Posttraumatic stress disorders in long-term Egyptian survivors after childhood cancer Mohamed A. Afify a, Heba H. Elshahawi b and Amira A.

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1 40 Original article Posttraumatic stress disorders in long-term Egyptian survivors after childhood cancer Mohamed A. Afify a, Heba H. Elshahawi b and Amira A. Adly a a Departments of Pediatrics and b Neuropsychiatry, Faculty of Medicine, Ain Shams University, Cairo, Egypt Site of conductance: Oncology Survivors Clinic, Children s hospital, and Neuropsychiatry Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt. Correspondence to Dr Heba H. Elshahawi, MD, Assistant Professor of Psychiatry, Neuropsychiatry Department, Ain Shams University, 66 Elmontazah st, Heliopolis, Cairo, Egypt Tel: ; fax: hebaelshahawi@yahoo.com Received 20 August 2011 Accepted 2 October 2011 Middle East Current Psychiatry 2012, 19:40 47 Background Seventy-five percent of children who are diagnosed with cancer are expected to survive. As this population has grown, the study of the impact of this traumatic event has become increasingly important. Objectives The current study aimed to investigate the prevalence and risk factors of posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) in long-term childhood cancer survivors. Methods Eighty survivors of childhood cancer who were between 9 and 17 years of age (mean ± SD = 12.9 ± 2.28), had stopped therapy for at least 2 years, had no history of previous central nervous system relapse or cranial irradiation, and did not have premorbid medical diseases, were enrolled in the study. They were assessed in terms of PTSD, PTSS, and Children s Global Assessment Scale. They were compared with age-matched and sex-matched healthy controls. Results Fourteen survivors (17.5%) met the criteria of lifetime diagnosis of PTSD according to Kiddie-Sads-Present and Lifetime Version diagnostic and clinical versus 5% of the control group (v 2 = 6.26, P = 0.04, odds ratio = 4.03, confidence interval = ). In the survivor group, current PTSS were severe in 10%; moderate in 32.5%; and mild in 50%, according to the children posttraumatic stress disorder reaction index. None of the children in the control group had severe PTSS. Severe PTSS are associated with older age at diagnosis, older age during study, relapse, increased duration of therapy, and use of chemotherapy plus irradiation and/or surgery. Severe PTSS are associated with lower scores on Children s Global Assessment Scale. Conclusion Both PTSD and PTSS may be prevalent in cancer survivors even after a complete physical cure. Adequate treatment of traumatic memories, arousal and avoidance, may improve social and psychological functioning, and quality of life. This will lead to better orientation toward health services. Keywords: cancer, childhood, Egyptian, posttraumatic stress, survivors Middle East Curr Psychiatry 19:40 47 & 2012 Okasha Institute of Psychiatry, Ain Shams University Introduction Childhood cancer-survival rates have increased drastically over the past 30 years. In 1970, the 5-year survival rate was less than 30%, whereas today more than 75% of children who are diagnosed with cancer are expected to survive the disease. As this population has grown, the quality of life in terms of long-term survival has become increasingly more important [1]. Thus, the psychological late sequelae are becoming increasingly important, which could be a result of cancer, treatment-related factors, or late medical side effects [2]. A diagnosis of cancer in childhood causes psychological trauma that may affect psychological and social development of young adults [3]. This may evoke feelings of intense fear (reexperiencing the traumatic event, arousal, numbing, and avoidance of event reminders), together with occupational and social impairment, that fulfill the criteria for posttraumatic stress disorder (PTSD). This diagnosis has been documented in both pediatric and adult patients with cancer while on active therapy and many years after the successful completion of therapy. Prevalence estimates for PTSD in patients with cancer and survivors range from 2.5 to 20% [4]. Therefore, the advantage of systemically assessing the prevalence of PTSD in this population is to allow for specific questions about the impact of illness and examine symptoms and reactions typically seen in persons affected by extreme stress [5]. Eventually, PTSD as a result of exposure to extreme stress can be a major & 2012 Okasha Institute of Psychiatry, Ain Shams University DOI: /01.XME f

