Mental Health and Psychosocial Concernsand Provision of Services for AdolescentSyrian Refugees in Jordan

Yousef S. Khader

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Syrian Crisis, Displacement, and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Depression Symptoms and Generalized Anxiety in Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 Post-Traumatic Stress Disorder (PTSD) in Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Psychosocial Problems Among Syrian Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Racial Discrimination Against Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Safety Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Behavioral and Emotional Problems in Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Heath Services for Jordanians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Health Services for Syrians in Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Mental Health Psychosocial Problems and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Child Mental Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Financing of MoH Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Utilization and Access to Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Approaches that Helped Syrian Adolescents in Jordan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

AbstractAfter years of the Syrian crisis, it continues to have an enormous social andeconomic impact on the countries hosting Syrian refugees. This chapter reviewsthe mental health and psychosocial support (MHPSS) problems and the provisionof services for Syrian children and adolescent refugees in Jordan. The relevantliterature and reports were reviewed. Conflict-related violence coupled with the

Y. S. Khader (*)Department of Community Medicine, Public Health and Family Medicine, Jordan University ofScience & Technology, Irbid, Jordane-mail: yskhader@just.edu.jo

© Springer Nature Switzerland AG 2019I. Laher (ed.), Handbook of Healthcare in the Arab World,https://doi.org/10.1007/978-3-319-74365-3_170-1

1

ongoing stressors related to displacement had a significant and ongoing impact onthe mental health and psychosocial well-being of Syrian refugees. Syrian childrenand adolescents in Jordan suffered and continue to suffer from various mentalhealth and psychosocial problems including depression, anxiety, post traumaticdisorders, racial discrimination, and behavioral and emotional problems. Morethan half of the children suffer from nightmares, various forms of sleep disorders,or bedwetting as a result of the distress they have been exposed to since the onsetof the crisis. What is more troublesome is the limitations in child mental healthservices. MHPSS services provided by nongovernmental organizations (NGOs)are provided by mostly nonspecialized staff (75%) and specialized national staff(20%). However, such specialized services still only represent one tenth ofservices, with the remaining services focused on nonspecialist service provision,strengthening family and social supports, and the integration of MHPSS consid-erations into other sectors providing humanitarian aid. In conclusion, manypsychosocial problems are still affecting Syrian refugee children and adolescentsin Jordan despite the fact that many of them started living in Jordan many yearsago, and as a result of these outputs, more psychosocial and financial support isstill necessary to help them.

KeywordsMental health · Psychosocial problems · Mental health services · Syrianrefugees · Children · Adolescents · Jordan

AbbreviationsCES-DC The Center for Epidemiological Studies Depression Scale for

ChildrenGIZ Deutsche Gesellschaft für Internationale ZusammenarbeitIMC International Medical CorpsJHAS Jordan Health Aid SocietyJICA Japan International Cooperation AgencyJRP Jordan Response PlanmhGAP Mental Health Gap Action ProgrammeMoH Ministry of HealthMOI Ministry of InteriorMoSD Ministry of Social DevelopmentNCMH National Center for Mental HealthNGOs Nongovernmental organizationsNHF Noor al-Hussein FoundationOR Odds ratioPHC Primary Health CarePHQ Patient Health QuestionnairePTSD Post Traumatic Stress DisorderPTSDSSI Posttraumatic Stress Disorder Semi-Structured InterviewRCADS-25 Revised Children’s Anxiety and Depression ScaleRMS The Royal Medical Services

2 Y. S. Khader

SDQ Strengths and Difficulties QuestionnaireUNHCR United Nations High Commissioner for RefugeesUNRWA United Nations Relief and Works AgencyVAF Vulnerability Assessment FrameworkWHO World Health Organization

Introduction

The Syrian conflict started in 2011 and has resulted in a large displacement ofSyrians, particularly into neighboring countries such as Turkey, Lebanon, and Jordan(Sijbrandij et al. 2017). In 2017, the United Nations High Commissioner forRefugees (UNHCR) estimated that there were nearly five million registered Syrianrefugees; Turkey hosted about three million, Lebanon hosted almost one million, andin Jordan, there were about 650,000 with children younger than 18 years accountingfor approximately 50% of the refugees in Jordan (UNHCR 2017).

After years of crisis, refugees from Syria are losing hope that a political solutionwill be found to end the conflict in their homeland. In addition, the crisis in Syriacontinues to have an enormous social and economic impact on the countries hostingSyrian refugees, with many national services such as health, education, and waterunder severe strain (Refugee Regional and Resilience Plan 2016–2017). In Jordan,the influx of refugees from Syria has compounded already existing challengesresulting from hosting refugees from other countries, including Iraqis, Palestinians,and Yemenis.

Jordan was making enhancements before the influx of Syrian refugees, but sincethen government-funded schools have ended up with overcrowded classrooms, andall aspects of Jordanian life has been impacted including healthcare, labor, and watersupply (Almoshmosh et al. 2016). Jordanians have publically demonstrated theirconcerns about the dire situation in Jordan.

The report of the International Labor Organization in 2015 revealed that whilealmost 100% of Jordanian children were registered in primary schools, only 65% ofSyrian refugee children were registered. In addition, nearly 95% of Jordanianchildren were still registered in school at the age of 17 while registration rates forSyrian refugee children started to decrease from the age of 11, and by the age of 15,less than 40% of Syrian refugee children were registered in school (Stave andHillesund 2015).

Lebanon was a global model of strength for accepting the most elevated numberof displaced people per country around the world (UNICEF, UNHCR, WFP 2017;Geha and Talhouk 2018). About 80.9% of registered Syrian refugees in Lebanon arechildren and women as of December 2017 (Geha and Talhouk 2018). In addition,76% of Syrian refugee families were reported in 2017 to be living below the povertyline, and 74% of Syrian refugees aged 15 or above reside illegally in Lebanon(UNICEF et al. 2017). In Lebanon, child labor remains a worry, with 4.8% of Syrianrefugee children aged 5–17 years stating that they are working, according to the 2017Vulnerability Assessment of Syrian Refugees in Lebanon (UNICEF et al. 2017).

Mental Health and Psychosocial Concerns and Provision of Services for. . . 3

According to the same report, child marriage was a considerable problem in bothfemales and males, although girls were lopsidedly influenced; one in five girls aged15 to 19 were married, and 18% of those married were married with husbands ten ormore years older than them (UNICEF et al. 2017). Youngsters with disabilitiescontributed to 2.3% of the Syrian refugee population in Lebanon in 2017, and,unfortunately, they are among the most underestimated and neglected groups inLebanon. In addition, the privileges of Syrian refugees in Lebanon were not pro-tected by international law, and their access to education, job opportunities, andhealthcare was totally left to the impulse of political gatherings and local committees(UNICEF et al. 2017). Syrians escaped to informal settlements for the most part inSouth and North of Lebanon and confronted random unregulated nearby practices,for example, work without pay and gender-based violence, which adverselyimpacted their children (Geha and Talhouk 2018).

The literature on the prevalence of mental health problems among children andadolescents has significantly increased over the last few years in many countriesaround the world, and worldwide the prevalence of mental illness among childrenand adolescents was 13.4%, according to a meta-analysis study conducted in 2015(Polanczyk et al. 2015).

