The role of environmental sensitivity in post-traumatic stress symptoms in Lebanese children and adolescents.

Children differ substantially in their sensitivity to the quality of their environment. Some are more sensitive and more likely to develop Post-Traumatic Stress Disorder (PTSD) in response to Childhood Adversities (CAs), but might also benefit more from Positive Home Experiences (PHE). The aim of this study is to investigate the role of Environmental Sensitivity (ES), CAs and PHEs in PTSD development in children and adolescents. Data was collected from N = 2,569 children/adolescents. PTSD symptoms, CAs, PHEs and ES were assessed with self-report measures. We found that higher ES and CAs emerged as risk factors for PTSD development whereas higher levels of PHEs protected against PTSD. ES moderated the effects of CAs (ß = 1.08, p < .001) on PTSD symptoms in the total sample. This moderating effect was more pronounced in girls, suggesting that highly sensitive girls with high childhood adversities were more likely to have higher PTSD symptoms than girls with low levels of sensitivity (ß = 1.09, p < .001). In conclusion, Environmental Sensitivity played an important role as a risk factor for PTSD and as a moderating factor that accentuated the main effects of childhood adversities, particularly in girls.

The role of affective temperaments in bipolar disorder: The solid role of the cyclothymic, the contentious role of the hyperthymic, and the neglected role of the irritable temperaments.

BACKGROUND: The aim of the present study is to evaluate the role of individual affective temperaments as clinical predictors of bipolarity in the clinical setting. METHODS: The affective temperaments of 1723 consecutive adult outpatients presenting for various symptoms to a university-based mental health clinical setting were assessed. Patients were administered the Hypomania Checklist-32 and the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego - Auto-questionnaire (TEMPS-A) and were diagnosed by psychiatrists according to the DSM-5 criteria. TEMPS-A scores were studied as both continuous and normalized categorical z-scores from a previously established nationwide study on the general population of Lebanon. Simple and multiple binary logistic regressions were done on patients who have any of the DSM-5 defined bipolar types, as a combined group or separately, versus patients without any bipolar diagnosis. RESULTS: At the multivariable level and taking into account all temperaments, the irritable temperament is a consistent predictor of bipolar I and bipolar II disorders. Cyclothymic temperament also played a strong role in bipolarity but more decisively so in bipolar II and substance-induced bipolarity. The hyperthymic temperament had no role in bipolar I or bipolar II disorder.

War exposure, post-traumatic stress symptoms and hair cortisol concentrations in Syrian refugee children.

Altered secretion of cortisol, the primary effector of the hypothalamus-pituitary-adrenal axis, has been proposed as a means by which traumatic experiences compromise later mental health. However, despite the popularity of cortisol as a potential biomarker for stress and adversity, findings are inconsistent, and little is known about the impact of war-related trauma on stress physiology of children and adolescents. Here we aimed to evaluate the relationships between war exposure, current living conditions, hair cortisol concentrations (HCC) and post-traumatic stress disorder (PTSD) symptoms in a large cohort of Syrian refugee children and adolescents (6-18 years) and their caregiver. This longitudinal observational study assessed Syrian refugee children and adolescents in two waves, 1 year apart, within informal tented settlements in Lebanon. The relationships between war exposure, time since leaving Syria, PTSD symptoms and HCC were investigated using linear mixed-model regression utilising both waves of data collected (Y1: N = 1574, Y2: N = 923). Hair cortisol concentration was positively, but weakly associated with the number of war-related events experienced. This was limited to those who were at least 12 years old at the time of war exposure. Conversely, HCC decreased with time since leaving Syria. HCC was also associated with PTSD symptoms but not with the quality of their current living conditions. This study revealed that changes to hypothalamic-pituitary-adrenal axis activity may accompany both earlier war exposure and current PTSD symptoms in children and adolescents. Additionally, early adolescence may be a particularly sensitive time in terms of trauma-related changes to the hypothalamic-pituitary-adrenal axis.

