Rates of Trauma Exposure, Posttraumatic Stress Disorder (PTSD), Depressive, and Anxiety Symptoms in Primary School Children: Findings Six Months before Covid-19 Pandemic

Rates of Trauma Exposure, Posttraumatic Stress Disorder (PTSD), Depressive, and Anxiety Symptoms in Primary School Children: Findings Six Months before Covid-19 Pandemic | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Rates of Trauma Exposure, Posttraumatic Stress Disorder (PTSD), Depressive, and Anxiety Symptoms in Primary School Children: Findings Six Months before Covid-19 Pandemic Siti Raudzah Ghazali, Yoke Yong Chen, Ask Elklit, Sana Rehman, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4101167/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Studies on mental health rates among primary school children are still limited particularly related to psychological trauma and its relationship to other mental health challenges. This is the first cross-sectional study examining the rates of trauma exposure, posttraumatic stress disorder (PTSD), depressive, and anxiety symptoms in primary school children before covid-19 pandemic in Malaysia. Two hundred and twenty-one students participated in this study. They were recruited from four primary schools that volunteered to participate in the study. PTSD) Checklist for DSM-5 (PCL-5), Child PTSD Symptoms Scale-5 (CPSS-5), The Center for Epidemiologic Studies Depression Scale version (CESD) and the Spence Children's Anxiety Scale (SCAS) were used to survey psychological symptoms. Most of the students, or 54.3% of them, have experienced at least one traumatic event. Of 221 students, 39.4% reported having PTSD symptoms, 38% reported having depressive symptoms and 19% reported having anxiety symptoms. Female students were more likely to report PTSD symptoms compared to male students. The first regression analysis model showed that only depressive symptoms were significant predictors for PTSD. In the second model, religion, family income, anxiety and PTSD symptoms were significant predictors of depressive symptoms. In the third model, only depressive symptoms were significant predictors of anxiety. Findings, limitations, research future directions and recommendations were discussed. Trauma PTSD Depressive Anxiety Primary school children Introduction Mental health issues in children in Malaysia and other countries have been increasing in the past few years (Idris et al., 2019, Ahmad, et al., 2014). According to the World Health Organization (WHO), one in every seven individuals aged between 10 to 19-year-olds worldwide has mental health challenges, accounting for 13% of the global disease burden in this age group (WHO, 2019). Meanwhile, the rate of mental health issues among children and adolescents in Asian countries varies from 10 to 20% (Dahlan et al., 2018). While more than half of mental health issues begin throughout childhood and adolescence (Garcia-Carrion et al., 2019), mental health cases among children have been increasing every year compared to the previous year including posttraumatic stress disorder (PTSD) (Langley et al., 2015), depression (Ghazali et al., 2015), and anxiety (Sahril et al., 2021). The most recent study showed that 11.1% of children reported having mental health issues (Sahril et al., 2021). Trauma Exposure among Children Lifetime trauma exposure has significantly affected our children (Chen et al., 2021; Ghazali et al., 2021; Ghazali et al, 2016). Globally, t rauma exposure among children and adolescents is far more prevalent than was previously believed during these few decades, affecting nearly 70% or two-thirds of this population before age 17 (Gonzalez et al., 2015; Langley et al., 2015). In 2012, the United States National Survey of Children’s Health (NSCH) (2012), comprehensively reported that one in every two children had at least one traumatic incident in their lives, 26% of children had two or more traumatic experiences by the age of four, and some children had several traumatic events (NSCH, 2012). Childhood traumatic events can be in different forms. It includes physical, emotional, or sexual abuse, neglect, accidents, natural catastrophes, or criminal crime victims (Stone & Bray, 2015). A school-based study by Gonzalez et al. (2015) reported that 34% of students from four primary schools in a southern California district experienced one or more of those traumatic events. The most frequently stated traumatic events in the study were being a witness of a family member being apprehended or deported (28%), physical violence (22%), community violence (21%), followed by a victim of physical violence (17%), and a witness of a dangerous accident (17%). Meanwhile, Verlinden et al. (2013) reported that most schooled children in the Netherlands mentioned the death of a loved one (40%), the loss of a pet (11%), and bullying (10%) as the most terrible events. Previous studies of trauma exposure are available but very limited and specific to aftermath traumatic incidents, particularly among primary school children. Multiple outcomes of traumatic experiences have been observed such as PTSD, anxiety, and depression. The recorded prevalence rate of mental health issues during the pre-COVID-19 era is listed below. PTSD Symptoms Children who suffer from trauma exposure may experience PTSD, emotional distress, terror, helplessness, or severe anxiety (Jowf et al., 2022; Stein et al., 2014). Therefore, some children might have traumatic stress even by only having a dysfunctional home life, such as staying with people who are drug dependent , mentally or physically ill, alcoholic, or having witnessed a family member being arrested. Furthermore, childhood trauma can increase the chance of developing significant clinical symptomatology even though it is not vicious nor lethal (Gonzalez et al., 2015). Following a traumatic event, children are at risk of developing PTSD. In a study conducted by Yue et al. (2022), at least 3.53% met the diagnostic criteria for PTSD. A higher prevalence of PTSD has been reported among children following earthquake trauma. In their meta-analysis study reviewing 39 earthquake disasters, Rezyat et al. (2020) found that the overall prevalence of PTSD among children and adolescent survivors after earthquakes and floods was 19.2% and 30% during the first and the second month following an earthquake. This study analyses both children and adolescent trauma and PTSD symptoms. Depressive and Anxiety Symptoms The