In Jordan, the long-lasting nature of the Syrian crisis has been damaging; both theSyrian refugees and the host community in Jordan are paying a huge price (Achilli2015). For children and adolescents, growing up under difficult conditions caninfluence their development through direct exposure to traumatic and stressful events(Sim et al. 2018). Compared to Jordanian adolescents, Syrian adolescent refugeesresiding in Jordan have been subjected to life encounters that are much moreagonizing, and they have confronted greater psychological distress (Panter-Bricket al. 2018).

Syrian Crisis, Displacement, and Mental Health

Conflict-related violence coupled with the ongoing stressors related to displacementcan have a significant and ongoing impact on the mental health and psychosocialwell-being of Syrian refugee adults and children. Furthermore, the Syrian crisis hasundoubtedly impacted the resources and resilience of Jordan and its host community,as a result of an increased economic burden and increased competition for scarceresources and opportunities.

The crisis in Syria can not only exacerbate the preexisting mental disordersamong Syrian refugees, but it may also trigger the emergence of new mental andpsychosocial problems (Francis 2015). Experiences of war-related violence andcrime are multiplied by the everyday stressors resulting from displacement. Thesestressors include poverty, shortage of basic needs and services, a risk of exploitation,loss of family support, and discrimination (Hassan et al. 2015; Gormez et al. 2018).

Few studies have been conducted to assess mental disorders and psychosocialneeds of young refugee children in Jordan and Lebanon. However, surveys of Syrianadolescent refugees have detected a range of mental and psychosocial problems,

4 Y. S. Khader

including depression, aggressiveness, persistent fear, anxiety, bedwetting, somaticsymptoms, and speech problems (Francis 2015; Doren 2011).

In 2012, Jordan Health Aid Society (JHAS) in collaboration with InternationalMedical Corps (IMC) conducted a mental health and psychosocial support (MHPSS)assessment incorporating focus group discussions, and key informant interviews ofdisplaced Syrians in the north of Jordan (Jordan Health Aid Society and IMC 2012).Results showed that displaced Syrians reported various concerns related to mentalhealth, especially fear, worry, and grief. In 2015, IMC published an updated reporton mental health and psychosocial needs and trends based on data collected throughservice provision in various countries throughout the Middle East, which host Syrianrefugees. The most common mental health diagnoses reported were severe emo-tional disorders (54%), including depression and anxiety. Furthermore, rates ofepilepsy (17%) and psychotic disorders (11%) were high across the region. Forchildren, the most common mental and neurological conditions were reported to beepilepsy (27%), intellectual and developmental disorders (27%), and severe emo-tional disorders (4%) (IMC 2015).

In general, with the growth of displaced Syrian children in communities, severalyears after their arrival in Jordan and Lebanon, their mental health needs are likely tobe linked to post-displacement pressures influencing their development, rather thanto direct events of war. However, this does not mean that they do not encounter themin a roundabout way. In this sense, symptoms cannot be seen in isolation and mayreverberate as secondary trauma associated with parental experiences or reactions tocurrent living conditions (Boehm 2018).

In qualitative terms, fears of Syrian adolescent refugees may be partly connectedto war experiences, such as fear of darkness after the memories of night blasts. Inaddition, nightmares may not always be directly related to war but can be connectedto media utilization, such as violent phone games and watching Syrian news, wherethe lines between ideation and reality are obscured among children and adolescentswhose families have been subjected to war events and displacement challenges (Care2017).

Moreover, cases such as incontinence might be caused by trauma, but it alsomight be a manifestation of a delay in growth or decline in living conditions. It isparticularly likely to be spotted alongside other issues such as inactivity, wherechildren are kept indoors throughout the day (Boehm 2018). Hyperactivity due topainful life events can cause aggressive behavior in children and adolescents, oraggressive behavior may result from family violence or high family stress due toovercrowding (Care 2017). Furthermore, difficulty in obtaining statutory and civicdocuments, refugee registration process, and lodging rights issues and labor issues ofrights and contentions indicate that, although theoretically they have access toindispensable resources such as education, refugees, after years of displacement,keep on confronting challenges in their daily situation, which can be a major sourceof stress and vulnerability in Syrian children living in Jordan (Care 2017).

The qualitative information provided by parents in mental health assessmentsdemonstrated that a large proportion indicated that male family members remain athome due to illness, disability, or security concerns, or that girls stay at home since

Mental Health and Psychosocial Concerns and Provision of Services for. . . 5

they must be kept indoors and secure. This information sets the mental health needsof children in the context of economic instability and restricted family roles, as wellas the context of newborn stress and concern about the future of children (Wells et al.2016). In addition, expectations may change in children’s behavior due to trepidationof discrimination or safety concerns for Syrian refugee children in Jordan (Achilli2015).

Studies on the mental health of Syrian refugee children have demonstratedastounding levels of trauma and distress among them, but considerably, less isknown about the influence of these problems on children still inside Syria, andone in four of whom is currently at risk of developing mental disorders (Save theChildren 2017). The report of Save the Children in 2017 on mental health and well-being of children inside Syria revealed that nearly all youngsters indicated thatcontinuous bombardment is the main source of psychological stress in their every-day life. In addition, 48% of adults have identified children who have lost thecapacity to talk or who have developed speech problems since the beginning ofthe conflict. In addition, and according to the same report, 51% reported thatadolescents illegally used drugs to adapt with their problems, and one in fourchildren reported that they scarcely or never have a place to go or someone toconverse with when they are terrified, dejected, or disturbed (Save the Children2017).

Depression Symptoms and Generalized Anxiety in Adolescents

According to previous research studies, depression was the most prevalent mentalhealth problem among children who experience stressful life events, such as vio-lence and war (Ranttila and Shrestha 2011). Depending on the severity of depressionsymptoms, psychosis may be comorbid with a depressive disorder, and psychoticsymptoms in adolescents were generally manifested by feelings of guilt or failure,while depression in young children was mainly manifested by disinterest in sharingpleasant activities with others (WHO 2017).

Regarding Syrian students, a recent study on mental health of Syrian childrenaged 8–15 years in Syrian schools revealed that 50.2% of students were internallydislodged and 32.1% reported a negative experience, while depression accounted for32.0% of the sample using a brief version of the revised children’s anxiety anddepression scale (RCADS-25) (Perkins et al. 2018).

A comprehensive qualitative and quantitative study by GIZ (GIZ study) wasconducted in 2018 among Syrian refugee children in Jordan to assess their mentalhealth status and psychosocial needs (Deutsche Gesellschaft für InternationaleZusammenarbeit (GIZ) GmbH 2018). The quantitative study included 1773 Syrianrefugee adolescents. About 28.3% of Syrian adolescents had depression as assessedby the CES-DC. According to PHQ-9-Modified, a higher percentage of adolescentswas found to have depressive symptoms (37.1%). Among males, about 19% ofSyrian adolescents had moderate to severe anxiety. Among females, about 27.3%had moderate to severe anxiety. Not feeling safe, not having resilient traits, having

6 Y. S. Khader

high emotional symptoms, having peer relation problems, not having support fromfriends, and having generalized anxiety were significantly associated with depres-sion symptoms.

4 Post-Traumatic Stress Disorder (PTSD) in Adolescents

The prevalence of PTSD among children and adolescents in the Arab nationsaffected by war and strife events has reached an alarming level with figures rangingbetween 35% and 50%, according to a review conducted in 2015 (Baddoura andMerhi 2015). The recent study on the mental health of Syrian children aged8–15 years in Syrian schools reported that PTSD was the most widespread mentaldisorder among Syrian students with a prevalence of 35.1% using the Arabic versionof children’s revised impact of event scale (CRIES-8) (Perkins et al. 2018).

