Syrian Refugee Children: A Study of Strengths and Difficulties

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Abstract

This research examined the psychological status of Syrian refugee children residing in Antalya, Turkey using the Strengths and Difficulties Questionnaire (SDQ). The psychological aspects explored in the SDQ are emotional symptoms, hyperactivity, conduct disorder, peer relationship problems, and prosocial behavior. We analyzed scores for Syrian refugee children between the ages of 9 and 15 years living in the city center of Antalya, Turkey. For comparison, a similar group of Turkish students completed the same questionnaire. Significant effects of psychological deficit were found for the Syrian refugee children. We conclude that Syrian refugee children in Antalya suffer from severe emotional and conduct problems compared to the Turkish children (who have heightened hyperactivity). Most startling is that both Syrian and Turkish youth in this study have the highest averages for Total Difficulties worldwide, with Syrian refugee children scoring twice as high as their United States counterparts. The results of this study strongly support the need for psychological counseling for refugee children. Additionally, access to counseling should be understood to be critical to refugees’ human right to rehabilitation.

Keywords

Syrian refugee children Psychological effects Strengths and difficulties questionnaire (SDQ) Human rights and sociology Turkey 

Background

The armed conflict in Syria has forced millions of people to be internally displaced and over 5.4 million others, fearing for their lives, were forced to flee their country (UNHCR 2018). The humanitarian crisis is severe and considered the most drastic of the century (UNICEF 2015). More than 13.5 million Syrians are affected by the conflict, of whom more than 6 million are children (UNICEF 2017). In addition, 6.5 million Syrians have been internally displaced and around 3 million of them are children (UNICEF 2017). By July 2017, the United Nations High Commissioner for Refugees (UNHCR) estimates showed that more than 5 million Syrians are registered as refugees in other countries and over 1 million are internationally displaced with no refugee status. The vast majority of Syrian refugees in the neighboring countries live in urban areas, with around only 8% accommodated in refugee camps (UNHCR 2018).

Turkey hosts the largest number of registered Syrian refugees in the Middle East North Africa (MENA) region, and of the more than 3.3 million people registered in Turkey, almost half are children (UNICEF 2017). Out of the registered refugee population, nearly 2.5 million are children (UNHCR, 09 July 2017).

Children bear disproportionate consequences of armed conflict and war (Pearn 2003), exacting an enormous toll of suffering. The health condition of Syrians, whether internally displaced or seeking refugee status in other countries, is tragic. Major efforts have been made by foreign countries to help Syrian children medically, and medical treatment was offered to around 3 million Syrian children by 2017 (UNICEF 2017). The same report says that Syrian refugee children in camps are in desperate need of nutrition, vaccines, education, and clean drinking water. Turkey hosts the highest number of child refugees and, according to UNICEF (2017), over 40% of Syrian refugee children in Turkey are missing out on education.

Refugees do not only suffer from physical illnesses; they are also psychologically affected (Basheti et al. 2015). They have higher demonstrated prevalence of mental health issues, particularly depression (Fazel et al. 2009; Heptinstall et al. 2004), post-traumatic stress disorder (PTSD) (Alpak et al. 2015; Heptinstall et al. 2004), and neurological problems (Jones 2008). Psychosocial distress stemming from a host of problems such as family separation, displacement, loss of family and home, lack of food and education, illness, sexual abuse, and violence add to a sense of hopelessness about their future (Miller and Rasco 2004; Boothby et al. 2006; Fernando and Ferrari 2013), especially for teenagers (Wessells 2016).

Fifty-six percent of Syrian refugees in camps suffer from psychological distress while 46% believe that psychological therapy is needed (Basheti et al. 2015). According to a study by Jabbar and Zaza (2014), Syrian children residing in camps suffer the worst. Syrian children residing at Zaatari, a border camp in Jordan, demonstrated symptoms of anxiety and depression higher than their peers living in the city of Amman (Jabbar and Zaza 2014). Additionally, Basheti et al. (2015) found that 66% of refugees staying in tents demonstrated the urgent need for therapy, while only 14.5% of refugees in camps received such therapy. The Migration Policy Institute (MPI) has reported that 50% of Syrian refugees at camps display symptoms of PTSD (Sirin and Rogers-Sirin 2015). In other words, Syrian refugee children have been—and continue to be—deeply affected by the crisis on a psychological level, and immediate psychological support is needed for those affected by the war in Syria. The more recent finding, whereby the vast majority of Syrian refugees live in urban areas with around only 8% accommodated in refugee camps (UNHCR 2018), strongly suggests more research is needed on refugees living in urban areas.