prevalence of depression among adolescents has been documented in a few previous studies (Ghazali et al., 2015; Li et al., 2019). Patki et al. (2015) added that about 25 to 30% of those who witness a traumatic event might acquire mental disorders including depressive and PTSD symptoms. Similarly, anxiety symptoms are also frequently reported following traumatic events (WHO, 2022). The co-morbidity occurrence of PTSD symptoms and anxiety frequently occurs among adolescents (Regehr et al., 2019; Zhou et al., 2021), thereby implying that they are highly co-morbid and may contribute to other future mental disorders. Justification of the Study The literature indicates a surge in trauma exposure. As a result, children are at risk of developing and suffering from PTSD, depression, and anxiety symptoms during the preCovid-19 pandemic. However, a few gaps are observed in the literature in this regard. Primary school children have been overlooked as empirical studies regarding mental health issues in response to traumatic events in primary children are scarce. Previous studies have been depicting the prevalence rate of PTSD in high-income (Germany, Italy, Japan, Netherlands, United States, Spain, Belgium), middle-income (Mexico, Bulgaria, Romania, Sao Paulo & Brazil, China), and low-income countries (Columbia) (Stein et al., 2014; Gonzalez et al., 2015; Yue et al. 2022; Rezyat et al., 2020). Hence, the data in this regard is limited in Asian countries such as Malaysia. Ghazali et al., (2014) carried out two studies to investigate the prevalence of PTSD due to traumatic events, but the study population were adolescents. In the current study, the population is primarily children. In addition, the previous data did not illustrate the religious and race-based disparities for primary school children. Method Participants Two hundred and twenty-one students participated in this study. They were recruited from four primary schools that volunteered to participate in the study. Most of the students were males (50.7%), and Malays (64.3%) with the age of 12 years (86.9%). The inclusion criteria were children who can read English, obtained permission from a legal guardian or parents, and voluntarily participated in the study to ensure their willingness and cooperation during the data collection. The remaining sociodemographic characteristics are shown in Table 1 . Table 1 Sociodemographic characteristics of the participants ( N = 319) Socio-demographic characteristics n % Gender Male 112 50.7 Female 109 49.3 Age 11 years old 29 13.1 12 years old 192 86.9 Religion Islam 157 71.0 Christian 58 26.2 Buddhist 3 1.4 Hinduism 2 0.9 Race Malay 142 64.3 Iban 27 12.2 Bidayuh 26 11.8 Chinese 8 3.6 Indian 3 1.4 Others 15 6.8 The Order of Child Oldest 61 27.6 Middle 68 30.8 Youngest 66 29.9 Adopted 2 0.9 Design This study adopted a cross-sectional research design to capture lifetime trauma exposure, symptoms of PTSD, depressive symptoms, and anxiety symptoms in children. Data was collected between January to June 2019. Measures Sociodemographic. This section reports some sociodemographic information of the participants. Items such as gender, age, family income, religion, ethnicity, name of the school, parental education, and the number of siblings are included in this section. Trauma exposure. Trauma exposures were measured by Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) (Weathers et al., 2013 ). PCL-5 consists of a list of traumatic events that might occur in the children’s life. A list of potentially traumatic events was listed including natural disasters, car accidents, robbery, and a few other established traumatic events in DSM-5. Children are required to respond if they have gone through any of the listed traumatic events in their lives. PTSD Symptoms. PTSD symptoms were measured by the Child PTSD Symptoms Scale-5 (CPSS-5) (Foa et al., 2017 ). The CPSS-5 is a 27-item self-report questionnaire that assesses PTSD DSM-5 diagnosis and symptom severity in the past month. It includes the 20 items assessing DSM-5 PTSD symptoms. Children would rate each item from 0 (not at all) to 4 (6 or more times a week/almost always) based on the frequency and severity of the reported symptom experienced in the past month related to the index traumatic event. The total severity score ranges from 0 to 80 and is calculated by summing the ratings of the first 20 items. The CPSS-5 also yields subscale scores for intrusion (Items 1–5), avoidance (Items 6–7), changes in cognition and mood (Items 8–14), and increased arousal and reactivity (Items 15–20). Seven items assess impairment of endorsed symptoms on daily functioning pertinent to youth (e.g., fun things you want to do). The children would rate these items on a scale of 0 (not at all) to 4 (6 or more times a week/almost always), resulting in an impairment score that ranges from 0 to 28. The total impairment score does not contribute to the overall severity score. ROC analysis was conducted for the CPSS-5-SR severity score based on the CPSS-5 diagnosis. A score of 30.5 or higher on the CPSS-5-SR was associated with high sensitivity (.93) and specificity (.82) for a probable diagnosis of PTSD. Thus, a score of 31 can be used as a cutoff point for identifying a probable PTSD diagnosis. In this study, the internal consistency of CPSS-5 was high, α = .923. Depressive symptoms. The Center for Epidemiologic Studies Depression Scale version (CESD) (Radloff, 1977 ) was used for screening depression among school children. It contains 20 items with a scale to measure symptoms of depression in nine different groups as defined by the American Psychiatric Association Diagnostic and Statistical Manual, fifth edition (Eaton et al., 2012 ; Van Dam & Earleywine, 2011 ). A total sum of the scores is calculated based on the 20 questions asked. CESD is rated on a four-point scale ranging from 0 (rarely or none of the time) to 3 (most or all of the time). Total scores ranging from 0 to 60 or higher scores indicate a greater risk of depression. For the Malaysian population, a score of 27 or above is considered to be indicative of clinically significant depressive symptoms (Ghazali et al. 2014 ). The internal consistency of this questionnaire in this study was α = .888. Anxiety symptoms. The Spence Children's Anxiety Scale (SCAS) (Spence et al., 2003 ) was used to screen levels of anxiety among school children. The SCAS is a self-report measure of anxiety symptoms in children and