Submitted to the
Joint Centre of Excellence for Research on
Immigration and Settlement (CERIS) -Toronto
Dr. Joanna Anneke Rummens
Culture, Community and Health Studies
Department of Psychiatry, Faculty of Medicine
University of Toronto & Clarke Site
Centre for Addiction and Mental Health
Dr. Rajko Seat
Family Service Association of Toronto
Community Action Team
This research initiative was funded and/or supported by:
This mixed-methodological study assessed the psychosocial impact of the 1999 Kosovo conflict on the mental health and well being of newcomer Serbian children and youth in the Greater Toronto Area two-and-a-half years after the NATO intervention in Serbia. Detailed survey questionnaires were administered to eighty school-aged Serbian children and youth – and separately to their most knowledgeable parent, - and six semi-structured confirmatory focus group interviews held with key stakeholders. The study also analyzed the response of parents, educators, healthcare professionals, social service providers, and settlement workers during the crisis itself to determine - in light of research findings - effective response strategies and trauma-recovery interventions that would help safeguard the well being of other war-affected immigrant and refugee children faced with similar stresses. Research findings suggest that explicit war coverage, negative media portrayal, ethnic discrimination, ambivalent feelings towards the host country, parental distress and compromised family functioning appear to act as amplifiers of both pre- and post-migration trauma, thereby producing more severe mental health effects than these children and youth might otherwise have experienced.
Brief Research Overview
Background - An increasingly violent struggle between Serbs and Albanians in the Federal Republic of Yugoslavia over control over the southern Serbian province of Kosovo led to a February 1999 meeting between Serbian and Albanian officials in Rambouillet, France, organized by the international community to discuss peace. Serbs were seeking to protect the cradle of their culture, civilization and identity against Albanians’ battle for an independent Kosovo. When agreement could not be reached NATO countries, in order to protect Albanians from "ethnic cleansing," launched an air and missile bombardment campaign of Serbia on March 24, 1999, that lasted 78 days. NATO’s intervention in what came to be known as "the Kosovo conflict" injured and killed innocent civilians, destroyed factories, workplaces, schools and hospitals, damaged the country’s energy, transport and communications systems, triggered economic, social and ecological disaster, and rendered thousands homeless. It traumatized families and individuals on all sides of the conflict, including those in the diaspora who had fled Yugoslavia’s civil war in the early 1990s.
The majority of the Greater Toronto Area’s estimated 70,000 Serbian population is comprised of immigrants and refugees from this earlier civil war. Many had been forced to flee their homes for political and religious reasons, against their will, under direct threat and in extremely dangerous and stressful conditions. Many of these newcomers witnessed firsthand casualties and injuries to neighbours, friends and loved ones, or had been victims of torture themselves. Whether exposed to direct combat or not, all had been subject to years of escalating conflict, bombardment, and deprivation of basic needs, as well as to a climate of deadly hatred between ethnic groups.
The widespread destruction of Yugoslavia and loss of innocent lives during NATO’s intervention in the more recent Kosovo conflict has had an enormous impact on this newcomer community. According to the Family Service Association’s direct experience with the Serbian community during this time, the bombardment re-activated previous war-trauma, created additional resettlement-related stresses for newcomer Serbian families, and adversely affected the quality of life of the entire community, including their children and youth.
Research Topic - This research study assessed the psychosocial impact of the 1999 Kosovo conflict on the mental health and well being of newcomer school-aged Serbian children and youth in the Greater Toronto Area as measured two years later. The experiences and responses of parents, educators, settlement and social services workers and healthcare providers during the conflict itself were also analyzed to determine effective response strategies that would help safeguard the mental health and well being of all war-affected immigrant children in distress, and thereby also facilitate their resettlement, adaptation and social integration.
Research Objectives –
Key Research Issues Questions –
2) What is the nature, level and extent of psychopathology in these children?
4) What factors help to explain these findings?
Other study questions included: How did parents, educators, health care professionals, settlement service workers and social service providers respond to the children’s distress? What lessons may be learned that could contribute to the development of effective response strategies to meet the needs of traumatized war-affected immigrant children and youth?
Research Methodology – An in-depth mixed-methodological approach was employed in undertaking this research. The impact of the Kosovo conflict on the mental health and wellbeing of immigrant Serbian school children and youth in the Greater Toronto Area was assessed via detailed survey questionnaires. Experiences and responses by parents, community leaders, educators, health care providers, settlement service workers and social service providers were ascertained via semi-structured focus-group interviews. Validity was ensured through the use of multiple researchers, interviewers, methods, survey instruments and measures, as well as through interdisciplinary and cross-sectoral research collaboration and consultation.