Rights of the Child

The 1989 United Nations Convention on the Rights of the Child (CRC) was the first legally binding international instrument to incorporate the full range of human rights for people under 18 years old. All United Nation countries signed the CRC treaty, though the United States has not ratified it. As the most ratified human rights treaty in the world, the Convention sets out the civil, cultural, economic, political, and social rights of children; in essence, it declares a universally agreed set of non-negotiable standards and obligations for people under the age of 18 years of age.

The Committee on the Rights of the Child monitors implementation of the CRC through its State parties and is critical to the development and safeguarding of children. The Convention is made up of 54 articles and two Optional Protocols. The Optional Protocols address involvement of children in armed conflict; sale of children, child prostitution, and child pornography; and a communications procedure to allow children a way to submit complaints regarding violations to their rights under the Convention and the two Optional Protocols (UNCRC 2002). Every right spelled out in the Convention is inherent to the human dignity and the holistic and harmonious development for every child. That said, two Articles resonate especially for the purposes of this research:

Article 22 (Refugee children): Children have the right to special protection and help if they are refugees (if they have been forced to leave their home and live in another country), as well as all the rights in this Convention.

Article 38 (War and armed conflicts): Governments are obliged to do everything they can to protect and care for children affected by war. Children under 15 should not be forced or recruited to take part in a war or join the armed forces.

The Optional Protocols also pertain to the participants in this research, particularly as they address involvement of children in armed conflict stating explicitly that parties shall accord all appropriate assistance for their physical and psychological recovery and their social reintegration. Additionally, the UN resolution adopted by the UN General Assembly in 2012 addresses issues for the protection of the child, such as psychological recovery, including in times of war.
Importantly, governments of countries that have ratified the Convention are required to report to, and appear before, the United Nations Committee on the Rights of the Child periodically to be examined on their progress with regards to the status of child rights in their country. One combined report of Turkey, dated 2012 and long before the Syrian refugee crisis reached its height, points to numerous challenges experienced by asylum-seeking and refugee children, including with regard to receiving a residence permit—a requirement for accessing basic assistance, such as health and education- and the lack of interpreters to communicate their situation of concern.

Also, in accordance with the Guidelines on protection and care of refugee children… the Committee recommends the State party ensure every effort is made to identify children who require special support on their arrival and consider providing adequate psychological assistance to them. The Committee encourages the State Party to seek technical assistance from UNHCR (Committee on the Rights of the Child 2012).

Turkey was to respond to the challenges faced by 3 May 2017; yet, we were unable to find any reports for publication in this paper. Needless to say, the Syrian war has escalated since 2012 and Turkey is now home to over 3 million Syrian refugees (UNHCR 2017). We can say that Turkey has established a national asylum framework through the Law on Foreigners and International Protection and the Temporary Protection Regulation (UNHCR 2017) and the government leads the refugee settlement program. Antalya, where this research is focused, is considered a Refugee Urban Location.

The Study

The aim of this study was to better understand the psychological stress of Syrian refugee children in Turkey. Clearly, this is a critical problem, and to that end, we examined strengths and difficulties of refugee children affected by the Syrian crisis. We used the framework of the Strengths and Difficulties Questionnaire (SDQ) to help answer the following research question: What are the strengths and difficulties faced by Syrian refugee children residing in Antalya Turkey?

Studies of a similar nature were conducted to study the psychology of Syrian refugees in Europe (German Federal Chamber of Psychotherapists 2015) and those who sought shelter and safety in refugee camps in Jordan and Lebanon (War Child Holland 2013; UNICEF 2013; 2014). However, we found no studies conducted in Turkey that focused on strengths and difficulties of Syrian refugee children. For the purpose of comparison, we applied the same questionnaire to a group of Turkish students in the same age group attending a school in the same city.

This study adds to the research literature in two ways: (1) it addresses Syrian refugee children in Turkey, the largest migration center for Syrian refugees; and (2) it provides a comparison of scores between Syrian refugee children and Turkish children in the same age group. Finally, this work provides recommendations for teachers, human rights and social practitioners, and others working with refugee children and their families.

