Effects of Psychosocial Intervention on the Level of Stress: A Pre- Experimental Research on School Children Who Experienced Displacement in Marawi City, Philippines

Tashmera P. Datukali1,2*, Hamdoni K. Pangandaman2\

1Mindanao State University, Buug Campus, Datu Panas, Buug, Zamboanga Sibugay, 7009, Philippines

2College of Health Sciences, Mindanao State University, Marawi, Lanao Del Sur, 9700, Philippines

*Corresponding Author’s Email: laranjotashmera@gmail.com

ABSTRACT

Background: Armed conflicts have a profound impact on the psychosocial well-being of children, particularly those belonging to the most vulnerable displaced groups. Understanding and addressing the psychosocial needs of these children is of paramount importance. Aim: This study aimed to investigate the effectiveness of a psychosocial intervention in mitigating stress levels among school- aged children displaced from their homes within the conflict zone of Marawi City. Methods: Employing a pre-experimental design with a single group and utilizing a pre-post-test approach, 38 displaced children aged 7-12 were selected based on specified criteria. The participants underwent a 13-session psychosocial intervention guided by predetermined criteria. Data were collected using three questionnaires encompassing personal and socio-demographic details (part 1), an adapted children's stress symptom scale (part 2), and an assessment of children's emotions before and after the psychosocial interventions (part 3). Results: The results demonstrated a statistically significant difference between pre-test and post-test stress levels among the displaced children who participated in the psychosocial intervention. Conclusion: Participation in various psychosocial interventions was associated with a significant decrease in displacement-related stress levels among the children. This underscores the potential effectiveness of targeted psychosocial interventions in ameliorating the stress experienced by displaced children. Recommendation: Future research endeavors should focus on further enhancing therapeutic approaches tailored to the unique needs of displaced children, particularly those susceptible to the adverse effects of stress. A concerted effort is needed to develop and implement interventions that can comprehensively address the psychosocial well- being of children affected by armed conflicts and displacement.

Keywords: Displaced; Homeless; Level of Stress; Psychosocial Intervention; School-Aged Children

INTRODUCTION

The conflict between ISIS-affiliated rebels and Philippine armed forces devastated Marawi City, preventing almost a thousand families from returning home, which forced them to live in temporary shelters (Pangandaman et al., 2019; Usami et al., 2018). Within days and weeks of displacement, several Maranao youngsters perished from starvation, respiratory infections, and diarrheal illnesses. Some children were assaulted physically, detached from their families, exploited, and kidnapped, putting them in bodily danger (Collado, 2019). The status of being homeless, loss of living space, and community have impacted children in various ways.

Moreover, the phenomenon led to stress, which negatively affected the mental health of those affected. According to Dungey and Ansell (2020), displacement or relocation is not only physical but also socioeconomic, in which destroying a home frequently results in losing hope for the present and future. Children struggle when they are pushed to migrate to a new location, as the housing situation for evacuating families might be inconducive and inadequate. At some point, they are deprived of the right to meet fundamental demands for sufficient housing, water, sanitation, energy, and safety (Collado, 2019; Dungey & Ansell, 2020). Most frequently, the right to growth is infringed because displacement areas lack an adequate number of schools and prospective sources of income for parents and guardians (Collado & Arpon, 2021). Also, there are reports of young females being exploited sexually (Distor, 2019). As future-oriented dispositions, aspirations are crucial in motivating young people in participating in the reconstruction process. But too often what they can offer is limited by the structures and opportunities on the ground (Cornelio & Calamba, 2023).

The experience of being displaced in another place that seems unfamiliar produces a dangerous and threatening stimulus because a powerless child lacks the dexterity to meet unexpected demands, is susceptible to various scenarios, and is especially vulnerable to having mental health issues. Indeed, the protection and care a relocated child receives from his or her family and other systems are essential for overcoming such traumatic situations (Collado, 2019; Collado & Arpon, 2021).

The scope of challenges surrounding child displacement necessitates a more comprehensive systemic comprehension, support, and knowledge of their specific needs and interests. This will permit the continued and consistent assistance of displaced children and their families until they can resume their regular routines. More assistance and orientation are required for displaced children and their families (Pangandaman et al., 2019; Usami et al., 2018). In order to address and advocate for the unique needs of displaced families and their children, there is a need to increase access to the resources that are readily available and investigate the possibility of service partnership and coordination (Vold et al., 2019).

