European Child & Adolescent Psychiatry

https://doi.org/10.1007/s00787-020-01656-8

ORIGINAL CONTRIBUTION

Working memory and emotional interpretation bias in a sample

of Syrian refugee adolescents
Sven C. Mueller1,2 · Cagla Unal3 · Michela Saretta1 · Fadwa Al Mughairbi4 · Joana Gómez‑Odriozola2 ·
Esther Calvete2 · Baris Metin5

Received: 5 June 2020 / Accepted: 25 September 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
The number of adolescent refugees around the world has been continuously increasing over the past few years trying to
escape war and terror, among other things. Such experience not only increases the risk for mental health problems including
anxiety, depression, and post-traumatic stress disorder (PTSD), but also may have implications for socio-cognitive devel-
opment. This study tested cognitive-affective processing in refugee adolescents who had escaped armed conflict in Syria
and now resided in Istanbul, Turkey. Adolescents were split into a high trauma (n = 31, 12 girls, mean age = 11.70 years,
SD = 1.15 years) and low trauma (n = 27, 14 girls, mean age = 11.07 years, SD = 1.39 years) symptom group using median
split, and performed a working memory task with emotional distraction to assess cognitive control and a surprise faces task
to assess emotional interpretation bias. The results indicated that high (vs. low) trauma symptom youth were ~ 20% worse
correctly remembering the spatial location of a cue, although both groups performed at very low levels. However, this find-
ing was not modulated by emotion. In addition, although all youths also had a ~ 20% bias toward interpreting ambiguous
(surprise) faces as more negative, the high (vs. low) symptom youth were faster when allocating such a face to the positive
(vs. negative) emotion category. The findings suggest the impact of war-related trauma on cognitive-affective processes
essential to healthy development.

Keywords War · Trauma · Adolescents · Refugee · Emotion · Working memory · interpretation bias

Introduction of global refugees has been estimated at 25.9 million, with

Increasing worldwide war, conflict, or political turmoil is
leading to an ever-greater number of migrants wishing to
escape these desperate situations. In 2018 alone, the number
* Sven C. Mueller
Sven.Mueller@UGent.be
1
Dept. of Experimental Clinical and Health Psychology,
Faculty of Psychology and Educational Sciences, Ghent
University, Ghent, Belgium
2
Department of Personality, Psychological Assessment
and Treatment, University of Deusto, Bilbao, Spain
3
Graduate School of Psychology, Özyeğin University,
Istanbul, Turkey
4
Psychology Program, College of Humanities and Social
Sciences, United Arab Emirates University, Al Ain,
United Arab Emirates
5
Department of Psychology, Uskudar University, Istanbul,
Turkey
41.3 million being internally displaced due to violence and
conflict [1]. The continuing armed conflict in Syria forced
around 2.7 million people to seek refuge in Turkey, many
among them minors [2]. Yet, the cognitive-affective conse-
quences of these experiences and displacement from their
homes in youths are still little understood.
Experience of war and conflict has many consequences
including, but not limited to, scarcity of food, loss of jobs,
death, physical, emotional, sexual traumatic experiences
including life threats, beatings, rape, murder, torture, impris-
onment, and disappearance of family [3, 4]. Furthermore,
once in safety, the post immigration phase continues to carry
stressful consequences such as the loss of contact with the
family and social network, culture shock, and an inability to
communicate (foreign language). Particularly children and
teenagers are at elevated risk of encountering such stressful
life experiences, which may leave long-term mental (and
physical) scars and result in a reduced quality of life and low
life attainment goals. Many children stay in refugee camps

