American Journal of Orthopsychiatry
© 2023 Global Alliance for Behavioral Health and Social Justice
2023, Vol. 93, No. 2, 156–165
https://doi.org/10.1037/ort0000665
Difficulties in Emotion Regulation Among Syrian
Refugee Girls: Risk and Protective Factors
Vivian Khamis
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Department of Education, American University of Beirut
Exposure to war and forced migration have been widely linked to child subsequent adaptation.
What remains sparse is research spanning multiple risk and protective factors and examining their
unique, and relative implications to difficulties on emotion dysregulation in refugee girls. This
study investigated the mechanisms through which emotion dysregulation in Syrian refugee girls is
impacted by exposure to war traumas, comorbidities, and other risk and protective factors such
as coping styles, family relationships, and school environment. The sample consisted of 539
Syrian refugee girls who ranged in age from 7 to 18 years attending public schools in various
governorates in Lebanon and Jordan. Two school counselors carried out the interviews with
children at school. Results indicated that war trauma and the combination of comorbidities
associated with negative coping styles could lead to an overall state of emotion dysregulation in
refugee girls. Enhanced understanding of the mechanistic role of risk and protective factors in
contributing to emotion dysregulation in refugee girls may contribute to the development of
effective interventions to target the psychological effects of the refugee experience.
Public Policy Relevance Statement
This study helps policymakers recognize that exposure to war traumas are risk factors for
experiencing difficulties in emotion regulation among refugee girls and that the resulting
comorbidities indicate a need for appropriate mental health services. In addition, policymakers
should pay increased attention to the types of programs and policies that should be adopted,
such as compensation laws, bills of rights, provision of services, and assistance programs.
T
often exposed to high stress that has the potential to negatively affect
their development (Boswall & Al Akash, 2015; International Rescue
Committee [IRC], 2013, 2014). They are frequently exposed to a
variety of stressors such as socioeconomic disadvantages, changes
in family structure and functioning, loss of social support, difficulty
in accessing education, living in very crowded places, experiencing
hostility and racism, and navigating problems caused by cultural
differences. Furthermore, they are exposed to gender-related problems such as forced early marriage, harassment and exploitation,
and survival sex (Bartels et al., 2021; Hattar-Pollara, 2019; IRC,
2014; United Nations Population Fund [UNFPA], 2017). According
to UNFPA (2017), approximately 35% of Syrian refugee girls are
now married before they reach the age of 18. Their dual nature as
refugees and as females, often means that Syrian girls must face
stressful experiences, beginning with child marriage (El Arab &
Sagbakken, 2019) and continuing to current inequities in social
resources and barriers to education (Hassan et al., 2016; HattarPollara, 2019). Cultural norms often limit girls from accessing
medical or mental health services related to rape, sexual, or domestic
violence (Hattar-Pollara, 2019; IRC, 2014).
Exposure to the atrocities of war and disruption in their emotional
processes (Khamis, 2019) place refugee girls at risk for maladaptive
outcomes (e.g., internalizing problems, aggressive and antisocial
he protracted crisis in Syria has led to the displacement of
over 5.5 million Syrian people into neighboring countries.
Of those, approximately 825,081 reside in Lebanon, whereas
676,496 reside in Jordan (United Nations High Commissioner for
Refugees [UNHCR], 2022).
Refugee children, and in particular girls, experience a wide range
of psychiatric disorders related to their exposure to war, violence,
torture, and forced migration (Bennouna et al., 2020; Guruge &
Butt, 2015; Kirmayer et al., 2011; Nolen-Hoeksema & Aldao, 2011;
Wilson et al., 2010). Syrian refugee girls in resettlement contexts are
This article was published Online First January 12, 2023.
Vivian Khamis received funding from Grant FAS.VK. 2 from the
University Research Board at the American University of Beirut.
Ethics approval for the study was obtained from the American University
of Beirut; institutional review board number FAS.VK. 11. The author
especially grateful to Syrian refugee children and adolescents who participated in the research.
Correspondence concerning this article should be addressed to Vivian
Khamis, Department of Education, American University of Beirut, Bliss
Street, P.O. Box 11-0236, Beirut 1107 2020, Lebanon. Email: vk07@
aub.edu.lb
156
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EMOTION DYSREGULATION IN REFUGEE GIRLS
157
behavior). The mental health and psychosocial well-being of
refugee children are of particular concern because their experiences of insecurity occur at a formative stage in their development
(Reed et al., 2012).