PTSD was also recently assessed in a German camp of Syrian refugees using thepost-traumatic stress disorder semi-structured interview (PTSDSSI) and the Kinder-DIPS, and it was detected in 11 out of 42 children aged 6 years or less (26%), and in18 out of 54 children aged 7–14 years (33%). PTSD prevalence among Syrianchildren in the study was elevated compared with the general population (Soykoeket al. 2017).

The GIZ study (Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ)GmbH 2018) in Jordan showed that the prevalence of moderate to severe PTSDamong Syrian school children refugees in Jordan was 31%. This prevalence washigher in female adolescents compared to males (OR = 1.5, 95% CI 1.2–1.9, p-value = 0.001), in children where one or both parents had died compared to thosewhose parents were living together (OR = 1.7, 95% CI 1.2–2.5 p-value = 0.006).

Psychosocial Problems Among Syrian Adolescents

The qualitative part of the GIZ study (Deutsche Gesellschaft für InternationaleZusammenarbeit (GIZ) GmbH 2018) in Jordan included a total of 80 participants(20 PHC professionals, 20 school teachers, 20 Syrian parents, and 20 Syrianadolescents) who were interviewed. The majority of PHC professionals, schoolteachers, Syrian parents, and Syrian adolescents were in agreement that stress,depression, fear of war, lack of a sense of security, loneliness, isolation, aggressive-ness, and family disintegration were the main psychosocial problems that Syrianadolescents are facing. Loss of school years, poor educational achievement, anddifficulties related to coping with the new environment were reported by the majorityof school teachers, Syrian parents, and Syrian adolescents. Many Syrian adolescentsreported that they suffered from many problems resulting from the demolition oftheir household in Syria; death of their parents, relatives, or neighbors; displacement;and bombing. Racial discrimination and violence against adolescent Syrian refugeeswere reported by the majority of PHC professionals and Syrian adolescents. Mostschool teachers and PHC professionals reported that both genders are suffering so

Mental Health and Psychosocial Concerns and Provision of Services for. . . 7

much but adolescent female Syrian refugees are at a bigger disadvantage than theirmale counterparts.

The same study reported that Syrian parents reported that the reasons behind thepsychosocial problems of their children were related to the ongoing Syrian crisis,illness of the head of the household (mostly the father), discrimination againstSyrians, domestic problems such as separation and parent cruelty, and financialconstraints.

Racial Discrimination Against Adolescents

According to the IMC report in 2014, Syrian adolescent refugees in Jordan consid-ered themselves victims of discrimination because they are Syrians, and the reportindicated that there was no statistically significant difference between females andmales in their perceived racial discrimination (Song 2014).

This difference in the state of education between Syrian and Jordanian childrenwas considerable. Many Syrian parents stated that they remove their children out ofschools because they were afraid that their children might be bullied or attacked ontheir way to school, and school teachers reported that Syrian girls might be taken outof school for early marriage (Stave and Hillesund 2015).

The GIZ qualitative study (Deutsche Gesellschaft für InternationaleZusammenarbeit (GIZ) GmbH 2018) reported that verbal and physical violenceagainst adolescents is a common problem, but it is decreasing when compared tothe last few years. PHC professionals and teachers reported that the help offered bydifferent security agencies, Family Protection Department, and humanitarian orga-nizations is commendable. In addition, they reported that educational advisors andteachers, awareness campaigns, financial support, social activities and services,educating the parents, and reporting cases of violence had a great role in supportingabused children in Jordan.

Safety Problems

The perception of safety in school and the neighborhood environment is critical inadolescence and plays a considerable role in the academic performance of adoles-cents (Milam et al. 2010). For instance, a study in 2010 assessed perceptions ofsafety in school and the neighborhood environment and its association with aca-demic achievements overbank schoolchildren in Maryland. The study reported astrong association between the perceived school and neighborhood safety and theacademic achievement of adolescents; a high level of neighborhood problems waslinked to a significant decline in reading and math achievement, while a high level ofneighborhood safety was linked to a statistically significant increase in reading andmath achievement (Milam et al. 2010).

Syrian children have experienced many traumatic events that, without properinterventions in the host countries, would likely influence their development into

8 Y. S. Khader

adulthood. Those children and their families lack feelings of security, and fulfillingthese needs is costly without fundamental international support, particularly in hostcountries such as Jordan, Lebanon, and Turkey. According to a recent study inTurkey, as an example, 56.2% of a total of 218 Syrian children and adolescents aged9–15 years lost someone special for them, 55.1% had seen injured or dead persons,42.5% saw persons being tormented, 70.4% had seen gun battles or explosions, and25.6% personally suffered from harshness or torture (Gormez et al. 2018). Moreover,Muslim Syrian adolescent refugees in the United States reported being angered andbullied for having Arabic names or for their religious identity (Gormez et al. 2018).

In Jordan, Syrian girls felt less secure than boys when they were away from theirparents, according to the IMC report in 2014. In addition, females felt more fearful ofwalking alone or being kidnapped than males, while males said that they saw morehitting and experienced more teasing and bullying than females. The report alsoexposed that 24% of Syrian adolescent refugees stated being bullied, and 12% ofthem reported the existence of general community violence (Song 2014).

In addition, a recent research study on Jordanian adolescents’ perceptions ofbullying in schools reported that a considerable share of students connected bullyingto psychosocial factors. For instance, 70% of assessed Jordanian students reportedthat a bully is a person lacking respect for others, while 60.8% of adolescents definedthe bully as the person who intends to impact others, and 67.5% mentioned that he isa person tending to show control. Also, 68.2% of the students perceived that victimsof bullying have low self-esteem while 35% and 27.1% of them mentioned that theyare timid and with no friends, respectively (Al Ali et al. 2017). Another recent studyin Jordan involved a sample of 436 in-school adolescents, showing that relational-verbal bullying was the most widespread form of bullying, and cyberbullying wasthe least popular among adolescents. The tool used for measuring bullying in thestated study was the personal experiences checklist (Shaheen et al. 2018). Further-more, a 2013 study in Jordan included 920 Jordanian schoolchildren aged11–12 years, showed that the prevalence of bullying was 47%, and the number ofmales who indicated being bullied was significantly higher than the number offemales who reported being bullied (P < 0.001) (Al-Bitar et al. 2013).

In the GIZ study (265), the majority of Syrian adolescents (89.6% of males and88.2% of females) felt a lot or always safe. No significant gender differences wereseen in the perceived safety among both Jordanian and Syrian adolescents.

Resilience

Regarding the importance of resilience, a study in 2014 examined the relationshipbetween having resilience traits and lifetime drug and alcohol abuse in adults whoexperienced serious childhood traumatic events. The study reported that resiliencetraits reduced risks for not only major depressive disorder, PTSD, and suicideattempts but also for alcohol and drug abuse in adults who have had childhoodproblems such as abuse and trauma. Resilience traits in the study were assessedusing the Connor-Davidson resilience scale, while lifetime alcohol and drug abuse

Mental Health and Psychosocial Concerns and Provision of Services for. . . 9

and childhood traumatic experiences were assessed using alcohol use disorderidentification test, drug abuse screening test, and childhood trauma questionnaire,respectively (Wingo et al. 2014).