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for several years, facing difficult living conditions and lack
of education [4–6].
Youths are double at risk, because on one hand being
exposed to such traumatic experiences increases vulner-
ability for psychopathologies, including learning difficul-
ties, anxiety disorders, depression, or post-traumatic stress
disorder (PTSD) [7]. On the other hand, traumatic experi-
ence may also impair cognitive and affective processing and
future psycho-social and cognitive development. Affected
cognitive functions include cognitive control functions such
as working memory and inhibitory control, but also atten-
tion, emotion processing, or language acquisition [8, 9].
Cognitive control, for example, is related to the prefrontal
cortex, which is still maturing throughout the adolescent
period and, therefore, is especially vulnerable to stress [10].
Furthermore, traumatic experiences could have an impact
on behavioural and emotional processes, self-regulation,
motivation, aggression, and frustration tolerance [11, 12].
Emotion regulation also driven by prefrontal cortical devel-
opment includes several domains such as awareness and
understanding emotions, acceptance of emotions, or the
capacity to control impulsive behaviours, using emotion
regulation strategies [13, 14].
Few studies to date have experimentally examined the
cognitive-affective impact of war-related trauma in youths
[8, 15, 16], while much research has been conducted in
(adult) military samples [17]. Recently, Mirabolfathi et al.
[15] examined working memory, which is an essential cog-
nitive control skill and hypothesized to underlie emotion
regulation [18], in Afghani refugee youths. They [15] docu-
mented poorer working memory capacity in these youths
relative to comparisons. Likewise, earlier, we were able to
document impaired sustained attention during an inhibitory
control task (Stroop task) in youths who had experienced
parental loss and who were living in a high conflict zone
[16]. Hecker et al. [8] documented an association between
working memory and PTSD symptoms in adult refugees
from the African continent. Yet, these studies are still few
in number and require replication and extension.
Moreover, to our knowledge, no studies have yet exam-
ined emotional interpretation biases in such youth, although
interpretation bias has been postulated as a maintaining fac-
tor of post-traumatic stress disorder (PTSD) in cognitive
models [19]. In one classic study, Amir et al. [20] presented
homographs (words with two meanings, e.g., “arms” mean-
ing either weapons or the part of your body) to people with
and without PTSD and found delayed response times when
individuals with PTSD had to inhibit the negative connota-
tion word (e.g., weapon) to complete the task. Most simi-
lar to the present study, Gebhardt et al. [21] documented
a negative interpretation when participants had to evaluate
emotional facial expressions in post-deployment soldiers
with trauma (relative to controls). Focusing on the features
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European Child & Adolescent Psychiatry
that may drive such effects, Gutiérrez-García [22] examined
eye movements and documented an interpretation bias that
was linked to the parts of the face individuals focused on.
Whereas high socially anxious undergraduates focused on
the eye region, undergraduates low in social anxiety focused
more on the mouth region of the presented faces. Taken
together, these data point at some possible underlying fac-
tors that maintain a negative bias.
Crucially, understanding both how working memory and
interpretation bias changes in traumatized youth may con-
tribute to therapeutic approaches. While working memory
training in healthy children [23] and those with PTSD [24]
has shown promising results, support for interpretation bias
modification training in youths has been ambivalent [25, 26].
Yet, undoubtedly, knowledge on areas of need is essential
when trying to establish therapeutic approaches that might
be required when aiming to facilitate integration into their
new host countries and educational systems.
Therefore, to enhance our understanding of the influence
of war and trauma on working memory and interpretation
bias, we recruited and tested adolescents who had escaped
the war in Syria and who were residing as refugees in Istan-
bul, Turkey. Youths high in trauma symptoms (HTS) were
compared with youths low in trauma symptoms (LTS).
We had two main hypotheses. (1) With regard to working
memory, we predicted that HTS youths would show worse
working memory performance relative to LTS youths, given
prior findings in adult [17] and adolescent [8] samples. In
addition, given previous findings in maltreated women [27]
and youths with PTSD [24], we expected that emotion would
further modulate this performance. (2) With regard to inter-
pretation bias, we predicted that HTS individuals would
interpret ambiguous faces (surprise) as more negative than
LTS individuals, given prior findings of a negative interpre-
tation bias in soldiers with war-related trauma [21].