adolescents initially developed with community samples (Spence et al., 2003 ). SCAS is a 44-item with six positive filler items. This self-reported scale responded using a 0 (never) to 3 (always) point scale. This scale consists of six subscales assessing specific anxiety disorders, social phobia, panic disorder, agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, separation anxiety disorder, and specific phobias. The internal consistency of this questionnaire in this study was α = .882. Procedure & Ethical Permission This study was reviewed and approved by the Faculty of Medicine and Health Sciences Ethics Committee with reference number: UNIMAS/NC/-21.02/03-0.2 Jld 2 (11) Analysis The total and mean scores for trauma exposure, PTSD, depressive symptoms, and anxiety symptoms scores were calculated through descriptive analyses. Pearson correlation was used to establish a relationship between variables. An independent t -test was used to analyze the significant difference in reporting sex difference scores for PTSD, depressive and anxiety symptoms. Finally, univariate analysis of variance (ANOVA) was used to analyze if trauma exposure is related to PTSD and depressive symptoms. Results Most of the students, 54.3% of them, have experienced at least one traumatic event. Approximately (16.3%) experienced almost drowning, followed by bully incidents (10.4%), severe physical illness (5.9%), car accidents (5.4%), death of someone close (5%) and almost being killed or injured (3.6%). Of 221 students, 39.4% ( n = 87) reported having PTSD symptoms when using PCL-5 ≥ 33 cut-off score. Of 221 students, 38% ( n = 84) reported having depressive symptoms when using the CESDR cut-off score of 27. Of 221 students, 19% ( n = 42) reported having anxiety symptoms when using the Spencer Child Anxiety Scale. PTSD is significantly correlated with depressive symptoms, r = 0.644, n = 221, p < 0.001. Similarly, PTSD is also significantly correlated with anxiety symptoms, r = 0.534, n = 221, p < 0.001. Both anxiety and depressive symptoms are significantly correlated, r = 0.643, n = 221, p < 0.001. Independent t-test showed that there was a significant gender difference in reporting PTSD symptoms, t (219) = 2.03, p < .05. Female students ( M = 30.10, SD = 16.52) were more likely to report PTSD symptoms compared to male students ( M = 25.21, SD = 19.15). There was no significant gender association between anxiety and depressive symptoms. A regression analysis examining the relationship between PTSD symptoms, socio-demographic data and other psychological symptoms was conducted. The model accounted for a significant amount of variance in PTSD scores ( R ² = .52, F (8, 35) = 4.68, p < .001) with only depressive symptoms a significant predictor for the model, t = 2.69, p < .05. The model accounted for a significant amount of variance in depressive symptoms scores ( R ² = .66, F (8, 35) = 8.65, p < .001). Religion, family income, and total anxiety and PTSD scores were significant predictors for depressive symptoms, t = 2.16, p < .05, t = 2.16, p < .05, t = 3.34, p < .05 and t = 2.69, p < .05 respectively. Similarly, the model accounted for a significant amount of variance in anxiety scores ( R ² = .56, F (8, 35) = 5.56, p < .001) with only depressive symptoms a significant predictor for the model, t = 3.34, p <. 05. Discussion 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. Conclusion The study has found that primary school children in Sarawak experience substantial amounts of trauma exposure, PTSD, depression, and anxiety symptoms in response to traumatic events. The surge was higher in the pre-COVID-19 era. However, during the first and second phases of COVID-19, primary children's mental health issues in Malaysia so far remain overlooked. The preventative measures and therapeutic interventions are limited for primary school children. Future studies should be conducted to document the prevalence rate particularly related to the pandemic of Covid-19. Declarations Ethical Approval This study was reviewed and approved by the Faculty of Medicine and Health Sciences Ethics Committee with reference number: UNIMAS/NC/-21.02/03-0.2 Jld 2 (11). All participants were given consent to participate and publish. Funding Funding for this study was provided to Siti Raudzah Ghazali, Universiti Malaysia Sarawak by the National Center of Psychotraumatology, the University of Southern Denmark for a Grant entitled “PTSD, Trauma Exposure Among Primary School in Sarawak” with the grant number of GL/F05/PTSD/2018 05 and the finance reference number of FA052000-0706-0003. Availability of data and materials Not applicable Disclaimer This article has not been published elsewhere and has not also been submitted simultaneously for publication elsewhere and there is no conflict of interest. Acknowledgement Funding for this study was provided to Siti Raudzah Ghazali, Universiti Malaysia Sarawak by the National Center of Psychotraumatology, the University of Southern Denmark for a Grant entitled “PTSD, Trauma Exposure Among Primary School in Sarawak” with the grant number of GL/F05/PTSD/2018 05 and the finance reference number of FA052000-0706-0003. 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Anxiety, depression and PTSD among children and their parent during 2019 novel coronavirus disease (COVID-19) outbreak in China, Current Psychology, 4 1, 5723–5730. https://doi.org/10.1007/s12144-020-01191-4 Zhou, Y. G., Shang, Z. L., Zhang, F., Wu, L. L., Sun, L. N., Jia, Y. P., Yu, H. B., & Liu, W. Z. (2021). PTSD: Past, present and future implications for China. Chinese journal of traumatology = Zhonghua chuang shang za zhi , 24 (4), 187–208. https://doi.org/10.1016/j.cjtee.2021.04.011. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4101167","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":280218624,"identity":"163c88ad-928b-47f9-b511-758739795d08","order_by":0,"name":"Siti Raudzah Ghazali","email":"","orcid":"","institution":"Universiti Malaysia Sarawak","correspondingAuthor":false,"prefix":"","firstName":"Siti","middleName":"Raudzah","lastName":"Ghazali","suffix":""},{"id":280218626,"identity":"5f21cb6b-335b-4e83-b5b7-145cde0623e2","order_by":1,"name":"Yoke Yong Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAr0lEQVRIiWNgGAWjYHACNiC2YWBgJlFLGulaDpOg3uBG8rMHH3ecT9zOzp348QfDtsQGwlrSzA1nnrmduLOZd7M0D8NtYrTksEnztt1O3HCYd4M0A9Fa/radA2nZ/PMH0VoY2w6AtGyTIMphkmeemUn2tiUbg7RY8xjcNiaohe948jOJn212shvOn91880fFbVmCWhQuJKC4k8GRoBb5/gOoAvaEdIyCUTAKRsHIAwAuRUQpCxWn8wAAAABJRU5ErkJggg==","orcid":"","institution":"Universiti Malaysia Sarawak","correspondingAuthor":true,"prefix":"","firstName":"Yoke","middleName":"Yong","lastName":"Chen","suffix":""},{"id":280218628,"identity":"35dfb02a-3b5b-4313-bd8a-1e5b4f869305","order_by":2,"name":"Ask Elklit","email":"","orcid":"","institution":"University of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Ask","middleName":"","lastName":"Elklit","suffix":""},{"id":280218629,"identity":"7a427813-9b36-4a2e-9120-1257357a2c9a","order_by":3,"name":"Sana Rehman","email":"","orcid":"","institution":"Universiti Malaysia Sarawak","correspondingAuthor":false,"prefix":"","firstName":"Sana","middleName":"","lastName":"Rehman","suffix":""},{"id":280218630,"identity":"ab4abda4-eb1f-42b7-8e67-32077fb74a7f","order_by":4,"name":"Ai Ling Ang","email":"","orcid":"","institution":"Universiti Malaysia Sarawak","correspondingAuthor":false,"prefix":"","firstName":"Ai","middleName":"Ling","lastName":"Ang","suffix":""}],"badges":[],"createdAt":"2024-03-14 13:21:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4101167/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4101167/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53332449,"identity":"71e5d3ca-e548-451d-8ec2-adc4fa8713ce","added_by":"auto","created_at":"2024-03-24 11:37:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":333197,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4101167/v1/4bea4f8b-6b2f-40d3-91b2-10ee286aa2c8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rates of Trauma Exposure, Posttraumatic Stress Disorder (PTSD), Depressive, and Anxiety Symptoms in Primary School Children: Findings Six Months before Covid-19 Pandemic","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental health issues in children in Malaysia and other countries have been increasing in the past few years (Idris et al., 2019, Ahmad, et al., 2014). According to the World Health Organization (WHO), one in every seven individuals aged between 10 to 19-year-olds worldwide has mental health challenges, accounting for 13% of the global disease burden in this age group (WHO, 2019). Meanwhile, the rate of mental health issues among children and adolescents in Asian countries varies from 10 to 20% (Dahlan et al., 2018). While more than half of mental health issues begin throughout childhood and adolescence (Garcia-Carrion et al., 2019), mental health cases among children have been increasing every year compared to the previous year including posttraumatic stress disorder (PTSD) (Langley et al., 2015), depression (Ghazali et al., 2015), and anxiety (Sahril et al., 2021). The most recent study showed that 11.1% of children reported having mental health issues (Sahril et al., 2021). \u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrauma Exposure among Children\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLifetime trauma exposure has significantly affected our children (Chen et al., 2021; Ghazali et al., 2021; Ghazali et al, 2016). Globally,\u003cstrong\u003e t\u003c/strong\u003erauma exposure among children and adolescents is far more prevalent than was previously believed during these few decades, affecting nearly 70% or two-thirds of this population before age 17 (Gonzalez et al., 2015; Langley et al., 2015). In 2012, the United States National Survey of Children\u0026rsquo;s Health (NSCH) (2012), comprehensively reported that one in every two children had at least one traumatic incident in their lives, 26% of children had two or more traumatic experiences by the age of four, and some children had several traumatic events (NSCH, 2012). Childhood traumatic events can be in different forms. It includes physical, emotional, or sexual abuse, neglect, accidents, natural catastrophes, or criminal crime victims (Stone \u0026amp; Bray, 2015). A school-based study by Gonzalez et al. (2015) reported that 34% of students from four primary schools in a southern California district experienced one or more of those traumatic events. The most frequently stated traumatic events in the study were being a witness of a family member being apprehended or deported (28%), physical violence (22%), community violence (21%), followed by a victim of physical violence (17%), and a witness of a dangerous accident (17%). Meanwhile, Verlinden et al. (2013) reported that most schooled children in the Netherlands mentioned the death of a loved one (40%), the loss of a pet (11%), and bullying (10%) as the most terrible events. Previous studies of trauma exposure are available but very limited and specific to aftermath traumatic incidents, particularly among primary school children. Multiple outcomes of traumatic experiences have been observed such as PTSD, anxiety, and depression. The recorded prevalence rate of mental health issues during the pre-COVID-19 era is listed below. \u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePTSD Symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChildren who suffer from trauma exposure may experience PTSD, emotional distress, terror, helplessness, or severe anxiety (Jowf et al., 2022; Stein et al., 2014). Therefore, some children might have traumatic stress even by only having a dysfunctional home life, such as staying with people who are drug dependent\u003cstrong\u003e, \u003c/strong\u003ementally or physically ill, alcoholic, or having witnessed a family member being arrested. Furthermore, childhood trauma can increase the chance of developing significant clinical symptomatology even though it is not vicious nor lethal (Gonzalez et al., 2015). \u003c/p\u003e\n\u003cp\u003eFollowing a traumatic event, children are at risk of developing PTSD. In a study conducted by Yue et al. (2022), at least 3.53% met the diagnostic criteria for PTSD. A higher prevalence of PTSD has been reported among children following earthquake trauma. In their meta-analysis study reviewing 39 earthquake disasters, Rezyat et al. (2020) found that the overall prevalence of PTSD among children and adolescent survivors after earthquakes and floods was 19.2% and 30% during the first and the second month following an earthquake. This study analyses both children and adolescent trauma and PTSD symptoms. \u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepressive and Anxiety Symptoms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe prevalence of depression among adolescents has been documented in a few