A study in 2018 revealed that the linkage between resilience among adolescentsand adolescent-parent relationships, including perceived parental support and par-ent-adolescent conflict, was interposed by self-esteem in adolescents, and thatperceived support from parents was more strongly associated with adolescentresilience than parent-adolescent conflict. The tool used in the study for assessingperceived parental support and parent–adolescent conflict was a network of relation-ships inventory, while Rosenberg’s self-esteem scale and adolescent resilience scalewere used for assessing self-esteem and resilience traits, respectively (Tian et al.2018).

Relating to Syrian adolescent refugees, Syrian adolescent girls in Jordan hadmore resilience traits, including personal strength, coping ability, and good relation-ships with parents and friends than Syrian adolescent boys on the perceived resil-ience scale, according to the assessments of the IMC in 2014 (Song 2014).According to the GIZ study (Gormez et al. 2018), 41.8% of Syrian adolescents(39.6% of males and 43.5% of females) had resilience traits.

Lack of social support has adverse effects on the mental health of adolescents, asit has been reported that frequent bullying at school and low social support amongstboth sexes contribute considerably and independently to a less healthy mental statein adolescent schoolchildren (Rigby 2000). A study showed that students with poorperceived social support had significantly higher levels of behavioral problems andlower levels of positive behavior such as self-concept than those with higherperceptions of social support (Demaray and Malecki 2002).

In Jordan, a recent study reported that parental support can be used for predictionsabout well-being in adolescents, in addition to the academic performance, bullyingproblems, eating practices, and other factors linked to well-being (Arabiat et al.2018). For Syrian adolescent refugees, the 2014 IMC report illustrated that Syrianadolescent girls in Jordan had a greater perception of support from parents, siblings,and friends than boys. Feelings that parents can care for themselves was higheramong Syrian females than males (Song 2014). In the GIZ study (Deutsche Gesell-schaft für Internationale Zusammenarbeit (GIZ) GmbH 2018), the majority of Syrianadolescents reported that they are supported. No significant gender difference wasfound in the perception of being supported among Syrian adolescents.

Behavioral and Emotional Problems in Adolescents

Many factors play a role in manifesting emotional and behavioral problems inadolescents (Sirin and Rogers-Sirin 2015). For example, a 2013 study in Englandrevealed that adolescents suffering from specific language impairment were morelikely to have higher levels of peer problems, emotional problems, conduct prob-lems, and hyperactivity than those who developed well (Conti-Ramsden et al. 2013).In addition, a separate study in 2013 assessed strengths and difficulties in children

10 Y. S. Khader

living in socioeconomically deprived environments and showed that children livingin families below the poverty line had more difficulties and fewer strengths thanthose living in families above the poverty line, and there were no significant genderdifferences (Devi et al. 2013).

In the literature, many studies assessed prevalence of emotional and behavioralproblems among adolescents in different countries. For instance, a 2018 study inJordan assessed the prevalence of behavioral and emotional problems among Jorda-nian adolescents. It involved a sample of 810 Jordanian adolescents using the SDQinstrument. It reported that the prevalence of emotional problems was 14.2%, and12.5% and 7.5% for conduct problems and hyperactivity, respectively (Atoum et al.2018).

The results of the SDQ in the IMC assessments in 2014 illustrated that Syrianadolescent girls in Jordan showed more prosocial behavior and strengths than boys,but they had more emotional and conduct difficulties than boys (Song 2014). Inaddition, a recent study on psychopathology among Syrian children aged 9–15 yearsin Turkey showed that the prevalence of having difficulties generally using the SDQtool was 23.1%, and the prevalence proportions of emotional, conduct, hyperactiv-ity, and peer problems were 14.0%, 17.4%, 17.8%, and 26.6% respectively, and3.3% for prosocial behavior (Gormez et al. 2018).

Using the same questionnaire, the GIZ study (Deutsche Gesellschaft fürInternationale Zusammenarbeit (GIZ) GmbH 2018) showed that 60.7% of Syrianadolescents had peer relation problems, 31.8% had hyperactivity/inattention prob-lems, 50.1% had conduct problems, and 26.5% had emotional symptoms. On theother hand, 48.5% of Syrian adolescents had prosocial behaviors.

Heath Services for Jordanians

Primary health care services are managed through a wide network of MoH primaryhealth care centers (95 comprehensive health centers, 375 primary health carecenters, and 205 health subcenters in 2013), in addition to providing maternal,childhood, and dental health services (448 Motherhood and Childhood Centersand 387 dental clinics). The Royal Medical Services (RMS) is involved in providingprimary health care services through field clinics and eight comprehensive medicalcenters. UNRWA also provides primary health care services through 24 medicalclinics. The Jordanian Society for Family Planning and Protection provides servicesthrough 19 clinics. Moreover, the private sector is a major player in providingservices. Health services in Jordan are characterized by ease of access, equitabledistribution amongst governorates, and covering the needs of remote areas.

Health Services for Syrians in Jordan

Health services are provided for refugees at public, private, or NGO/philanthropycenters and hospitals, and they are accessible on a pro-bono basis for camp

Mental Health and Psychosocial Concerns and Provision of Services for. . . 11

occupants but might be costly for host community inhabitants if they do not haveaccess to philanthropy centers and facilities (Boehm 2018). Preceding the 2014strategy alteration, Syrian refugees could get health services at rates that are thesame as uninsured Jordanians (Nijs et al. 2014). Since 2014, the approach has beenchanged, and Syrians having MOI benefit cards have been dealt with like uninsuredJordanians at public clinics and also pay an “outsider’s rate”which is 35–60% higherthan for uninsured Jordanians (Nijs et al. 2014). About 55% of the Syrian populationholds health insurance, while 68% of Jordanians are reportedly covered by healthinsurance (Sirin and Rogers-Sirin 2015). Syrians without UNHCR status or MOIcards are not eligible for treatment at government health facilities (AmnestyInternational).

At present, humanitarian funding is supporting the costs for essential healthservices in primary and secondary care. It has been estimated that 2866 additionalinpatient beds, 1022 additional physicians, and 22 new comprehensive health centersare needed to meet the national standard (Department of Statistics 2017). Accordingto the primary health care report, conducted in 2015, the following are the primaryconcerns of the MoH when looking at the current state of the health system as a resultof the Syrian crisis:

• Increasing demand for health services at an unprecedented rate exceeding thecapacity of the public health sector, especially in the northern governorates.

• High pressure on human resources, medical staff, hospital infrastructure, andhealth facilities.

• Lack of human resources and medical supplies.• Negative impact on Jordanian patients competing at times with Syrians for

valuable and limited health resources, for example, bed rate has become 15beds per 10,000 Jordanians, when it was 18 beds per 10,000 citizens prior tothe Syrian crisis.

• There is a fiscal deficit as a result of the lack of financial resources and the failureof donor countries to provide adequate funding required for the Syrian response.

• Increased risks of the spread of diseases among Jordanians (i.e., polio andmeasles), especially the host communities, and the need for additional vaccina-tion campaigns.