2 Posttraumatic stress disorders Afify et al. 41 risk factor for development of a first depressive episode, generalized anxiety disorder, and alcohol and substance abuse [6]. Study of related posttraumatic stress symptoms (PTSS) is another important issue. PTSS are broader and more normative than the psychiatric diagnosis of PTSD. PTSS are defined as a set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences. These symptoms do not cause impairments in social and occupational functioning, but may allow an understanding regarding why patients continue to suffer psychologically years after treatment ends [7]. Therefore, the aim of the current study is to investigate the prevalence and risk factors of PTSD and in Egyptian long-term childhood cancer survivors. Materials and methods Participants This cross-sectional study included 80 children and adolescent who were survivors of childhood malignancies. The study period was from 1 February 2008 to 30 June Eligibility criteria for participants included those with a history of childhood cancer, a diagnosis of cancer that was made when they were at least 4 years old, current survivors who are 8 years of age or old enough to comprehend the scales, and survivors currently in remission or who have been cured and have not received active treatment for their disease for at least 2 years. The exclusion criteria were central nervous system (CNS) relapse, cranial irradiation, CNS tumors, severe cognitive impairment, illiteracy, and current residence farther than 150 miles from the hospital. A total of 150 survivors were identified through the survival clinic registries. Forty-five survivors (30%) were found to be ineligible (i.e. beyond the limits in terms of age, time since treatment, or geographic range). Of the 105 contacted families whose eligibility was confirmed, 80 survivors (76.5%) were enrolled in the study. Those declining participation (n = 25, 23.8%) were asked the reasons for refusal: 45.8% indicated that they did not want to revisit the cancer clinic; 61.4% cited time and scheduling difficulties. The survivors had been treated for a variety of cancers. They ranged in age from 9 to 17 years, so that they could comprehend the scales, and eventually, their age at diagnosis ranged from 4 to 8 years. The time since completion of therapy ranged from 24 to 96 months. Only eight survivors (10%) had a relapse during the course of treatment. Further sociodemographic and clinical data are presented in Table 1. Eighty normal children were selected from among healthy school children as a comparison group from sibs of patients attending the outpatients clinic in Children s hospital, Ain Shams University. The comparison group matched the survivors in terms of age and sex (Table 1). Eligibility criteria for the healthy comparison group Table 1 Basic clinical data of the survivors and the healthy controls Controls Basic clinical data Survivors (n =80) (n = 80) Age (years) ± 2.06 (mean ± SD) ± 2.17 (mean ± SD) Sex (males/females) 44/36 42/38 Age at diagnosis (years) 5.71 ± 0.98 (mean ± SD) Duration of therapy 25.1 ± 4.86 (mean ± SD) (months) Time since completion of 54.6 ± 4.5 (mean ± SD) therapy (months) Type of cancer Acute lymphoblastic leukemia 54 (67.5%) Acute myeloid leukemia 8 (10%) Hodgkin lymphoma 10 (12.5%) Non-Hodgkin lymphoma 6 (7.5%) Neuroblastoma 2 (2.5%) Treatment Chemotherapy 54 (67.5%) Chemotherapy and radiotherapy 24 (35%) Surgery 2 (2.5%) included individuals who had not been treated for childhood cancer and did not have a current chronic health condition or a history of chronic health conditions, did not have a life-threatening illness, could read and write, did not have cognitive impairment, and did not have an immediate family member (e.g. sibling, parent, spouse, or child) with a history of chronic illness. Procedures The names and contact information of childhood cancer survivors were obtained from our hospital s tumor registry. After a review of medical records, eligible families were sent letters inviting participation. Follow-up phone calls were made to ensure eligibility, describe the research program, answer questions, and secure enrollment. All participants