The present study aimed at investigating the prevalence of PTSD, depressive symptoms, and anxiety symptoms in primary school students. According to study findings, 54.3% of participants experienced trauma. Drowning and bullying-related traumas were reported as more common compared to other types of traumas. The previous study supported the current findings as drowning was found to be the third biggest reported trauma among adolescents (Ghazali et al, 2014). However, humiliation was also found to be a significant traumatic event in adolescents' lives at Sarawak (Ghazali et al., 2014). Humiliation is a form of bullying and causes substantial damage in children later in life. As far as primary school students are concerned, so the primary children experience death, disaster, and humiliation trauma (Alisic et al., 2008).
Research on the prevalence of PTSD among primary school children is still in its early stages (Kolaitis, 2017), thus, any comparison to the existing literature is limited. In this study, the prevalence of PTSD was high in primary school children (39.4%) in comparison to what has been reported in the previous study among adolescents (7.1%) in Ghazali et al (2014) study. One of the reasons is that the current study focused on primary school children (aged 11–12 years old), while Ghazali et al (2014) studied older children (aged 13 to 17 years old). However, the current findings are consistent with the study conducted by Yue et al. (2022) and Rezyat et al. (2020). Examining PTSD among children is quite challenging due to their limited ability to recognize and express their emotional experiences. The high reported prevalence could be due to the children’s overrating tendency to deal with their emotional experiences.
The current study finding reported that due to traumatic events, a surge in depressive symptoms (38%) was reported compared to anxiety symptoms (19%). In previous studies, both depressive and anxiety symptoms were found to be high in response to traumatic events (Ghazali et al., 2015; Li et al., 2019; Patki et al., 2015; Regehr et al., 2019; WHO, 2022; Zhou et al., 2021). However, in the current study, we note a lower surge in reported anxiety symptoms among this population of primary school children. This is an interesting finding, especially because the median onset for anxiety disorders is as early as 6 years of age (Merikangas et al., 2010; Solmi et al., 2021). However, this could be due to childhood anxiety disorders often remitting within 3 to 4 years, and low to moderate stability rates of diagnoses(Freidl et al., 2017; Last et al., 1996), as well as other factors influencing developmental trajectories of anxiety symptoms, such as behavioural inhibition and internalizing symptoms (Broeren et al., 2013). This could also lend some direction to future areas of research, which may address age-related and cultural differences in the reporting of anxiety symptoms in children. According to the findings of the current study, a significant positive correlation between anxiety, depressive symptoms, and PTSD was observed. It is evident from the literature that comorbidity in mental health issues is common among adults (Liu et al., 2020). Similar clinical co-morbidity occurs in children, consistent with previous research findings (Vallance & Fernandez, 2016).
In the present study, the females were found to report higher PTSD symptoms. Literature is enriched with evidence-based studies that illustrate the same findings and report the higher PTSD prevalence among females compared to males. The lifetime prevalence of PTSD in adult females is about 10–20% and 5–6% in men (Olff, 2017; Charak et al., 2014). As far as youth and young children are concerned the cross-cultural data also illustrates the higher ratio of PTSD in females as in India boys were found to have 3.7% and girls 6.3% PTSD symptoms respectively (Kilpatrick et al., 2003). In addition, the data from Pakistan also depict that female children manifest more PTSD (67.6%) symptoms compared to boys 61.9% (Ayub et al., 2012). Furthermore, similar findings have been found in the UK, the US and Saudia Arabia (Haag et al., 2020; Sayed et al., 2021; Wamser-Nanney et al., 2018).
The above literature demonstrates the prevalence of PTSD among children from 3–18 years. The DSM-5-TR has merged the diagnostic criteria for children, adolescents and young adults still the discrepancies in the magnitude of age and gender are visible throughout literature (American Psychiatric Association, 2022). The discrepancy in the magnitude of adult females is higher perhaps due to cognitive maturity in multiple domains of life. The current study demonstrated the interesting finding that females either school children or adults experience more PTSD symptoms. Here the question arises as to why the gender difference is evident since childhood even though children are indifferent to adults. According to massive studies, the gender difference in PTSD symptoms among adult females is due to family system discrepancies, diverse coping strategies, cultural values, personality differences and stereotypes. However, literature exemplifies that primary school girls exhibit more PTSD symptoms due to neuroendocrine, hormonal and stress response systems. The socialized expression of PTSD starts from an early age (Pervanidou et al., 2017). Some contradictory findings in the literature depicted that in elementary school children, no gender difference was observed in PTSD and trauma exposure (Gonzalez et al., 2015). Cultural, cognitive abilities and individual differences can be a reason for such contradictory findings. Another reason for contradictory findings can be a replication crisis. It was observed that replication studies are showing falsification in reporting data (Hunter et al., 2017).
According to the present study on depression and anxiety, no significant gender differences were observed. However, the data from 73 countries illustrated the significant gender differences in depression, anxiety and other mental health issues who were exposed or not exposed to any traumatic events (Campbell et al., 2021). Furthermore, the data from the Netherlands, Turkey, Dutch, and Tehran, show that female adolescents and children show more depression and anxiety in response to trauma (Kösters et al., 2022; Hosseini et al., 2013). A study from Iran depicted more depressive symptoms in males compared to females in response to migration. However, on the anxiety scale, females reported more anxious feelings compared to males (Khesht-Masjedi et al., 2019). The previous data depict contradictory findings due to cultural differences. Multiple factors are responsible for female gender differences such as hormonal differences, intense experience, traumatic antecedents, cognitive development, and emotional characteristics (Kirmayer et al., 2001; Hofmann et al., 2010). In the current study, the primary school male children must have had antecedents, emotional sensitivity and intense feelings towards trauma therefore exhibiting a similar magnitude of PTSD.