Materials and methods
Participants
Sixty-two Syrian teenagers (26 girls) who resided in
Istanbul, Turkey as asylum seekers participated (mean
age = 11.43 years, age range 10–15 years). We used a median
split procedure to divide the sample on adolescents reporting
high symptoms (HTS) vs. low symptoms (LTS) on a trauma
scale (Impact of Events Scale Revised) (cf. Table 1). That
median value was 36 in the present sample and is close to
the clinically suggested cut-off of 33 or more [28]. HTS
(relative to LTS) youths had more symptoms of depression
(t(57) = 4.06, p < 0.001, d = 1.05), anxiety (t(57) = 2.57,
p < 0.001, d = 0.66), and experience of traumatic events
(IES-R) (t(57) = 10.55, p < 0.001, d = 2.18), but did not
European Child & Adolescent Psychiatry
Table 1 Demographic Mean (SD)
information of the study sample
split by group Age, years
CDI*
STAI-C*
IES-R total*
IES-R internalizing*
IES-R avoidance*
IES-R hyperarousal*
Resilience
War trauma total
Demolition of property
Violence against self
Violence against others
CDI child depression inventory, STAI-C state-trait anxiety inventory-child version, IES-R impact of event
scale-revised
*Indicates significant difference between groups at p < 0.05
differ in levels of resilience (t(56) = 0.49, p = 0.62), expe-
rience of war traumatic events (t(56) = 1.11, p = 0.27), or
gender distribution (x2(1) = 0.59, p = 0.44). Ethical approval
was obtained by the Institutional Review Board of Uskudar
University in accordance with the Declaration of Helsinki
(1964 and its later amendments). Participants for the current
study were recruited through the Hiraeth Refugee Integra-
tion and Support Association. Adolescents consented to par-
ticipate in the study and their parents gave written informed
consent. Children were compensated with small gifts for
participation.
Measures
Sociodemographic data were collected for each participant
with five questionnaires, to assess the nature of their stress
conditions, and each questionnaire had previously been
translated and validated in Arabic.
The Impact of Events Scale (IES) is a self-report measure
that assesses responses to stressful and traumatic experi-
ences. It has 15 items, of which 7 items evaluate intrusion
(ideas, images, feelings) and 8 items evaluate avoidance
(feelings, situations). It analyses how often the subjects
experienced those reactions in the last week. The total dis-
tress score is the sum of the 15 items [29]. Developers of the
instrument and psychometric investigations have suggested
a cut-off of 33 for a probable diagnosis of PTSD [28]. Given
the present sample’s median split of 36 nicely follows this
suggested cut-off. Although this cut-off has to be taken with
caution and does not replace a clinical assessment, it was
useful within the present context. Good discriminant validity
for the scale in its Arabic version had been confirmed [30].
Reliability for the present sample Cronbach’s alpha = 0.73.
Low trauma LTS N = 27 High trauma HTS N = 31
11.07 (1.39) 11.70 (1.15)
7.34 (4.08) 12.77 (6.09)
17.57 (6.62) 22.86 (9.11)
25.48 (7.82) 44.74 (5.96)
8.41 (3.87) 16.78 (4.17)
11.02 (4.83) 17.93 (5.08)
5.96 (3.56) 9.99 (3.35)
62.02 (18.24) 64.09 (13.08)
10.35 (5.17) 11.85 (5.12)
2.68 (1.30) 2.59 (1.42)
3.58 (2.16) 4.48 (2.06)
4.10 (2.60) 4.78 (2.76)
The Children’s Depression Inventory (CDI) is a paper and
pencil self-report questionnaire, used to assess childhood
depression. It has 27 items and each of them has three state-
ments that are assigned values from 0 (sad sometimes) to 2
(sad always), with total score between 0 and 54. Examiner
reads the items and the subjects have to choose the sentences
that better describe their feelings in the last two weeks [31].
CDI was validated in Arab population [32]. A cut-off score
of 19 has been suggested [32, 33], which indicated that none
of the LTS youth but 5 of the HTS youth met this cut-off.
Reliability was Cronbach’s alpha = 0.67.
The Connor–Davidson Resilience Scale (CD-RISC) is a
brief self-rated assessment used to quantify resilience. It has
25 items with 5 points of responses, from 0 (not true at all)
to 4 (true nearly all the time), with the total score between
0 to 100 and highest score represents a better resilience [34,
35]. The scale was validated in Arab population [35]. Reli-
ability was Cronbach’s alpha = 0.87.
The State-Trait Anxiety Inventory for children (STAIc) is
a self-report measure used to assess the presence and the
severity of anxiety’s symptoms with 40 items [36]. There are
two subscales: the State Anxiety Scale, which has 20 items
that evaluate the current intensity of feelings with 4 points
from 1 (not at all) to 4 (very much so). The Trait Anxi-
ety Scale, instead, has 20 items and it evaluates the stable
aspects and frequency from 1 (almost never) to 4 (almost
always). The scale was validated in Arab population [37]. A
cut-off score of 39 has been suggested [36], which indicated
that none of the LTS youths and only 1 of the HTS youth met
this cut-off. Reliability was Cronbach’s alpha = 0.76.
The War-Traumatic Events Checklist [38] has 28 items
and probe exposure to different kinds of war experiences.