Despite the growing presence of displacement among this group of children in the Philippines and around the world, its effects have yet to be thoroughly studied (Distor, 2019; Usami et al., 2018). The core of this study is particularly relevant to the nation, where conflict-related factors and environmental factors are the leading causes of displacement. As more people are relocating to different parts of the country, the study's findings aim to shed light on unrecognized problems like the psychosocial and psychological needs of displaced children and their families and help them address them. Since many displaced people are unsupported and in need of protection, efforts are undertaken to address the needs and interests of this vulnerable group as well as their families (Collado, 2019; Collado & Arpon, 2021). Numerous studies have linked a nutritious diet to psychological well-being and lifestyle factors, particularly behaviours related to physical activity (Hassan, 2017). This study's results could contribute to improving protection and assistance services for the afflicted community. Utilizing experimental techniques, the purpose of this study was to evaluate the effectiveness of psychosocial interventions and determine if they could be successful in reducing the stress level of the affected school-aged children.

METHODOLOGY

This study was pre-experimental, single-group, and pre- and post-test. Hence, the researchers identified displaced children who received developmental and psychosocial interventions. These examined whether developmental psychosocial therapies reduced stress among 7- to 12-year-old displaced children in Marawi City due to armed conflict. The children from Marawi City as participants were selected based on two criteria: (a) a displaced child who had experienced atrocities of war; and (b) has been prevented or cannot be able to go back to their homes after the war. An exclusion are those children with physical and psychological disorders who left the area of armed conflict with their families before it had happened, those who migrated to other places other than transitory shelter, and those diagnosed with a clinical mental problem.

This study included 38 children, equally male and female, based on the record listed as among displaced children temporarily living in Sarimanok shelters. A non-randomization through a self- selection procedure guided by inclusion criteria has generated an equal representative of 19 participants, both male and female, with an age range of 7 to 12 years. This study included equal numbers of girls and boys since an ecological study discovered that girls experienced stronger intervention effects than boys, and it came to the conclusion that these different impacts were understudied (Schlund et al., 2021; Vold et al., 2019). A study on psychosocial therapies for traumatized children in low- and middle-income countries found similar results (Stark et al., 2019).

This investigation was carried out at the temporary shelters in the Site 1 Sarimanok Area for the approximately one hundred war-affected families living at ground zero. The Lanao del Sur Municipal Disaster Risk Reduction and Management Council (MDRRMC) and the Local Government Unit (LGU) of Marawi City that manages the shelters were asked for permission before the research could be conducted. The relocated families' authorities discussed the project's methods, goals, confidentiality, and voluntary nature. Before gaining informed consent, parents reviewed the study's purpose and addressed any questions or concerns. Given parental approval, researchers discussed ethical issues utilizing the subject's common medium of education. Before interviews, verbal assent was obtained from children with the assistance of parents and local volunteers skilled in Maranao communication who were oriented on data collection principles for children.

In the pre-treatment phase, trained local female research assistants interviewed respondents using questionnaires I and II. Interviews lasted 20–30 minutes. Second, after four weeks, questionnaires II and III were re-administered for a post-treatment assessment. This study conducted a post- assessment five days after the culmination ceremony, where children performed and received gifts and food. Structured interview data were collected from experimental group participants using three questionnaires. The 20–30-minute pre-assessment interview employed Questionnaires I and II. Questionnaire I include age, sex, living circumstances (parents, relatives, or guardians), and camp/temporary shelter duration. Questionnaire II is a 26-item Children's Stress Symptom Scale (CSSS) self-report questionnaire (Enlow et al., 2010; Myers et al., 2016).

Post-evaluation used Questionnaire II again to assess distress symptoms and Questionnaire III, a three-item subjective assessment of children's feelings before and after psychosocial interventions. This questionnaire also questioned children about what activities they enjoyed most in the psychosocial intervention over a 4-week period. The post-assessment took 20–30 minutes. This study used back-translated Maranaw questionnaires.

Table 1: Summary of Research Questionnaire

The data were analyzed using statistical tools such as frequency, mean, percentage, and T-tests processed through SPSS 22. The data gathered has been strictly managed to maintain and preserve children's privacy and confidentiality. This study followed general and particular principles from the National Ethical Guidelines for Health Research to protect the welfare and rights of children.