The preponderance of studies indicates that girls are at highest
risk of affective disorders, mental health problems, and difficulties
with emotions (Andersson et al., 2010; Scherer et al., 2020).
However, studies that investigate the variables that shape the lives
of Syrian refugee girls as it pertains to mental health and psychosocial well-being are scarce. Therefore, this research posits that
emotion regulation in refugee girls is a function of their responses
to risk and protective factors, with negative outcomes linked to
exposure to risk factors such as war trauma and positive outcomes
linked to protective factors such as coping styles (Lustig et al., 2004)
and family and school environment (Berman, 2001).
inferences from them. Refugees’ psychosocial needs and ways of
coping are related to cultural concepts of mental health as well as to
influencing factors in host countries (Hassan et al., 2015; Silove et al.,
2017), which underlines the importance of investigating the specific
coping styles of Syrian refugee girls in Lebanon and Jordan. To date,
only one empirical study has examined how different forms of coping
may affect emotion dysregulation in refugee children (Khamis, 2019).
A number of coping strategies were identified as common to emotion
dysregulation, including social withdrawal, self-criticism and resignation, blaming others, and wishful thinking (Khamis, 2019). Further
research on coping and emotion regulation may possibly identify
resilience factors that could be incorporated and evaluated in transdiagnostic models of preventive interventions and psychological
treatments for a range of psychological problems and disorders in
refugee girls (Compas et al., 2013; Trosper et al., 2009).
Emotion Dysregulation and Comorbidities
Emotion Dysregulation and Family Relations
Growing evidence indicates that exposure to war exerts a pernicious influence on refugees’ emotion regulation (Doolan et al.,
2017; Khamis, 2019; Nickerson et al., 2016, 2017; Specker &
Nickerson, 2019). The theoretical and empirical literature highlights
the role of emotion dysregulation in diverse forms of psychopathology in children. Specifically, posttraumatic stress disorder (PTSD)
has been found to be positively associated with overall emotion
dysregulation and the specific dimensions of lack of emotional
acceptance; difficulties engaging in goal-directed behaviors and
controlling impulsive behaviors when upset; limited access to emotion regulation strategies; and lack of emotional clarity (Ehring &
Quack, 2010; Tull et al., 2007). Furthermore, research provides
evidence of heightened emotion dysregulation among children
who are at risk for high levels of neuroticism (Kokkonen &
Pulkkinen, 2001; Mącik et al., 2019; Weinstock & Whisman,
2006) and emotional and behavioral disorders (e.g., Khan et al.,
2005; Lahey, 2009; Martel & Nigg, 2006). The ability to manage
emotions holds promise for favorable outcomes for children and
adolescents in high-risk contexts (Buckner et al., 2003). Although
the aforementioned findings provide support for a relationship
between emotion dysregulation and children’s mental health
outcomes, a better understanding of these comorbidities is important in order to promote resilience and prevent emotion regulation
problems among refugee girls.
Another variable that may influence the course of refugee
children’s adjustment to war atrocities and displacement is family
relations. Children’s emotion regulation abilities are influenced
by parent, child, and family characteristics (Morris et al., 2007).
Therefore, the family relationship may be critical in protecting
children from maladaptive outcomes during times of stress,
because this relationship offers unique opportunities to develop
emotion regulation skills to manage stress and other difficult
emotions (e.g., Eisenberg et al., 1998; Lindsey, 2020; Morris
et al., 2007). It has been postulated that family relationships affect
children’s emotional development (e.g., Davies & Cummings,
2010) and that these relationships set a developmental context
for emotion regulation in children (Morris et al., 2007). While
family support and positive family relationships have been identified as protectors from stress during the phases of the refugee
experience, family conflict negatively influenced children’s emotion regulation (Iraklis, 2021b; Pieloch et al., 2016). Families in the
Arab world have been characterized as being collective and
authoritarian (Dwairy, 1998). As an integral part of their families,
girls may be affected by these patterns of family interactions.
Research on refugee children revealed that girls reported that they
were not as equally valued or supported as their male siblings
and that they are perceived as a burden on their families. Their
gendered role as females offered a constricted range of possibilities
and opportunities, and restrained and confined their lives and
behaviors within clearly prescribed expectations that were reinforced with verbal threats and physical punishment. The mere
rumor of violations of these expectations was invariably and
swiftly met with punishment, beatings, and severe restrictions
(Hattar-Pollara, 2019). Hence, examining how refugee girls perceive their family environment and how these perceptions affect
their emotion regulation remains an important gap in refugee
children’s developmental research.