provided written consent, signed by their guardian, on joining the study. Sociodemographic data were collected from the patients and their families. Medical data on treatment were collected from hospital records. All psychiatric measures were conducted by a consultant psychiatrist, in order to guide the survivors and the comparison group through clinical interviews and questionnaires. To promote privacy interviews were conducted privately, with individual family members. Measures Both the survivors and the controls were subjected to the following: (1) Kiddie-Sads-Present and Lifetime Version interview (K-SAD-PL): K-SAD-PLS is a semistructured diagnostic interview for children and adolescents aged 6 to 18 years, based on Diagnostic and Statistical Manual of Mental Disorders, 4th edition diagnostic criteria [8]. The K-SADS-PL PTSD section was administered by interviewing the parent, preferably the mother, the

3 42 Middle East Current Psychiatry child, and finally by summary ratings that included both sources of information. When administering the instrument to preadolescents, we conducted the parent interview first. In working with adolescents, we began with them. In the current study, no discrepancies were found between the parents and the children reports about the current diagnosis of PTSD. First, we asked the child about the traumatic events that happened to the child now or at any point in time. The traumatic events included car accidents, other accidents (e.g. bike or other forms), fire, witnessing a disaster, witnessing a violent crime, victim of violent crime, witnessing domestic violence, physical abuse, sexual abuse, or experience of traumatic events or others. On inquiring about other traumatic events, we asked whether the child had learned of a sudden, unexpected death of a loved one or that a loved one had a life-threatening disease. An inquiry about other forms of trauma was made by asking Is there anything else that happened to you that was really bad or something else you saw that was really scary, that you want to tell me about? If there was evidence of past trauma, we completed the PTSD screening items. If the child received two or more on screening items, we completed the rest of the current and past PTSD items [8]. A validated Arabic version was used [9]. The items of the K-SAD-PL were rated on a 0 2-point rating scale: 0 implies no information, 1: the symptom is not present, and 2 implies that the symptom is present. Symptoms were rated for current and most severe past [10]. In order to ensure a definite diagnosis of current and past posttraumatic stress disorder, K-SAD-PL was assessed by a consultant psychiatrist. (2) Children s Global Assessment Scales (C-GAS): A C- GAS score was assigned to estimate all children s current level of functioning. For children without any lifetime history of psychiatric illness, only a current C-GAS score was assigned [11]. A validated Arabic version of C-GAS was used [9]. Children posttraumatic stress disorder reaction index (CPTSD-RI): The CPTSD-RI is a PTSD-specific interview. It is a 20-item self-report questionnaire that assesses PTSS through the total score and the scores of the following subscales: intrusion, avoidance, and arousal subscale. The frequency of occurrence of each item is indicated on a 4-point scale. A translated Arabic version was used, through forward and backward translation by the authors. Data indicated a strong association of empirically derived categories of symptom severity with clinical diagnoses of PTSD based on diagnostic measures. Scoring: mild, o25; moderate, 25 39; and severe, 440 [12]. (3) Children Impact of Event Scale (CIES): The CIES consists of two subscales that are related to intrusion (four items) and avoidance symptoms (four items). Children are required to rate the frequency of symptoms they have experienced during the past week (not at all = 0, rarely = 1, sometimes = 2, and often = 3). CIES differentiates between different populations and symptom levels, in medical and nonmedical samples. Scorings were as follows: mild: o8, moderate, 8 25; and severe, 426 [13]. A translated Arabic version was used, which was prepared by the authors themselves, through forward and backward translation. Statistical analysis The Statistical Package for the Social Sciences software (SPSS for Windows, English version 12.0; SPSS