Symptoms of Posttraumatic Stress Disorder in Middle School Students After the Covid-19 Outbreak

COVID-19 bears various traumatic impacts on students. This study aims to identify PTSD symptoms in junior and senior high school students after the COVID-19 outbreak. The study was conducted using a cross-sectional survey method. Meanwhile, the data was collected using a problem checklist instrument. Further, the obtained data were analyzed using non-parametric statistics with the Mann-Whitney test to identify differences in PTSD symptoms based on gender and level of education. The results of the analysis show that symptoms appear in every physical, emotional, mental, behavioral, and spiritual aspect. Besides, we also found a significant difference in the level of anxiety disorder between male and female students after COVID-19, while there is no significantly distinct anxiety disorder between junior and senior high school students. In the end, we recommended that more in-depth research regarding the forms of intervention to reduce PTSD in students should be carried out.


Introduction
The educational process is inseparable from various problems, including the students' psychological problems.Their psychological issues will further affect the independent educational process (Faizah, Rahma, Dara, & Gunawan, 2020;Weist, Rubin, Moore, Adelsheim, & Wrobel, 2007).Additionally, students will experience difficulties in the learning process, which is one of the stepping stones to reach maturity.One of the psychological problems carrying a substantial impact on the maturity process is post-traumatic stress disorder (PTSD).
PTSD is a psychological disorder that develops after someone experiences or witnesses a traumatic event.Mostly, PTSD is induced by unusual and sudden traumatic events (Schiraldi, 2019).Meanwhile, the COVID-19 pandemic carries numerous unpleasant experiences and appearances that can be traumatic events.According to data from the Indonesian Ministry of Social Affairs (2021), on September 29, 2021, there have been 30,766 children lost their parents and became orphans.Losing a parent is an exceptionally traumatic event for a child.Moreover, they have not developed sufficient (Varghese & Natsuaki, 2021).Without proper treatment, this situation enables children to create other PTSD symptoms that may crystallize into abnormal behavior.Further, symptoms can also be stimulated by the consumption of media content displaying a lot of traumatic events related to the COVID-19 pandemic.
A study conducted by Miranda et al. (2020) reported the possible massive occurrence of mental health problems, including PTSD, during and after the COVID-19 pandemic.Linearly, Cao et al. (2022) also discovered a higher percentage of PTSD occurring during and after the COVID-19 pandemic than other mental health disorders.Additionally, children are more susceptible to prolonged PTSD, which may interfere with their future development.Besides, children are also reported to have distinct levels of stress depending on their developmental level.High levels of anxiety, depression, and other post-traumatic symptoms have been identified among the children.A study conducted by Rahmadian et al. (2016) concluded that after experiencing a traumatic event, individuals would encounter stress, difficulty adapting to their environment, which further affects their interactions, high anxiety, unstable emotional pressure, and symptoms of depression.Linearly, Dewanti et al. (2021) also described that excessive anxiety can develop after an extraordinary event.Consequently, as school serves as the greatest support system for children, especially in overcoming mental health disorders, it has to formulate specific strategies to reduce post-traumatic anxiety disorder in children.
In extreme cases, PTSD results in abnormal behaviors.Several studies recorded that individuals who experience long-term PTSD may potentially be at risk of suicide, addiction to illegal drugs, excessive alcohol consumption, which causes chronic pain in the brain, and even deviant sexual orientation (Egli, Koob, & Edwards, 2012;Gilmour, 2014;Papazoglou, 2017;Schiraldi, 2019).Extreme physical and emotional symptoms have also been observed in individuals who experience PTSD.Further, with inappropriate treatment or without treatment, individuals with PTSD experience physical and emotional symptoms.Extreme physical symptoms found in those people include obesity, cancer, heart disease, and other chronic diseases.
Accordingly, schools need to pay close attention to students' mental health in order to aid them in avoiding PTSD, since PTSD will hinder their development.As an alternative, schools need to provide facilities for enhancing students' independence (Edeh et al., 2022).The preventive and curative alternatives should also be carried out to prevent PTSD as well as lowering the PTSD symptoms experienced by students.However, in order to provide the preventive and curative measures, the PTSD symptoms in students should be identified since the symptoms will demonstrate the level of student's PTSD.
Previously, Febriana et al. (2022) examined PTSD experienced by individuals who had to selfquarantine during the COVID-19 pandemic, reporting the impact of quarantine on individual psychology.As a continuation of that previous research, in this study, we specifically investigate the PTSD symptoms among the survivors of the COVID-19 pandemic, primarily among junior and senior high school students.Particularly, this research aims to identify the significance of PTSD symptoms between male and female students, as well as between the students from junior and senior high school students.In the end, the results of this study will serve as a reference for experts and practitioners in exploring the possible solutions to reduce PTSD symptoms and deepening information related to PTSD symptoms at a more comprehensive educational level.