It features 3 categories: personal trauma, witnessing trauma
to others, and seeing demolition of property. Items include,
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for example, witnessing the destruction of the own home
by shelling or bulldozing, being beaten or shot by oppo-
nent forces, being used as a human shield, or having had to
watch the opponent forces destroying land, farms, killing or
hurting people. Response options include “Yes” and “No”,
and are added up to get a total score. However, because the
original questionnaire by El-Khodary and Samara [38] was
designed to examine trauma in Palestine youth in Gaza, we
had to alter the wording in items that specifically referred
to the IDF (Israeli Defence Forces) of their questionnaire
to ‘foreign army’ as IDF was not applicable in the present
context. Cronbach’s alpha = 0.82.
Experimental tasks
Spatial emotional match to sample (SEMTOS)
The SEMTOS task has previously been used to assess vis-
ual working memory in the presence of distracting emo-
tional stimuli in adult women with childhood abuse history
[27]. Based on the effect sizes of this previous work [27],
a priori power calculations revealed that only 14 partici-
pants would be necessary to obtain a statistically significant
within-between factor group interaction. The task measures
the influence of incidental emotional stimuli (happy, angry,
and neutral facial expressions) on remembering the accurate
location of a white oval and a black screen. The task has
120 trials divided into four blocks of 30 trials each. Within
each block, the face of each actor was shown only once.
The emotions are given via faces of 10 individuals perform-
ing 24 expressions (20 female actors and 24 male actors).
At the time of planning the study, we were unaware of any
face database that consisted of faces that displayed faces of
a Middle Eastern ethnic background. We therefore selected
faces from the most used and cited databases in the litera-
ture, namely, from the NimStim face stimulus database [39]
for the trials proper and from the Radboud Face Database
[40] for the practice trials. Importantly, we used the same
oval faces as in the previous study as here it was also cultur-
ally relevant; namely, because women in Muslim cultures are
not allowed to show their hair, our ovals permitted seeing
both male and female faces without hair. Moreover, we used
black and white versions of the faces to limit visual salience
and reduce a potential influence of ethnicity (skin bright-
ness). However, like most research in anxiety, we opted to
present emotional faces of adults rather than children or ado-
lescents for easier comparison [41]. The task started with
a yellow cross for 1000 ms followed by a memory cue as
face with one of the three emotions, in 1 of 24 locations
for 400 ms. In the next 1000 ms, a blue or red colour probe
appeared and participants had to select the colour, “w” or
“x” on the keyboard (with the index and middle finger of
the left hand). In the last 1500 ms, the face, memory probe,
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was shown another time and the subjects had to indicate
if it was in the same locations as before [27] (for a sample
trial, see Fig. 1a). The participants had to press “ = ” when
the memory probes were in the start location, and they were
defined as ‘match’ trials, while the other conditions were
the ‘miss’ trials and participants had to press “ ≠ ” when the
probe did not match the cue’s location (with the index and
middle finger of the right hand). Furthermore, to manipulate
the level of difficulty, there were three kinds of ‘miss’ trials
depending on distance between memory cue and memory
probe: 15° (miss1), 20° (miss2), and 25° (miss3) away from
the cue [27]. The participants had the goal to respond as
quickly as possible, and reaction times (in ms) and accuracy
(% correct) were recorded.
Surprise faces task
The surprise face task was based on the one by Neta et al.
[42] and included 18 gender-balanced (nine males and nine
females) facial expressions, which were again obtained
from the NimStim standardized facial expression stimulus
set [39], also using ovals to avoid the display of women’s
hair. These expressions represented three of the six uni-
versal and basic emotions: anger, happiness, and surprise
[42]. The three facial expressions were randomly shown
in three blocks of 54 trials, with the same numbers of the
three emotional faces, for 1000 ms which was followed by a
blank screen for a variable ITI (intertrial interval) of 1500,
2000, or 2500 ms. This jittering was done to avoid anticipa-
tory responses and enforce task compliance. In this task,
participants were asked to recognize and label each facial
emotion as a negative or a positive emotion (for a sample
trial see Fig. 1b). To this goal, they were asked to press one
of two response buttons on the keyboard, one for positive
and one for negative expressions, respectively. The order
of response assignment was counterbalanced across partici-
pants. A priori power calculations based on the effect size
