الفهرس 
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Abstract
Adolescence and early years of adulthood are a time full of events. during this period, many changes take place in the process of normal development, it is characterized by an enormous pace in growth and change, such as changing schools, leaving home and starting a university life or working in a new job. These events are fun and exciting for many, but when any traumatic event occurs in this period it will affect their life and may extend to the rest of the time.
The war is one of traumatic events that adolescents may experience. it not only cause destruction and devastation in the infrastructure of the society, but also has serious consequences for their members, especially adolescents, which affect their physical, psychological and social health and it may cause displacement, refuge and migration for them.
High-profile traumatic events, as the wars in Syria and Iraq, and the terrorist attacks of September 11, 2001 on the World Trade center, have led to a larger public interest and increase dealing with refugees’ issues in the risk and protective factors for diverse reactions in their life, especial adolescent.
Globally in 2017, 68.5 million people were displaced due to war and political conflict, of whom 25.4 million were recognized as refugees according to the United Nations High Commissioner for Refugees (UNHCR); More than half of all displaced and refugees’ people are children and adolescent.
Numerous studies have also documented a high prevalence of symptoms of PTSD and other mental disorders among refugee children and have linked these symptoms to exposure to trauma prior to migration
In Syria, Hundreds of thousands have been killed and more than half of the population have been displaced from their homes, half of those affected were children and adolescents, those are at risk of becoming ill, malnourished, abused and to mental disorders and psychosocial problems as PTSD.
The adolescents who had exposed to trauma have differ requirements. It is important to find methods for them to control their own life since PTSD effects on them and particularly on their growth and development.
Adolescents and their guardians need more information and awareness about mental health, building life skills, and providing with psychosocial support in schools and other community settings to grow to be healthy and resilient.
Hence, this study was conducted with the aim of identifying the effect of cognitive behavioral intervention program (CBITS) on post-traumatic stress disorder among Syrian adolescent refugees in Egypt.
A Quasi experimental research design was adopted to carry out this study. It had been carried out at ten in 10 Syrian schools established in Egypt for Syrian refugees’ students at 6 October in Cairo Governorate and Alexandria Governorate.
An initial assessment using child PTSD symptom scale (CPSS) to identify the students with PTSD symptoms for all Syrian adolescent refugees’ students (613) enrolled in the previously mentioned schools with age ranged between 11 – 15 years, and were registered in the UNHCR. All students (206) with moderate level of PTSD according to initial assessment were selected to be included in the (CBITS) program. Those students were divided into two matched groups according to number of students in each school.
Also, all guardians of students with moderate levels of PTSD ’’whether affiliated to study or control groups” were included in the study, and asking them to complete Pediatric Symptom Checklist (Y-PSC) To identify cognitive, emotional and behavioral problems in daily lives at home of their children.
Tools of study
Three tools were used in this study.
• Tool One: Tool I: Students’ and Parents’ Personal and Socio- demographic Data Structured Interview Questionnaire: It composes four parts: 1st part: Students and parents, Personal and Socio-demographic data. 2nd part: students’ and parents Medical History. 3rd part: Students’ social relations and academic achievement.4th part: Support Services.
• Tool Two: Child PTSD Symptom Scale (CPSS): It was developed by Foa et al, 2001. It was subjected to forward translation into Arabic backward translation into English by two independent professional and designed as a self-reported measure to assess the frequency of all post-traumatic stress disorder symptoms within the past month among children and adolescents experienced a traumatic event. It composed of The CPSS is composed of 24- items divided into two parts: part 1 is made up of 17 items and it contained three subscales; re-experiencing, avoidance and hyper-arousal. Part 2 is made up of the last set of 7 items to measure impairment functioning. The tool was tested for validity and reliability.
• Tool Three: Pediatric Symptom Checklist – youth Report (Y- PSC): It was developed by Pagano et.al at 2000. It was subjected to forward translation into Arabic backward translation into English by two independent professional and it used to facilitate the recognition of cognitive, emotional and behavioral problems in major areas of children’s and adolescent’s daily life at home, in school, with friends, and in activities. This tool reflects parents’ opinions of their child’s psychosocial functioning. it includes three subscales; attention problems, internalizing problems and externalizing problems.
Approvals were obtained for conducting the study at the specified settings. A pilot study was carried on 20 students to assure the clarity, applicability and comprehensiveness of the tools. Data was collected by the researcher during the period from September 2016 to March 2017. Appropriate descriptive and analytical statistics were carried out.
The main findings obtained from the study were as follow:
Biosocio-demographic characteristics of the Syrian refugees’ students and their families:
• Syrian refugees’ students age ranges from 11-15 years with a mean of 13.45 ± 1.10 years.