Mental Health Psychosocial Problems and Resources

The MoH National Center for Mental Health (NCMH) is the lead agency for theprovision of mental health services, treatment, awareness, supervision, and training,in addition to the issuance of judicial reports for cases referred to them from all civiland military courts. The MoH utilizes a biopsychosocial approach and partnersclosely with the NGO community in the provision of mental health services.Additionally, NCMH provides services to nongovernmental institutions such asthe Jordan River Foundation, the elderly shelters, orphans institutions, and peoplewith special needs (Norwegian Refugee Council). Treatment is conducted through

12 Y. S. Khader

Karama Hospital for psychiatric rehabilitation, which can accommodate up to 150beds, and the National Center for the rehabilitation of “persons with substance abuseissues,” which can accommodate up to 40 beds. The RMS provides Mental HealthServices through the psychiatric department in Marka Hospital and can accommo-date up to 34 beds. Other inpatient units are available in general hospitals (KingAbdullah Hospital, Jordan University Hospital, and Ma’an Governmental Hospital)with 20, 12, and 15 beds, respectively, for a total of 47 beds. There is a network ofpsychiatrists under the NCMH, covering a total of 49 hospital outpatient clinics,health centers, and prisons, delivering treatment in all governorates for an average of2–3 days per week. With the exception of these types of outpatient services andclinics, throughout the Kingdom resources are concentrated in the psychiatrichospitals (Primary Health Care Department 2015).

The number of psychiatrists is no more than 2 per 100,000 population in Jordanand the number of nursing cadres is 0.04 per 100,000 population. The lack ofinsurance coverage for Syrian refugees and the Jordanian community with mentalillnesses combined with the high cost of private psychiatric treatment exacerbatesaffordability issues for refugee community. All primary health care facilities inJordan are physician-based. Nurses and other primary health care workers (exclud-ing doctors) are not permitted to prescribe psychotropic medications. Primary healthcare doctors working in the public sector are allowed to prescribe psychotropicmedications but with restrictions. For instance, they can prescribe for follow-uptreatment but cannot initiate treatment for moderate or severe mental health condi-tions. Despite this restriction in psychotropic prescription, there are difficultiesenforcing such regulations. As such, training within the WHO recommendedmhGAP intervention guide is essential to support appropriate, evidence-based man-agement of mental health conditions in primary care.

Numerous nongovernmental organizations (NGOs) in Jordan give free psycho-social support to Syrian refugees, both in camps and urban zones. However, in spiteof the fact that these services are accessible to all, not everybody effectively looks forthese services (The National Strategy for Health Sector in Jordan, 2015–2019).There are many projects that try to encourage access to medicinal services amongSyrian refugees in Jordan. For instance, the Japan International Cooperation Agency(JICA) and the Noor al-Hussein Foundation (NHF) administer mobile dispensariesthat serve rural-based populations (Salemi et al. 2018). In specific areas, healthmonitoring programs screen child health and disclose cases of malnutrition. Repro-ductive and family planning services are accessible through open offices and somenongovernmental facilities. For instance, the NHF’s Institute of Family Health isworking in all formal camps and various host communities (Kisilu and Darras 2018).In addition to family medicine services, their centers give antenatal and postnatalcare, family planning counselling, and screenings for breast and cervical cancer.Campaigns to boost reproductive health practices arranged by associations such asMedair offer education to mothers on maternal and infant care and breastfeeding.Campaigns additionally enhance the utilization of family services among womenand additionally men in and out of camps (Kisilu and Darras 2018).

Mental Health and Psychosocial Concerns and Provision of Services for. . . 13

The most recent mapping exercise conducted by the MHPSS Working Group inJordan, co-led by IMC and WHO, documented the MHPSS activities of 35 organi-zations. The document outlines the 4Ws of MHPSS activities in Jordan; who isdoing what, where, and when. In total, the document captured 1253 MHPSS-relatedactivities provided by agencies to vulnerable Jordanian citizens and Syrian refugees.In general, MHPSS services provided by NGOs and INGOs were provided bymostly nonspecialized staff (75%), and specialized national staff (20%). Mostactivities (38%) were aimed at strengthening community and family supports. Agrowing number of actors were found to offer specialized services provided bypsychologists and psychiatrists, compared to that identified in previous years.However, such specialized services still only represent 19% of services, with theremaining services focused on nonspecialist service provision, strengthening familyand social supports, and the integration of MHPSS services into other sectorsproviding humanitarian aid. A high number of services were provided in thegovernorates of Amman (21%), Irbid (17%), Zarqa (14%), and Mafraq (14%),with few MHPSS services being offered in the governorates of Aqaba (3%), Madaba(3%), and Tafileh (3%). Key findings from the mapping highlight the geographicbias toward more centrally located governorates, with a strong need to increaseservice provision in the South. Furthermore, few to no services within the NGO andINGO community reported to be targeting persons with substance and/or alcohol usedisorders, and persons with developmental delays and/or disabilities.

Child Mental Health Services

As of August 6th 2017, UNHCR stated that they had registered 660,582 thousandpersons of concern documenting them as refugees from Syria: over 80% of themcurrently live outside refugee camps. Of these, approximately 265,000 are childrenunder 18 years of age. UNICEF data indicates that 50% of children suffer fromnightmares, various forms of sleep disorders, or bedwetting as a result of the distressthey have been exposed to since the onset of the Syrian crisis. What is moretroublesome is the lack of child mental health services; currently child and adoles-cent mental health services are not available at MoH. Jordan has one child psychiatryclinic at Princess Aisha Medical Complex. The university hospitals provide mentalhealth services through clinics in each of the Jordan University Hospital and KingAbdullah University Hospital. In 2012, King Abdullah Hospital allocated 10 beds tomanage cases presenting with mental illness and 12 beds were allocated for treat-ment of mental illness in the University of Jordan Hospital during 2014. The privatesector is a key provider of mental health services through Al Rasheed Mental HealthHospital with a capacity of 120 beds (MoH, Primary Health Care Department 2014).The RMS has three outpatient clinics also targeting child and adolescent mentalhealth needs, while the Ministry of Social Development (MoSD) has three residen-tial institutions for children and adolescents with mental disabilities (The NationalStrategy for Health Sector in Jordan, 2015–2019).

14 Y. S. Khader

Financing of MoH Services

The Jordan Response Plan (JRP) outlines funding needs and funding received fromthe international community (Jordan Ministry of Planning and International Coop-eration). In 2016, international donors committed $1.02 billion USD for the annualneeds of Jordan, considering the additional burden placed on the country by theincreasing refugee population. The amount committed represented only 37.5% of theactual needs anticipated by the JRP. Of the funding received by international donors,$325.9 million USD was directed to the Government of Jordan and their generalbudgetary needs, while $465.6 million USD was filtered to UN agencies, NGO,INGO, private, and academic institutions through the Jordan Information System forthe Syria Crisis (JORISS).

To date, no fixed budget is dedicated to health or mental health services due to themultiple sources of funding received by the MoH. Therefore, it is difficult toaccurately estimate the percentage of the total health budget allocated to mentalhealth. Despite recent efforts to shift attention and resources to community-basedprovision of services, the majority (estimated at over 90%) of financial resources formental health are currently directed towards hospitals treating mental disorders(WHO-AIMS 2011). This has presented a large challenge to developing andexpanding community-based services. Such services have only received ad-hocfunds for individual activities by external organizations (including IMC), oftenwith gaps or shortages, limiting the sustainability of such community-based reha-bilitation interventions. It is common for a Jordanian citizen to use more than onehealth provider or to be insured under more than one health insurance program.