reported by Neta et al. [42] indicated that we would need a
minimum of 56 participants across two groups to obtain a
power of 0.95 for a within-between factor interaction on the
emotional interpretation task.
Procedure
Participants completed two computer-based tasks assess-
ing emotional working memory and affect recognition and
filled out questionnaires. Tasks and questionnaires were
conducted by a trained researcher accompanied by a native
Arabic speaker who was trained on the aims and ethical pro-
cedures of the study and helped with translation of the tasks
and study aims as well as instructions. The tasks and forms
were administered in a silent room provided by the Hiraeth
European Child & Adolescent Psychiatry
Fig. 1 Sample trial for (a) the SEMTOS task, in which a miss1 trial is presented (i.e., a slight change between cue and target). b Sample trial of
the emotional interpretation task. Please note that the ITI in the task was variable and differed from trial to trial to avoid anticipatory responding
Association and lasted approximately 60–90 min for each
participant.
Statistical analysis
For the SEMTOS task, a repeated-measures ANOVA was
conducted with the within factors of emotion and location
and the between-subjects factor of trauma group (HTS vs.
LTS) resulting in a 3 (emotion: angry, happy, neutral) by 4
(location: match, miss1, miss2, miss3) by 2 (group: high
vs. low trauma symptoms) design. This rmANOVA was run
separately for accuracy (percent correct) and reaction time
(only including correct trials). Follow-up tests were con-
ducted with paired t test (within group) or ANOVA (between
group) and Bonferroni corrected for multiple comparisons
(corrected alpha two-tailed p = 0.008). By contrast, the sim-
plicity and straightforward hypothesis of the surprise face
task allowed us to simply compare the percentage of surprise
faces allocated to positive vs. negative emotions by means
of a univariate ANOVA with the difference score as depend-
ent and the group as independent variable, run separately
for RT and allocation. For RT, reaction time differences to
the different allocations were calculated. Effect sizes are
reported as Cohen’s d or partial eta squared, as appropriate.
Alpha was set at p = 0.05, two-tailed.
Results
SEMTOS task
Accuracy
The analysis of the accuracy data revealed a significant
location-by-group interaction (F(3,165) = 3.99, p = 0.009,
ηp2 = 0.07). In addition, the main effect of location was
also significant (F(3,165) = 8.93, p < 0.001, ηp2 = 0.14).
No other effects were significant. Follow-up of the interest-
ing location-by-group interaction revealed that LTS youths
were statistically significantly better at identifying match
trials relative to HTS youth (F(1,54) = 8.06, p = 0.006,
d = 0.76), but did not differ from each other on any of the
miss trials. When following-up within group, LTS youth
had significantly better accuracy on match trials vs. miss1
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Fig. 2 a The difference in % accuracy (from 0.00–1.00, 1.00 = 100%)
between the HTS (dotted line) and LTS (dashed line) youths for the
four different locations in the SEMTOS task. b The corresponding
reaction times in ms showing no evidence for any influence of reac-
tion time on the accuracy finding. Error bars denote S.E.M.
Fig. 3 a The percent to which surprise faces were allocated to a positive or a negative category. b The significant group difference in reaction
time, with a lower value indicating faster allocation to the positive category. Error bars denote S.E.M
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European Child & Adolescent Psychiatry
trials (t(29) = 5.12, p < 0.001), match trials vs. miss2 trials
(t(29) = 4.09, p < 0.001), while accuracy was better on miss3
trials vs. miss1 trials (t(29) = − 4.79, p < 0.001) and miss2
trials (t(29) = − 4.14, p < 0.001). Comparisons between
match and miss3 and miss1 vs. miss2 trials did not survive
Bonferroni correction. By contrast, none of the compari-
sons within the HTS group were significantly different from
one another (all p > 0.07) (Fig. 2a). The follow-up test on
the main effect of the location indicated higher accuracy
on match vs. miss1 trials (t(65) = 3.12, p = 0.003), but also
larger accuracy as the miss trials became more dissimilar
from one another, i.e., better performance on miss2 vs.
miss1trials (t(65) = 4.46, p < 0.001), better performance on
miss3 vs. miss1trials (t(65) = 7.34, p < . 001), and, in turn,
better performance on miss3 vs. miss2 trials (t(65) = 4.36,
p < 0.001).
Reaction time
The ANOVA on reaction time only revealed a significant
effect of location (F(3,162) = 2.88, p = 0.038, ηp2 = 0.05)
(Fig. 2b). This effect indicated faster performance on match
trials relative to (a) miss1 trials (t(61) = 3.01, p = 0.003), (b)
miss2 trials (t(60) = 3.67, p = 0.001), and (c) miss3 trials
(t(62) = 3.35, p = 0.001). No other effects were significant.
Surprise faces task
Emotion allocation
As predicted, adolescents likened surprise faces more to neg-
ative emotions (60.49%) than to positive emotions (39.55%),
European Child & Adolescent Psychiatry