previous studies (Ghazali et al., 2015; Li et al., 2019). Patki et al. (2015) added that about 25 to 30% of those who witness a traumatic event might acquire mental disorders including depressive and PTSD symptoms. Similarly, anxiety symptoms are also frequently reported following traumatic events (WHO, 2022). The co-morbidity occurrence of PTSD symptoms and anxiety frequently occurs among adolescents (Regehr et al., 2019; Zhou et al., 2021), thereby implying that they are highly co-morbid and may contribute to other future mental disorders. \u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJustification of the Study \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe literature indicates a surge in trauma exposure. As a result, children are at risk of developing and suffering from PTSD, depression, and anxiety symptoms during the preCovid-19 pandemic. However, a few gaps are observed in the literature in this regard. Primary school children have been overlooked as empirical studies regarding mental health issues in response to traumatic events in primary children are scarce. Previous studies have been depicting the prevalence rate of PTSD in high-income (Germany, Italy, Japan, Netherlands, United States, Spain, Belgium), middle-income (Mexico, Bulgaria, Romania, Sao Paulo \u0026amp; Brazil, China), and low-income countries (Columbia) (Stein et al., 2014; Gonzalez et al., 2015; Yue et al. 2022; Rezyat et al., 2020). Hence, the data in this regard is limited in Asian countries such as Malaysia. Ghazali et al., (2014) carried out two studies to investigate the prevalence of PTSD due to traumatic events, but the study population were adolescents. In the current study, the population is primarily children. In addition, the previous data did not illustrate the religious and race-based disparities for primary school children. \u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eTwo hundred and twenty-one students participated in this study. They were recruited from four primary schools that volunteered to participate in the study. Most of the students were males (50.7%), and Malays (64.3%) with the age of 12 years (86.9%). The inclusion criteria were children who can read English, obtained permission from a legal guardian or parents, and voluntarily participated in the study to ensure their willingness and cooperation during the data collection. The remaining sociodemographic characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of the participants (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;319)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocio-demographic characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e11 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChristian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuddhist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHinduism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003cp\u003eMalay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBidayuh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChinese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe Order of Child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOldest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYoungest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdopted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThis study adopted a cross-sectional research design to capture lifetime trauma exposure, symptoms of PTSD, depressive symptoms, and anxiety symptoms in children. Data was collected between January to June 2019.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMeasures\u003c/h2\u003e \u003cp\u003e \u003cb\u003eSociodemographic.\u003c/b\u003e This section reports some sociodemographic information of the participants. Items such as gender, age, family income, religion, ethnicity, name of the school, parental education, and the number of siblings are included in this section.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTrauma exposure.\u003c/b\u003e Trauma exposures were measured by Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) (Weathers et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). PCL-5 consists of a list of traumatic events that might occur in the children\u0026rsquo;s life. A list of potentially traumatic events was listed including natural disasters, car accidents, robbery, and a few other established traumatic events in DSM-5. Children are required to respond if they have gone through any of the listed traumatic events in their lives.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePTSD Symptoms.\u003c/b\u003e PTSD symptoms were measured by the Child PTSD Symptoms Scale-5 (CPSS-5) (Foa et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The CPSS-5 is a 27-item self-report questionnaire that assesses PTSD DSM-5 diagnosis and symptom severity in the past month. It includes the 20 items assessing DSM-5 PTSD symptoms. Children would rate each item from 0 (not at all) to 4 (6 or more times a week/almost always) based on the frequency and severity of the reported symptom experienced in the past month related to the index traumatic event. The total severity score ranges from 0 to 80 and is calculated by summing the ratings of the first 20 items. The CPSS-5 also yields subscale scores for intrusion (Items 1\u0026ndash;5), avoidance (Items 6\u0026ndash;7), changes in cognition and mood (Items 8\u0026ndash;14), and increased arousal and reactivity (Items 15\u0026ndash;20). Seven items assess impairment of endorsed symptoms on daily functioning pertinent to youth (e.g., fun things you want to do). The children would rate these items on a scale of 0 (not at all) to 4 (6 or more times a week/almost always), resulting in an impairment score that ranges from 0 to 28. The total impairment score does not contribute to the overall severity score. ROC analysis was conducted for the CPSS-5-SR severity score based on the CPSS-5 diagnosis. A score of 30.5 or higher on the CPSS-5-SR was associated with high sensitivity (.93) and specificity (.82) for a probable diagnosis of PTSD. Thus, a score of 31 can be used as a cutoff point for identifying a probable PTSD diagnosis. In this study, the internal consistency of CPSS-5 was high, α\u0026thinsp;=\u0026thinsp;.923.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDepressive symptoms.