• More than half (54%) of the Syrian adolescents were girls, while 46% of them were boys
• The majority (80.3%) of the adolescents were in preparatory schools and 19.7% of them were in the primary schools.
• Most of the adolescents (79.6%) lived with their both parents, 18.1% of them lived with one of their parents and the least percentage (2.3%) of adolescents lived with their relatives.
• The majority of the adolescents (87.3%) reported that, they did not have any health problems. Whereas 12.7 % of them were suffering from health problems, most (98.7%) of them had physical problems (and 7.7% of them had psychological problems.
Syrian adolescent refugee’s scholastic achievement; spare time activities; and work status.
• About three quarters (75.1%) of the Syrian adolescents were ever failed at school, whereas about one quarter (24.9) of them did. In addition to, more than one quarter (28.2%) of adolescents had less than average scores in the last year, while 71.8% of them had good level and above.
• Slightly more than half (50.7%) of them were watching TV and listing music in their leisure time, just less than one tenth (9.8%) of them were reading books or newspapers. However, 15.2% of adolescents were going out with their friends and more than one fifth (21.7%) of them spent time in computer and internet, 13.1% of them were practice sports. Whereas, little percent (6.2%) of them were went to sports club. While, 14.7% of the Syrian adolescents reported that they haven’t free time,
• The majority (90.4%) of the adolescents were not working besides studying and slightly less than one tenth (9.6%) of them were working.
• Only 4.4% of the students reported that they did not have friends. More than one tenth (13.9%) of them had one to three friends. Whereas, most (81.7%) of adolescents had more than four friends. On the other hand, slightly more than two thirds (66.9%) of adolescents had both Syrian and Egyptian friends. While, more than one quarter (28.7%) of them had Syrian friends only, and only 4.4% of them had Egyptian friends only.
• Most (86%) of the adolescents reported having good and excellent relationship with their friends, while, 14% of them had bad relations.
Syrian adolescent refugees intra familial and social relationships.
• The Majority (95.3%) of adolescents reported excellent and good relations with their teachers, while, just 4.7% stated bad relation.
• More than two thirds (67.6%) of the adolescents reported excellent and good relation with their fathers and only 14.5% reported bad relation.
• Most (86.8%) of the adolescents had excellent and good relationship with their mothers and just more than one tenth (10.6%) of them had bad relation.
• More than one third (83.4%) of adolescents had excellent and good relationship with their siblings and only 15.8% of them had bad relationship.
• More than two thirds (68.7%) of the adolescents reported excellent and good relationship between their parents while 13.4% reported bad relationships between parents.
Syrian adolescent refugee’s exposure to violence.
• Physical violence was the most common type reported by adolescents who admitted exposure to violence (47.9%) followed by psychological violence (39.6%), and more than one quarter (27.1%) of them reported exposure to other types of violence like emotional, verbal, while only 2.1% reported sexual abuse.
• The majority (94.3%) of the adolescents were not exposed to domestic violence while only 5.7% of them did. Meanwhile the majority (92.2%) of the adolescents did not report exposure to violence and just 7.8% of them were exposed to violence.
• More than half (54.2%) of adolescents stated the fathers, while 45.8% of them mentioned their mothers. However, less than one fifth (18.8%) of them stated the brothers and only 4.2% stated friends.
Syrian adolescent refugee’s severity of PTSD.
More than one quarter (27.57%) of the adolescents had normal symptoms of PTSD. More than one third (34.75%) of them had mild symptoms of PTSD, one third of the adolescents (33.6 %) had moderate symptoms of PTSD and only 4.08% had severe PTSD symptoms.
Bio- socio demographic characteristics of guardians.
• Concerning adolescent’s guardians, more than a quarter (27.2%) of them were their fathers, while mothers constituted (69.9%) of guardians, and little percent (2.9 %) of them were relatives.
• The guardian’s age ranged from 30 to 62 years with a mean of 50.3 ± 7.5 years. More than one quarter (26.7%) of them was 30 to less than 40 years old. Less than half (47.1 %) of them aged 40 to less than 50 years old, approximately one quarter (25.2%) of them aged from 50 to less than 60 years old. Those in the age group of 60 and over constituted 1% of the guardians.
• The majority of parents (88.1%) were living together, 4.4% of them were widowed, also 4.4% were either divorced or separated and the rest (2.9%) of them were died.
• Less than half (43.2%) of fathers had secondary education and those who attained university/higher education constituted 30.6%, while less than one fifth (18.4%) of them had preparatory education and only 1.5% of the fathers had primary education.
• Less than three quarters (73.2%) of fathers were skilled workers, while11.2% of them had professional work. Just slightly less than one tenth (9.2%) of them were traders or businessmen.