The culturally and contextually sensitive assessment of mental health using a structured diagnostic interview (MINI Kid) for Syrian refugee children and adolescents in Lebanon: Challenges and solutions.

Elevated rates of mental health difficulties are frequently reported in conflict-affected and displaced populations. Even with advances in improving the validity and reliability of measures, our knowledge of the performance of assessment tools is often limited by a lack of contextualization to specific populations and socio-political settings. This reflective article aimed to review challenges and share lessons learned from the process of administering and supervising a structured clinical interview. We administered the MINI International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) and used the Clinical Global Impression (CGI) severity scale with N = 119 Syrian refugee children (aged 8-17) resident in ITSs in Lebanon. Qualitative data were derived from supervision process notes on challenges that arose during assessments, analyzed for thematic content. Five themes were identified: (1) practical and logistical challenges (changeable nature of daily life, competing demands, access to phones, temporary locations, limited referral options); (2) validity (lack of privacy, trust, perceptions of mental health, stigma, false positive answers); (3) cultural norms and meaning (impact of different meanings on answers); (4) contextual norms (reactive and adaptive emotional and behavioral responses to contextual stress); and (5) co-morbidity and formulation (interconnected and complex presentations). The findings suggest that while structured assessments have major advantages, cultural and contextual sensitivity during assessments, addressing practical barriers to improving accessibility, and consideration for inter-connected formulations are essential to help inform prevalence rates, treatment plans, and public health strategies.

Predictors of psychological risk and resilience among Syrian refugee children.

OBJECTIVES: War-exposed refugee children are at elevated risk for mental health problems, but a notable proportion appear resilient. We aimed to investigate the proportion of Syrian refugee children who can be considered resilient, and applied a novel approach to identify factors predicting individual differences in mental health outcomes following war exposure. METHODS: The sample included 1,528 war-exposed Syrian refugee children and their primary caregiver living in refugee settlements in Lebanon. Children were classed as having low symptoms (LS) if they scored below clinically validated cut-offs for post-traumatic stress disorder (PTSD), depression and externalising behaviour problems. Children scoring above any cut-off were classified as having high symptoms (HS). Each LS child was matched with one HS who reported similar war exposure, to test what differentiates children with similar exposures but different outcomes. RESULTS: 19.3% of the children met our resilience criteria and were considered LS. At the individual level, protective traits (e.g. self-esteem; OR = 1.51, 95% CI [1.25, 1.81]) predicted LS classification, while environmental sensitivity (OR = 0.69, 95% CI [0.59, 0.82]), poorer general health (OR = 0.71, 95% CI [0.58, 0.87]) and specific coping strategies (e.g. avoidance; OR = 0.90, 95% CI [0.85, 0.96]) predicted HS classification. Social/environmental predictors included perceived social support (OR = 1.23, 95% CI [1.02, 1.49]), loneliness and social isolation (OR = 0.85, 95% CI [0.80, 0.90]), child maltreatment (OR = 0.96, 95% CI [0.94, 0.97]), and caregiver mental and general health (e.g. caregiver depression; OR = 0.94, 95% CI [0.92, 0.97]). CONCLUSIONS: Future research should take multiple dimensions of functioning into account when defining risk for mental health problems and consider the identified predictors as potential targets for interventions.

First Onset in Adulthood of Mental Disorders: Exposure to War vs. Non-war Childhood Adversities: A National Study.

Background: There is evidence that some childhood trauma increases the risk of the first onset of mental disorders and for the first time into adulthood. There are no studies that assessed whether exposure to war has this delayed long-term effect. Objectives: To fill this gap by investigating the comparative roles of war and non-war trauma on the first onset of adulthood mood and anxiety disorders. Methods: A nationally representative sample of 2,857 Lebanese was assessed using the World Health Organization Composite International Diagnostic Interview 3.0. with the onset of exposure to trauma and of first onset of mood and anxiety disorders. Results: Non-war childhood traumata especially those belonging to family malfunctioning continue to exert their effect for the first time well beyond their occurrence as they were the most universal predictors for adult onset of both mood and anxiety disorders. War trauma during childhood predicted mood anxiety and mood (anxiety only in males) only below age 18 y. war childhood trauma predicts the first onset of mood and anxiety disorders before age 18 y in females, but only anxiety in males. Conclusion: Childhood traumata are not equal in predicting the first onset of mood and anxiety disorders into adulthood. Family malfunctioning looks to carry the longest such risk and war more of shorter immediate effects. This might change though with re-exposure to war in adulthood which might unravel dormant vulnerability.

