Trauma-induced distress and behavioural problems among children and adolescents in Kashmir: a descriptive study

among children and adolescents in complex ways. Our findings highlight the importance of examining trauma and distress at early life cycle stages across age cohorts of children and adolescents in school populations.

The study aimed to examine and understand the psychological distress and BEPs among children and adolescents aged 10 to 18 years in Kashmir who have been either directly or indirectly affected by political conflicts.

Methods
The present study used a mixed research design in which data was collected with a sequential explanatory procedure. The final database represented both quantitative and qualitative information.
The data was collected from secondary and higher secondary school students after obtaining assent/ informed consent depending on their age as well as the https://doi.org/10.4038/sljpsyc.v14i1.8414 consent from their parents or guardians. Five secondary and six higher secondary schools were selected from a list of 138 schools by simple randomisation and 112 children and adolescents were randomly selected from this cohort (55 students from secondary grades, and 57 from higher secondary grades). The study included participants who could read and write English. Client-Oriented Practical Evidence Search (COPES) interview guidelines were used to conduct the interviews (7). A convenient sampling method was employed to identify teachers, children, parents, clinical psychologists, psychiatric social workers, faith healers, and community leaders who participated in the qualitative phase of the study and three children, two teachers, three parents, two clinical psychologists, two psychiatric social workers, one faith healer, and one community leader were interviewed.
The English version of the DASS-21 which has been validated among Kashmir children and adolescents was used in the study (8). The DASS-21 is a self-report instrument designed to assess stress, anxiety, and depressive symptoms. It has a 4-point Likert scale with answers ranging from 0 ("Did not apply to me at all") to 3 ("Applied to me very much, or most of the time") and is drafted to evaluate each of the 21 items (9). The ratings are classified as: normal, mild, moderate, severe, and profound. In both clinical and non-clinical samples, the DASS-21 has been shown to have excellent internal consistency and reliability (10).
Quantitative data were analysed using the SPSS version 25.0. The relationship among the DASS-21 variables scores was determined using Pearson correlation analysis (significant at the probability level <0.05).
Prior to the commencement of the study, an information session was conducted for all the participants. The ethical clearance to conduct the study was obtained from the Chief Education Office of Kulgam District, Jammu and Kashmir.

Results
Out of the sample, 73.2% of students were male and 47.3% were from the age group of 10-12 years. Just above half of the group (50.9%) were higher-secondary students and 42.0% were directly or indirectly affected by conflictrelated trauma ( Table 1).
Out of the total 85.7%, 76.8%, and 54.9% had some level of depression, anxiety, and stress respectively as per the DASS-21 (Table 2). Conflict-related trauma showed a significant mean association with stress, t (40) = 1.76, p<0.05. where children and adolescents exposed to conflict exhibited higher scores in the stress subscale (M=5.83, SD= 1.76) compared to those who were not exposed to such conflicts (M=5.23, SD= 1.78) ( Table 3).
Depression (r= 0.026, p<0.05) and stress (r= 0.134, p<0.05) had a significant relationship with age (Table 4).   "Our observation describes that families believe that supernatural powers cause mental illness and reach out to traditional healers to seek out treatment. In Kashmir, faith healers are the primarily preferred source of obtaining treatment, which could also be due to sparse psychiatric facilities and social stigma." -Psychiatric social worker 2.

Discussion
We found high rates of psychological issues among our study population where more than 70% of the sample had some level of depression, stress and anxiety according to the DASS -21. A Ukrainian study conducted under similar circumstances reports much lower levels of depression among their population (11). A previous study conducted among adolescents above the age of 16 years, reports that depression was prevalent among 55.72% of the population (12).
The prevalence of anxiety among the children and adolescents in our sample was higher than reported in a recent systematic review (13). We also found that the stress levels were higher among those who were exposed either directly or indirectly to political conflicts than those who have not been exposed to trauma. A previous report suggests that anxiety and stress as the most common psychological issues seen among children and adolescents exposed to political violence (14).
Charlson, et al., highlight that children and adolescents living in regions where there are political conflicts experience higher incidences of psychological distress (15). They also mention that, when global figures are considered, one in five children and adolescents affected by political conflicts may encounter mental health issues (15).
In our study, depression and stress had a significant correlation with age. A previous study reports that children and adolescents as the most vulnerable group to develop psychological issues during political conflicts (16).
Some of the other factors that have been bound to have an association with psychological effects among individuals of this age group include low social support, traumatic events, perceived threats to life, and dysfunctional families (17). Stress caused by political conflicts is reported to also cause a significant negative impact on their social and scholastic functioning (17,18). The cohesion and integrity of families are gravely threatened in political conflict regions (19,20).
We observed that some individuals in our study group tended to reach out to faith healers for psychological support when distressed. Engrained cultural and religious beliefs, low levels of mental health literacy and scarcity of mental health resources may have also contributed to this finding. A previous review on psychological issues in war-torn areas also reports similar findings (21).
More than 85% of low-and middle-income countries (LMICs) including those with active political unrest, lack access to adequate mental health care (22). Traditional faith healers and community leaders are identified as potential resources for support in our type of settings in the WHO mental health action plan 2013-2020 (23,24). However, in India, collaborations between mental health services and faith healers are rarely observed. It is our opinion that inclusion and working together with faith healers and community leaders may promote the early recognition and treatment of BEPs, depression, and anxiety disorders. Singh in his paper, "Comprehensive mental health action plan 2013-2030" highlights the need for the integration of mental health care with primary healthcare services which may also apply to other countries in our region (25).

Limitation
We used the validated English version of DASS-21, and some cultural psychological connotations may not have been captured in this version. Our study population was restricted to one district in Kashmir and therefore the results may not be generalizable.

Conclusion
We report high levels of depression, anxiety and stress among the study population who have been exposed to political conflicts. We highlight the importance of strengthening the support systems, mental health literacy as well as the mental health services in order to treat this group of vulnerable people.