Utilization and Access to Health Services

According to a study in 2016 on health service utilization among Syrian refugeechildren in Jordan, 90.9% of families with a youngster less than 18 years got healthcare the last time it was necessary. In addition, families were usually getting healthcare for their children from the public sector (54.6%), followed by private health care(36.5%) and philanthropy divisions (8.9%). Among child care seekers, 88.6% wereprescribed medications during their last visit and 90.6% of them adhered to takingthe medication (Doocy et al. 2016).

A recent systematic review in Jordan reported that the overall access to healthcareis moderately useful for most enrolled Syrian refugees, but some groups still do nothave access to services due to financial and structural obstacles, such as not havingthe proper legal documentation. In addition, the review reported that the healthcarerequirements of Syrian refugees, as well as the community in Jordan, cannot be meteffectively without the global community accepting mutual responsibility andincluding financial support (El Arab and Sagbakken 2018).

The 2015 Vulnerability Assessment Framework (VAF) found that 86% of Syrianrefugees were living below the Jordanian poverty line of 68 JD every month. Rentallease costs weigh intensely on families, and families may depend on sharingapartments to cut their expenses, bringing about overcrowding. The cost of public

Mental Health and Psychosocial Concerns and Provision of Services for. . . 15

health treatment restricts access to the care required by some poor refugees. Cashassistance helps enlisted family units; however, most families report that presentallocation levels are insufficient to cover their essential needs. In addition, aftermany years of displacement, numerous families have depleted their savings andfallen into debt (Al-Rousan et al. 2018).

An absence of awareness and access to mental health services, together with thestigma attached to mental health, were identified to be major difficulties in seekingtreatment. Lack of trust in specialists, utilizing medication without consultation, andutilization of home-cures was found to be common among Syrian refugees in Jordan(Doocy et al. 2016).

In another study (IMC 2017), Jordanians and Syrians shared concerns about accessto healthcare and the inability to reach services. Stigma surrounding mental healthissues was frequently reported by respondents, which appeared to represent a signif-icant barrier to seeking help. Women in particular, reported an increased need forprivacy when accessing mental health services, for fear of stigma within the commu-nity. A sense of helplessness and hopelessness was strongly reported amongst theSyrian refugee community, with the Jordanian host community reporting lower levelsof helplessness and a stronger tendency to use work as a distraction from emotionaldistress. For both the Syrian and Jordanian populations, economic instability wasfound to be a source of great concern for both adult males and females, leading to areported decline in mental well-being and the capacity to care for young children andolder adults, particularly in light of the protracted nature of the crisis. Such situationswith respect to financial concerns were common in both camp and urban settings.

The qualitative findings of a study in 2018 reported many problems related tohealth care services provided for Syrian refugees in Jordan, including cost, changingplans, and lack of health education, which adversely affected the mental health ofSyrian refugee children in Jordan (Deutsche Gesellschaft für InternationaleZusammenarbeit (GIZ) GmbH 2018).

Referring to the high medicinal services costs, the Jordanian Ministry of Healthstopped full coverage of health care for Syrian refugees in September 2014. TheUNHCR presently takes care of 100% of the expenses of essential and secondarymedicinal services for refugees coming from the camps. However, 80% of Syrianrefugees live in the urban zones of Jordan and should now pay the charge forforeigners at government dispensaries (Al-Rousan et al. 2018).

Approaches that Helped Syrian Adolescents in Jordan

In the GIZ study (Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ)GmbH 2018), the majority of Syrian parents reported that the Jordanian governmentand community helped Syrian children and adolescents by embracing them, wel-coming them, providing financial support, providing psychological support, helpingstudents to continue their education, making recreational centers available for them,providing health services, and through awareness campaigns. In addition, theymentioned that the humanitarian organizations had played a great role in helpingtheir children.

16 Y. S. Khader

Conclusion

Many psychosocial problems are still badly affecting Syrian refugee children andadolescents in Jordan in spite of the fact that many of them started living in Jordanmany years ago. As a result, more psychosocial and financial support is still requiredto help refugee children and adolescents.

Recommendations

Based on the findings of reviewed studies, we recommend the following services andactions:

Family and Community Supports1. Promote networking between NGOs and other entities providing psychosocial

support on different levels and establish a community center by a non-governmental actor to synchronize all efforts.

2. Advocate and scale up lower level MHPSS community-based services andsupports, such as outreach volunteers, community councils, and peer-to-peersupport.

3. Ensure training of outreach workers and community mobilizers to providecommunity-based integrated care.

4. Support integration and engagement between the Syrians and Jordanians to helprefugees overcome their psychosocial problems.

5. Implement activities to stop discrimination against Syrian refugee children.Educating Jordanian students about the Syrian suffering could help them acceptrefugee colleagues.

6. Enforce school rules related to discrimination and violence against Syrianstudents.

7. Train teachers on how to deal with Syrian refugee students and how to educateJordanian students about the new environment to reduce bullying and fighting inschools.

8. The government should expand support for institutions presenting psychosocialsupport programs for children.

9. Expand psychological counselling and intervention to include not only adoles-cents but their families.

10. Implement parent support programs, including training courses and discussionsabout psychosocial problems of adolescents, family violence, and handling ofviolence and stress.

11. Implement gender-specific psychosocial support programs and educational pro-grams. These programs help each group understand more about defense mech-anisms, which are different for each group, to ensure safety and protection.

12. Implement activities based on interaction with community members that canenhance resilience traits and perceived social support in adolescents.

Mental Health and Psychosocial Concerns and Provision of Services for. . . 17

13. Establish central supportive groups from professionals and community membersin all regions of the country.

14. Help adolescents to cope with their psychosocial problems15. Increase the number of recreational activities provided by professionals in

schools, after school hours, or in other suitable places.16. Implement summer play programs that allow for integration of Jordanians and

Syrian refugee children17. Hold events and programs for teaching handicrafts, science clubs, poetry clubs,

reading and writing clubs, language classes, computer courses, trips, competi-tions, drawing and sketching classes, cooking plays, music and acting classes,fitness courses, for Syrian and Jordanian adolescents.

Focused, onspecialized Supports and Services1. Strengthen primary health care system to provide mental health services and

psychosocial support.• Strengthen management of MHPSS problems by nonspecialists and reduce

pressure on specialized MH services by:– Training of general health care providers in mental health– Training of paraprofessionals (social workers, counselors, etc.) on MHPSS

case management that includes basic counseling and other evidence basedinterventions.

• Expand on existing efforts for training of trainers (specialists) to ensurefollow-up and supervision.

2. Strengthen the collaboration between institutions that have well-trained mentalhealth professionals with other associations in different fields.

3. Strengthen screening for mental health problems and psychosocial support needsand referral system.

4. Implement evidence-based mental health and psychosocial support interventionsin schools.

5. Implement gender-specific mental health support programs because it is obviousthat each group has its own stresses and concerns.

6. Train various mental health staff about mental health and psychosocial support.The most important target groups for training are: primary health-care workers;staff responsible for the management of shelters and refuges; volunteers andhumanitarian assistance staff; teachers; community leaders; and health promoters.

7. Increase public awareness about the availability of mental health services andinstitutions that offer help and care for mental health problems for their children.

8. Conduct awareness campaigns about the stigma surrounding mental health and itsconsequences in all regions of Jordan. Awareness campaigns should focus onimproving knowledge about symptoms of depression, anxiety, and PTSD amongadolescents. Awareness campaigns can take different forms, including distribut-ing booklets and brochures, seminars, workshops, courses, conferences, and liveperformances. Also, using social media, television, and radio programs is a goodmethod to reach a wider audience and educate more individuals.