Emotion Dysregulation and Coping Strategies
The ability to successfully regulate affective states is central to
mental health, and indeed, it has been noted that coping figures
prominently in a healthy lifestyle and quality of life (Goldberger &
Breznitz, 1993). Despite the enormity of the impact of war trauma
and forced migration on children’s developmental trajectories, there
is a lack of research on coping among refugees (Siriwardhana
et al., 2014). The strategies refugee children use to regulate their
emotions are the focus of a great deal of recent theoretical and
empirical work, and a number of specific strategies have been
argued to be generally adaptive or maladaptive (see reviews in
Gross & Thompson, 2007; Kring & Sloan, 2010). However, these
studies were qualitative in nature and had a small sample size (Iraklis,
2021a, 2021b; Maegusuku-Hewett et al., 2007; Ní Raghallaigh
& Gilligan, 2010), hence limiting our capacity to draw general
Emotion Dysregulation and
School Environment
The struggles associated with the integration of refugee children
into the education system have been noted to include problems with
learning the Lebanese and Jordanian curriculum as well as challenges of adapting to new ways of learning in a context where they
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158
KHAMIS
increasingly face exclusion and discrimination (Alkhawaldeh, 2018).
The majority of Syrian students attend second-shift classes at public
schools (Alkhawaldeh, 2018; UNHCR, 2018) which may affect
not only academic aspects of school life but also extracurricular
activities and general discipline as well as the ability of refugee
students to socially integrate. Refugees’ experience in schools also
affected whether they stayed in school or dropped out. Children and
parents often cited bullying and violence in schools as contributing to dropping out (Norwegian Refugee Council, 2020).
Studies of the general student population indicate strong associations between school climate and indicators of mental health
across a range of academic, behavioral, and socioemotional outcomes; and in early adolescence, a positive school climate is
predictive of better psychological health (Thapa et al., 2013). In
addition, a growing body of literature has documented the central
role that schools play in supporting the adjustment of resettled
refugees (Bennouna et al., 2019; Khamis, 2019). In a systematic
review, Fazel et al. (2005) noted that effective schools and teachers
have the potential to promote resilience in refugee children by
becoming the focal point for educational, social and emotional
development. Support from teachers and peers has been identified
as a protector from stress during the phases of the refugee experience (Berman, 2001), but the mechanisms of such associations are
not yet fully elucidated. Alternatively, researchers have revealed
that refugees are often subject to various modes of discrimination
and bullying (Montgomery & Foldspang, 2008; Schwartz et al.,
2010). Researchers have indicated that postmigration experiences
of discrimination, hostility, and bullying in schools are commonly
reported and represent a significant threat to the mental well-being
of refugee children (Fazel et al., 2015; Kandemir et al., 2018;
Samara et al., 2020). The influence of the school environment on
refugees’ mental health is insufficiently investigated because the
emphasis has been placed on what children bring with them when
they enter schools (e.g., children’s social background) rather than
on school environment or the complex interaction between multiple
influences (Montgomery, 2010; Porter & Haslam, 2005). Research
that investigates the relation between school environment and emotion regulation are limited. They indicated that the student–teacher
relationship is related to emotion regulation and academic success
(Fried, 2011; Graziano et al., 2007). In addition, perceived supportive
school climate, support from adults in school and at home, and peer
belonging were each independently associated with better emotional
health (Emerson et al., 2022). To my knowledge, no study to date has
examined the impact of school environment on emotion regulation in
refugee girls. It is important to recognize that students’ and teachers’
emotion regulation are influenced by the emotional climate of the
school (Fried, 2011; Hargreaves, 2000). Given the established
importance of the postresettlement environment and the significance of school in the daily lives of refugee children, there are
compelling reasons to study school environment as a predictor of
emotion regulation in refugee girls. This will allow clear directives
and actionable recommendations regarding how climate can support
good mental health and resettlement outcomes for refugee girls.
A widely used theoretical model that generates insight in the
multiple factors associated with developmental outcomes in refugee
children is the ecological model of Bronfenbrenner (Ager, 1993;
Arakelyan & Ager, 2021). The Bronfenbrenner (1979, 1995) human
ecology model provides a useful theoretical framework for this
study. This model primarily focuses on the social contexts in which
children live and the people who influence their development.
Bronfenbrenner’s ecological theory identifies five environmental
systems that range from close interpersonal interactions to broadbased influences of culture (Bronfenbrenner & Morris, 2006). The
focus of this study is on the microsystem setting, which is the most
immediate environmental social context containing the developing
refugee girl, including the family and school.
