29-

THE PSYCHOLOGICAL EFFECTS OF THE WAR IN

AFGHANISTAN ON YOUNG AFGHAN REFUGEES FROM DIFFERENT ETHNIC BACKGROUNDS

RIM MGHIR &

ALLEN RASKIN

SUMMARY
This study examined the psychological effects of the war in Afghanistan on two groups of young Afghan refugees currently residing in the United States. One group, with Tajik parents showed significantly less evidence of post-traumatic stress disorder (PTSD) and depression than the second group with Pashtun parents. These two groups of young refugees came from very different socioeconomic and cultural backgrounds. Some of these differences persist to the present. The Tajik parents are wealthier, more likely to speak English at home and less religious than the Pashtun parents. Their wartime experiences were also different. The Pashtun parents and their children spent more time in Afghanistan during the war, and experienced or witnessed more traumatic events, such as torture or combat, than the Tajik parents and their children. The possible effects of these ethnic differences on current psychopathology are described and discussed.

INTRODUCTION
studies describing the effects of war, migration, and acculturation on the of refugees (Kinzie et al. 1990; Mollica et al. 1987; Williams & effects of war trauma on refugee children and adolescents have been studied in such diverse places as Beirut, Mozambique, Cambodia, Central America and the United States (Kinzie et al. 1986; Arroyo & Eth, 1985). High rates of post-traumatic stress disorder (PTSD) and affective disorders have been identified in these studies. Since 1979 Afghanistan has experienced widespread destruction, as a result of the invasion by the Soviet Union, subsequent civil war and recent take-over of most of the country by the Taliban. Over one million were killed. Many escaped the country and sought refuge in Pakistan. Around 20,000 Afghan refugees have emigrated to the U.S. (Center for Applied Linguistics, 1981). A large number have resettled in Washington, D.C. Others now live in New York, California, Nebraska and Washington state. This research will describe the effects of war trauma on the psychological functioning of adolescent and young adult refugees from Afghanistan who are now living in the United States in Seattle, Washington. However, the focus of this study, in contrast to a prior report (Mghir et at. 1995), will be on the differential effects of the war in Afghanistan and subsequent refugee status on two ethnic subgroups of adolescent and young adult refugees. The groups divide on the basis of ethnic origin and languages spoken by their parents.
are numerous

There

psychological functioning Westermeyer, 1983). The

30

One group, the Pashtuns, make up about half the population in Afghanistan and have traditionally been the dominant ethnic group (Shroder, 1997). Their homeland lies south of the Hindu Kush, but Pashtun groups live in all parts of the country. Pashtuns are usually farmers though a large number are nomads. The Pashtuns speak Pashto, which is an IndoIranian language and one of the two official languages of Afghanistan. The other group, the Tajiks - a people of Iranian origin, are the second largest ethnic group in Afghanistan. They live in the valleys north of Kabul and many live in the capital city of Kabul. They are farmers, artisans, and merchants. The Tajiks speak Dari (Afghan Persian) also an Indo-Iranian language and the other official language of Afghanistan. Dari is more widely spoken that Pashto in most of the cities and is the language in which most business is conducted. Recent events in Afghanistan provide additional evidence of the importance of the ethnic divisions in that country. Our reference is to the emergence of the Taliban as the dominant political force in Afghanistan today. The Taliban, a Pashtun-dominated group, started as an armed collection of Islamic fundamentalist students in the fall of 1994. The movement began in the south and the Taliban now occupy most of the country. One of their missions is to impose their strictly orthodox version of Islamic law. Opposition to the Taliban comes mainly from armed groups in the north directed by ethnic Tajik leaders. Members of both ethnic groups have settled in Seattle and maintain their separate identities. When they were interviewed it became apparent that in addition to language and ethnic differences, they also differed in socioeconomic status, both in Afghanistan and in this country, as well as their adaptation to life in this country. Another important difference was the nature and degree of war trauma they experienced in Afghanistan, their difficulty in escaping from Afghanistan and their difficulty in emigrating to the United States. An especially poignant example of this war trauma by a young female subject of Pashtun background appeared in her high school journal and describes an air raid in her village in which she received shrapnel wounds in her leg, arms, forehead and back. The purpose of this study was to document the socioeconomic, cultural and war trauma differences between these two groups of young Afghan refugees and to determine if these differences have heuristic value in predicting current levels of psychopathology in these youngsters and in their parents.