Ethical Consideration

Ethical clearance for this study was obtained from the UPOU Ethical Review Board of University of the Philippines Open University, Philippines with reference number UPOU-REC:03272019 on March 27th, 2019.

RESULTS

The age distribution showed 19 males and 19 girls. 10 of 19 male participants (52.63%) were 7 to

9 years old, and 11 of 19 female participants (57.89%) were 10–12 years old (Table 2). During pre- treatment among children in Sarimanok Site 1, it was shown that the most common psychosocial symptoms were sadness (92.1%), crying (91.2%), bad temper (81.6%), madness (86.8%), fear (57.9%), embarrassment and shame (57.9%), and the desire to hit someone (53.5%). Sweating, headaches, weariness, stomach aches, colds, nausea, and vomiting are children's most common physical indications of stress. Based on the findings, 35 out of 38 children showed signs of stress, with a frequency rate of 57% to 92% (Table 3).

Table 2: Distribution of Participants in Terms of Their Age

Table 3: Ranked Common Stress Symptoms of Children in Pre-and-Post-Test

*The data are given as n (%)

Among the 38 children in the pre-test, 20 reported moderate stress, 10 had low stress, and 8 had severe stress. Stress levels changed in the post-test, with 26 of them having moderate stress (an increasing number), 8 having low stress, and 4 having high stress (a decreasing number). Psychosocial intervention activities improved children's post-test stress scores, as they displayed low scores of stress symptoms from pre-test to post-test (Table 4).

Table 4: Level of Stress of the Participants in Pre-Test and Post-Test

Table 5 shows the t-test to compare the pre- and post-test levels of stress among displaced school- aged children. There is a statistically significant difference in the level of stress experienced by displaced school-age children between pre- and post-test, as shown by the result in the t-value (- 1.727) and the p-value (0.046). This noteworthy finding confirms that children who received psychosocial interventions experienced less stress related to being displaced.

After participating in the intervention for a total of thirteen sessions, the children gave their responses to three questions on their emotions. The 38 children who responded to the questionnaire all took part in activities that were either creative, recreational, or focused on rebuilding their community. About 13.57% of them chose clean-up drives and gardening as their favorite activities; 5.26% stated that watching Islamic movies and short films about friendship, forgiveness, and peace helped them understand the hows of making friendships with one another; and 57.89% of them claimed that art therapy helped them become better and more expressive. The participants, who made up 89.47% of the total, were satisfied to participate in the activities. After participating, 76.3% of people reported feeling happier and more energetic. About 23.7% of the children expressed sadness that the activities had to end because it meant they could not play anymore.

Table 5: Displaced School-Aged Children Test of Statistical Difference between Pre-Test and Post-Test

DISCUSSION

In Marawi City, Philippines, a psychological intervention was evaluated among displaced children to determine its effect on their stress levels. Depending on age and gender, school-aged children's developmental abilities and coping skills appear to be linked to stress adaptation and management. A study found that younger children are more susceptible to the adverse effects of unfamiliar environments and stress (Karam et al., 2019). According to a different study, children under the age of ten who were born preterm, had temperaments that were "difficult" or "slow-to-warm-up," were male, had low cognitive function, or had experienced prenatal stress suffered worse from stress (Kim et al., 2021; Shawi, 2016). On a side note, seven of the eight children in this study with elevated stress levels were older than ten.

According to the Transactional Model of Development, parents’ incapacity to deal with trauma and stress in children may prevent us from understanding their suffering (Barrantes et al., 2020). Children who are stressed are more likely to have symptoms such as frequent crying, outbursts of anger or defensiveness, headaches, stomachaches, tense fine motor movements (such as tugging or hair twirling, chewing and sucking, biting skin and fingernails), sleep disruptions, and poor academic performance (Maqsood et al., 2014; Radwan et al., 2021). Hence, parents may characterize their children as "difficult" or "irritable," ignoring the possibility that their child is already exhibiting stress-related symptoms (Zendarski et al., 2022).