Predictors and severity of probable acute stress disorder following the Beirut Port Blast.

Background: The Beirut Port Blast on August 4, 2020 is the largest (non-nuclear) explosion on record. St George Hospital University Medical Center (SGHUMC), a leading academic medical centre in Lebanon, adjacent to the Port, sustained a massive loss in lives and infrastructure. Objective: The current study uses the baseline data of an ongoing longitudinal study to explore the prevalence, severity, and predictors of probable Acute Stress Disorder (ASD) among health workers at SGHUMC following the blast. Methods: In the context of COVID-19 tests administered 9-15 days after the blast, SGHUMC staff were asked to complete a questionnaire that included socio-demographic details, the Beirut Port Exposure Inventory, and the Acute Stress Disorder Scale (ASDS). Results: A total of 570 health workers participated in the study. The prevalence of probable DSM-5 ASD [95%CI] was 38.34% [31.41; 45.32]. Many specific exposures were related, on a bivariate level, to ASD be it as a probable DSM-5 diagnosis or its severity as measured by the ASDS. A classification and regression tree (CART) analysis identified the highest risk predictors of probable DSM-5 ASD diagnosis to be: being a female, seeing dead or mutilated bodies, death of a close one, and being scared at the time of the explosion. Nurses carried the highest risks of all health workers with a probable DSM-5 ASD prevalence of 51.28%, (OR = 3.72 [95% CI: 2.22; 6.25]). Being scared at the time of the blast was the most single predictor of probable ASD. Conclusion: Both the prevalence and severity of probable DSM-5 ASD in this sample are higher than most reported in the literature, which may be explained by the severity of the trauma and the ongoing stress in the context of the pandemic. Fear at the time of the explosion was independently the most predictive parameter of probable ASD.

Antecedentes: La explosión del Puerto de Beirut el 4 de agosto de 2020 es la explosión (no nuclear) más grande registrada. El Centro Médico Universitario del Hospital St George (SGHUMC), un centro médico académico líder en el Líbano, adyacente al puerto, sufrió una pérdida masiva de vidas e infraestructura. Objetivo: El estudio actual utiliza los datos iniciales de un estudio longitudinal en curso para explorar la prevalencia, gravedad y predictores del probable Trastorno de Estrés Agudo (TEA) entre los trabajadores de la salud en SGHUMC después de la explosión. Métodos: En el contexto de las pruebas de COVID-19 administradas entre 9 y 15 días después de la explosión, se le pidió al personal de SGHUMC que completara un cuestionario que incluía detalles sociodemográficos, el Inventario de Exposición del Puerto de Beirut y la Escala de Trastorno de Estrés Agudo (ETEA). Resultados: Un total de 570 trabajadores de la salud participaron en el estudio. La prevalencia de probable TEA DSM-5 [IC 95%] fue del 38,34% [31,41; 45.32]. Muchas exposiciones específicas se relacionaron, en un nivel bivariado, con TEA, ya sea como un diagnóstico probable del DSM-5 o su gravedad medida por el ETEA. Un análisis del árbol de clasificación y regresión (CART, por sus siglas en inglés) identificó que los predictores de riesgo más alto del diagnóstico probable de TEA según el DSM-5 son: ser mujer, ver cuerpos muertos o mutilados, la muerte de alguien cercano y tener miedo en el momento de la explosión. Las enfermeras tenían los riesgos más altos de todos los trabajadores de la salud con una prevalencia probable de TEA según el DSM-5 del 51,28%, (OR = 3,72 [IC del 95%: 2,22; 6.25]). Sentirse aterrorizados en el momento de la explosión fue el predictor más determinante de probable TEA. Conclusión: Tanto la prevalencia como la gravedad del probable TEA DSM-5 en esta muestra son más altas que la mayoría de las reportadas en la literatura, lo que puede explicarse por la gravedad del trauma y el estrés continuo en el contexto de la pandemia. El miedo en el momento de la explosión fue independientemente el parámetro más predictivo de probable TEA.