Research Design - The quantitative research component entailed the administration of survey questionnaires to 80 newcomer Serbian students (10-18 years of age) and their ‘most knowledgeable’ parent, a total of 180 participants. Three complementary, partially matching, questionnaires were developed for the project: a Child About Child (CAC) questionnaire; a corresponding Parent About Child (PAC) questionnaire; and a Parent About Family (PAF) questionnaire. Specially-developed questionnaire modules sought information regarding family background; Kosovo conflict context, experience and response; and included assessments of child/youth mental health and well-being using various standardized scale measures in both self-reports and parental reports. Care was taken to ensure that all questionnaire instruments were both age-appropriate and sensitive to the cultural and situational context of newcomer Serbian children and youth. They were also translated into Serbian and back-translated to English to ensure that all research participants could respond in their language of choice.
The survey component was complemented by six in-depth qualitative focus group interviews with key stakeholders - parents, community leaders, educators and school administrators, community-based and mainstream settlement service workers, and mental health professionals - that were both confirmatory and exploratory in nature. Their three-fold purpose was: a) to seek a deeper understanding of the major issues and challenges faced by newcomer Serbian families during the Kosovo conflict; b) to disseminate and compare initial project findings with participants’ personal and/or professional experiences; and c) to solicit expert and/or experience-based advice that would enable the investigators to develop sound recommendations for effective trauma response strategies.
Research Participants – Survey Inclusion/Exclusion Criteria: The study’s target population sample consisted of 80 newcomer school-aged Serbian children who had emigrated from the former Yugoslavia to Canada after 1991, were living in the Greater Toronto Area during the Kosovo conflict (March-June 1999), and were between 7-18 years of age. The achieved sample of 80 newcomer Serbian children and youth aged 10-18 years, together with their ‘most knowledgeable’ parent, yielded a total of 160 participants. Focus Group Participants were selected for their knowledge and expertise regarding related issues to form interview groups of five to six participants. Care was also taken to ensure adequate representation of salient differences within each stakeholder group.
Ethical Issues: Possible re-traumatization of child survey participants was avoided by asking specific traumata questions only of parents. Research interviewers were trained to spot signs of distress in both parents and youth and instructed to stop the interview and ensure necessary follow-up if needed. Having a child trauma specialist as referral resource ensured immediate access to appropriate professional support. Recruitment Difficulties: Recruiting study participants for this study proved to be an enormous challenge. Despite thorough saturation of the entire Serbian community in the Greater Toronto Area with informational recruitment letters, project posters, community newspaper notices, website postings, electronic mailings and community presentations, and despite the direct involvement of three well-respected community members on the research team, we received not a single participant-initiated response. All participating families had to be recruited through direct contact by investigators and research assistants at community events and via voluntary referrals. Even then, the study’s overall refusal rate was 1 in 3 (33.75%). Reasons for this recruitment difficulty include: the continuing sensitivity of the topic; fear of re-traumatization; ambivalence about Canada; resettlement pressures; security concerns; as well as specific current events. A Shifting Context: During the course of this research (Sept. 2000-March 2002) a) there was a change of government in Yugoslavia; b) Former Yugoslavian leader Slobodan Milosevic was brought before the War Crimes Tribunal in the Hague; c) the 9/11 attack on the World Trade Centre and Pentagon occurred in the United States. Each of these events had an immediate negative impact on participant recruitment and interviewing.
Data Collection - All survey interviews and focus group discussions were strictly voluntary. Study participants are anonymous and all information gathered has been treated as strictly confidential. Participants are not identified by name on questionnaires or other research materials; signed letters of consent are also kept separately at an undisclosed location.
Survey Interviews were undertaken by two research assistants. Children, youth and parents were interviewed separately at their home and in their language of choice regarding their experiences both during and since the Kosovo conflict. Family interviews averaged 2.5 to 3 hours: child interviews lasted approximately 60 minutes and parent interviews 90 minutes. Participants unanimously expressed a preference to be interviewed in Serbian. Focus Group Interviews with key stakeholders were held after the data entry and initial analysis had been completed. They were lead by both investigators, involved five to six interview participants and were approximately two hours in duration. These semi-structured focus group sessions were taped using a micro-cassette recorder, with the full knowledge and informed consent of all involved; the only exception was the Serbian-origin community settlement worker group interview in which at least one individual expressed a preference that the session not be taped. In this case both investigators took copious notes that were later compared to ensure validity and then compiled.