but this did not differ between groups (Fig. 3a). When these
two values were directly compared against one another,
the difference was statistically significant (t(61) = − 3.78,
p < 0.001). Also as expected, happy faces were generally
evaluated as positive (83.70%) and angry faces were pre-
dominantly evaluated as negative (85.20%). Groups did not
differ statistically in their frequency of allocation across the
three emotions (cf. Table 2).
Reaction times
Although groups did not differ in the frequency of their allo-
cation, an interesting effect of group emerged when exam-
ining the speed with which this was done. For the RT, the
difference score of how long it took participants to qualify
a respective emotion as positive or negative was calculated.
A significant effect of group (F(1,51) = 6.53, p = 0.014,
ηp2 = 0.11) indicated that LTS youth were equally fast when
deciding whether surprise faces were positive or negative
(mean = − 4.31 ms, SD = 68.89), but HTS youth were faster
allocating a positive judgement to surprise faces relative to
negative judgements (mean = − 57.42 ms, SD = 82.32 ms)
(Fig. 3b).
symptoms. This association indicated that the more war trau-
matic events youths had experienced, the more they allo-
cated surprise faces to the negative category (r(51) = 0.281,
p = 0.046)(Fig. 4).
Discussion
Because of the tremendous impact of war experience on the
cognitive-affective skills in adolescents, this investigation
specifically aimed to examine the influence of emotion on
working memory as well as the interpretation of emotion-
ally ambiguous faces. Two main findings emerged. First,
HTS (vs. LTS) were ~ 20% worse at remembering the correct
location in a working memory task. This was not qualified
by emotion. Second, although both groups also interpreted
surprise faces ~ 20% more negative than positive, a statis-
tically significant group difference indicated that HTS vs.
LTS were faster when allocating surprise faces to positive
(relative to negative) emotions.
With regard to the working memory task, the findings
are in-line with the expectations and indicated worse visual
working memory accuracy in HTS relative to LTS youth.