• 39.3% of mothers attained secondary education and one third (30.1%) of them had preparatory educated while 16.1% of them had university/ higher education. 10.6% of the mothers had primary education and less than.
• The majority (80.5%) of the mothers were not working, while 7.8% of them were professionals and 7.8% of them skilled workers.
• More than one quarter (28.2%) of the families had enough monthly income. While less than two thirds (65.5%) of them had insufficient monthly income. Those who had insufficient monthly income and borrowed constituted 6.3% of them.
• The number of families’ members ranged from 3 to more than 6 members. just 2.4% of the families consisted of 3 members. Approximately one tenth (11.7%) of them consisted of 4 members. Slightly more the one third (36.4%) of the families consisted of 5 members. Those who had 6 members constituted (28.6%) of the sample. While the rest (20.9%) of them consisted of more than 6 members.
• The majority (80.6%) of the fathers had no health problems, while 13.1% of them had. Furthermore, the vast majority (92.6%) of ill father’s had physical health problems. While 11.1% of them reported that they had psychological problems.
• The majority of the mothers (86.9%) had not any health problems compared to 9.2% of them who had. In addition to, all of those who had physical problems, 15.8% of them had also psychological problems.
Psychosocial functioning problems as perceived by their guardians.
• Less than two thirds (63.1%) of the Syrian adolescent refugees had psychosocial functioning problems, while more than one third (36.9%) of them had not.
The results also revealed the following:
• No statistically significant relation was found between PTSD and Syrian adolescent refugees’ sex (X2= 1.557, P=0.669).
• Statistically significant relation was detected between PTSD and Syrian adolescent refugees’ age (X2= 54.317, P=0.001).
• Statistically significant relation was observed between PTSD and education level of adolescent refugees’ (X2= 27.686, P=0.001).
• PTSD symptoms was significantly more encountered among adolescents who were living with one of parents and those living with relatives Statistically t relation was noted between PTSD and the person with whom adolescent live (X2=112.47, P=0.002).
• Statistically significant relation was existed between PTSD and presence of health problems among Syrian adolescent refugees’ (X2=120.542, P=0.001). PTSD was significantly more prevalent among those who had psychological health problems (X2= 120.542, P=0.001). Also, no statistically Significant relation was found between PTSD and take treatments (X2= 68.909, P=0.831).
• It can be observed that PTSD symptoms were significantly more encountered among students who were previously failed at school (X2= 123.685, P=0.001).
• Statistically significant relation was found between PTSD and previous academic year’s scores (X2= 306.778, P=0.001).
• No statistically significant relation was found between PTSD symptoms and spending leisure time (X2=226, P=0.094).
• PTSD symptoms were significantly more among working adolescents compared to those not working (X2=92.252, P=0.001).
• PTSD symptoms were significantly more encountered among students who did not have friends compared those who have more friends (X2=61.750, P=0.001).
• No statistically significant relation between PTSD and from where friends (X2=61.75, P=0.975).
• No statistically significant relation existed between PTSD and relation with friends and teachers (X2=272.489, MCP=0.061; X2=170.559, MCP=0.0271 respectively).
• Statistically significant relation existed between PTSD and relationship with both fathers and mothers (X2=299.727, MCP=0.001; X2=317.037, MCP=0.001 respectively).
• No statistically significant relation founded between PTSD symptoms and adolescent’ relationship with their sibling (X2=239.909, MCP=0.093).
• PTSD were significantly more encountered among adolescents who reported bad relationship between parental (X2=324.541, MCP=0.001).
• PTSD were significantly more prevalent among those exposed to each of domestic violence and other violence (X2=38.204, P=0.001; X2=53.533, P=0.001 respectively). On the other hand, no statistically significant relation existed between PTSD and each of perpetration of violence and type of violence (X2=50.559, MCP=0.080; X2=44.531, FEP=0.440 respectively).
Relationship between psychosocial functioning problems and socio demographic characteristics of guardians
• Psychosocial functioning problem was significantly highest among adolescents who their relative had responded to the assessment tool compared who their parents responded (X2=7.278, MCP=0.021).
• The guardian’s age and marital status of adolescents’ parents had no statistically significant impact on recognition of psychosocial functioning problems where (X2=48.818, P=0.206, X2=6.791, MCP=0.170 respectively).
• No statistically significant relation between parental occupation (father, mother) and psychosocial functioning problems among adolescents (X2=1003, MCP=0.660, X2=2.417, MCP=0.389 respectively).
• Psychosocial functioning problems were significantly more encountered among adolescents who their family income had not enough (X2=7.862, MCP=0.020).