Data Analysis - Quantitative Analyses: The basic analytical challenges involved determining the relationships between different groups of variables, including the type of trauma, trauma symptoms, various personality characteristics, attitudes toward the host society, discrimination, identification, family socio-demographics, dynamics, migration history, resettlement, and experiences during the Kosovo conflict. The dependent variable in these analyses - psychopathology or psychology of Kosovo trauma among newcomer Serbian children/youth - was assessed via various mental health measures and personality characteristics, and related to the nature and level of traumatization found among research participants. Analyses were also undertaken to determine the impact of various factors on child/youth mental health and well being, as well as possible variations across groups (age, gender, previous trauma, parent/child, etc.). All data cleaning and statistical analyses have been undertaken by Ms. Joanne Daciuk, Research Coordinator, Centre for Applied Social Statistics, Faculty of Social Work, University of Toronto. This includes univariate descriptives and frequencies, bi-variate analyses (T-tests; cross-tabulations; correlation matrices), and multi-variate analyses (factor analysis, linear regression, canonic analysis, Achenbach cluster analysis), as per instruction by the investigators. Qualitative Analyses: The analysis of the qualitative focus group data was in keeping with established principles and practices governing ethnographic research, and entailed careful examination of field notes and interview tapes in order to identify common themes. Validity was ensured via comparative analyses, repeated cross-triangulation, involvement of multiple researchers, and the use of both quantitative and qualitative research methodologies in this study.
Key Research Findings
Core Survey Findings
Sample Description: A total of 80 newcomer Serbian children/youth between the ages of 10 and 18 were surveyed, together with their 'most knowledgeable parent.' 63.8% (n=51) of these young respondents were female, and 36.3% (n=29) were male. The average age was 15.30 years. 40% of the survey population was between the ages of 10-14, 16.3% were 15-16 years old, and 43.8% were between the ages of 17-18. 78% (n=63) of the 80 parents interviewed were female, 21.3% (n=17) were male. Parent respondents were between the ages of 32 and 53 years with an average age of 43.25 for respondents and 44.25 for the non-respondent parent. Parent respondents and their spouses were born in Bosnia (n=77), Serbia (n=61), Croatia (15), Montenegro (n=4), Macedonia (n=1), with one spouse born in Poland, and one non-response. All child respondents were born in the former Yugoslavia. Survey families arrived between 1989-1999 with 1994 being the average year of arrival. The average length of stay in Canada at time of interviewing was 7.68 years for mothers and 7.73 years for fathers. All but one family had either landed immigrant status or Canadian citizenship.
Post-Traumatic Stress Disorder Stemming from the Kosovo Conflict
Experiences During the Kosovo Conflict
Previous Trauma Experience in the Former Yugoslavia
Mental Health and Psychosocial Well Being
Findings from the survey’s mental health measures are consistent with the study’s PTSD findings, PTSD symptomatology, and clinically-documented likely occurrence of co-morbidity.
Attitudes Towards Canadian Society
Core Focus Group Findings
Focus group findings and participant observations indicate that parents were not only overwhelmed and preoccupied by their own trauma concerns during the Kosovo conflict but also quite uncertain as to how to help their children and alleviate their distress. As suggested by the Family Service Association of Toronto’s experience during the Kosovo crisis, they also confirm that many schools were caught entirely unprepared to react appropriately to the unique stresses affecting their Serbian students. The same may be said of both the Serbian community itself and of Canadian society more generally. The qualitative analysis of interview tapes and/or detailed notes from six focus group interviews with Serbian community leaders, parents and service providers, and with teachers, health care professionals and mainstream service providers respectively, revealed ten major themes:
Overall Research Findings
The NATO bombardment during the Kosovo conflict re-triggered previous war trauma
The Kosovo conflict was itself sufficient to adversely affect the mental health and well being of newcomer Serbian children and youth in the GTA
War-related trauma associated with the Kosovo conflict was exacerbated by graphic media coverage of the NATO bombardment
War-related trauma associated with the Kosovo conflict was exacerbated by increasingly negative portrayal of Serbs in Canadian popular media and by both systemic and individual forms of ethnic discrimination
Ambivalence towards their host country and perception of a "double standard" caused additional distress
Normal family functioning was compromised
The effects of Kosovo-related traumata continue
This study represents the first comprehensive assessment of the impact of the Kosovo conflict on newcomer Serbian children and youth in the diaspora. It provides empirical as well as explanatory research data regarding the psychosocial effects of secondary traumata on the mental health and well being of marginalized newcomer children/youth, and considers the impact on their resettlement, adaptation, and integration process as well as on their personal development. Research analyses identify the major traumata and stressors that directly affect the well being of these children and youth and increase the probability of emotional, cognitive and social difficulties. In so doing this study provides a solid conceptual and empirical basis for meaningful comparisons with other war-affected newcomer populations both in Canada and overseas, including most notably Kosovo Albanian refugees.
