consequence of trauma, such as war and natural disasters, on children is the development of post-traumatic stress disorder (“PTSD”).[1] There are two types of trauma that a child experiences that can result in PTSD.

Type I of trauma “refers to a one time, horrific, and clear cut life-endangering experience.”[2] When “chronic stress and adversities . . . are a part of [a child’s] daily life,” it is considered Type II trauma.[3] Based on the following research, it appears Type I can develop into Type II.

To predict if a child, who has experienced one or more of the traumatic events listed above, will develop PTSD, the AACAP Pactive Parameters for the Assessment and Treatment of Children and Adolescents with PTSD looks at three factors:

  1. The severity of the traumatic event;
  2. The parental reaction to the traumatic event; and
  3. The physical proximity to the traumatic event.[4]       
  1. War

Ongoing war results in unsolved military conflict, material losses, and economic disasters, which can heavily burden a child’s mental health and development.[5] Children suffer from indirect consequences as well, including “malnutrition, ill health, and lack of education.”[6]

The cause of this is the unexpectedness of war and conflict; it leaves citizens unprepared, both materially and mentally, evoking feelings of hopelessness.[7] For children, it shatters the “fundamental, ‘childish’ beliefs that the world is a safe and fair place . . . and that one is worthy of protection.”[8] This inability to prepare and be protected creates a sense of loss of control, which, once again, “impacts the basic human illusion of invulnerability and security.”[9] In other words, a child may only observe or be involved in an one time life endangering experience (Type I trauma) but because that child is still living in a conflict area, he or she is living in constant fear that he or she may not survive (Type II Trauma).  

As a result, children began to show symptoms associated with PTSD, specifically they internalize their trauma. For instance, children who experience conflict tend to attempt to avoid “painful and shameful memories, to numb their trauma-related feeling and to deny the importance of trauma.[10] Consequently, these children end up living in a continuous state of hyper-arousal.[11] Similar to children who are classified as E.D. in the United States,[12] conflict children have a difficult time concentrating, appear irritable,[13] and experience nightmares and anxiety dreams.[14] Additionally, an externalizing characteristic that PTSD children may experience is posttraumatic play.[15] Posttraumatic play refers to acting in ways that rely on repetition, thematic narrowness, and ritualistic scheme.[16] It appears that these children are attempting to control their lives so that the likelihood that they experience something unexpected again is doubtful.

As of 2004, statistics showed that 25% of children living in Palestine during war conflict were suffering from PTSD.[17] This statistic fits a pattern that demonstrates a connection with exposure to war and conflict and development of PTSD in children.[18] In fact, other studies depict how “the psychological consequences of war on children currently living in conflict regions have shown increased rates of mental disorders in traumatized children, particularly PTSD.[19] For instance, children in Sarajevo during the Bosnian war had a PTSD prevalence rate of 41%[20] and 44% of Rwandan orphans, “10 years after the genocide,” were still suffering from PTSD.[21]

Case Study: Afghanistan

       While there are studies evaluating the mental health of adults exposed to violent conflict in Afghanistan, as of 2009, “there have been no studies . . . which have systematically addressed the mental health of school-aged children living in Afghanistan.”[22] Nevertheless, surveys on Afghan refugees living in the United States reported a high rate of PTSD and depression.[23] This result can indicate that children still living in Afghanistan might also be affected by “trauma-related mental health problems.”[24]

Additionally, it was found that there is a “strong gender difference[] with respect to the frequency of adverse childhood experiences as well as regarding the relationship between different type of stressors and their associations with PTSD symptoms.”[25] PTSD was found to be significantly more frequent in boys than in girls, with 26.1% and 14.1% respectively.[26] Male children reported observing or experiencing a “higher level of family violence, war experiences, . . . [and] general traumatic events” than female children.[27]

These results can likely be explained (to some extent) by the cultural characteristics of families living in Afghanistan, specifically, Muslim families.[28] Girls are mostly kept inside their family home.[29] The attendance rates for schools in Afghanistan, for example, illustrates this custom as boys attend primary school at a rate of 66% and secondary school at 18%, while girl’s rates are 40% and 6%, respectively.[30] The result is an “adult literacy rate of 43% for men and only 13% for women.”[31]

The cultural custom of keeping girls inside reduces their risk of exposure to “war or community violence in the streets.”[32] A study on Palestinian children provides support of this assumption as “boys were found to be exposed to a greater number of traumatic events.”[33] Consequently, boys, compared to girls, in Palestine had a higher PTSD prevalence.[34]

  1. Natural Disasters

Case Study: Hurricanes Katrina and Rita

The majority of the people who evacuated the areas affected by Hurricanes Katrina and Rita have reported being “traumatized by the sudden evacuation, fracturing of families, loss of lives and property, and dissolution of their home communities.”[35] Similarly to those exposed to war and violent conflicts, those who lived through these two hurricanes, experienced Type I Trauma, which eventually led to circumstances that reflect Type II Trauma.