\u003c/b\u003e The Center for Epidemiologic Studies Depression Scale version (CESD) (Radloff, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e1977\u003c/span\u003e) was used for screening depression among school children. It contains 20 items with a scale to measure symptoms of depression in nine different groups as defined by the American Psychiatric Association Diagnostic and Statistical Manual, fifth edition (Eaton et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Van Dam \u0026amp; Earleywine, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). A total sum of the scores is calculated based on the 20 questions asked. CESD is rated on a four-point scale ranging from 0 (rarely or none of the time) to 3 (most or all of the time). Total scores ranging from 0 to 60 or higher scores indicate a greater risk of depression. For the Malaysian population, a score of 27 or above is considered to be indicative of clinically significant depressive symptoms (Ghazali et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The internal consistency of this questionnaire in this study was α\u0026thinsp;=\u0026thinsp;.888.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAnxiety symptoms.\u003c/b\u003e The Spence Children's Anxiety Scale (SCAS) (Spence et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) was used to screen levels of anxiety among school children. The SCAS is a self-report measure of anxiety symptoms in children and adolescents initially developed with community samples (Spence et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). SCAS is a 44-item with six positive filler items. This self-reported scale responded using a 0 (never) to 3 (always) point scale. This scale consists of six subscales assessing specific anxiety disorders, social phobia, panic disorder, agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, separation anxiety disorder, and specific phobias. The internal consistency of this questionnaire in this study was α\u0026thinsp;=\u0026thinsp;.882.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eProcedure \u0026amp; Ethical Permission\u003c/h2\u003e \u003cp\u003e This study was reviewed and approved by the Faculty of Medicine and Health Sciences Ethics Committee with reference number: UNIMAS/NC/-21.02/03-0.2 Jld 2 (11)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eThe total and mean scores for trauma exposure, PTSD, depressive symptoms, and anxiety symptoms scores were calculated through descriptive analyses. Pearson correlation was used to establish a relationship between variables. An independent \u003cem\u003et\u003c/em\u003e-test was used to analyze the significant difference in reporting sex difference scores for PTSD, depressive and anxiety symptoms. Finally, univariate analysis of variance (ANOVA) was used to analyze if trauma exposure is related to PTSD and depressive symptoms.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eMost of the students, 54.3% of them, have experienced at least one traumatic event. Approximately (16.3%) experienced almost drowning, followed by bully incidents (10.4%), severe physical illness (5.9%), car accidents (5.4%), death of someone close (5%) and almost being killed or injured (3.6%).\u003c/p\u003e \u003cp\u003eOf 221 students, 39.4% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;87) reported having PTSD symptoms when using PCL-5\u0026thinsp;\u0026ge;\u0026thinsp;33 cut-off score. Of 221 students, 38% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;84) reported having depressive symptoms when using the CESDR cut-off score of 27. Of 221 students, 19% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;42) reported having anxiety symptoms when using the Spencer Child Anxiety Scale.\u003c/p\u003e \u003cp\u003ePTSD is significantly correlated with depressive symptoms, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.644, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;221, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Similarly, PTSD is also significantly correlated with anxiety symptoms, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.534, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;221, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Both anxiety and depressive symptoms are significantly correlated, \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.643, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;221, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003eIndependent t-test showed that there was a significant gender difference in reporting PTSD symptoms, \u003cem\u003et\u003c/em\u003e (219)\u0026thinsp;=\u0026thinsp;2.03, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05. Female students (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30.10, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16.52) were more likely to report PTSD symptoms compared to male students (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25.21, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;19.15). There was no significant gender association between anxiety and depressive symptoms.\u003c/p\u003e \u003cp\u003eA regression analysis examining the relationship between PTSD symptoms, socio-demographic data and other psychological symptoms was conducted. The model accounted for a significant amount of variance in PTSD scores (\u003cem\u003eR\u003c/em\u003e\u0026sup2; = .52, \u003cem\u003eF\u003c/em\u003e(8, 35)\u0026thinsp;=\u0026thinsp;4.68, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) with only depressive symptoms a significant predictor for the model, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.69, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e \u003cp\u003eThe model accounted for a significant amount of variance in depressive symptoms scores (\u003cem\u003eR\u003c/em\u003e\u0026sup2; = .66, \u003cem\u003eF\u003c/em\u003e(8, 35)\u0026thinsp;=\u0026thinsp;8.65, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Religion, family income, and total anxiety and PTSD scores were significant predictors for depressive symptoms, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.16, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.16, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.34, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05 and \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.69, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05 respectively. Similarly, the model accounted for a significant amount of variance in anxiety scores (\u003cem\u003eR\u003c/em\u003e\u0026sup2; = .56, \u003cem\u003eF\u003c/em\u003e(8, 35)\u0026thinsp;=\u0026thinsp;5.56, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) with only depressive symptoms a significant predictor for the model, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.34, \u003cem\u003ep\u003c/em\u003e \u0026lt;. 