This study aims to further elucidate the mechanisms through which
emotion dysregulation in refugee girls is impacted by exposure to war
traumas, comorbidities and other risk and protective factors such as
coping styles, family relationships and school environment. Specifically, it was hypothesized that self-reported rates of traumatic events
would be positively associated with emotion regulation difficulties
including lack of awareness of emotional responses, lack of clarity of
emotional responses, nonacceptance of emotional responses, limited
access to emotion regulation strategies perceived as effective, difficulties controlling impulses when experiencing negative emotions,
and difficulties engaging in goal-directed behaviors when experiencing negative emotions. Risk and protective factors were then examined as predictors of emotion dysregulation using multiple regression.
It was hypothesized that higher levels of war traumas and comorbidities (i.e., PTSD, neuroticism, and emotional and behavioral
disorders) and negative coping styles, would predict difficulties in
emotion regulation among refugee girls. Conversely, older age, a
longer resettlement period, positive coping style, positive family
relationships, and school environments were expected to predict
more emotion regulation in refugee girls.
Method
Setting and Participants
Data were derived from a large study on the educational and
psychosocial status of Syrian refugee children and adolescents
residing in two neighboring countries: Lebanon and Jordan. The
study was conducted in ten public schools in Lebanon across three
sites: Beirut, Bekaa, and Mount Lebanon, as well as ten public
schools in Jordan across three sites: Amman, Zarqa, and Balqa. Five
hundred and thirty-nine refugee girls (aged 7 to 17 years) were
included in this analysis. Informed assent and consent were obtained
from the girls and their parents, respectively. They were given a full
explanation of the study and were assured of the anonymity and
confidentiality of their responses. Ethics approval for the study was
obtained from the American University of Beirut. All instruments
were translated from English into Arabic and then back translated by
professionals except for the trauma exposure scale, which was
constructed in Arabic for the purpose of this study. Two trained
psychologists between March and June 2017 administered the
questionnaires in an interview format with the girls at school.
Completion of the interview took approximately from 35 to 45 min.
Instrumentation
Personal History Form. The personal history form collected demographic data on refugee girls such as age, grade level, host
country, and time spent in host country since they fled from Syria.
War-Related Trauma. Trauma exposure scale was used to
assess the number of war-related trauma experienced by children
EMOTION DYSREGULATION IN REFUGEE GIRLS
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and adolescents during the war (Khamis, 2019). The scale is
composed of 17 items scored as 1 “‘yes”’ and 0 “‘no”’. Responses
are summed to arrive at a total scale score. Scores vary from 0 (no
trauma exposure at all) to 18 (high trauma exposure). Examples of
the items are a family member, a relative or a close friend was
killed during the war, our house was bombarded or destructed,
hearing the sounds of rocket attacks, shelling and bombardment,
witnessing people injured and was forced to live in a refugee
camp. Cronbach is for the total scale in this sample is 0.85.
Emotion Dysregulation. The present study operationalized emotion dysregulation using a short form version of the
Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer,
2004). The DERS–short form (DERS-SF) is 18-item questionnaire
that measures emotion regulation difficulties such as (a) lack of
awareness of emotional responses, (b) lack of clarity of emotional
responses, (c) nonacceptance of emotional responses, (d) limited
access to emotion regulation strategies perceived as effective,
(e) difficulties controlling impulses when experiencing negative
emotions, and (f) difficulties engaging in goal-directed behaviors
when experiencing negative emotions. Participants responded
to each item on a 5-point scale from 1 (almost never) to 5 (almost
always) with higher summed scores indicating greater emotion
regulation difficulties. Internal consistency in this study for the
total DERS-SF scale was high (α = 0.84), and total scores ranged
from 18 to 90 (M = 81.69, SD = 26.24).
Behavioral and Emotional Disorder. Behavioral and
emotional disorders were assessed by the Strengths and Difficulties
Questionnaire–SDQ (Child Form). It contains four problem subscales with five items each assessing emotional symptoms, conduct
problems, hyperactivity/inattention, and peer relationship problems (Goodman, 1997). Items are rated on a 3-point scale (not
true; somewhat true; certainly true) and summed across the subscales to give a total problems score (0–40), with higher scores
indicating poorer mental health. The SDQ has high internal
reliability (α = 0.87; Khamis, 2019).
Neuroticism. The neuroticism scale of Eysenck Personality
Questionnaire (Eysenck & Eysenck, 1968) assessed neuroticism.