• No statistically significant existed between psychosocial functioning problems and number of families’ members where (X2=3.936, P=0.415, X2=0.12).
• No statistically significant relation was found between psychosocial functioning problems and health statues of fathers or mothers where (X2=0.340, FEp=0.725, X2=0.472, FEp=1.000 respectively).
• Lastly no statistically significant relation existed between psychosocial functioning problem and type of health problems where (X2=2.553, FEp=0.110, X2=0.694, FEp=0.405 respectively).
Effect of cognitive behavioral intervention program
• A statistically significant difference on PTSD severity post and evaluation after 3 months of intervention implementing program between study and control groups (X2=16.455, P=0.001 and X2=23.486, P=0.01).
• A statistically significant differences (F.221.505, P = 0.001) on PTSD severity found between pre, post and follow up among study group
• No significant differences (F. =75.247, P = 0.081) on PTSD severity found between pre, post and follow up among control group.
• With respect to the re-experiencing as CPSS subscale, The differences between pre CBITS evaluation, post and after 3 months evaluation were statistically significance (F =62.419, P = 0.001) among study group, while there was no statistically significant difference found between pre, post and follow up after 3 months evaluation (F =34.710, P= 1.223) among control group.
• Concerning to avoidance as CPSS subscale, the differences between pre CBITS evaluation, post and after 3 months evaluation were statistically significance (F =75.768, P = 0.001) among study group. But among control group, there were no statistically significant differences found between pre, post and after 3 months evaluation (F= 27.695, P = 0.158).
• In relation to hyper-arousal as CPSS subscale, the difference between pre CBITS, post and after 3 months evaluation were statistically significance (F =100.181, P = 0.001) among study group, it is amazing that there was statistically significant difference found between pre, post and after 3 months evaluation (F= 36,004, P = 0.041) among control group.
• Moreover, in regarding to impairment functioning as CPSS subscale, there was statistically significant difference between pre CBITS, post and after 3 months evaluation (F =46.866, P = 0.001) among study group, while there was no statistically significant difference found between pre, post and follow up after 3 months evaluation (F=13.357, P = 0.091) among control group.
• Concerning psychosocial functioning problems pre implementing CBITS, it was observed that no statistically significant difference was observed between study and control groups (X2=3.092, P=0.079). While, there was a statistically significant
difference between study and control groups in an immediate evaluation of program (X2=4.043, P=0.044). Additionally, A statistically significant difference was found between study and control groups follow up after 3 months evaluation (X2=9.711, P=0.002).
• Psychosocial functioning problems as reported by guardians. Significant differences (F =284.417, P= 0.001) was found between pre, post and follow up evaluation among the study group, whereas, no significant differences were found between pre, post and three months evaluation after program among control group (F = 124.344, P = 0.081).
• No statistical significance difference was observed between two groups pre CBITS (P=0.084), while a statistical significance difference was found in post and 3 months follow up evaluation (P=0.001, P=0.001) respectively).
• In regarding to attention problems as psychosocial functioning problems subscale, no statistically significant differences were found between pre, post and three months evaluation after program between study and control groups since (X2=0.144, P=0.704; X2=0.299, P= 1.000; X2=1.211, P =0.445 respectively).
• With respect to internalizing problems as psychosocial functioning problems subscale at pre implementing CBITS, no statistically significant difference was observed between study and control groups (X2=0.107, P=0.301). While a statistically significant difference was founded between study and control groups in immediate post (X2=0.187, P=0.036) and in the final evaluation after 3 months (X2=5.322, P=0.021).
• Concerning externalizing problems, no statistically significant difference was observed between study and control groups (X2=0.449, P=0.503) before implementing program. While a statistically significant difference was observed between study and control groups post and after 3 months of the program (X2=0.086, P=0.007, X2=0.525, P=0.046 respectively).
• Subscale mean scores of functioning problems as reported by guardians. in relation to attention problems, statistically significant (F =29.849, P = 0.001) were found between prior implementation of the CBITS, first evaluation and final evaluation after 3 months of the program among the study group. While, no statistically significant difference was found (F =20.398, P = 0.061) between prior implementation of the CBITS, post and evaluation after 3 months of the program among control group.
• No statistically significant differences between study and control groups before implementing the CBITS (P=0.664), while there were statistically significant differences immediately post and after 3 months evaluation of the program (P=0.009, P=0.587 respectively).
With respect to Internalizing problems, A statistically significance differences were found (F =56.785, P = 0.001) between pre, post and 3 months evaluation after CBITS among study group. While no significant differences (F = 20.555, P = 0.091) were found between prior implementation of the CBITS, post and evaluation after 3 months of the CBITS among control groups.