Research Design/Methodology

This empirical research used a quantitative approach to assess the Strengths and Difficulties experienced by Syrian refugee children in Antalya, Turkey. This methodology is a typical way to measure the SDQ developed by Goodman et al. (1998) and it is shown in the Appendix. The SDQ is a validated questionnaire that measures and evaluates child psychology on five different aspects, namely, (1) emotional symptoms, (2) hyperactivity/inattention, (3) conduct disorder, (4) peer relationship problems, prosocial behavior, and finally, (5) total difficulties. The SDQ is a brief behavioral screening questionnaire in several versions to meet various needs of researchers, clinicians, and educators. SDQ offers the following advantages: a focus on strengths as well as difficulties; better coverage of inattention, peer relationships, and prosocial behavior; a shorter format; and a single form suitable for both parents and teachers, perhaps thereby increasing parent-teacher correlations (Goodman et al. 1998).

This research used the 25-item self-rated SDQ which was adjusted in June 2014 for children and youth between the ages of 4 and 17. Arabic and Turkish translations were used in this study. All translations and internal reliability for the SDQ were conducted by Youth in Mind. Overall, Cronbach alpha coefficients for the SDQ are 0.82 for the total difficulties, 0.75 for emotional symptoms, 0.72 for conduct problems, 0.69 for hyperactivity, 0.65 for prosocial behavior, and 0.61 for peer problems. Our internal reliability for the various self-report scales for this study showed reported alphas of α = 0.47 for the Turkish sample and α = 0.56 for the Syrian sample. The low alpha score for the Turkish sample shows no sign of correlation among tested variables. Hence, the five dimensions of the questionnaire are internally inconsistent and each dimension tests an independent variable. However, although the score of the Syrian sample is higher than the Turkish one, it is still a relatively low alpha score. The latter signals a slight correlation among the five dimensions of the test and a weak internal consistency. In other words, the five dimensions are independent of each other, but slightly correlated (Kline 2000).

Operational Definitions

The SDQ is part of the Development and Well-Being Assessment (DAWBA) family of mental health measures. The SDQ is available on the Youth in Mind website started by Robert Goodman, Professor of Brain and Behavioral Medicine at King’s College London, and which undertakes research on psychological health throughout the world. Norms for ten countries are available for comparison; however, there are none for Syrian or Turkish youth. The questionnaire measures each child on five psychological aspects; each aspect represents an area of deficit. Emotional symptoms measure the child’s emotional instability demonstrated in nervousness and unhappiness. Moreover, conduct problems measure the child’s behavior within accepted manners—whether the child fights with others or cheats and lies. In addition, hyperactivity measure the child’s concentration—whether the child completes tasks of the principal investigator or is easily distracted. Furthermore, peer relationship problems measure the child’s ability of establishing healthy relationships with other children of the same age. Finally, prosocial behavior is a measure of the child’s behavior in the society, including extraversion and kindness.

Data Collection

The population for this research was Syrian refugee children (N = 41) and Turkish children (N = 51) between the ages of 9 and 15 residing in the city center of Antalya. The criteria for selection (for Syrian children) to participate in the survey was that they were refugees from the war in Syria, between the ages specified. The Turkish children who participated in our survey lived with their families in moderate apartment complexes.

It should be noted that Antalya province is the only state in Turkey that denies Syrian refugees to reside or seek asylum; however, refugees are welcomed in any other states. Antalya is officially off-limits for Syrian refugees because, with its attractive Mediterranean coastline, it is the tourism capital of Turkey. Hence, no services (medical, psychological, or social) were provided to refugees in Antalya, not formally at least, at the time of our study. In addition, non-governmental organizations (NGOs) or any other social work institution were denied permits to operate in Antalya. We had unique access to the Syrian refugee children and their families because of a volunteer student group. This situation was brought to the attention of the authorities, mostly out of a health concern, and some adjustments were made. For example, a group of volunteer doctors began to visit the sites to provide vaccinations to children or other emergency-related services.

Refugee situations, such as those in Antalya, are not as organized as one might think. Housing situations differ and children may or may not attend school. Most of the children who participated in our survey lived with their (mostly, maternal) relatives in very poor, impoverished homes located in the city center. Other children lived in makeshift tents located on farms. They were not part of any organized group coming to Turkey—they are refugees who heard about potential housing by word-of-mouth or friends-of-friends who knew about cheap housing. Most did not attend a formal school at the time of this survey. Sadly, this is the case for most refugee children who move to cities and who are sent to work at farms or factories. This housing is different than that of children in the official camps who are registered by an authority and usually live in tents provided by an NGO or large government entity. There is usually a school in the official camps and education is most often provided by a non-governmental organization. Finally, there is another type of camp that refugees set up in conjunction with people who are willing to rent them land, often in farm fields, where they work by day. These, too, are not part of the system. In these unofficial camps refugees live under plastic tarps or build some type of makeshift tent. Children at these makeshift camps rarely attend school.