Inc., Chicago, Illinois, USA) was used. t-tests for independent samples were performed to test for differences in continuous variables between patient subgroups. The w 2 -test was used to compare the frequencies of categorical variables between patient subgroups. Pearson s correlation coefficient was used to correlate variables. Logistic regression was used to examine the extent to which a set of variables predicts a dependent variable. A value of Po0.05 = significant, Po0.01 = moderately significant, and Po0.001 = highly significant. Also, odds ratio (OR) and its confidence interval (CI) were calculated (measure of the strength of the association). An OR of 1 indicates no association, less than 1 indicates that the exposure is protective, and more than 1 indicates that it is a risk factor. A higher OR indicates a more strong association (SPSS, 2004). Results The survivor group was compared with age-matched and sex-matched healthy controls (t = 1.06, P = 0.462, and w 2 = 0.101, P = 0.823, respectively) as described in Table 1. Two psychological domains were studied in the survivors group: the posttraumatic stress symptoms and level of functioning. In comparison with the controls, the survivors had very high scores on CPTSD-RI, CIES (Po0.001), and lower scores on C-GAS (P = 0.001, as shown in Table 2). According to CPTSD-RI, PTSS in survivors were severe in 8 (10%), moderate in 26 (32.5%), and mild in 40 (50%). In the control group, PTSS were mild in 18 (22.5%), moderate in four (5%), and negative in 58 (72.5%), and none of them had severe posttraumatic symptoms, with a significant difference between the survivors and the controls (w 2 = 40.95, P = 0.000) as illustrated in Fig. 1. According to K-SAD-PL, six of the survivors (7.5%) fulfilled the criteria of PTSD and eight (10%) fulfilled the criteria of past PTSD. Thus, the total rate of PTSD since diagnosis until now was found to be 14 (17.5%). Of the 14 survivors who reported current or past PTSD, the traumatic events were in the form of confrontation of traumatic news in 10 (12.5%) and others in four (5%). In the control group, past PTSD was rated in four (5%) and

4 Posttraumatic stress disorders Afify et al. 43 Table 2 Comparison between the survivors and the controls studied according to the psychological scales Survivors Controls Psychological variables Range Mean ± SD Range Mean ± SD t P value CPTSD-RI Intrusion ± ± *** Avoidance ± ± *** Arousal ± ± *** Total ± ± *** CIES Intrusion ± ± *** Avoidance ± ± *** Total ± ± *** C-GAS ± ± *** C-GAS, Children s Global Assessment Scale; CIES, Children Impact of Event Scale; CPTSD-RI, children posttraumatic stress disorder reaction index. ***Po Figure 1 Figure 2 Severity of PTSS in surviovrs 10% 80 Chi=6.26, P=0.01(odds ratio=4.03, CI=( )) % 50% mild moderate severe Severity of PTSS in contols 5% 0% 0 survivors negative positive controls mild moderate severe Comparison between survivors and controls in the prevalence of life time diagnosis of posttraumatic stress disorder according to the K-SAD-PL interview. CI, confidence interval; KSAD, Kiddie-Sads Diagnostic Interview Present and Lifetime Version. 95% Significant differences between the severity of posttraumatic symptoms in survivors and controls according to the children posttraumatic stress reaction index (w = 40.95, P = 0.000). PTSS, posttraumatic stress symptoms. there was no current diagnosis of PTSD. PTSD prevalence in survivors was three and half times that of the controls, as shown in Figs 2 and 3. On calculating the OR, we found that survivors had a four-fold greater risk than the controls for the diagnosis of life time PTSD (OR = 4.03 and CI = ) and no risk of current PTSD (OR 0.92, CI = ). Six men (7.5%) and eight women (10%) of the survivor group were diagnosed with PTSD according to K-SAD. This difference between men and women did not reach statistical significance (w 2 = 0.82, P = 1.06). However, men and women seemed to experience posttraumatic symptoms in different ways. Women had significant higher Figure Chi=6.26, P=0.01( odds ration 0.92, CI= ) survivors 6 negative positive controls Comparsion between survivors and controls in the prevalence of current diagnosis of posttraumatic stress disorder according to the Kiddie-Sads Diagnostic Interview Present and Lifetime Version interview. CI, confidence interval. arousal symptoms (P =0.003), intrusion (P =0.03), and total CPTSD-RI (P = 0.031). This is further clarified in Table 3. 0