18 Y. S. Khader

Specialized Services and Referrals1. Map existing mental health service providers in order to facilitate the referral of

severe or complex cases.2. Establish and announce specialized mental health care in selected health settings

covering the three regions of the country and establish mechanisms for referraland counter-referral of cases.

3. Provide training and support from mental health professionals to equip othertrained actors involved in basic psychological and/or psychotherapeutic supportto identify needs and make appropriate referrals.

4. Train local psychologists or counsellors to identify psychosocial needs andprovide an appropriate response. This response may include facilitating psycho-social support groups, running information and/or sensitization activities, ormaking referrals to quality service providers.

5. Ensure the regular supply of essential psychotropic medications to PHC centersaccording to the national essential list of psychotropic medication.

Community Mobilization and Participation1. Training of community actors (e.g., community leaders, religious leaders, or

teachers) and health service providers (e.g., community health workers, nurses,or doctors) by mental health professionals to provide basic psychological support.

2. Implement activities that address psychosocial problems throughpsychoeducation and by building trust, solving problems and sharing experiencesand information.

3. Advocate for the participation of displaced and host families and communities inthe design and implementation of community-based activities across all sectors.

4. Support and advocate to preserve dignity through governmental and non-governmental/community support whereby children receive psychosocial supportand continuously enhance their situation by providing youth and child-friendlyspaces.

5. Accurately record all affected persons and collect and store accurate data aboutthem.

Health Education1. Educate the population on how to identify problems that require assistance, and

some simple measures for coping with these situations. Educational strategies forthe population should include the following:• Ensure availability of easily understandable educational material, graded by

age group and level of vulnerability;• Group awareness-raising educational activities involving groups and families

deeply affected by the crisis.• Implement health promotion and education activities with participation of

community organizations, focused on children and adolescents in schools.

Mental Health and Psychosocial Concerns and Provision of Services for. . . 19

2. Implement information and sensitization activities to feature a psychosocialaspect in a comprehensible, engaging, and culturally appropriate way and raiseawareness of both mental health and psychosocial issues.• Establish awareness campaigns about the consequences of early marriage,

leaving school for work, and substance abuse on all aspects of life.• Increase awareness of the importance of school education. There is a large

percentage of school drop-outs in the age group 12–17, particularly in light ofSyrian child labor.

3. Conduct more research on drop-outs and child labor to obtain informative data tobuild the necessary interventions.

4. Rehabilitate Imams and clergymen (religious leaders) in spreading awarenessabout the importance of mental health and psychosocial support.

5. Develop Arabic-language references in psychosocial support – unlike abundantresources in English that may not all apply to our local context.

References

Achilli L (2015) Syrian refugees in Jordan: a reality check. Available from: http://cadmus.eui.eu/handle/1814/34904. Accessed 19 Apr 2019

Al Ali NM, Gharaibeh M, Masadeh MJ (2017) Students’ perceptions of characteristics of victimsand perpetrators of bullying in public schools in Jordan. Nurs Res 66(1):40–48

Al-Bitar ZB, Al-Omari IK, Sonbol HN, Al-Ahmad HT, Cunningham SJ (2013) Bullying amongJordanian schoolchildren, its effects on school performance, and the contribution of generalphysical and dentofacial features. Am J Orthod Dentofac Orthop 144(6):872–878

Almoshmosh N, Mobayed M, Aljendi M (2016) Mental health and psychosocial needs of Syrianrefugees and the role of Syrian non-governmental organisations. BJPsych Int 13(4):81

Al-Rousan T, Schwabkey Z, Jirmanus L, Nelson BD (2018) Health needs and priorities of Syrianrefugees in camps and urban settings in Jordan: perspectives of refugees and health careproviders. East Mediterr Health J 24(3):243–254

Amnesty International. The state of the world’s human rights. Available from: https://www.amnesty.org/download/Documents/POL1048002017ENGLISH.PDF. Accessed 19 Apr 2019

Arabiat DH, Shaheen A, Nassar O, Saleh M, Mansour A (2018) Social and health determinants ofadolescents’ wellbeing in Jordan: implications for policy and practice. J Pediatr Nurs 39:55–60

Atoum M, Alhussami M, Rayan A (2018) Emotional and behavioral problems among Jordanianadolescents: prevalence and associations with academic achievement. J Child Adolesc PsychiatrNurs 31(2–3):70–78

Baddoura C, Merhi M (2015) PTSD among children and adolescents in the Arab world. Arab JPsychiatry 26(2):129–3630

Boehm B (2018) Mental health amongst child Syrian refugees living in Jordan’s host community.Available from: https://www.researchgate.net/publication/323811701_Mental_Health_amongst_Child_Syrian_Refugees_living_in_Jordan's_Host_Community. Accessed 19 Apr 2019

Care I (2017) 7 years into exile: how urban Syrian refugees, vulnerable Jordanians and other refugeesin Jordan are being impacted by the Syria crisis. Available from: https://www.care.at/wp-content/uploads/2017/06/2017-summary-DRAFT-EMBARGO-14062017.pdf. Accessed 19 Apr 2019

Conti-Ramsden G, Mok PL, Pickles A, Durkin K (2013) Adolescents with a history of specificlanguage impairment (SLI): strengths and difficulties in social, emotional and behavioralfunctioning. Res Dev Disabil 34(11):4161–4169

Demaray MK, Malecki CK (2002) Critical levels of perceived social support associated withstudent adjustment. Sch Psychol Q 17(3):213

20 Y. S. Khader

Department of Statistics (2017) Population and Housing Census Jordan Department of StatisticsDeutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH. Mental health and psy-

chosocial problems and needs among Jordanian adolescents and Syrian Adolescents refugees.2018

Devi R, Verma N, Shekhar C (2013) Exploring strengths, difficulties and loneliness among childrenliving in socioeconomically deprived environment. J Indian Assoc Child Adolesc Ment Health 9(2):26–42

Doocy S, Lyles E, Akhu-Zaheya L, Burton A, Weiss W (2016) Health service utilization and accessto medicines among Syrian refugee children in Jordan. Int J Health Plann Manag 31(1):97–112

Doren C (2011) Psychosocial problems of refugees: understanding and addressing needs. Availablefrom: https://digitalcollections.sit.edu/cgi/viewcontent.cgi?referer=https://www.google.com/&httpsredir=1&article=2168&context=isp_collection. Accessed 19 Apr 2019

El Arab R, Sagbakken M (2018) Healthcare services for Syrian refugees in Jordan: a systematicreview. Eur J Pub Health 28(6):1079–1087

Francis A (2015) Jordan’s refugee crisis: carnegie endowment for international peace. Availablefrom: https://carnegieendowment.org/files/Brief-Francis-Jordan.pdf. Accessed 19 Apr 2019

Geha C, Talhouk J (2018) Politics and the plight of Syrian refugees in Lebanon. Available from:https://www.aub.edu.lb/Documents/Politics-and-the-Plight-of-Syrian-Refugees-in-Lebanon.pdf. Accessed 19 Apr 2019

Gormez V, Kılıç HN, Orengul AC, Demir MN, Demirlikan Ş, Demirbaş S et al (2018) Psychopa-thology and associated risk factors among forcibly displaced Syrian children and adolescents. JImmigr Minor Health 20(3):529–535