At the time of the study, Syrian refugee children were not allowed to attend public or private Turkish schools in Antalya. Hence, we collected data from a makeshift school that was set up specifically for refugees and funded by donations from anonymous sources. The school operated in the shadows without any official presence. Later on, in 2017, the Syrian school was recognized by the Turkish government under pressure from the UNHCR. Turkish children were surveyed at a private Turkish school. Teachers from the private school volunteered at the Syrian school. Thus, the quality and level of education at the Syrian school and the private Turkish school were relatively similar as they had almost the same teachers.

Ethical aspects were taken into account in a few ways: (1) all Human Subject papers were submitted and signed at the university and reviewed by nine faculty members on the Ethics Committee; ( 2) Children and parents of the children allowed contributions to the survey data; (3) The principal at the school attended by the Turkish students allowed permission for the survey to be conducted at the school; and (4) Parents or representatives of the Syrian children were present when they answered questions.

The Syrian children filled the questionnaire at the school during class time under the supervision of the main researcher, the school principal, and the class teacher. For the Turkish students, the headmaster’s consent was granted and he supervised the process alongside the researchers. Children without parental permission did not participate in the survey.

Surveys were administered by the principal investigator at the schools in Antalya, Turkey. The questionnaires were completed by the children themselves after receiving instructions of the principal investigator. Data collection was anonymous. Upon the completion of the questionnaire, the investigator collected the questionnaires and coded them according to the citizenship of the child.

Data Analysis

The questionnaire consists of 25 questions that can be answered by “not true,” “somewhat true,” and “certainly true.” Each answer corresponds with a number between zero and two that was recorded on an Excel sheet to compile a relationship of completion of the questionnaire using the guidelines of the SDQ scoring sheet. The individual scores were summed at the end to generate a score that measures the interviewed child on each of the five psychological aspects. A quantitative analysis of the generated scores including correlation analysis and ANOVA was performed.

Findings

Analysis showed no significant difference in variance (p > 0.05) between the two samples for prosocial problems and peer problems. There was a significant difference in emotional problems (p = 0.01), conduct problems (p = 0.02), and total difficulties (p = 0.04) where Syrian children scored higher. Furthermore, there was a significant difference in hyperactivity problems (p = 0.04) where Turkish children scored higher.

This study shows Syrian children have higher Total Difficulties scores (x = 14.6), which is considered very high when compared to other children in the same age range across the world. Likely, in this comparison to the Turkish group, the psychology of Syrian children is significantly impacted by their refugee status on two main aspects: Emotional Problems (x = 5.4) and Conduct Problems (x = 2.8). It is expected for war to have adverse effects on children emotionally, as they encounter loss and deprivation, as well as conduct-wise, as they are forced to do what is necessary to survive.

The groups were similar for peer problems and exactly the same on prosocial behavior. Our observations from our interactions with the Syrian refugee children are that they relate to and play with friends and siblings in a typical fashion. On the other hand, the Turkish children scored higher on Hyperactivity Problems (i.e., problems focusing and completing tasks).

What is most startling from this study is comparing SDQ scores for both the Syrian and Turkish populations in this study with the SDQ norms for other countries (presented on the Youth in Mind website). For example, the highest averages for Total Difficulties score is 7.1 (5.7) for the United States and 9.0 (5.6) for Australia. It is worth noting that Turkish youth in our study had a Total Difficulties Score of 12.4, which is quite high relative to other countries. However, Syrian youth in our study had a Total Difficulties Score of 14.6, nearly twice as high as the United States, and this disparity continues for almost all the items (Tables 1 and 2).
Table 1

Self-reported SDQ results of Syrian refugee children and Turkish children

 

Group mean (SD) values

p valuea

Syrian refugees (N = 41)

Turkish children (N = 51)

SDQ total

14.6

12.4

0.04b

SDQ subscales

 Emotional symptoms

5.4

3.0

0b

 Hyperactivity

3.6

4.4

0.04b

 Conduct disorder

2.8

2.0

0.02b

 Peer problems

2.8

2.9

0.67

 Prosocial behavior

8.3

8.3

0.99

ANOVA is performed assuming unequal variances

ap two tail

bp < 0.05

Table 2

Comparison of average strengths and difficulties scores for Syrian refugees and United States