5 44 Middle East Current Psychiatry We attempted to identify disease-related variables and sociodemographic data that could be related to severe PTSS according to CPTSD-RI. Therefore, we compared survivors with severe PTTS (n = 8) with those with mild and moderate PTSS (n = 72). Severe, posttraumatic stress symptoms were correlated with older age at diagnosis (P = ), older age during the study (P = 0.048), relapse (P = 0.000), and use of chemotherapy plus other modes of treatment (P = 0.002) (Table 4). Furthermore, on logistic regression analysis, PTSD diagnosis according to K-SAD-PL was associated with older age at diagnosis and the use of chemotherapy plus other forms of treatment (Table 5). Finally, survivors with severe posttraumatic symptoms had lower C-GAS scores in comparison with survivors with mild to moderate posttraumatic symptoms ( vs , respectively, t = 3.68, P =0.045). Discussion Over time, the number of childhood cancer survivors has increased, and consequently, the presence of psychological problems is increasing. Researchers recognized that children s responses to major stress are similar to those of adults (reexperiencing the events, avoidance, and arousal) and these responses are not transient [14]. Therefore, the current study examined the prevalence of PTSD and its severity in a sample of long-term cancer survivors. We also investigated related risk factors such as age at the time of study, age at diagnosis, participants sex, intensity of treatment, and time after completion of treatment. The present case control study demonstrated that, although survivors had not had treatment for at least 2 years, the impact of this trauma was still affecting them psychologically and socially. The survivors demonstrated higher posttraumatic symptoms on all subscales, intrusion (Po0.0001), avoidance (Po0.0001), arousal (Po0.0001), and total posttraumatic symptoms according to CPTSD-RI (Po0.0001). CIES scores and its two subscales, intrusion and avoidance scales, were significantly higher in survivors than those in controls (Po0.0001). The survivors also demonstrated lower psychological and social functioning as evidenced from scores of C-GAS (P = ), as shown in Table 2. Table 3 Comparison between the studied male and female survivors regarding the psychological scales Psychological scale Males n = 44 (55%) Sex Females n = 36 (45%) t P CPTSD-RI Intrusion 5.63 ± ± * Avoidance 8.74 ± ± Arousal 4.8 ± ± ** Total ± ± * CIES Intrusion 5.96 ± ± Avoidance 4.35 ± ± Total ± ± C-GAS ± ± C-GAS, Children s Global Assessment Scale; CIES, impact of event scale; CPTSD-RI, children posttraumatic stress disorder reaction index. *Significant. **Highly significant. Table 5 Logistic regression analysis of factors affecting the lifetime prevalence of PTSD in survivors K-SAD-PL diagnosis of PTSD Variable w P Age at study (years) (12.91 ± 2.28) Age at diagnosis (years) (5.71 ± 0.98) ** Diagnosis acute leukemia, 77.5% Lymphoma, 20% Neuroblastoma, 2.5% Duration of treatment in months (25.3 ± 9.4) Time after treatment in months (57.0 ± 18.05) Treatment with chemotherapy, 77.5% Treatment with chemotherapy and other, 32.5% * K-SAD-PL, Kiddie-Sads-Present and Lifetime Version interview; PTSD, posttraumatic stress disorder. *Significant. **Highly significant. Table 4 Comparison between survivors with severe posttraumatic stress symptoms and those with mild to moderate posttraumatic stress symptoms according to children posttraumatic stress disorder reaction index Variable Survivors with severe PTSS n = 8/80 Survivors with mild to moderate PTSS n = 72/80 Statistical value P Age at study (years) ± ± 2.84 t = * Age at diagnosis (years) 8.40 ± ± t = * Sex Males 44/80 (55%) 2/8 (25%) 42/72 (58.3%) Females 36/80 (45%) 6 /8 (75%) 30/72 (41.7%) Diagnosis Acute leukemia, 77.5% 6/8 (75%) 56/72 (36%) w = Lymphoma, 20% 2/8 (25%) 14/72(19.4%) w = Neuroblastoma, 2.5% 0 2/72 (2.8%) w = Relapse: n = 8/80 (10%) 6/8 (75%) 2/72 (2.8%) w = *** Duration of treatment (months) ± ± 9.71 t = * Time after treatment (months) 57.6 ± ± 21.0 t = Mode of treatment chemotherapy, 67.5% 2/8 (25%) 26/72 (36%) w = Chemotherapy and others, 32.5% 6/48 (75%) 16/72 (22.2%) w = ** PTSS, posttraumatic stress symptoms. *Significant. **Highly significant. ***Highest significance.