Children were asked to complete the 19-item Arabic version of the
neuroticism scale (El Khalek, 1978), which asked children to
answer yes or no questions about their negative affectivity.
Composite scores could range from 0 to 19, with higher scores
indicating higher neuroticism. Cronbach’s α for the total scale in
this sample was 0.87.
PTSD. PTSD was assessed by using the diagnostic criteria
for an assessment of PTSD as outlined in the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition (American
Psychiatric Association, 1994). A structured clinical interview was
used to ensure coverage of all the relevant signs and symptoms of
PTSD. The PTSD module of the structured clinical interview for
the Diagnostic and Statistical Manual of Mental Disorders, fourth
edition has been previously used on children and adolescents in
the Arab world, and the interrater kappa coefficients measuring
the reliability of interviewers was .90 for current and lifetime
PTSD (Khamis, 2005, 2008, 2012). The characteristic symptoms
of PTSD included reexperiencing the traumatic event, avoiding
159
stimuli associated with the trauma and experiencing a lack of general
responsiveness, and experiencing symptoms of increased arousal.
Coping Strategies. The Kidcope (Spirito et al., 1988) is an
inventory designed to assess coping strategies employed by children. Children have to report the major problem experienced in their
lifetimes and are then asked to indicate if they have used the
10 general coping strategies included in the inventory. The Kidcope
targets positive coping styles such as cognitive restructuring, problem solving, emotional regulation, and social support, whereas the
negative coping style includes distraction, withdrawal, criticizing
self, blaming others, wishful thinking, and resignation. Cronbach’s
α for the total scale in this sample is .79.
Family Relationships. Family relationships were assessed
by the relationship dimension of the Family Environment Scale
(Moos & Moos, 2002). The Relationship domain has three subscales
that account for 27 items with a true–false response format: Cohesion (the degree of commitment and support family members
provide for each other), Expressiveness (the extent to which family
members are encouraged to express their feelings directly), and
Conflict (the amount of openly expressed anger and conflict among
family members). Representative items for the relationship domain
include “In my family, we really help and support each other,” “We
are a close and cohesive family,” “We tend to lose our tempers a lot
in our family,” “We fight a lot,” and “Family members sometimes
hit each other.” Cronbach’s α for the family relationship scale in this
sample is .86.
School Environment. The School Environment Scale
(Khamis, 2015) is an instrument designed to evaluate the school
environment based on students’ perceptions. It addresses 10 school
experiences over three broad domains, including social support
received from teachers, peers, and friends (emotional support, advice,
encouragement, companionship, and morale boosting); meaningful
and genuine relationships with peers, and instructional and academic
support. Cronbach’s α for the total scale is .87.
Statistical Analysis
Descriptive statistics was used to investigate sample characteristics. Pearson correlation was conducted to investigate the relationship between difficulties in emotion regulation and the study
variables. Multivariate analysis of variance (MANOVA) was
employed to examine differences between high and low levels
of war trauma on the six dimensions of difficulties in emotion
regulation. Then hierarchical regression was used to predict difficulties in emotion regulation. Model 1 included only the girls’ age,
war trauma and time lapse since resettlement. Model 2 included the
comorbidities (PTSD, behavioral and emotional disorders, and
neuroticism) as well as the variables in Model 1. Model 3 included
all the variables in Model 2 plus the coping strategies (i.e., positive
and negative coping). Model 4 included all of the variables in
Model 3 plus the family relationships processes (i.e., cohesion,
expressiveness, conflict). Model 5 included all of the variables
in Model 4 plus the school environment. The predictor blocks
were entered in the order listed. This order was based upon
chronology of occurrence. The early entry of a variable block
into the regression equation provided a statistics control for the
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KHAMIS
p < .001, difficulties controlling impulses when experiencing
negative emotions t(537) = −6.77, p < .001, and difficulties
engaging in goal-directed behaviors when experiencing negative
emotions t(537) = −5.93, p < .001 compared to their counterparts
with lower levels of trauma (see Table 1). There was no significant main effect of war trauma on lack of awareness of emotional
responses t(537) = −.93, p <. .35 (see Table 2).
impact of those variables upon difficulties in emotion regulation.
Analyses were conducted using PASW Statistics 27.0 (IBM
Corporation Released, 2020).