Exploratory analyses of comorbid psychopathology

and dimensional associations of psychopathology
with task performance

To examine to what extent individual differences and

comorbid symptoms may have driven the findings, the
main rmANOVA was repeated including CDI, STAI, and
resilience as covariates (separately). These analyses did
not change the significant interaction between location and
group and also indicated no main effects of these variables
thus suggesting little influence of depression, anxiety, or
resilience on the SEMTOS task. Likewise, re-running the
ANOVA for the RT difference score in allocating surprise
faces to a happy or a negative category did not change the
significant difference when adding resilience or anxiety, but
reduced the significant effect when adding depression to
p = 0.07 thus showing a slight effect. The direct correlation
(Pearson’s Product–Moment correlation) between these two
variables was trending (r(54) = -0.25, p = 0.065). Fig. 4 Scatterplot illustrates the positive association between war
traumatic events (y-axis) and allocation of surprise faces to the nega-
Finally, an interesting positive correlation emerged tive category (x-axis) for the low trauma symptom group (white cir-
between performance on the interpretation task and trauma cles, LTS) and high trauma symptom group (black circles, HTS)

Table 2 Allocation ratios for the three different types of emotions (happy, angry, and neutral faces) and whether they were perceived to be posi-
tive or negative
Mean(SD) Happy—positive Happy—negative Angry—negative Angry—positive Surprise—positive Surprise—negative

Low trauma (LTS) 85.57% (12.11%) 15.54% (11.43) 85.05% (13.29%) 14.96% (3.28%) 40.29% (24.25%) 59.71% (24.25%)
High trauma (HTS) 81.27% (20.88%) 13.92% (13.27%) 85.39% (11.96%) 14.7% (11.73%) 38.58% (24.71%) 61.51% (24.80%)