05.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe 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, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). However, humiliation was also found to be a significant traumatic event in adolescents' lives at Sarawak (Ghazali et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). 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., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eResearch 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 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) study. One of the reasons is that the current study focused on primary school children (aged 11\u0026ndash;12 years old), while Ghazali et al (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) studied older children (aged 13 to 17 years old). However, the current findings are consistent with the study conducted by Yue et al. (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) 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\u0026rsquo;s overrating tendency to deal with their emotional experiences.\u003c/p\u003e \u003cp\u003eThe 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., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Patki et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Regehr et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; WHO, 2022; Zhou et al., \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). 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., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Solmi et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). 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., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Last et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e1996\u003c/span\u003e), as well as other factors influencing developmental trajectories of anxiety symptoms, such as behavioural inhibition and internalizing symptoms (Broeren et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). 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., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Similar clinical co-morbidity occurs in children, consistent with previous research findings (Vallance \u0026amp; Fernandez, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 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\u0026ndash;20% and 5\u0026ndash;6% in men (Olff, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Charak et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). 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., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). 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., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Furthermore, similar findings have been found in the UK, the US and Saudia Arabia (Haag et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Sayed et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Wamser-Nanney et al., 2018).\u003c/p\u003e \u003cp\u003eThe above literature demonstrates the prevalence of PTSD among children from 3\u0026ndash;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, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). 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., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). 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., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). 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).\u003c/p\u003e \u003cp\u003eAccording 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., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). 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 (K\u0026ouml;sters et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; 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., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). 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., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). 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.\u003c/p\u003e \u003cp\u003eOur 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., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). 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., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). 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 \u0026amp; Foa, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Shattered world assumptions challenge previous belief systems, causing reexamination and \"rumination\" (Janoff-Bulman, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). 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., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). 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., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Therefore, it was suggested that mental health programs focused on the dysphoria-related symptoms in promoting psychological well-being among children after trauma exposure.\u003c/p\u003e \u003cp\u003eSecond, 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 \u0026amp; Li,2023; Forouhari et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). 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., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). As far as children\u0026rsquo;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., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Furthermore, parental religious practices such as worship, fasting, prayer, and other religious activities decrease depressive symptoms among primary school children (Kim et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). 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\u0026rsquo;s behaviour, manifest poor religious beliefs and learn maladaptive responses to trauma (Carone, \u0026amp; Barone, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Huth et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). 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 \u0026amp; Malinauskas, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Children with low socioeconomic status manifest the least mental health issues compared to those belonging to high socioeconomic status (e.g. Yang et al., \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). 