This research contributes to the documentation and analysis of long-term impacts of crisis and disaster on the mental health and well being of children and youth. By extending consideration to newcomer children and youth, it extends the analysis to a consideration of the impact of war trauma during the resettlement process itself. The study also examines the ways in which being an "enemy of the state" affects the mental health and well being of new immigrants to Canada and explores the implications thereof for social integration. The Serbian experience in Canada during the Kosovo conflict is in many ways comparable to that of Japanese Canadian "enemy aliens" during World War II and Vietnamese Americans during the Vietnam war; what makes the current study population unique is their actual war trauma experience, migrant status, youth, and degree of marginalization. By looking at "ethnic" discrimination rather than "racial" discrimination per se, the study also contributes to the Canadian literature on minority rights in Canada (see Kallen 1995; Henry 1995). Finally, Palmer (1997) and others have examined Canadians' attitudes towards immigrants; this research effectively reverses direction and examines instead the attitudes of newcomer children and youth towards their host country, together with possible links with their mental health and well being.
The current research is unique in its consideration of both secondary war-trauma and related traumata, and multiple traumatic exposure; and in its comparisons between previously exposed and non-exposed populations as well as between parental and self-reports of mental health and well being. Several study findings also represent new contributions to the field. These include the identification of ethnic discrimination and consistently negative media portrayal as significant secondary traumata; the links between ‘enemy alien’ status, ambivalent feelings regarding the host country, discriminatory experiences, and mental health outcomes; the surprisingly strong impact of secondary war-trauma on individuals safely removed from the area of conflict; and perhaps most importantly, the finding of some variation but relatively little difference in overall mental health impact of a secondary trauma between children/youth who experienced previous war-trauma and those without such prior exposure.
Relevance to Policy and Practice
Contributions to Policy Development: The psychological consequences of war - particularly among children - involve a dynamic process whose lasting impact is strongly influenced by the availability of appropriate services, culturally sensitive treatment initiatives, as well as broader psychosocial support. The impact of war trauma, ambivalent attitudes towards the host society, explicit and/or negative media portrayal, and ethnic discrimination on newcomer children’s mental health and well being will be of particular interest to Health Canada. It is hoped that this study will help inform effective, sensitive and comprehensive mental health treatment interventions, thereby enhancing the capacities and development potential of all new Canadian children previously exposed to war. Study findings suggesting that ethnic discrimination (including negative media portrayal) and ambivalent feelings toward the host society can act as an amplifier of both pre- and post-migration traumata, thereby producing even more severe repercussions, will also be of concern to the Department of Canadian Heritage (Multiculturalism). Immigrant and refugee children vary tremendously in terms of the pre-migration experiences and resources they bring with them. This research will also be of use to Citizenship and Immigration Canada as it touches directly on issues of settlement service delivery for newcomer immigrant and refugee children and youth who have been exposed to war in their countries of origin. Informed, group-specific, culturally-sensitive knowledge and response is essential not only for ensuring the psychological well being of particularly vulnerable immigrant populations but also their successful settlement adaptation and social integration.
Contributions to Practice: Study findings will be helpful to service providers in designing crisis response strategies that ensure immediate, comprehensive and equitable interventions related to acute, often enduring, psychological trauma. It is hoped that the dissemination of study results will help increase awareness among health care professionals and settlement service workers regarding the impact of war trauma, discrimination, and other resettlement stresses on the health and wellbeing of immigrant and refugee children; this would help inform the development of effective, sensitive and comprehensive mental health treatment interventions, thereby enhancing the capacities and development potential of all new Canadian children previously exposed to war. A key output of the study is the development of a crisis intervention Trauma Response/Recovery Manual to assist various stakeholders in dealing with war trauma, ethnic discrimination and related settlement distress experienced by immigrant and refugee children. This resource compendium will consist of stand-alone modules offering a summary of the key issues, practical solutions, important contacts and resources, and target parents, educators, health care providers, social service providers, media representatives and policy makers respectively. These will be made available singly and collectively in both hard copy and in an electronic format suitable for cross-posting on relevant websites. The resource manual aims to offer practical help to parents by informing them about the particular difficulties traumatized children experience and the actions that can be taken to promote their well being, and assist educators to more quickly recognize symptoms of war-trauma and to coordinate more effective and appropriate crisis responses. The manual also seeks to help increase the media’s awareness of the ways in which seemingly factual reporting can inadvertently result in a negative presentation of certain immigrant groups in such a way as to seriously compromise their emotional well being and social integration. Since communities have the potential to not only confer risk but also promote resilience, this trauma response/recovery manual will also point to ways in which the structure of response and respective roles of government, schools, health institutions, and various service agencies can incorporate community involvement to effectively safeguard the well being of all Canadian children.