Studies have reinforced that a child can be assessed erroneously as delinquent or an "ill child," which reinforces parents' misery and lowers their hopes for the child's future (Curley & Kotera, 2023; Devine & Hughes, 2017). The consistently labeled children could acquire a weaker sense of self-worth and self-esteem, which could be partly based on the parents treatment, what they say about their child, how the child behaves through his confidence in play and study, and his capability to connect effectively to other children. Researchers educate parents as part of a psychosocial intervention related to children's stress-coping mechanisms and reaction activities. This type of psychosocial intervention prioritizes protective variables and resources. Culture, geographical environment, and personal circumstances determine a child's resources for stress management.

Based on a study, protective elements, including a healthy emotional relationship with a parent or guardian, social support inside and outside the home, an emotionally open, directed, pleasant, and norm-oriented educational climate, good self-esteem, and cognitive competence, protect children from the most detrimental consequences of stress (Kahraman & Ceylan, 2017; Pangandaman, 2023; Simonič & Osewska, 2023). Hence, parents were provided valuable teachings and insightful information about children suffering stress (being displaced) before exposing them to psychosocial activities so that they might assist their children in managing stress at home. Most parents reported learning about the effects of stress on children during orientation. In addition, they indicated that their children's stress symptoms include usual behavior or stubbornness. They claimed that they did not know enough about children's stress and could not assist them in coping with it.

As parents acknowledged their children's physical and cognitive-emotional stress, researchers worked closely with war-displaced children. In this study, exposure to psychosocial intervention activities lowered the stress symptoms of children. Specialists evaluated the treatments to verify that they were culturally competent, age-appropriate, and fundamental to the needs of the children. After exposure, it was necessary to re-evaluate the children to determine if they had overcome stress. Based on the result, the intervention for anxious displaced children reduced stress symptoms, except for fatigue, which increased from 25 (65%) to 26 (68%). It could be related to the intervention activities that somehow made them exhausted. Several risk factors expose displaced children to the possibility of psychological instability. According to studies, displaced children's most prevalent emotional and behavioral illnesses were PTSD, anxiety with sleep issues, and depression (Tanaka et al., 2023). Children escaping war zones have difficulty adjusting to their new environments (Khater, 2023; Ungar & Seymour, 2024). Furthermore, it demonstrated that as children gain risk factors, their chance of psychological disturbance rapidly increases (Boam & Pulford, 2017; DiPietro, 2018).

The prolonged and severe stress associated with displaced children can sometimes develop into post-anxiety. Based on studies, prolonged and excessive stress can have an immediate and long- term impact on children's adaptability to new environments, even those unrelated to stressful events (Boam & Pulford, 2017; Tereshchenko & Tolkunova, 2023). Hence, war-affected and displaced children may have experienced chronic stress. After 13 months in inadequate evacuation camps, adjusting to a new environment may have been stressful. Consistent with other research, it has been discovered that prolonged stress has the most detrimental impacts on children, such as altering brain chemistry and function and decreasing illness resistance (Battaglia et al., 2023; Green et al., 2021; Kim et al., 2021).

The brains of anxious children respond rapidly to terrifying situations. When stress has been eliminated, the brain may still respond. Stressed children may exhibit excessive behavior due to an imbalance in brain development. Due to persistent stress, an imbalance in brain development may manifest as anxiety, impulsivity, poor impulse control, hyperactivity, a lack of empathy, and inadequate problem-solving skills (Halliburton et al., 2017; Wilson & Olino, 2021). Common cognitive-emotional signs of stress among evacuation camp children, which parents and guardians misread as normal behavior, included hysteria, sobbing, having a nasty temper, wanting to hit someone, and feeling sad. It can be challenging for parents who are less familiar with children's stress symptoms to identify and address their children's stress issues because certain indicators of stress appear gradually and are disregarded or accepted as "normal" by the child (de Bruin et al., 2018; Porter et al., 2022).

In addition to stress, children have been observed by the facilitators of the various activities to have hostility and aggression. The first few sessions were challenging for the children, who appeared to despise each session. The facilitators provided them with guidance to aid in their recovery from traumatic stress. During preliminary meetings, the facilitators also saw that the children competed and antagonized one another. The children's misbehavior spurred the facilitators to work relentlessly to achieve the goal of the intervention, which involved reaching out to the children with activities designed to help them feel at peace with themselves and others as they gradually de-stress. As the children's behavior changed, it became apparent that the numerous tasks given to them—including proper and ongoing observation of their everyday attitude and behavior, monitoring of their social exposure, consultation with the psychologist, and routine application of psychosocial interventions—were effective. Table 4 demonstrates that the number of children with high stress levels decreased from eight to four, and the frequency of the most prevalent symptoms decreased. Hence, psychosocial intervention helps children gradually manage their stress symptoms.