METHODS

Subjects Subjects were recruited through an Afghan community leader who had a list of the known Afghan families in the Seattle area. Fifteen of the 25 families in the area agreed to participate. These 15 families yielded 38 adolescents and young adults who were included in the study. Their ages ranged from 12 to 24. The subjects studied had all experienced the trauma of war either first-hand or indirectly as well as refugee status during their teenage years. Twentythree subjects came from Tajik families and 15 from Pashtun families.
Measures for adolescents and young adults 1.. ~Iar-va~d Trauma Questionnaire (HTQ). This is
a

self-report

scale

consisting of

four

31

sections (Mollica et al. 1992). Part 1 is a 17 item checklist that measures traumatic events and whether or not the subjects experienced, witnessed, and/or heard of these events. Part 2 is a personal description of the traumatic events. Part 3 inquires about various forms of head and brain injuries. Part 4 inquires about post-traumatic related symptoms experienced in the past week with a rating from 1-4 in severity. The questionnaire was scored in terms of trauma events (Part 1) and post-traumatic symptoms (Part 4). Trauma events are broken down into the total number of events. This includes events experienced, witnessed and heard about, and the total number of events experienced. The post-traumatic symptom scoring is broken down into a I)SM-III-IZ score and the total score. Individuals scoring greater than 2.5 on the total score are considered symptomatic for PTSD. The HTQ was developed by the Harvard Program in Refugee Trauma as a cross-cultural instrument for measuring torture and war-related trauma and post-traumatic stress disorder. The reliability and validity of this instrument was assessed on a sample of 91 Cambodian, Laotian and Vietnamese refugees living in the Boston area. Two measures of inter-rater reliability were in the high 90s. In addition, the HTQ had a sensitivity of 78% and a specificity of 72%. The authors concluded that the cultural sensitivity of this instrument made it useful for assessing other highly traumatized non-Western populations. The scale items also have high face validity, e.g., witnessing or experiencing events such as &dquo;rape or sexual abuse,&dquo; &dquo;torture,&dquo; and &dquo;forced separation from family members.&dquo; 2. Beck Depression Inventory (BDI) (Beck et al. 1961) is a 21-item inventory scaled on a 0 to 4 measure of severity. Acceptable reliability, validity and internal consistency have been demonstrated for the BDI. Scores greater than 25 are indicative of moderate to severe

depression.
Parental
measures

Parents were interviewed using the Harvard Trauma Questionnaire (HTQ) (described above), the Beck Depression Inventory (BDI) (described above), and the Hopkins Symptom Checklist-25 (HSCL-25). The HSCL-25 consists of 10 anxiety symptoms and 15 depressive symptoms, with each item scored on a four-point intensity scale. Responses are summed and divided by the number of items to generate total scores for anxiety and depression and a combined total score. This has proved to be a reliable and valid instrument for measuring depression and anxiety in Southeast Asian refugees (IVlollica et al. 1987).

Procedure The community Afghan leader contacted the families and briefly explained the purpose and method of our study. Once the families agreed to be interviewed, a home visit was arranged and written informed consent was obtained from both parents and children. In general two home visits were required to complete the assessment instruments. All interviews were conducted by the first author (12.1~.). All adolescents and young adults spoke English fluently and therefore an interpreter was not used. Some parents spoke English and for those who did not an interpreter from the community was used to assist the parents and to answer questions subjects had about completing these forms. These interpreters, who had themselves emigrated from Afghanistan and had ties to the Pashtun and Tajik communities in Seattle, were fluent in both Pashtu and Dari as well as English.