6 Posttraumatic stress disorders Afify et al. 45 These results could be explained by the diagnosis of cancer itself, problems related to puberty, and intellectual disability that occurs after treatment [2,15]. Alterations in the neuroactive steroids as a result of stress may play a role in the pathophysiology of anxiety-related disorder [16]. Moreover, radiation damage to the normal tissue of CNS may lead to chronic inflammation with various cytokine secretions and emergence of various neuropsychiatric disorders [17]. The current study found higher scores on CPTSD-RI than those in previous reports [18,19]. This could be attributed to the longer period after the completion of treatment of survivors in the last two studies, older age at interview, the inclusion of different types of cancers not included in the current study, larger sample size in other studies, and culture differences. These high scores in CPTSD-RI reflect high arousal and avoidance symptoms. Arousal symptoms can directly affect the use of medical services where non-cancerrelated physical symptoms are misinterpreted as relapse. Avoidance may affect the child s well-being through possible failure to comply with follow-up care and recommendations [20]. As predicted, the survivors were almost three and half times more likely to have a lifetime diagnosis of PTSD than the controls (17.5 and 5%, respectively, with P = 0.041, OR 4.03, CI = ). Previous researches reported a four-fold increase in the prevalence of PTSD: 18, 13, and 16%, respectively [18,21,22]. Some studies have reported a very high prevalence, up to 29%, which could be related to the area of living in this study, as it was conducted in Israel [23]. Posttraumatic symptoms were found to be severe in 10%, moderate in 32.5%, and mild in 50% of the survivors. None of the controls had severe posttraumatic symptoms. In the control group, 5 and 22.5% were in the moderate and mild range, respectively. Previous reports have shown that 31 and 50% of the survivors had moderate to severe posttraumatic symptoms, respectively [19,24]. Expression of posttraumatic symptoms differed according to sex. Women showed higher levels of intrusion, arousal, and total posttraumatic symptoms (Table 3). However, the number of women suffering from severe PTSS did not differ significantly from that of men, although more women had severe PTSS (Table 4). This finding agrees with previous research [20,25]. This could be related to the fact that sex differences are negligible under circumstances of severe stress. However, the severity of PTSS in women could be related to persistent PTSS over time in women [26]. Survivors with severe PTSS were older at the time of diagnosis and older during the study. They had a longer duration of treatment, a history of relapse, and exposure to combined chemotherapy and others (Table 4). Increasing age at diagnosis might be related to more avoidance of cancer nature and its treatment. Older children may be more aware of the nature of the disease [24]. Increasing age of the survivors is associated with less parental protection, more challenges in completion of education, and problems in coping with peer pressure. The difficulty with developmental tasks may act as a reminder to survivors of traumatic events, bringing PTSD symptoms, clinical distress, or emotional impairment to the surface that may have been previously latent. Survivors with severe posttraumatic symptoms experienced more intense treatment (the use of chemotherapy plus other agents). Eventually, more intense treatment causes late effects of disease, functional impairment, and emotional distress. This paves the way for the occurrence of severe posttraumatic symptoms and the full syndrome of PTSD [21,27]. There was no significant association between severe posttraumatic symptoms, duration of treatment, and time since completion of treatment (P = 0.18 and 0.31, respectively) among the survivors. This is despite the fact that patients with severe posttraumatic symptoms had increased duration of treatment and decreased time after treatment, but not to a statistically significant level, which could be related to the small number of patients experiencing severe posttraumatic symptoms (eight patients). However, many researchers have demonstrated the latter finding [4,21]. This finding could be related to other confounding factors that were not studied, such as genetics, temperament, family function, degree of functional impairment, and peer relationships. In the survivor group, there was an evident lower social and psychological functioning, which might be a reflection of posttraumatic symptoms [4]. PTSS may cause problems in self-regulation, interpersonal relationships, and associated comorbidities such as depression or other forms of anxiety-related disorders. All these factors contribute to lower social and psychological functioning [28]. An important question is whether reduction in the severe anxiety of the patients and their families at the time of diagnosis and treatment can prevent the later development of posttraumatic symptoms. Although actual life threat can be reduced significantly by improving the efficacy of treatment, but perceived life threat may be altered with preparation and communication. The intrusiveness of the treatment and its attendant anxiety can be reduced successfully through the effective use of analgesics, sedation, and psychological interventions. Preliminary evidences suggest that a support group, in addition to improving the emotional and social well-being of the participants, may improve the immunologic competence and prolong survival [3]. Moreover, there is a need for long-term follow up studies during different phases with and without psychological interventions. The current study has several limitations. Family, social support, and socioeconomic status need to be investigated more in detail. Parents psychopathology should also be assessed along with longitudinal follow-up studies.

7 46 Middle East Current Psychiatry Conclusion Although survivors were cured of their physical illness, they continued to have a greater lifetime prevalence of PTSD, current PTSS, and lower psychological and social functioning. The understanding that intrusion, avoidance, and arousal symptoms continue after treatment could help with the choice of psychotherapy. There is a need for an early intervention in this group through psychotherapy, especially through self-help groups and even pharmacotherapy. Acknowledgements We are very grateful to Dr Ahmad Samy Khalifa and Dr Azza Abdelgawad, professor of Pediatrics, Ain Shams university. It was their clinical observation that survivors continue to have posttraumatic symptoms even after physical cure. We really appreciate the time spent by the patients and their families in the completion of the assessment and thank them for recalling their traumatic memories. 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8 Posttraumatic stress disorders Afify et al. 47