13

Interestingly, while this finding was cemented by a strong
effect size and a 20% difference in accuracy between groups
on the match trials, no group differences emerged on any of
the miss trials. Moreover, no specific modulation of emo-
tion was found in the previous study of women with expe-
rience of interpersonal violence using the same task [27].
However, direct comparison between the studies is difficult
given fundamental differences across samples (i.e., youths
vs. adults, war-related trauma vs. sexual abuse trauma, and
Western sample vs. Middle Eastern sample). Whereas the
general response pattern of the task was replicated, indicat-
ing increasing accuracy with increasing spatial distance from
the target stimulus, the overall performance of both groups
was surprisingly poor. Of note, although the data indicated
that, within the present sample, there did not appear to have
been a speed-accuracy trade-off (cf. Fig. 2a vs. Fig. 2b),
interestingly, relative to the previous study [27], youths in
the present study were on average 100–150 ms faster than
the traumatized adult women from that earlier work, but
also showed much worse accuracy. Three sets of findings
suggest that even though there may not have been a speed-
accuracy trade-off within the present sample, there may have
been one between the two studies. This line of reasoning is
based on (1) the fact that typically developing youths are
normally slower than adults on reaction time tasks [43], (2)
adolescents relative to children and adults have been shown
to exhibit altered speed-accuracy trade-off behaviour in the
presence of emotional stimuli [44] and (3) developmental
evidence of protracted lateral prefrontal cortical develop-
ment during adolescence [45], which appears essential for
accurate performance within speed-accuracy trade-off set-
tings [46]. Despite this low performance, the presence of
a statistically significant interaction between the groups
and memory condition suggests that a floor effect may not
play an important role. In addition, a finding of severely
decreased visual working memory accuracy fits perfectly
with a recent meta-analysis of cognitive performance in trau-
matized adults relying mostly on military and interpersonal
violence samples. In these adults (mean age ~ 44 years), an
average effect size of d = 0.5 was documented for poorer
performance of the traumatized groups [17]. The main find-
ing also fits with the few existing studies in similar cohorts.
Ainamani et al. [8] have reported an association between
PTSD symptoms severity and working memory capacity
using a classic neuropsychological task in African refu-
gees (mean age ~ 31 years of age), while a recent study in
Afghani refugee adolescents with a slightly higher mean age
(~ 15 years) also indicated poor working memory capacity in
youth with high PTSD symptoms relative to a control group
[15]. These findings further cement the notion of impaired
working memory after war-related trauma.
With regard to the interpretation bias, previous research-
ers have postulated how negative interpretation bias may
13
European Child & Adolescent Psychiatry
play a role in maintaining PTSD [19]. In our simple ambi-
guity task, both groups interpreted surprise faces 20% more
as negative than positive (or 10% more relative to chance).
While this bias confirmed our hypothesis, this finding is a)
smaller than expected and b) did not differ between groups.
Yet, a group difference emerged in the reaction times when
making these judgements. While LTS youth showed no dif-
ference, HTS youth responded faster once they had decided
that a surprise face appeared positive (vs. negative) to them.
Generally speaking, the main effect is consistent with the
study by Gebhardt et al. [21], who found a negative bias
in soldiers post-deployment when evaluating ambigu-
ous faces. However, the differential reaction time effect
deserves further scrutiny and any conclusions are specula-
tive at this stage. One possible explanation may be linked
to how trauma affects basic low-level visual processes. For
example, in a sample of healthy participants, Neta et al. [42]
had documented a differential influence of spatial frequency
on the perception of surprise faces depending on whether
people had a positive or negative interpretation bias. In addi-
tion, during an fMRI study, persons with PTSD had lower
neuronal activity in the ventral visual stream when compared
to controls [47]. Taken together, these findings might sup-
port the notion of altered visual processes after trauma that
may contribute to the interpretation bias and a gearing of the
attention system toward threat.
In terms of clinical relevance, understanding what
cognitive-affective factors may contribute to maintaining
mental health problems including anxiety, depression, and
post-traumatic stress symptoms will aid in improving ther-
apeutic approaches. Within the present context, research-
ers have advocated the use of working memory training as
well as interpretation bias training in people with affective
problems [24, 48]. Whereas working memory training in
healthy children [23] as well as those with PTSD [24] has
shown some promising results, support for interpretation
bias modification training in youths is limited [25, 26, 49].
The current data illustrate the severe impact of war trauma
on both of these abilities in adolescents and underscore the
importance of further research into this area. One inter-
esting mechanistic question is why studies of interpreta-
tion bias training do not appear to exert the desired effect
despite clear presence of negative interpretation biases
in the present study (among many others). The current
finding of speeded response times (in absence of differ-
ences in overall allocation rates) in the HTS group vs. the
LTS group may suggest a more downstream effect of early
visual processing. In other words, HTS youths interpreted
ambiguous faces more quickly. This would be consist-
ent with one reported finding that attention bias training
improves interpretation bias but not vice versa [50] and
the importance of early threat perception in such biases
[41]. Unfortunately, the potential influence of depressive
European Child & Adolescent Psychiatry
symptoms on the interpretation bias finding has to be
interpreted with caution, because (1) it did not reliably
influence the outcome nor did it convincingly not show any
influence and (2) the reliability for this questionnaire in the
present sample was low. However, because interpretation
biases are hypothesized to be more associated with depres-
sive symptoms and later stages of cognitive processing, the
trending effects appear consistent with the literature [51].
This also highlights some notable limitations. While
desirable, one problem was that no other comparison group
was collected. The main problem was that Turkish and Syr-
ian cultures have different alphabets and speak different
languages, which would have required to compare ques-
tionnaires across different languages (with likely different
validations etc.). Second, relatedly, although both tasks
were validated and have been used in prior work [27, 42],
direct comparison of performance to prior work is difficult
because of differences in language, culture, and age although
direct comparison with another group would have been ben-
eficial in light of the overall very poor working memory
performance. Third, the selection of questionnaires was
partly driven by the availability of validated versions in the
Arabic language. Given the presently rather limited avail-
ability of validated mental health questionnaires in Arabic,
future development and cross-cultural validation of scales
are desired. Yet, an important strength of the present study
relative to earlier work [8, 15] was that we assessed both
skills thus facilitating cross-task comparison, which allows
for a more comprehensive clinical picture. Fourth, unfortu-
nately, information about IQ and general cognitive abilities
and school attendance prior to becoming refugees was not
available. However, we would like to point out that unlike
in the traditional clinical studies where the two groups are
recruited via separate pathways (e.g., via outpatient clinic
and school) in the present study, we collected as many youth
from the same organization and then applied the median split
afterwards thus somewhat mitigating this problem of ‘two
different groups’.
In summary, the present data highlight problems in work-
ing memory and negative interpretation bias in youths with
high trauma symptoms. Any attempt at integrating refugee
youths in host countries may need to take into consideration
not only youths’ traumatic experiences, but also account for
possible cognitive-affective perturbations that may require
extra attention. However, given the continued scarcity in the
field, more definitive knowledge is required.
Funding This work was supported by a 2–4 year grant (01J05415)
from the Special Research Fund (Bijzonder Onderzoeksfonds, BOF)
at Ghent University to SCM.
Data availability Both tasks are available from the authors. Due to the
sensitive nature of the data, aggregated data were only available upon
reasonable request.
Compliance with ethical standards
Conflict of interest None of the authors have a conflict of interest to
declare.
Ethical approval Ethical approval granted by the Institutional Review
Board of Uskudar University, Istanbul, Turkey.
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