32

Dari and Pashtu versions of the self-report forms were available for the parents who could English. These forms were first translated and then back-translated to ensure accuracy of the meaning of the translations. Dari and Pashtu versions of the questionnaires were also checked to ensure that the language used was harmonious and consistent with the cultural, linguistic and educational background of the Afghan people. Fifteen of the adolescent and young adult refugees came from Pashtun parents and 23 from Tajik parents. These two groups were compared on 16 identifying and background variables using independent t-tests for continuous data and chi-square analyses and Fisher exact probability tests for categorical data. The background variables included data related to socioeconomic and religious differences, time in the United States and evidence of acculturation in this country. Independent t-tests, chi-squares and exact probability tests were also used to compare the two groups of youngsters and their parents on their war trauma experiences and on measures of current psychopathology such as the presence of post-traumatic stress disorder (PTSD) and
not read

depression. Although differences between the two groups of adolescents on gender and age were not statistically different we performed the t-tests on war trauma experiences and current psychopathology two ways, with and without age and gender as covariates. The results
were

similar in both instances.

RESULTS
Differences between the Pashtun and Tajik refugees in identifying and background variables are listed in Table 1. The Pashtun adolescents and young adults tended to be older and more were male than their Tajik counterparts. However, these differences were not statistically significant. As anticipated, the Tajik adolescents came from higher socioeconomic backgrounds than the Pashtun adolescents. Their parents were better educated and wealthier than the Pashtun parents. These socioeconomic differences were present in Afghanistan and persist to the present in Seattle. More of the Tajik parents (fathers as well as mothers) spoke English at home. These two groups of refugees also showed a number of significant differences related to their practice of the Moslem religion. The Pashtuns were more likely to attend a Mosque, fast during Ramadan and pray regularly than the Tajiks. The wartime experiences of these two groups while in Afghanistan also showed a number of important differences. The Pashtun refugees spent a mean of 72 months in Afghanistan during the war compared to a mean of 53 months for the Tajiks. Hence both groups spent a considerable period of time in Afghanistan during the war. However, the war had a more direct impact on the Pashtuns (see Table 2). Six significant differences between these groups emerged on the Harvard Trauma Questionnaire (HTQ). These included two global scores, the HTQ total score and the HTQ score for number of traumatic events actually experienced. Specific traumatic events differentiating these groups included torture, combat, imprisonment, and being close to death. In all instances the Pashtun refugees scored highest reflecting greater personal involvement with the event. The HTQ traumatic events are scored to indicate whether or not the subjects experienced, witnessed or heard of these events. The highest

33 Table 1

Demographics

1 N.S.

Not

Significant; These significance levels

are

for two-tailed tests

is given to experiencing an event. For example, four Pashtun subjects experienced torture, four were in combat and four were imprisoned. None of the Tajik subjects experienced torture or combat although two were imprisoned. However, 10 Tajik subjects did say they were close to death at some time and 13 Pashtun subjects similarly said there were times when they were close to death. Differences between the Tajik and Pashtun subjects on current and past psychopathology are listed in Table 3. The Pashtun adolescents and young adults showed greater evidence of PTSD on the Harvard Trauma Questionnaire and on the I~S~I-III-I~ score. They also scored higher than the Tajik youngsters on the Beck Depression Inventory. Among their parents differences emerged only for their mothers. The Pashtun mothers scored higher than their

weight

Table 2 War Trauma

Harvard Trauma tailed tests

1IIT~ =

Questionnaire; significance

levels

are

for two-

34 Table 3 Past and Present

Psychopathology -

1HSCL

= =

3PTSD

Post-Traumatic Stress Disorder;