The impact of the COVID-19 pandemic on the mental health of healthcare workers: study protocol for the COVID-19 HEalth caRe wOrkErS (HEROES) study.

BACKGROUND: Preliminary country-specific reports suggest that the COVID-19 pandemic has a negative impact on the mental health of the healthcare workforce. In this paper, we summarize the protocol of the COVID-19 HEalth caRe wOrkErS (HEROES) study, an ongoing, global initiative, aimed to describe and track longitudinal trajectories of mental health symptoms and disorders among health care workers at different phases of the pandemic across a wide range of countries in Latin America, Europe, Africa, Middle-East, and Asia. METHODS: Participants from various settings, including primary care clinics, hospitals, nursing homes, and mental health facilities, are being enrolled. In 26 countries, we are using a similar study design with harmonized measures to capture data on COVID-19 related exposures and variables of interest during two years of follow-up. Exposures include potential stressors related to working in healthcare during the COVID-19 pandemic, as well as sociodemographic and clinical factors. Primary outcomes of interest include mental health variables such as psychological distress, depressive symptoms, and posttraumatic stress disorders. Other domains of interest include potentially mediating or moderating influences such as workplace conditions, trust in the government, and the country's income level. RESULTS: As of August 2021, ~ 34,000 health workers have been recruited. A general characterization of the recruited samples by sociodemographic and workplace variables is presented. Most participating countries have identified several health facilities where they can identify denominators and attain acceptable response rates. Of the 26 countries, 22 are collecting data and 2 plan to start shortly. CONCLUSIONS: This is one of the most extensive global studies on the mental health of healthcare workers during the COVID-19 pandemic, including a variety of countries with diverse economic realities and different levels of severity of pandemic and management. Moreover, unlike most previous studies, we included workers (clinical and non-clinical staff) in a wide range of settings.

Cohort profile: biological pathways of risk and resilience in Syrian refugee children (BIOPATH).

The BIOPATH cohort was established to explore the interplay of psychosocial and biological factors in the development of resilience and mental health problems in Syrian refugee children. Based in Lebanon, a middle-income country significantly impacted by the refugee crisis, it is the first such cohort of refugees in the Middle East. Families were recruited from informal tented settlements in the Beqaa region using purposive cluster sampling. At baseline (October 2017-January 2018), N = 3188 individuals participated [n = 1594 child-caregiver dyads; child gender, 52.6% female; mean (SD) age = 11.44 (2.44) years, range = 6-19]. Re-participation rate at 1-year follow-up was 62.8%. Individual interviews were conducted with children and primary caregivers and biological samples collected from children. Measures include: (1) children's well-being and mental health problems (using tools validated against clinical interviews in a subsample of the cohort); (2) psychosocial risk and protective factors at the level of the individual (e.g. coping strategies), family (e.g. parent-child relationship), community (e.g. collective efficacy), and wider context (e.g. services); (3) saliva samples for genetic and epigenetic (methylation) analyses; (4) hair samples to measure cortisol, dehydroepiandrosterone (DHEA) and testosterone. This cohort profile provides details about sampling and recruitment, data collection and measures, demographic data, attrition and potential bias, key findings on resilience and mental health problems in children and strengths and limitations of the cohort. Researchers interested in accessing data should contact Professor Michael Pluess at Queen Mary University of London, UK (e-mail: m.pluess@qmul.ac.uk).