Some individuals who had to be relocated because of the Hurricane had pre-existing mental health problems, thus, most were unprepared for the rapid resettlement.[36] For other individuals, the Hurricanes left communities vulnerable to psychological disorders.[37] The Children’s Health Fund and the National Center for Disaster Preparedness, in April 2006 and January 2007, conducted “health assessments of families displaced due to Hurricane Katrina.” The results showed that children and families were experiencing the following:

  • chronic diseases were going untreated;
  • clinical-level anxiety, depression, and PTSD were on the rise; and
  • fragile safety nets that had protected these vulnerable populations in the past had been badly shredded by the hurricanes.[38]


Furthermore, “[r]esearchers have found that age, (being older), having another anxiety disorder, and multiple traumatic experiences increased the likelihood that a child would develop PTSD.”[39] Observing and experiencing the devastation of the Hurricane is not the only traumatic experience that would increase the probability that a child will suffer from PTSD. Families, after the Hurricane passed, would visit, on several occasions, the area where their homes and surrounding communities once was. It is plausible that this repetitive viewing increased the students’ trauma as it created and reminded them of horrific memories of the Hurricane.[40]

Moreover, it has been reported that many parents, who experience traumatic stress and depression as a result of their experiences, are isolating themselves.[41] Consequently, they are isolating their children and stopping them from attending schools.[42] Researchers have interviewed teachers in Houston, where the majority of evacuees moved to, who “indicated that even basic rules such as showing up school on time” were difficult for these children and parents.[43] The majority of students missed a portion of the school year while some had not regularly attended school.[44]

The results of the Hurricane and the subsequent displacement, 60% of evacuees experienced “nervousness, restlessness, worthlessness, hopelessness, and spells of terror.”[45] While 15% of the children displaced had serious emotional disturbance, only two-thirds of those disturbances were a direct result of their hurricane experience.[46] Unlike children affect by war conflicts, there is no gender difference as 52% of trauma children are male and 48% are female.[47] However, the ways in which children these children tended to behave differed depending on their age.

Internalizing behavior was prevalent in younger children.[48] They tended to experience “fear, behavior regression, or apathy.”[49] Yet, middle school and high school aged children externalized their trauma.[50] In contrast to younger children, older children were aggressive and angry, “which led to many unpleasant student-to-student and student-to-teacher interactions.”[51]

Therefore, following a major disaster, it is vital to recovery that the community has the ability to address these issues.[52] A protective factor that can negate the mental health and PTSD outcomes of experiences with natural disasters is school-based mental health services.[53] Houston school districts are an example of this.

After the Hurricane, Houston relaxed their enrollment policies and added provisions for mental health relief services related to trauma. For example, “mental health counselors competent in disaster response . . . were needed to provide expedient services.”[54] DelPelchin Children’s Center had their mental health staff members work in some of Houston’s school districts.[55] They also “provided trauma awareness training for 192 school personnel and 70 community mental health professionals.”[56]

       Case Study: Haiti

       In comparison to those who experienced Hurricane Katrina, the individuals who experienced the earthquake in Haiti experience “high levels of psychological distress.”[57]  However, in contrast to the children victims of Hurricane Katrina, it is reported that being female and young are two potential risk factors in developing PTSD.[58]

In a study conducted two and a half years after the earthquake, PTSD was prevalent in 36.93% of children, with 41.58% being girls and 30.18% being boys.[59] Additionally, 46.21% of children experience depression, distributed between girls and boys at 52.14% and 38.58%, respectively.[60] In comparison, similar studies conducted 18 months after the Sichuan, China earthquakes found a rate of 12.2% for PTSD and 40.8% for depression.[61] In Greece, a PTSD rate of 8.8% and a depression rate of 13.7% was found 32 months after their earthquake.[62]

The high rates of PTSD and depression in Haiti compared to those in other areas that have experienced earthquakes is explainable “by the fact that [Haitian] children continue to live their day-to-day lives amid the chaos which the earthquake had left.”[63] Contrary to children living in Houston after evacuating the areas affected by Hurricane Katrina, it is estimated that 400,000 people, at the time the study was completed (30 months after the earthquake in 2010),[64] “were sill living in camps, children were going hungry, and poverty levels . . . had reached an all time high.”[65]




[1] Kristina Sesar, Natasa Simic, and Marijana Barisic, Multi-type Childhood Abuse, Strategies of Coping, and Psychological Adapataions in Young Adults, 51 CROATIAN MED. J 406, 407 (2010).

[2] Samir Qouta, Raija-Leena Punamaki, and Eyad El Sarraj, Child development and family mental health in war and military violence: The Palestinian experience,  32 INT’L J. OF BEHAV. DEV. 310, 311 (2008).

[3] Id.