Hopkins Symptom Checklist; ZHTQ Harvard Trauma Questionnaire; 4These significance levels are for two=

tailed tests

Tajik counterparts on the total score on the Hopkins Symptom Checklist (HSCL), on the total depression score from the HSCL and on the Beck Depression Inventory. There were no significant differences between the Tajik and Pashtun fathers on any of the psychopathological variables.
DISCUSSION
The Afghan refugees included in this study fall into two very distinctive groups based on ethnic origin, i.e. Tajiks and Pashtuns. Both refugee groups spent in excess of four years in Afghanistan during the war and both experienced the trauma of that war and subsequent relocation to Pakistan and then to the United States. However, one group, the Tajiks, were more insulated from the effects of these experiences. As compared to the Pashtuns, the Tajiks had less first-hand experience with events such as combat and torture. They were also better educated and wealthier than the Pashtuns which undoubtedly gave them an edge in terms of sheer physical survival during the war, e.g. in obtaining food and other necessities. It would appear that this socioeconomic difference also made it easier for the Tajiks to leave Afghanistan during the war and relocate in Pakistan. The Pashtun refugees are also retaining old customs more than the Tajik refugees. This is especially true with regard to religion where the Pashtun refugees are more likely to practice their Moslem faith than the Tajiks. In terms of acclimatisation to this country, fewer Pashtun fathers and mothers speak English at home compared to their Tajik counterparts. However, time in this country may be partially responsible for this latter difference. The Tajik refugees have been in this country longer (mean 5.39 years) than their Pashtun counterparts 2.53 years). (mean The circumstances outlined above appear to have had a differential effect on the current mental health of these refugees. The Pashtun adolescents and young adults scored significantly higher on the Beck Depression Inventory and more received a PTSD diagnosis based on both DSM-111-R and HTQ criteria. Current psychopathology in these youngsters appears to have its roots in their war experiences. For example, the correlation between the HTQ experienced score and PTSD score derived from the HTQ was .69, p < .01, and the
= =

35

correlation between the HTQ experienced score and a DSM-III-I~ diagnosis was .52, p < .Ol . We have previously noted that the Pashtun youngsters had significantly higher HTQ total and
scores than the Tajik youngsters. The circumstances described also appear to have had a differential effect on the current mental health of their parents. There were no significant differences on these measures between the Pashtun and Tajik fathers but the Pashtun mothers showed more current psychopathology than their Tajik counterparts. These differences emerged on two separate measures of depression (HSCL Depression and Beck Depression Inventory) and on the total pathology score from the HSCL. These groups did not differ significantly on the PTSD measures. Variables showing significant correlations with the Beck Depression Inventory scores of the study mothers included ethnicity (.53), whether English was spoken at home (.70), finances (.44), going to a Mosque regularly (.50), when they arrived in the United States (.60), and fasting for Ramadan (.41). Time spent in Afghanistan (.57) and in Pakistan (.49) were also significantly correlated with Beck Depression. The language barrier suggests the Pashtun mothers are more insulated from their American neighbors, they are also closer to their religious heritage and although we have no direct evidence, they appear to be having a more difficult time adjusting to life in this country than the Tajik mothers. The high correlation between fluency in English and Beck Depression (.70) speaks to this latter point. Hence their current depression has its roots both in present events and circumstances as well as events that occurred when they were in Afghanistan during the war. Is it ethnicity or socioeconomic status that is primarily responsible for the study findings? We feel both factors played a role. Ethnicity placed the Pashtun refugees, who were primarily farmers, in rural areas where they were subject to some of the heaviest fighting. Economic factors made them more susceptible to hunger and starvation and also made it more difficult for them to leave the refugee camps in Pakistan and emigrate to the United States. In addition to highlighting the fact that ethnicity and socioeconomic status can either potentiate or moderate the wartime experiences and trauma of various refugee groups entering this country, the study points up the need to identify particular refugees who may need mental health services. The groups most at risk in this study were the Pashtun youngsters and the Pashtun mothers. The Pashtun youngsters are still worling through the effects of their wartime experiences which has left some with PTSD and depression. Efforts should be made to make counseling and psychiatric treatment available to those in need. The situation with the Pashtun mothers is more complex. Current circumstances as well as experiences in Afghanistan are contributing to depressive symptoms in many of these women. How many of these women, who are devout Moslems, would be willing to enter treatment is problematic. It bears repeating that a major lesson from this study is the cautionary note that ethnic differences in a country may override purely national differences in matters such as exposure to calamities such as war and famine as well as the physical and psychological effects of these

HTQ Experienced

events.