Results
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Preliminary Analyses
Distributions of scales were normal and scatterplots revealed no
multivariate outliers. Means, standard deviations, and correlations
are presented in Table 1. While the bivariate correlations indicated
that emotion dysregulation had small association with PTSD, it had
strong association with neuroticism and emotional and behavioral
disorders. In addition, a moderate positive relationship was found
between emotion dysregulation and negative coping. In analyzing
family relationships, family cohesion and expressiveness were
negatively related to emotion dysregulation whereas family conflict
was positively related to emotion dysregulation. A moderate negative relationship was found between school environment and emotion dysregulation (see Table 1).
Prediction of Emotion Dysregulation
Table 3 indicates that the model containing all five predictor
blocks accounts for 43.9% of emotion dysregulation variance. In
the first step, girls’ age, war trauma, and time spent in host country
collectively accounted for 16.9% of the variance in emotion
dysregulation among refugee girls. Of these variables, age and
war trauma had statistically significant b weight. Adding the
comorbidities in the second step did produce a significant increase
in the amount of variance explained in emotion dysregulation.
Only emotional and behavioral disorders and neuroticism were
positively related to emotion dysregulation and accounted for
25% of additional variance, (see Table 3). However, when the
comorbidities entered the model in the second step, the age of
girls and their exposure to war trauma became nonsignificant. In
the third regression step, coping strategies produced an increment
of 1.4%, in the variance explained; while negative coping stood
out as a significant predictor, positive coping was not significant.
Emotion dysregulation in refugee girls was associated with
greater use of coping styles such as distraction, withdrawal,
criticizing self, blaming others, wishful thinking, and resignation.
Adding the family relationships in the fourth step produced an
increment of .003 indicating that family cohesion, expressiveness, and conflict were not significant predictors of emotion
dysregulation addition. Similarly, school environment appeared
to be a nonsignificant predictor (.004) of emotion dysregulation in
the fifth step. Therefore, the resulting effect sizes were medium
for age and war trauma and comorbidities, whereas it was small
for coping strategies, family relationships, and school environment
(see, Cohen, 1988).
War Trauma and Emotion Dysregulation
The amount of exposure to war atrocities was examined in more
detail by dividing participants into two groups using median splits
for high/low exposure to war trauma (based on the war trauma
measure). Girls with high level of trauma exposure and low level
of trauma exposure were compared to determine whether the two
groups differed on the various dimensions of emotion dysregulation.
MANOVA was employed to examine differences between
refugee girls with high levels of trauma and low levels of trauma
on the six dimensions of difficulties in emotion regulation.
Results indicated a significant multivariate effect, Wilks’ λ =
0.869, F(1, 539) = 13.41, p < .001. The univariate analyses for the
war trauma effect revealed that refugee girls with higher levels of
trauma exposure reported greater lack of clarity of emotional
responses t(537) = −5.58, p < .001, nonacceptance of emotional
responses t(537) = −7.12, p < .001, limited access to emotion
regulation strategies perceived as effective t(537) = −6.87,
Table 1
Intercorrelations of Predictor and Outcome Variables
Variable
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
M
SD
Age
Time lapse
Trauma
Positive coping
Negative coping
Family cohesion
Family expressiveness
Family conflict
School environment
Emotion dysregulation
PTSD
Behavior and emotion disorder
Neuroticism
1
2
—
.05
—
.21** −.15**
−.12** −.05
.15** −.02
−.21** −.03
−.18**
.07
.20** −.02
−.30** −.05
.28** −.08
.04
−.19**
.28** −.05
.34** −.10*
11.30
49.56
2.60
15.24
Note. PTSD = posttraumatic stress disorder.
* p < .05. ** p < .01.
3
4
5
6
—
−.09*
.24**
−.35**
−.17**
−.17**
−.40**
.35**
.25**
.50**
.45**
9.61
4.05
—
.12**
.17**
.16**
−.26**
−.26**
−.06
.04
−.16**
.02
2.79
1.26
—
−.15**
−.15**
.21**
.21**
.32**
.12**
.19**
.37**
2.36
1.45
—
.22**
−.47**
.41**
−.24**
−.07
−.44**
−.33**
6.46
1.43
7
8
9
10
—
−.48**
—
.26** −.45**
—
−.24** .28** −.36**
—
−.19** .06
.01
.21**
−.27** .44** −.51**
.53**
−.26** .28** −.38**
.60**
5.39
2.25
16.37
50.21
1.67
1.90
3.72
11.41
11
12
13
—
.19**
—
.29**
.57** —
.43
11.11
7.81
.49
6.56
4.74
161
EMOTION DYSREGULATION IN REFUGEE GIRLS
Table 2
Mean Difference of Syrian Refugee Girls on the Dimensions of Emotion Dysregulation Across
High/Low Levels of War-Related Trauma (n = 539)
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Refugee girls
High trauma (299)
Low trauma (240)
Variable
M
SD
M
SD
Limited access to emotion regulation strategies
perceived as effective
Nonacceptance of negative emotions
Difficulties controlling impulsive behaviors
Inability to engage in goal-directed behaviors
Lack of emotional awareness
Lack of emotional clarity
9.31
2.94
7.68
2.43
9.12
8.60
9.70
8.12
8.90
3.01
2.61
3.38
3.25
3.44
7.42
7.20
8.13
7.88
7.43
2.38
2.03
2.59
2.60
2.45
Discussion
This study investigated the mechanisms through which emotion
dysregulation is impacted by exposure to war traumas, comorbidities,
and other risk and protective factors such as coping styles, family
relationships, and school environment.