[4] Stacey Clettenberg, Judy Gentry, Matthew Held, and Lou Ann Mock, Traumatic loss and natural disaster: A case study of a school-based response to Hurricanes Katrina and Rita, 32 SCHOOL PSYCHOLOGY INT’L 553, 560 (2011).

[5] Qouta, supra note 2, at 310

[6] Claudia Catani, Elisabeth Schauer, Thomas Elbert, Inge Missmahl, Jean-Paul Bette, and Frank Neuner, War Trauma, Child Labor, and Family Violence: Life Adversitites and PTSD in a Sample of School Cildren in Kabul, 22 J. OF TRAUMATIC STRESS 163, 163 (2009). See also id. at 164 (citing Rodriquez N. Pynoos, Steinberg, A., Stuber, and Frederick, C. UCLA PTSD Index for DSM-IV (1998) (unpublished manuscript) (on file with University of California at Los Angeles)).

[7]  Qouta, supra note 2,  at 311.

[8] Id.

[9] Id.

[10] Id. 314

[11] Id.

[13] Qouta, supra note 2,  at 314.

[14] Id. at 316.

[15] Id.

[16] Id.

[17] Catani, supra note 6, at 164 (citing Abed, Y  Thabet, and P. Vostanis, Comorbidity of PTSD and depression among refugee children during war conflict, 45 J. of CHILD PSYCHOLOGY AND PSYCHIATRY, 533 (2004)).

[18] Id.

[19] Id.

[20] Id. (citing Bell-Dolan, D. Allwood and S.A. Husain, Children’s trauma and adjustment reactions to violent and nonviolent war experiences., 41 J. OF THE AMERICAN ACAD. OF CHILD AND ADOLESCENT PSYCHIATRY 450 (2002)).

[21] Id. (citing S. Schaal, and T Elbert, Ten years after the genocide: Trauma confrontation and posttraumatic stress in Rwandan adolescents, 19 J. OF TRAUMATIC STRESS, 95 (2006)). 

[22] Id.

[23] Id. (citing Freed Mghir, A. Raskin, and W. Katon, Depression and posttraumatic stress disorder among a community sample of adolescent and young adult Afghan refugees, 183 J. OF NERVOUS AND MENTAL DISEASE 24 (1995)).

[24] Id.

[25] Id. at 168-169

[26] Id. at 169.

[27] Id.

[28] Id.

[29] Id.

[30] Id at 164

[31] Id.

[32] Id. at 169.

[33] Id.

[34] Id.

[35] Clettenberg, supra note 4, at 554.

[36] Id.

[37] Id. at 556. 

[38] Id.

[39] Id. 561 (citing W.E. Copeland, G. Keeler, A. Angold, and E.J. Costello, Traumatic events and posttraumatic stress in childhood, 64 ARCHIVES OF GEN. PSYCHIATRY, 577 (2007)).

[40] Id. at 560-61

[41] Id. at 562.

[42] Id. at 562.

[43] Id.

[44] Id.

[45] Id. at 557.

[46] Id. at 559 (citing K.A. McLaughlin, J.A. Fairbank, M.J. Gruber, R.T. Jones, M.D. Lakoma, B. Pfefferbaum, N.A. Sampson, and R.C. Kessler, Serious emotional disturbance among youths exposed to Hurricane Katrina 2 Years postdisaster, 48 J. OF THE AMERICAN ACAD. OF CHILD AND ADOLESCENT PSYCHIATRY 1069 (2009)).

[47] Id. at 560.

[48] Id. at 559.

[49] Id.

[50] Id.

[51] Id.

[52] Id. at 554 (citing S.M. Smith, L. Peoples, and P. Johnson, Disaster response: Community mental health service capacity in the USA, 5 THE INT’L J. OF EMERGENCY MGMT 311 (2008)).

[53] Id. at 558.

[54] Id. at 554 (citing J.R. Rogers, Disaster response and the mental health counselor, 29 J. OF MENTAL HEALTH COUNS. 1 (2007)). 

[55] Id. at 559

[56] Id.

[57] Jude Mary Cenat and Daniel  Derivois, Long-Term Outcomes Among Child and Adolescent Surviviors of the 2010 Haitian Earthquake, 32 DEPRESSION AND ANXIETY 57, 58 (2015).

[58] Id.

[59] Id. at 60.

[60] Id.

[61] Id. at 61. (citing Z. Qu , D. Tian , and Q. Zhang, The impact of the catastrophic earthquake in China’s Sichuan province on the mental health of pregnant women 136 J. AFFECT DISORD 117 (2007)).

[62] Id.  (citing A.K. Goenjian, A. Rousssos, and AM Steinberg, Longitudinal study of PTSD, depression, and quality of life among adolescents after the Parnitha earthquake, 133 J AFFECT DISORD 509 (2011)).

[63] Id.

[64] Id. at 58.

[65] Id. at 61.