ACKNOWLEDGMENTS
The authors thank Dr. Noor Ahmed Aof, Khalid Roshan, and Farid Axm for their support and help in recruitment and in the translation of instruments.

36

REFERENCES

(1985) Children traumatized by Central American warfare. In Post-traumatic Stress (eds. R.S. Paeans & S. Eth). Washington D.C.: American Psychiatric Association. BECK, A.T., WARD, C.H., MENDELSON, M., MOCK, J.E. & ERBAUGH, J.K. (1961) An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. CENTER FOR APPLIED LINGUISTICS (1981) CAL Fact Sheet Series #5 The Afghani. Washington, D.C.:
ARROYO, W. & ETH, S. Disorders in Children

Language and Orientation Resource Center.

KINZIE, J.D., SACK, W.H., ANGELL, R.H., MANSON, S. & RATH, B. (1986) The psychological effects of
massive trauma on Cambodian children: I. The children. Journal Adolescent Psychiatry, 25, 370-376.

of the

American

Academy of Child

and

KINZIE, J.D., BOEHNLEIN, J.K., LEUNG, P.K., MOORE, L.J., RILEY, C. & SMITH, D. (1990) The prevalence of

post-traumatic stress disorder and its clinical significance among Southeast Asian refugees. American Journal of Psychiatry 147, 913-917. MGHIR, R., FREED, W., RASKIN, A. & KATON, W. (1995) Depression and post-traumatic stress disorder among a community sample of adolescent and young adult Afghan refugees. Journal of Nervous and Mental Disease, 183, 24-30. MOLLICA, R.F., WYSHAK, G. & LAVELLE, J. (1987) The psychological impact of war, trauma and torture on Southeast Asian refugees. American Journal of Psychiatry, 144, 1567-1572.
MOLLICA, R.F., WYSHAK, G., DE MANEFFE, D., KHUON, F. & LAVELLE, J. (1987) Indochinese versions of Hopkins Symptom Checklist-25: a screening instrument for the psychiatric symptoms of refugees. American Journal of Psychiatry, 144, 497-500. MOLLICA, R.F., CASPI-YAVIN, Y., BOLLINI, P., TRUONG, T.S. & LAVELLE, J. (1992) The Harvard Trauma Questionnaire: Validation of a cross-cultural instrument for measuring torture, trauma, and post-traumatic stress disorder in Indochinese refugees. Journal of Nervous and Mental Disease, 180, 111-116. SHRODER, J.F. Jr. (1997) Afghanistan. Microsoft Encarta Encyclopedia. Seattle: Microsoft Corporation. WILLIAMS, C.L. & WESTERMEYER, J. (1983) Psychiatric problems among adolescent Southeast Asian refugees: A descriptive study. Journal of Nervous and Mental Disease, 171, 79-85.
Rim Mghir, MD, is in USA

private practice. Mailing address:

2323 Ashmead Place NW,

Washington, D.C. 20009-1413,

Allen Raskin, PhD, is Research Professor in the Division of Geriatric Psychiatry in the Institute of Psychiatry and Human Behavior at the University of Maryland School of Medicine, 645 W. Redwood Street, Baltimore, Maryland 21201, USA. Tel: (410) 360-0254; Fax (410) 363-1889

Correspondence

to Dr.

Mghir

COMMENTARY

The

psychological effects of the

war in Afghanistan on young from different ethnic backgrounds

Afghan refugees

War, refugee status and e~t~l health Through the history of mankind, wars have resulted in individuals moving around and seeking pastures anew to build their lives and families. Although there have been mentions of the impact of war on the individuals, the recognition of its role in generating asylum-seeking

refugees is a relatively recent one. Migration too has been an activity well recognised in human history although reasons for such migration have varied tremendously. From active