Method
This research was conducted using a cross-sectional survey method.Data collection was carried out using a problem checklist instrument that was developed based on the concept of PTSD proposed by the emergence of PTSD symptoms in individuals.The problem checklist instrument contained 69 items representing five aspects, namely, physical, emotional, mental, behavioral, and spiritual symptoms.The validity and reliability of the instrument were assessed through the SPSS program.From the validity test, on average, the instrument items attained a corrected item-total correlation value of 0.65, exceeding the r-table value of 0.468.Meanwhile, for the instrument reliability, we gained a Cronbach alpha value based on standardized items of 0.834, which is greater than the r table of 0.468 (Rusmana, 2008).
In addition, the instrument was digitized using Google Form to facilitate more accesssible data collection and processing.Then, the constructed instrument in Google Form was given to the research subjects.A total of 63 junior high school students and 182 high school/ vocational high school students participated as our research respondents.In detail, 35 junior high school students were female, while 28 junior high school students were male.In addition, 146 of the senior or vocational high school students were female, and 36 of them were male.Data analysis was performed using the non-parametric Mann-Whitney U test to observe the differences in PTSD symptoms based on the participants' gender and level of education.The analysis was carried out using SPSS software.

Results
After collecting data from junior high and high school students, our obtained results include the general profile of PTSD symptoms caused by the COVID-19 pandemic and a specific profile based on aspects of post-traumatic anxiety symptoms.

General Profile of PTSD Symptoms Due to the COVID-19 Pandemic
In general, our respondents' profile of post-traumatic PTSD symptoms based on physical, emotional, mental, behavioral, and spiritual aspects is presented in Figure 1.

Figure 1. PTSD Symptoms in General (N=245)
As illustrated in Figure 1, students experience PTSD symptoms in all aspects.On the physical aspect, most students experience headaches and dizziness, by 34 and 32%, respectively.In the emotional aspect, the symptoms frequently faced by students are boredom, worry, anger, and fear, with percentages of 36, 34, 36, and 44%, respectively.In the mental aspect, the highest symptoms frequently encountered by the participants include difficulty in making decisions, excessive thinking, forgetfulness, and issues concentrating, with percentages of 40, 46, 49, and 34%, respectively.In the behavioral aspect, the majority of students mainly experience irritability, anxiety, crying, and sleeping issues, with a percentage of 39, 33, 38, and 38%, respectively.In the spiritual aspect, 36, 38, and 30% of students mostly easily feel sorry for themselves, disappointed, and preoccupied with themselves.
The general profile was further classified based on the respondents' gender and education level.Table 1.describes the respondents' PTSD symptoms based on there to identify the significance of difference.1. summarizes that, on average, the PTSD symptoms in male students are higher than their female counterparts.From the Mann-Whitney analysis, we found a significant difference between men and women.However, the significance value of PTSD symptoms based on gender does not exceed 0.05.
In addition, Table 2 presents the analysis results on PTSD symptom scores based on respondents' educational levels.In this analysis, we involved two different levels of education, namely junior high and senior high school levels.The analysis results on PTSD symptoms based on respondents' education level are shown in Table 2.As presented in Table 2, junior high school students averagely experience higher PTSD symptoms than senior high school students.However, the Mann-Whitney analysis results suggest no significant difference in PTSD symptoms encountered by junior high school students and senior high school students.The significance value of PTSD symptoms based on educational level exceeds 0.05.

Special Profile of Post-traumatic Anxiety Symptoms Due to the COVID-19 Pandemic
The specific profile of students' PTSD symptoms was examined through the data collected through the problem checklist, which included physical, emotional, mental, behavioral, and spiritual aspects.In Table 3, we present the respondents' PTSD symptoms on their gender.In all aspects of PTSD symptoms, we obtained a significance value of < 0.05, signifying significant differences between male and female students based on gender.The respondents experience the most severe post-COVID-19 PTSD symptoms in the mental and behavioral aspects, as shown by the significance of 0.002.Meanwhile, the results of the Mann-Whitney test on parts of PTSD symptoms based on educational level are presented in Table 4.