Influence of a University Tobacco-Free Policy on the Attitudes, Perceptions of Compliance, and Policy Benefit Among the University Students: A Pre-Post Investigation.

Objective: To evaluate the effectiveness of a university tobacco-free policy by examining differences in students' attitudes, perceptions of compliance and policy benefits, after one year of the policy's implementation. Methods: Cross-sectional studies were undertaken to collect data pre- and 1 year post-policy implementation. The two samples were selected using stratified random sampling. Results: The prevalence of smoking decreased from 26% pre-policy implementation to 21% 1 year after (p = 0.035). The proportion of smokers who thought the policy had contributed to a reduction in smoking frequency increased from 10% to 70% (p < 0.001). Smokers' support for the policy rose from 42 to 58% (p = 0.007). Conclusion: Against the background of a strongly pro-tobacco environment in Lebanon, it is possible to create a positive change in the mindset of smokers at the levels of the education and smoking cessation and more efforts should be expended to bring it about.

Effect of tobacco control policies on intention to quit smoking cigarettes: A study from Beirut, Lebanon.

INTRODUCTION: In Lebanon, the tobacco control policy, Law 174, became effective in 2011. Using the International Tobacco Control Policy Evaluation Project (ITC) conceptual model, this study aims to assess the association between exposure to control measures related to the policy and the intention to quit, which is a mediator in the pathway leading to behavioral change (quitting). METHODS: This is a secondary data analysis of 154 cigarette smokers from a cross-sectional survey that assessed compliance with Law 174 among Beirut residents aged 15-65 years. Data were collected face-to-face, three months after the implementation of indoor public places and tobacco advertisement/promotion bans. Intention to quit smoking was the main outcome. Exposure to policy control measures such as seeing smokers in restaurants, and noticing warning labels on cigarette packs were the explanatory variables. Sociodemographics, past smoking behavior, and psychosocial variables were also considered for their moderating and mediating effects, respectively. Crude and adjusted odds ratios (ORs) were generated. Sobel test was used to check for possible mediation. RESULTS: Intention to quit was reported by 24% of cigarette smokers. The association between noticing warning labels and having intentions to quit was statistically significant (adjusted OR=6.27). Concerns about influencing children's smoking behavior had a statistically significant mediation effect on the relationship. After adding the interaction term between noticing the warnings and previous quit attempts, the OR was inflated to 12.92, suggesting a possible interaction. CONCLUSIONS: This study offers preliminary insight into how Lebanese smokers are influenced by policy related control measures like health warning labels on cigarette packs. Tobacco control policy advocates should push for stronger enforcement of public smoking bans in general. Behavioral intervention should work on the mediator variables to influence smoking behavior and encourage quitting. Further prospective studies modelling quitting as outcome are needed.

Correction to: Association of Autism with Maternal Infections, Perinatal and Other Risk Factors: A Case-Control Study.

The original version of this article unfortunately contained a mistake. The family name of Hadi Abou El Hassan was incorrect. The correct name is Hadi Abou-El-Hassan.

Association of Autism with Maternal Infections, Perinatal and Other Risk Factors: A Case-Control Study.

This case-control study explores the association between pregnancy/birth complications and other factors with Autism Spectrum Disorder (ASD) in Lebanese subjects aged 2-18 years. Researchers interviewed 136 ASD cases from the American University of Beirut Medical Center Special Kids Clinic, and 178 controls selected by systematic digit dialing in the Greater-Beirut area. Male gender (Adjusted Odds Ratio [95% CI]: 3.9 [2.2-7.0]); postpartum feeding difficulties (2.5 [1.2-5.4]); maternal infections/complications during pregnancy (2.9 [1.5-5.5], 2.1 [1.1-3.9]); consanguinity (2.5 [1.0-6.0]); family history of psychiatric disorders (2.2 [1.1-4.4]) were risk factors for ASD. Being born first/second (0.52 [0.28-0.95]) and maternal psychological support during pregnancy (0.49 [0.27-0.89]) were negatively associated with ASD. Identifying ASD correlates is crucial for instigating timely screening and subsequent early intervention.