See also Project Recommendations click here.
Dissemination Activities and Research Outputs
Research findings are being widely disseminated to various stakeholders via public talks, professional workshops, community and organizational newsletters, media interviews, website postings, conference presentations and submissions to scholarly journals. Research participants and other members of the Serbian community both in Canada and abroad will receive a summarized report of the findings; the study will also continue to receive media coverage. A trauma response/recovery manual geared at key stakeholders is in preparation, as is the posting of executive research summaries on relevant organizational websites. In keeping with the mandate of the Joint Centre of Excellence for Research on Immigration and Settlement (CERIS), the research findings will also be disseminated to Health Canada, Citizenship and Immigration Canada, and Canadian Heritage (Multiculturalism) in order to help inform policy recommendations aimed at normalizing war-affected children’s lives in Canada.
Please consult www.ceris.metropolis.net for copies of project reports and ensuing publications.
Presentations To-Date (11/2002)
Presentation Commitments (11/2002)
Research Reports To-Date (11/2002)
In Progress (11/2002)
Media Coverage To-Date (11/2002)
Nature of Research Collaboration
Academic/community research partner-ships were integral to the design and implementation of this study and remain essential for effective research dissemination. Academic partnerships among investigators, research assistants, collaborators, consultants and contributors, were interdisciplinary in nature (anthropology, education, international relations, medicine, political science, psychiatry, psychology, sociology) and included two individuals specialized in the recognition and treatment of trauma. Community collaboration was cross-sectoral (newcomer Serbian families; Toronto’s Serbian community; educators; settlement and social service workers; mental health professionals; media representatives). This collaboration also bridged the research/practice divide by involving both scholars and clinicians. International collaboration with researchers in the Former Yugoslavia permits immigrant/non-immigrant group comparisons.
The Research Team consisted of two co-investigators: Joanna Anneke Rummens Ph.D. (sociologist/anthropologist), Assistant Professor and Scientist, Department of Psychiatry, Faculty of Medicine, University of Toronto and Centre for Addiction and Mental Health – Toronto; and Rajko Seat, Ph.D. (trained clinical psychologist), Community Worker, Family Service Association of Toronto. They were assisted by a university-based research assistant - Bojan Djuricic (graduate student, International Relations, University of Toronto) - and a community-based research assistant - Ms. Gorana Gligorevic (teacher; journalist).
Collaborative partners include: Mr. Dragomir Radojkovic, President, The Serbian Centre for Newcomers and Serbian Heritage Academy; Father Vasilije Tomic, Protopresbyter, St. Sava Serbian Orthodox Church; Mr. Radmilo Anicic, President of "Strazilovo" Folklore Group, Member of St. Sava's Board of Directors; and Mr. Ray Cunninghan, Principal, Chester Public School. International collaborators include researchers at the University of Belgrade, Faculty of Philosophy-Psychology Department with whom survey instruments and methodology were shared for the purpose of later comparative analyses between Canada and the Former Yugoslavia. Consultants included the project’s statistical analyst, Joanne Daciuk, Research Coordinator, Centre for Applied Social Statistics, Faculty of Social Work, University of Toronto; and our child trauma expert and referral resource, Patti Schabas M.D., Child Psychiatrist, Trauma Team, Mount Sinai Hospital. Other contributors included colleagues at Culture, Community and Health Studies – Programme Head Morton Beiser M.D., Samuel Noh Ph.D. and Violet Kaspar Ph.D. who granted permission to use a few of the instruments also included in the survey component of this study.
Training Opportunities Provided
Both the full-time graduate student and community-based research assistant associated with this research project received in-depth training and experience in survey research design, implementation and coordination. This included project presentation, participant recruitment, interviewing techniques and community collaboration. The graduate student received additional training in database design and data entry.
Project Recommendations are available via www.ceris.metropolis.net
For additional information please contact:
Dr. Joanna Anneke Rummens Dr. Rajko Seat
Assistant Professor and Scientist I Family Service Association of Toronto
Culture, Community and Health Studies Community Action Team
Department of Psychiatry, Faculty of Medicine 902-2 Carlton Street
University of Toronto & Clarke Site Toronto, Ontario M5B 1J3
Centre for Addiction and Mental Health tel. 416.586.9777 ext. 258
250 College Street, Toronto, Ontario M5T 1R8 fax. 416.595.0242
tel. 416.535.8501 ext. 4870 fax. 416.979-0564 firstname.lastname@example.org