Discussion
Our analysis results suggest distinct PTSD symptoms experienced between men and women, with more excellent average scores for men than women.The results of the Mann-Whitney analysis presented in Table 1 showed a significance value of 0.001, showing significant differences between men and women.Similar findings have also been reported in previous studies discussing PTSD symptoms based on gender.Research conducted by Zhen et al. (2022) reported different PTSD symptoms experienced by men and women, similar to what we have found in this study.In detail, significant differences were observed in the emotional, mental, behavioral, and spiritual aspects.A study conducted by Rohmatillah and Kholifah (2021) also suggested that men and women have different levels of stress.
Differences in PTSD symptoms between men and women are inseparable from various factors.A study conducted by Park et al. (2020) reported that women are more prone to experiencing stress than men.Financial problems, age, and lack of attention (caregiver) are the influencing factors for an individual's stress.Another study conducted by Danet (2021) uncovered that symptoms of stress, anxiety, depression, sleep disturbances, and fatigue often appear in women.Referring to the DSM-V developed by the American Psychiatric Association (2013), stress, anxiety, depression, sleep disturbances, and fatigue are the leading symptoms of PTSD.However, further analysis concerning their traumatic experience needs to be carried out.
The individual's PTSD symptoms are reflected in their behavior.In male students, behavior that triggers fights and aggressive attitudes in cyberspace is recorded after experiencing a post-traumatic event.Idsoe et al. (2012) described that men have the potential to be a bully after experiencing traumatic events, along with other PTSD symptoms.Their behavior will be worse if the individual is a bully as well as experiencing the bullying.In contrast to women, when experiencing a traumatic event, men experience intrusive and hyperarousal behaviors.Further, Xiong et al. (2020) described that women have a higher risk of experiencing stress.Meanwhile, stress is the early symptom of PTSD if it is ignored and protracted (American Psychiatric Association, 2013; Passavanti et al., 2021).Christiansen and Hansen (2015) characterized that women have higher levels of neuroticism, depression, sensitivity to physical anxiety, fear, and feelings of helplessness.
Meanwhile, other studies concluded that gender has no relationship with PTSD symptoms.Research conducted by Febriana et al. (2022) on post-traumatic anxiety symptoms in individuals who self-quarantine during the COVID-19 pandemic confirmed that gender has no relationship with their post-traumatic anxiety symptoms.Further, the study also found that age also had no association with the emergence of post-traumatic anxiety symptoms experienced by individuals.Edeh et al. (2022) also described no significant difference in the traumatic effects after the COVID-19 pandemic between individuals of a different gender.In a study conducted to find out the growing symptoms of post-traumatic anxiety in adolescents after the COVID-19 pandemic, Zhang et al. (2021) also found similar results.It was stated that men and women did not have significant distinct post-traumatic anxiety symptoms.
From the different educational levels, several studies have identified significant differences in post-traumatic anxiety symptoms between junior high and high school students.Research conducted by Xie et al. (2020) described no significant differences in post-traumatic anxiety symptoms among junior high and high school students.However, a study conducted by Zhang et al. (2021) suggested that junior high and high school students had significantly different post-traumatic anxiety symptoms.From these inconclusive findings, the absence of significant differences in PTSD symptoms between junior high and high school students could be caused by being in the same developmental phase.Further, the data from Central Statistics Agency (2022) described that the average age of junior and senior high school students is 13-18 years old.At that age, individuals are in the adolescent development phase and are experiencing various problems in achieving their developmental tasks (Marwoko, 2019) .
Accordingly, treatment for reducing post-traumatic anxiety symptoms needs to be formulated.Similarly, Irawan et al. (2021) also concluded the need for serious efforts to increase resilience in dealing with psychological disorders due to traumatic events.Edeh et al. (2022) described that interventions can significantly reduce symptoms of post-traumatic anxiety.Besides, interventions can also help change the individuals who experience common mental health disorders in society.The provided intervention also reported presenting a positive effect on individuals with post-traumatic anxiety symptoms.Traumatic symptoms that impact social abilities and interests can be reduced through appropriate interventions (Liyanage, Addison, Ham, & Hilton, 2022).Research from Qian et al. (2022) discovered that Cognitive Behavioral Therapy (CBT) and Mindfulness-Based approaches are widely used as interventions for reducing post-traumatic anxiety symptoms.In fact, some studies have combined the two.Trauma-related knowledge, emotion regulation, relaxation skills training, and psychological support from peers and psychologists are essential components of the intervention.In the end, we conclude the need for interventions for individuals who experience posttraumatic anxiety symptoms, especially for students who have experienced post-traumatic anxiety symptoms.

Conclusion
Our analysis results showed significant differences in PTSD symptoms based on gender.Meanwhile, if viewed from the level of education, there is no difference between PTSD symptoms experienced by junior high and senior high school students.The emotional and behavioral aspects have a higher level of significance than the physical, emotional, and spiritual aspects.Therefore, we recommend the formulation of interventions for students with PTSD symptoms.Despite these results, further research is necessary to obtain deeper findings of post-COVID-19 PTSD symptoms and the possible treatment.This research is expected to provide awareness, especially for practitioners to anticipate the occurrence of PTSD in students.This research did not use purposive samples, targeting respondents with traumatic experiences.In addition, the research subjects were still only junior and senior high school students.Additionally, our results only report the PTSD symptoms from the arousal symptom without identifying the response toward the traumatic experiences during the COVID-19 pandemic.Future research is expected to broaden information regarding PTSD profiles in students, especially in all regions of Indonesia.In addition, future research is expected to be able to develop interventions for lowering PTSD symptoms in schools.

Table 4 . PTSD Symptoms Based on Education Level
According to the data presented in Table4, all aspects of PTSD symptoms obtained a significance value of > 0.05.Therefore, there are no different PTSD symptoms experienced by junior and senior high school students.