Hassan G, Kirmayer LJ, Mekki-Berrada A, Quosh C, el Chammay R, Deville-Stoetzel J et al (2015)Culture, context and the mental health and psychosocial wellbeing of Syrians: a review formental health and psychosocial support staff working with Syrians affected by armed conflict.UNHCR, Geneva, pp 14–15

IMC (2015) Syria crisis: addressing regional mental health needs and gaps in the context of theSyria crisis. Available from: https://internationalmedicalcorps.org/wp-content/uploads/2017/07/Syria-Crisis-Addressing-Mental-Health.pdf. Accessed 19 Apr 2019

IMC (2017) Understanding the mental health and psychosocial needs, and service utilization ofSyrian refugees and Jordanian nationals – a qualitative & quantitative analysis in the Kingdomof Jordan

Jordan Health Aid Society and IMC (2012) Displaced Syrians in Jordan: a mental health andpsychosocial information gathering exercise. Available from: https://data2.unhcr.org/en/documents/download/36230. Accessed 19 Apr 2019

Jordan Ministry of Planning & International Cooperation. The Jordan Response Plan (JRP) For theSyria Crisis 2018–2020. Available from: https://static1.squarespace.com/static/522c2552e4b0d3c39ccd1e00/t/5a9d05ff24a69491feff8ba5/1520240134714/JRP+Summary+Final.pdf. Accessed19 Apr 2019

Kisilu AL, Darras L (2018) Highlighting the gender disparities in mental health among Syrianrefugees in Jordan. Intervention 16(2):140

Milam A, Furr-Holden C, Leaf P (2010) Perceived school and neighborhood safety, neighborhoodviolence and academic achievement in urban school children. Urban Rev 42(5):458–467

Nijs MM, Bun CJ, Tempelaar WM, de Wit NJ, Burger H, Plevier CM et al (2014) Perceived schoolsafety is strongly associated with adolescent mental health problems. Community Ment Health J50(2):127–134

Norwegian Refugee Council. Delivering through a bleak, challenging year 2016. Available from:https://www.nrc.no/globalassets/pdf/annual-reports/2017/nrc_annualreport2016_230616.pdf. Accessed 19 Apr 2019

Panter-Brick C, Hadfield K, Dajani R, EggermanM, Ager A, Ungar M (2018) Resilience in context:a brief and culturally grounded measure for Syrian refugee and Jordanian host-communityadolescents. Child Dev 89(5):1803–1820

Mental Health and Psychosocial Concerns and Provision of Services for. . . 21

Perkins JD, Ajeeb M, Fadel L, Saleh G (2018) Mental health in Syrian children with a focus onpost-traumatic stress: a cross-sectional study from Syrian schools. Soc Psychiatry PsychiatrEpidemiol 53(11):1231–1239

Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA (2015) Annual research review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J ChildPsychol Psychiatry 56(3):345–365

Primary Health Care Department (2015). Available from: http://www.hhc.gov.jo/uploadedimages/The%20National%20Strategy%20for%20Health%20Sector%20in%20Jordan%202015-2019.pdf. Accessed 19 Apr 2019

Ranttila J, Shrestha T (2011) Understanding depression in children and adolescents. Available from:https://www.theseus.fi/handle/10024/36696. Accessed 19 Apr 2019

Refugee Regional & Resilience Plan 2016–2017. Progress report of the regional refugee andresilience plan (3RP) in response to the Syria Crisis. Available from: http://www.3rpsyriacrisis.org/. Accessed 19 Apr 2019

Rigby K (2000) Effects of peer victimization in schools and perceived social support on adolescentWell-being. J Adolesc 23(1):57–68

Salemi C, Bowman J, Compton J (2018) Services for Syrian refugee children and youth in Jordan:forced displacement, foreign aid, and vulnerability. In: Economic research forum working paperseries 2018 Apr (No. 1188)

Save the Children (2017) The impact of six years of war on the mental health of Syria’s children.Available from: https://www.savethechildren.org.uk/content/dam/global/reports/emergency-humanitarian-response/invisible-wounds.pdf. Accessed 19 Apr 2019

Shaheen AM, Hammad S, Haourani EM, Nassar OS (2018) Factors affecting Jordanian schooladolescents’ experience of being bullied. J Pediatr Nurs 38:e66–e71

Sijbrandij M, Acarturk C, Bird M, Bryant RA, Burchert S, Carswell K et al (2017) Strengtheningmental health care systems for Syrian refugees in Europe and the Middle East: integratingscalable psychological interventions in eight countries. Eur J Psychotraumatol 8(sup2):1388102

Sim A, Fazel M, Bowes L, Gardner F (2018) Pathways linking war and displacement to parentingand child adjustment: a qualitative study with Syrian refugees in Lebanon. Soc Sci Med200:19–26

Sirin SR, Rogers-Sirin L (2015) The educational and mental health needs of Syrian refugeechildren. Migration Policy Institute, Washington, DC

Song S (2014) Mental health psychosocial and child protection for Syrian adolescent refugees inJordan. International Medical Corps (IMC), pp 47–52. Available from: https://www.alnap.org/help-library/mental-health-psychosocial-and-child-protection-for-syrian-adolescent-refugees-in. Accessed 19 Apr 2019

Soykoek S, Mall V, Nehring I, Henningsen P, Aberl S (2017) Post-traumatic stress disorder inSyrian children of a German refugee camp. Lancet 389(10072):903–904

Stave SE, Hillesund S (2015) Impact of Syrian refugees on the Jordanian labour market. ILO,Geneva. Available from: https://www.ilo.org/wcmsp5/groups/public/%2D%2D-arabstates/%2D%2D-ro-beirut/documents/publication/wcms_364162.pdf. Accessed 19 Apr 2019

The National Strategy for Health Sector in Jordan, 2015–2019. http://www.hhc.gov.jo/uploadedimages/The%20National%20Strategy%20for%20Health%20Sector%20in%20Jordan%202015-2019.pdf. Accessed 19 Apr 2019

Tian L, Liu L, Shan N (2018) Parent–child relationships and resilience among Chinese adolescents:the mediating role of self-esteem. Front Psychol 9:1030

UNHCR (2017) Information sharing portal. Available from: https://data2.unhcr.org/en/situations/syria. Accessed 19 Apr 2019

UNICEF, UNHCR, WFP (2017) Vulnerability assessment of Syrian refugees in Lebanon. Availablefrom: https://reliefweb.int/sites/reliefweb.int/files/resources/VASyR%202017.compressed.pdf.Accessed 19 Apr 2019

22 Y. S. Khader

Wells R, Steel Z, Abo-Hilal M, Hassan AH, Lawsin C (2016) Psychosocial concerns reported bySyrian refugees living in Jordan: systematic review of unpublished needs assessments. Br JPsychiatry 209(2):99–106

WHO (2017) Depression and other common mental disorders: global health estimates. Availablefrom: https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf?sequence=1. Accessed 19 Apr 2019

WHO-AIMS (2011). Available from: https://www.who.int/mental_health/evidence/mh_aims_report_jordan_jan_2011_en.pdf?ua=1. Accessed 19 Apr 2019

Wingo AP, Ressler KJ, Bradley B (2014) Resilience characteristics mitigate tendency for harmfulalcohol and illicit drug use in adults with a history of childhood abuse: a cross-sectional study of2024 inner-city men and women. J Psychiatr Res 51:93–99

Mental Health and Psychosocial Concerns and Provision of Services for. . . 23