The present study suggests that exposure to war traumas are risk
factors for emotion dysregulation in refugee girls. Consistent with
previous research, trauma exposure was significantly associated with
lack of clarity of emotional responses, nonacceptance of emotional
responses, limited access to emotion regulation strategies perceived as
effective, difficulties controlling impulses when experiencing negative emotions, and difficulties engaging in goal-directed behaviors
when experiencing negative emotion. However, trauma exposure
was not associated with lack of awareness of emotional responses
(Nickerson et al., 2015). This finding calls for future research that will
assess a wide range of traumatic war-related events in a broad range of
Syrian refugee girls who experienced events at different times and in
different geopolitical contexts (Hollifield et al., 2006).
Consistent with previous studies, the results also indicated no
substantial effect of the resettlement period on emotion dysregulation in refugee girls (Amin et al., 2020; Jensen et al., 2014).
That the prevalence of emotion difficulties was higher in older
refugee girls was in line with the literature as emotion regulation
difficulties are expected to be present in normative developing
adolescents to some degree, and impairing symptoms can be particularly frequent in adolescent females (Stringaris & Goodman, 2009).
Consistent with previous research, emotion dysregulation (as a
unitary construct) was directly associated with both neuroticism
(Kokkonen & Pulkkinen, 2001; Mącik et al., 2019; Weinstock &
Whisman, 2006) and emotional and behavioral disorders (Khan
et al., 2005; Lahey, 2009; Martel & Nigg, 2006), though, surprisingly, it was not directly associated with PTSD. Of note, emotion
dysregulation and PTSD were related at the bivariate level (Table 2).
Table 3
Regression Weights for Hierarchical Models Predicting Refugee Girls’ Emotion Dysregulation From Age and Trauma, Comorbidities,
Coping Strategies, Family Relationships, and School Environment
Emotion dysregulation/predictor
variables
Age and trauma
Age
War trauma
Time lapse
Comorbidities
PTSD
BED
Neuroticism
Coping strategies
Positive coping
Negative coping
Family relationships
Cohesion
Expressiveness
Conflict
School environment
Total R2
ΔR2
F
ΔF
Model 1
Model 2
Model 3
Model 4
Model 5
95% CI
.22*
.30*
−.05
.06
.01
−.02
.05
−.01
−.03
.05
−.01
−.02
.04
−.01
−.02
[−.12, .48]
[−.26, .18]
[−.07, .02]
.03
.26*
.42*
.169
.169
36.22
36.22
.419
.250
63.93
76.33
.03
.26*
.39*
.02
.26*
.39*
.03
.25*
.38*
−.04
.13*
−.03
.12*
−.02
.13*
.05
−.03
.02
.06
−.02
.01
−.07
.439
.004
37.00
3.30
.433
.014
50.56
6.50
.436
.003
37.00
.90
Note. Age is coded in years. CI = confidence interval; PTSD = posttraumatic stress disorder; BED = behavioral and emotional disorders.
* p < .001.
[−.85, 2.38]
[.27, .58]
[.69, 1.12]
[−.83, .41]
[.45, 1.57]
[−.13,
[−.66,
[−.43,
[−.49,
1.10]
.35]
.60]
.01]
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162
KHAMIS
Thus, these results indicate that, for refugee girls, PTSD did not
predict residual variance in emotion dysregulation over and above
that accounted for by neuroticism and emotional and behavioral
disorders. To further analyze this result, hierarchical regression
analysis was employed to examine the relationships among emotion
dysregulation and comorbidities including PTSD in the first step,
neuroticism in a second step, and emotional and behavioral disorders in the third step. The results revealed that emotion dysregulation was significantly associated with PTSD independent of the
already known risk factors neuroticism, and emotional and behavioral disorders. Notably, when neuroticism was included in the
second step, PTSD became nonsignificant. Each predictor block
separately accounted for the following percentage of difficulties in
emotion regulation variance: 4.5% by PTSD, 32.1% by neuroticism,
and 4.9% by emotional and behavioral disorders. Therefore, neuroticism was of more significance in predicting emotion dysregulation compared with PTSD and emotional and behavioral disorders.