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\u0026ndash;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.\u003c/p\u003e \u003cp\u003eThird, 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 \u0026amp; Malinauskas, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Salk et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). 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., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). 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., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitation and Future Research Direction\u003c/h2\u003e \u003cp\u003eThe 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\u0026rsquo;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.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study has found that primary school children in Sarawak experience substantial amounts of trauma exposure, PTSD, depression, and anxiety symptoms in response to traumatic events. The surge was higher in the pre-COVID-19 era. However, during the first and second phases of COVID-19, primary children's mental health issues in Malaysia so far remain overlooked. The preventative measures and therapeutic interventions are limited for primary school children. Future studies should be conducted to document the prevalence rate particularly related to the pandemic of Covid-19.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Faculty of Medicine and Health Sciences Ethics Committee with reference number: UNIMAS/NC/-21.02/03-0.2 Jld 2 (11). All participants were given consent to participate and publish.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study was provided to Siti Raudzah Ghazali, Universiti Malaysia Sarawak by the National Center of Psychotraumatology, the University of Southern Denmark for a Grant entitled \u0026ldquo;PTSD, Trauma Exposure Among Primary School in Sarawak\u0026rdquo; with the grant number of \u0026nbsp; GL/F05/PTSD/2018 05 and the finance reference number of FA052000-0706-0003. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDisclaimer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article has not been published elsewhere and has not also been submitted simultaneously for publication elsewhere and there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study was provided to Siti Raudzah Ghazali, Universiti Malaysia Sarawak by the National Center of Psychotraumatology, the University of Southern Denmark for a Grant entitled \u0026ldquo;PTSD, Trauma Exposure Among Primary School in Sarawak\u0026rdquo; with the grant number of \u0026nbsp; GL/F05/PTSD/2018 05 and the finance reference number of FA052000-0706-0003. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors were deeply involved in the conceptualization and design of this study. Siti Raudzah Ghazali and Yoke Yong Chen led the sample size determination, sampling approach, data collection and data analysis. All authors contributed to manuscript writing, and editing and ultimately approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAfzali, M. H., Sunderland, M., Batterham, P. J., Carragher, N., Calear, A., \u0026amp; Slade, T. (2017). Network approach to the symptom-level association between alcohol use disorder and posttraumatic stress disorder. Social Psychiatry and Psychiatric Epidemiology, 52(3), 329\u0026ndash;339. https://doi.org/10.1007/s00127-016-1331-3.\u003c/li\u003e\n\u003cli\u003eAhmad, N. A., Muhd Yusoff, F., Ratnasingam, S.; Mohamed, F., Nasir, N. H., \u003c/li\u003e\n\u003cli\u003eMohd Sallehuddin, S., Mahadir Naidu, B., Ismail, R., Aris, T. (2014). 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PTSD: Past, present and future implications for China. \u003cem\u003eChinese journal of traumatology = Zhonghua chuang shang za zhi\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(4), 187\u0026ndash;208. https://doi.org/10.1016/j.cjtee.2021.04.011.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Trauma, PTSD, Depressive, Anxiety, Primary school children","lastPublishedDoi":"10.21203/rs.3.rs-4101167/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4101167/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Studies on mental health rates among primary school children are still limited particularly related to psychological trauma and its relationship to other mental health challenges. This is the first cross-sectional study examining the rates of trauma exposure, posttraumatic stress disorder (PTSD), depressive, and anxiety symptoms in primary school children before covid-19 pandemic in Malaysia. Two hundred and twenty-one students participated in this study. They were recruited from four primary schools that volunteered to participate in the study. PTSD) Checklist for DSM-5 (PCL-5), Child PTSD Symptoms Scale-5 (CPSS-5), The Center for Epidemiologic Studies Depression Scale version (CESD) and the Spence Children's Anxiety Scale (SCAS) were used to survey psychological symptoms. Most of the students, or 54.3% of them, have experienced at least one traumatic event. Of 221 students, 39.4% reported having PTSD symptoms, 38% reported having depressive symptoms and 19% reported having anxiety symptoms. Female students were more likely to report PTSD symptoms compared to male students. The first regression analysis model showed that only depressive symptoms were significant predictors for PTSD. In the second model, religion, family income, anxiety and PTSD symptoms were significant predictors of depressive symptoms. In the third model, only depressive symptoms were significant predictors of anxiety. Findings, limitations, research future directions and recommendations were discussed.","manuscriptTitle":"Rates of Trauma Exposure, Posttraumatic Stress Disorder (PTSD), Depressive, and Anxiety Symptoms in Primary School Children: Findings Six Months before Covid-19 Pandemic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-19 15:16:44","doi":"10.21203/rs.3.rs-4101167/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"55b5abb3-e5f8-4f41-8715-6cacef281cbe","owner":[],"postedDate":"March 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-24T11:29:45+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-19 15:16:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4101167","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4101167","identity":"rs-4101167","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}