Prevalence of Autism Spectrum Disorder in Nurseries in Lebanon: A Cross Sectional Study.

In Lebanon, no estimate for autism prevalence exists. This cross-sectional study examines the prevalence of Autism spectrum disorder (ASD) in toddlers in nurseries in Beirut and Mount-Lebanon. The final sample included 998 toddlers (16-48 months) from 177 nurseries. We sent parents the Modified Checklist for Autism in Toddlers (M-CHAT) for screening, and a self-administered questionnaire (associated factors). We imputed missing M-CHAT data with successful answers. Since there were no follow-up interviews for the M-CHAT, we used the positive predictive value (0.058) from a large study for prevalence estimates. ASD prevalence was 1 in 66 children (comparable to US). Ratios were: male/female: 1.05; Beirut/Mount-Lebanon: 1.2. Using a more representative sample and ascertaining results are needed for better prevalence estimates in Lebanon.

The determinants of intention to smoke waterpipe among adolescents in Lebanon: a national household survey.

BACKGROUND: The phenomenon of waterpipe smoking (WPS) among adolescents has become eminent, and it is especially prevalent in Lebanon. Unlike cigarette smoking, WPS is parentally and socially acceptable. This study aims at examining the association between intention to smoke waterpipe in the next 6 months, and knowledge, attitudes and parental and social influences. METHODS: This is a secondary data analysis from a national survey in 2007 on 1028 households. This study addresses 258 non-smoking adolescents and their parents. Consent was sought and the study was approved by the Institutional Review Board at the American University of Beirut. Face-to-face interviews were conducted. Descriptive analysis, crude and adjusted odds ratios (ORs) were generated. RESULTS: At the bivariate level, late adolescence, mothers without university education, prior adolescents' WPS experiences, best friends' and parents' WPS habits and adolescents' and parents' lower attitude scores were associated with smoking intention. In the adjusted model, adolescents' beliefs about positive effects, best friends' similar habits and prior smoking remained significant (respective ORs [95% confidence interval ]: 1.81 [1.33-2.45], 2.51 [1.24-5.10], 4.91 [2.35-10.36]). Parents' perceived attitude against smoking was protective (OR: 0.57 [0.39-0.83]). CONCLUSIONS: Adolescents' intention to smoke is highly influenced by parents' permissive attitudes and peer pressure. Interventions targeting these two groups and limiting access to smoking by adolescents should be instigated.

Health status, epidemiological profile and prospects: Eastern Mediterranean Region.

BACKGROUND: This article aims at providing an overview of the current epidemiological situation in the heterogeneous Eastern Mediterranean Region (EMR). It is one in a series of eight articles appointed by the International Epidemiological Association to improve the epidemiological situation. METHODS: Several resources were used to extract morbidity, mortality and risk factors data that contribute mostly to the burden of disease and highlight health inequalities. Medline search was used to estimate epidemiological publications output by country. Indexing status of Index Medicus for the Eastern Mediterranean (IMEMR) journals in Medline/PubMed was checked. A questionnaire was designed to collect data from epidemiological associations on type of work and workforce. Authors' knowledge and networks were used to get a perspective on the training, research and funding sources. RESULTS: Large inequalities exist between EMR nations especially ones pertaining to social conflicts. The EMR age-standardized disability-adjusted life years rate per 1000 population is higher than the global one, with most contribution of communicable diseases in low- and middle-income countries (45%) and non-communicable diseases in high-income countries (64%). Iran and Pakistan have the highest number of publications from 1996-2012, but Kuwait has the highest rate of publications per 100,000 population. The majority of IMEMR journals are not indexed in Medline/PubMed. Masters in Public Health is the most common form of training. CONCLUSIONS: Efforts are required to ameliorate the epidemiological situation. There is a dire need for health evidence-based policy change and for field training of epidemiologists.