Indeed, when accounting for comorbidities, the direct impact of
age and war trauma were no longer significant, demonstrating that
neuroticism, emotion, and behavioral disorders were so intensely
overwhelming that the other variables were overshadowed. Future
work will need to evaluate the mediating roles of multiple process
variables among various forms of psychopathology simultaneously
to examine differential pathways and specific processes that may be
linked in each domain of emotion dysregulation.
While the use of negative coping styles was associated with
increased emotion dysregulation, the use of positive coping styles
had no significant relationship with emotion dysregulation. These
results are consistent with other findings that show that reliance on
negative coping style contributes to emotion dysregulation in refugee children (Khamis, 2021).
Contrary to previous research (Rivera et al., 2008; Sarmiento &
Cardemil, 2009), the findings of this study show that family relations
and school environment did not predict residual variance in emotion
dysregulation over and above that accounted for by neuroticism and
emotional and behavioral disorders, and negative coping styles. The
mechanism of this nonsignificant effect remains unknown, and a
variety of explanations is possible. One explanation for this result
might be that Syrian refugee families may not be able to manage the
emotional ramifications of the overwhelming refugee experience,
forced displacement, and resettlement in the interfamilial subsystem; it is possible that children from these families may be less
affected by family relationships (Bronfenbrenner, 1979). A second
explanation might be that Syrian refugee girls are more likely to
experience psychological maltreatment in their families because
they perceive themselves as less valued members in the family,
unwelcomed load, and a burden on the family (Hattar-Pollara, 2019).
Emotional expression is impacted by ones’ cultural background and is
particularly influenced by religion and ethics (Abu-Hamda et al.,
2017; Dwairy). Cultural norms often limit girls from regulating their
emotions. Women, as well as girls, are strictly controlled and are
expected to adhere completely to the paternally dictated norms of the
Arabic family (Weller et al., 1995). Hence, Syrian refugee girls’
feeling of disconnectedness in their overall family system may not
provide a context that promotes the development of emotion regulation, potentially as manifested in parent–child subsystems. In a similar
vein, the results of this study revealed that school environment was
not a significant predictor of emotion dysregulation. There is a need
for research focused on the experiences of Syrian refugee girls in
school setting. The multidimensional and collective character of
challenges facing refugee children and families calls for comprehensive psychosocial interventions through which healing the psychological wounds of war is complemented by restoring and supporting
the social and physical environment so that it is one in which children
and their families can thrive (Fazel & Betancourt, 2018). Examples
for possible interventions include the caregiver support intervention
which have been tested in studies with Syrian refugee children in
Lebanon. This intervention focuses on strengthening parenting in
adversity, which may ultimately promote positive family relations
among Syrian refugees (Miller et al., 2022).
Limitations
The primary limitations of this study arise from the use of crosssectional and retrospective data collection. Due to the crosssectional nature of the data, the results were unable to determine
the degree to which negative coping style, neuroticism, and emotion
and behavioral disorders are risk factors for the development of
difficulties in emotion regulation in refugee girls. Although the
present study adds to the growing body of literature on emotion
dysregulation and comorbidities including neuroticism and emotional and behavioral disorders, the correlational nature of the data
limits our ability to determine the exact nature and direction of the
relationships of interest. It is also possible that this association is
bidirectional and that regular engagement in impulsive behaviors
may lead to or exacerbate emotion dysregulation. Second, since the
Syrian refugee girls in this study were attending the public schools in
Lebanon and Jordan, the results may not be generalized to other
refugee girls who resided in other host countries and those who were
not attending school. Nevertheless, the results provide an important
step to understanding resilience in a highly vulnerable child population with considerable barriers to research access.
Conclusion
Findings from this study indicated that war trauma and the
combination of comorbidities associated with negative coping
styles could lead to an overall state of emotion dysregulation in
refugee girls. Enhanced understanding of the mechanistic role of
these variables in contributing to emotion dysregulation in refugee
girls may contribute to the development of effective interventions
to target the psychological effects of the refugee experience.
Keywords: Syrian refugee girls, war trauma, emotion dysregulation, coping style, family and school environment
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