 

Syrian refugees (N = 41)

United States (N = 9878)

SDQ total

14.6

7.1

Emotional symptoms

5.4

1.6

Hyperactivity

3.6

2.8

Conduct disorder

2.8

1.3

Peer problems

2.8

1.4

Prosocial behavior

8.3

8.6

Discussion

We believe these findings suggest that Syrian youth are affected negatively by their experiences of war, migration, and resettlement. This study shows credible evidence that children experiencing the stress of refugee status are undergoing severe psychological difficulties that need attention by the social science community. Our research determines that little to no psychological counseling is being offered to refugees. To our minds, the lack of psychological counseling to children and their families can result in grave future consequences, and this is a conversation that needs to be on the agenda at many levels.

This research provides a snapshot of the psychological struggles faced by Syrian refugee children. We believe it can help human rights practitioners, particularly mental health professionals, working with refugee populations to make a stronger cause to gain the support of States and international bodies to support refugee populations with psychosocial services. While this study has its limitations, namely a relatively small sample size, it does portend to serious issues for this population. This study can be extended to include different cities and countries with refugee populations to further an argument for psychological interventions that can help future generations.

Conclusion/Recommendations

Psychosocial distress remains an undertreated legacy of children who have been trapped in battle as well as those displaced as refugees (Pearn 2003). The impact from the effects of war and refugee status on the mental health of any civilian population is significant and studies show that women, children, the elderly, and the disabled are most affected (Murthy and Lakshminarayana 2006) and many cases resulting in PTSD go untreated (Goodman and Scott 2012). Our study corroborates these findings, particularly showing that refugee children suffer more difficulties than others of comparable age—not only in the same town, but across the world.

We conclude this paper with two recommendations: the first addresses the difficulties; the second addresses the strengths.

Our first recommendation is that the Committee on the Rights of the Child take up the task to place qualified mental health personnel inside and outside refugee camps. Trained social workers help to identify areas of need and recommend a way forward. We believe this can go a long way to help families and children through the struggles of war and what it means to be a refugee, whether inside or outside a camp.

The second recommendation builds upon work by Wessells (2016) who suggests that it is a mistake to focus exclusively on children’s deficits. Large numbers of war-affected children, he says, exhibit remarkable resilience and actively cope with, adapt to, and navigate complex situations of adversity (Wessells 2016). We saw this, too, in our interactions with the Syrian refugee children from this study. These children are still children—meaning they enjoy play, want to discuss their situation, and hold opinions about their needs. Mobilizing existing resources, such a community building, can help to support children’s mental health and psychosocial well-being in war-affected contexts. In order to alleviate difficulties, efforts can be made to build on strengths including relations with significant others—parents, extended family members, neighbors, peers, and teachers—people who can help them get through the horrors of war. We found that members from our student group who went to play and to talk with the refugee children were extremely successful in bringing a glimmer of happiness and hope on an otherwise dismal day—on both sides; for giving is often more rewarding that receiving. For example, students started a pen-pal exchange with refugee children. It was not official, and letters were delivered by hand, but it helped build language skills for one group and empathy for the other. In another example, a group of college women went and played “hairdresser” with the Syrian girls, shampooing and combing their hair, giving them bows and ribbons to wear. They also took information back to a group of doctors who were able to prescribe necessary medicines for things such as skin rashes. Another activity was when college students stood by to hold the hands of children as they received vaccination shots. A smile goes a long way and the refugee families were glad that members of the local community took a genuine interest in them.

We conclude that an important aspect of protection for the mental health of children in refugee crisis is an emphasis on addressing both strengths and difficulties—recognition by the larger, international community that professional care is absolutely necessary to help children and families get through the crisis; and further, emphasis on strengths, such as resilience and recognition of basic needs, and what local communities can do to support those needs.

Notes

Acknowledgements

The authors would like to thank Mina Fazel, Associate Professor at Oxford University, whose advice and suggestions inspired us during the study. We would also like to thank the Youth in Mind group started by Robert Goodman, Professor of Brain and Behavioral Medicine at King’s College, London, for providing instruments and data on psychological health across the world.

Compliance with Ethical Standards

Declaration of Interest

None.

Ethical Standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Business SchoolUniversity of EdinburghEdinburghUnited Kingdom
  2. 2.Department of Business AdministrationAntalya International UniversityAntalyaTurkey

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