The majority of child respondents were already interacting with other children and interviewers. The children stated their feelings about their relocation and the psychosocial activities they deemed essential. Compared to the pre-intervention phase, when the children were gloomy, reluctant, and aggressive, they now exhibited cheerful facial expressions and appeared to have risen beyond their concerns. The studies of the researchers accord with the preceding observations and findings. According to one study, children are eager to discuss their experiences and welcome opportunities (Kar, 2009). Children learn communication by expressing themselves. They mentioned that observation does not accept the notion that children should not be allowed to discuss the event, citing intellectual immaturity as the explanation, as children prefer to trust their peers and facilitators, who were always pleased when they expressed an interest in discussing their war and displacement experience (El-Khani et al., 2023; Williamson & Rayner-Smith, 2023). After spending numerous days and quality time with them during the intervention, the children discovered they could communicate and express themselves freely. Parents consistently express that the existing interventions fail to adequately meet their psychological needs (Chong et al., 2024).

Thus, time is significant; after days and almost two weeks of intervention activities, the participants reported that the facilitators increasingly released their anxieties and phobias to the point where they viewed their facilitators as trustworthy and open-minded individuals. Hence, time is required to make them feel valued and cared for and expose their combat experience, displacement, and fears.

Asking them to discuss their stress, illnesses, and unpleasant life experiences during the initial meeting or session may cause them to withdraw. So, it is essential to openly question the child about symptoms in the later part. Children's poor cognitive and expressive language skills may make it difficult to infer their thoughts and emotions in the beginning (Raszkowska, 2021). Accordingly, children may not report their psychological reactions to trauma if given insufficient time unless specifically prompted (Calhoun et al., 2022; Davies et al., 2021). Hence, there is a need for more time and a significant number of high-quality intervention activities that encourage children to become more expressive and share their feelings, life experiences, and challenges.

CONCLUSION

The findings of the study have left a lasting impression that psychosocial intervention is helpful in the management of the symptoms of stress among displaced children. The result indicated that a combination of parental support, recreational activities, community reconstruction, and art therapy effectively enhanced the children's coping mechanisms against the stress they encountered in evacuation facilities. Children may only disclose their psychological responses to stress once specifically questioned. Observations made during the study's execution indicate that systematic screening of children in the relocation region is better than routine evaluation of stress symptoms, as affected children may never be identified. The evaluation must be valid, age-appropriate, and sensitive to culture. Numerous children like to discuss how they and their families are feeling, so it is essential to assist children in making sense of and expressing their emotions.

Moreover, parental participation in assessment and intervention is crucial. Educating family members and their children about the symptoms of stress is particularly beneficial for preventing and managing stress. In addition, parents need assistance recognizing and accepting that the child's perplexing and distressing expressions and behaviors during challenging situations brought on by displacement are "normal" in an "abnormal" context. Adults should be more accommodating and responsive when addressing children's inquiries directly and truthfully, without providing more information than is necessary. They should shield their children from images of catastrophic events, such as the Marawi Siege, that are endlessly repeated. The family should be urged to immediately resume regular daily activities and accustomed schedules.

Furthermore, future research scope could focus on evaluating the effectiveness of specific components within psychosocial interventions for displaced children, such as the role of parental education and involvement in stress management techniques. Moreso, exploring the impact of trauma-informed approaches in psychosocial interventions could provide valuable insights into improving outcomes for displaced children.

Conflict of Interest

The authors declare that they have no competing interests.

ACKNOWLEDGEMENT

The researchers acknowledged the support and guidance of the MSU and UPOU administrators, faculty, and staff. The assistance and services extended by the local government unit of Marawi City through their MDRRMC office are unparalleled, which led to the smooth facilitation of the study. The individuals who took part in the study, including the displaced children and their parents, deserve a lot of credit for their voluntary and unsolicited participation in the research.

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