Our predictive analysis showed three significant models. First, depressive symptoms were a significant predictor for PTSD symptoms in primary school children. Findings from the Marmara Epidemiological Survey which investigated 683 survivors three years after an earthquake, showed a high comorbidity of depression and PTSD (Onder et al., 2006). The study also showed that those who experience comorbid PTSD and depression exhibited notably lower rates of recovery from PTSD compared to those with PTSD alone (26.4% vs. 47.4%, respectively). The comorbidity of PTSD and Major Depressive Disorder (MDD) was linked to heightened psychological distress and more severe PTSD symptoms (Onder et al., 2006). The fear processing theory suggests that post-trauma exposure activates fear information in the memory, leading to negative emotions and increased PTSD and depression (Rauch & Foa, 2006). Shattered world assumptions challenge previous belief systems, causing reexamination and "rumination" (Janoff-Bulman, 2004). Intrusive rumination triggers unwanted negative thoughts, increasing the likelihood of mood comorbidities and depression. The network analysis further supports the role of dysphoria-related symptoms in PTSD/MDD comorbidity and suggests identification of these symptoms would be beneficial for early intervention and understanding of the development of comorbidity (Afzali et al., 2017). During COVID-19, the association of depression and PTSD was attributed to the strong connection between restricted or diminished positive emotion, restlessness, and inability to relax (Chen et al., 2021). Therefore, it was suggested that mental health programs focused on the dysphoria-related symptoms in promoting psychological well-being among children after trauma exposure.
Second, religion, family income, anxiety and PTSD were significant predictors of depressive symptoms. Literature supported the findings of the current study as literature is enriched with empirical studies that show religious affiliation, beliefs, and practices are highly interlinked with depression, anxiety, and other mental health problems (Leung & Li,2023; Forouhari et al., 2019). People who belong to different religions possess different beliefs are consistent in their practices, and were found to have good mental health. There is no single religion that depicts high mental health but how people relate to their respective religion matters more (Ramadan et al., 2021). As far as children’s religion and depression are concerned, again literature reported religion as a significant predictor of depression in different ways. Primary school children understand and somehow practice the fundamental concept of religion. They can categorize their religious beliefs and practices such as pillars of Islam and the concept of justice, patience, equality, and kindness. The lack of religious understanding and practices led to depressive symptoms among school children and not their religious affiliation (Fruehwirth et al., 2019). Empirical data demonstrated that religious practices and awareness develop healthy reactions to diverse traumatic events or stimuli, and promote religious coping mechanisms and contentedness with God (Estrada et al., 2019). Furthermore, parental religious practices such as worship, fasting, prayer, and other religious activities decrease depressive symptoms among primary school children (Kim et al., 2009). According to the social learning theory, children learn adaptive and maladaptive behaviour by observation and discrimination. Lack of parental connectivity from religion may influence children’s behaviour, manifest poor religious beliefs and learn maladaptive responses to trauma (Carone, & Barone, 2001; Huth et al., 2021). Surprisingly, in the current study, other demographics such as family income were also found to be the predictor of depression. However, the literature depicts contradictory findings regarding family income and depression. According to some studies, family income predicts depressive symptoms among adolescents (Malinauskiene & Malinauskas, 2021). Children with low socioeconomic status manifest the least mental health issues compared to those belonging to high socioeconomic status (e.g. Yang et al., 2023). Anxiety predicts depressive symptoms among primary school children. Literature also supported the current study finding as Bufferd et al. (2013) conducted a longitudinal study and reported that anxiety predicts depression among 3–6 years old children. The model also depicts that PTSD is the predictor of depression. According to the above-mentioned literature, the relationship between PTSD and depression is bidirectional. The longitudinal study (Cheng et al., 2020), shows that PTSD leads to depressive symptoms among trauma-exposed children.
Third, depressive symptoms were significant predictors for anxiety. It is known that depressive symptoms are strongly correlated with anxiety in children and adolescents (Ghazali et al., 2015). Substantial data reported a strong relationship between depression and anxiety among children who experienced traumatic events. The co-morbid symptoms of depression in anxiety and anxiety symptoms in depressive clients have been observed on a high scale (Malinauskiene & Malinauskas, 2021; Salk et al., 2017). However, the data that illustrate depression as a predictor of anxiety is limited. Only one study was observed in the literature showed some evidence that depression precedes anxiety symptoms in preschool children (Bufferd et al., 2012). Regardless of the direction of this relationship, the co-occurrence of depression and anxiety has been well-established in previous studies (e.g. Salk et al., 2017).
Limitation and Future Research Direction
The data collection and screening for traumatic events and mental health issues in primary school children were challenging. Therefore, the current study finding should be cautiously interpreted considering the following limitations. Firstly, in the current study, self-report measures were used, hence, recall bias might have occurred. Secondly, the majority of children fall in the age range of 12 years compared to 11 years of age. Therefore, the age difference doesn’t depict the other primary school children representative age disparities. A more representative sample and larger size is needed to examine the other age and other demographic differences for targeted variables. Although we only recruited 11 and 12-year-olds, this early finding can help to compare with future studies that involve other age categories. Thirdly, in this study, we did not include the diagnostic interviews with parents, teachers, and children. In the future, face-to-face diagnostic interviews should be incorporated for a prevalence study to ensure prevalence rate estimation accuracy.