Prevalence Of Determinants Of PTSD Among Palestinian Children Exposed To Military Violence

“Prevalence and determinants of PTSD among Palestinian children exposed to military violence”

Samir Qouta, Raija-Leena Punamaki, and Eyad El-Sarraj; European Child & Adolescent Psychiatry, 2003

The prevalence and determinants of PTSD were assessed among 121 Palestinian children (6-16 years; 45% girls and 55% boys) living in the area of bombardment. The mothers (21-55 years) and the children themselves reported their exposure to military violence (being personally the target of violence or witnessing it towards others) and symptoms of posttraumatic stress disorders (PTSD: intrusion, avoidance and hypervigilance). The results showed that 54% of the children suffered from severe, 33.5% from moderate and 11% from mild and doubtful levels of PTSD. Girls were more vulnerable; 58% of them suffered from severe PTSD, and none scored on the mild or doubtful levels of PTSD. The child’s gender and age, mother’s education and PTSD symptoms were significant, and the exposure to traumatic experiences marginally significant determinants of children’s PTSD symptoms. The most vulnerable to intrusion symptoms were younger girls whose mothers showed a high level of PTSD symptoms, whereas those most vulnerable to avoidance symptoms were children who had personally been targets of military violence and whose mothers were better educated and showed a high level of PTSD symptoms. The results are discussed in the context of military violence inferring with the protective function of family and home.

Key words: Traumatic events- PTSD – Palestinians – children – mothers “Associations between self and other representations and posttraumatic adjustment among political prisoners”

Jari Salo, Raija-Leena Punamaki, and Samir Qouta; Anxiety, Stress and Coping, 2003, 1-19.

The content and structure of self and other representations and their association with posttraumatic stress symptoms, somatic symptoms, and positive growth were studied among 117 Palestinian male political prisoners. Further, the associations between the representations and the severity of trauma and the post-detention conditions (such as education, place of residency and employment), and the role of representation patterns as a moderator between trauma exposure and symptoms was studied. Cluster analysis identified three representation patterns based on participants’ descriptions of their spouse and themselves, and of childhood relationships with their mother and father. Representation patterns differed in negative vs. positive content and in the levels of differentiation and conceptual maturity: The Malevolent Others and Defeated Self representation pattern was characterized by very negative content, and poor differentiation and conceptual maturity in all descriptions; the Moderate Parents and Negative Spouse pattern was characterized by an average level of content negativity/positivity and reasonable levels of differention and conceptual maturity, and the Benevolent Spouse and Ambitious Self pattern showed the most positive content and the highest levels of differentiation and conceptual maturity in spouse and self descriptions. The results further showed that the self and other representations associated with both posttraumatic stress symptoms and the positive growth, but not with the somatic symptoms. The men with Malevolent Others and Defeated Self representation pattern reported higher levels of posttraumatic stress symptoms and lower levels of positive growth than those with other representation patterns. The representation patterns did not differ according to the severity of trauma or post-detention conditions. Finally, the self and other representations did not moderate between severe torture and ill- treatment and symptoms. “The role of psychological defenses in moderating between trauma and post-traumatic symptoms among Palestinian men”

Raija-Leena Punamaki, Katri Kanninen, Samir Qouta, Eyad El-Sarraj; International Journal of Psychology, 2002, 37 (5), 286-296.

Psychological defenses are conceptualized as protective processes that help individuals to maintain their integrity in the face of threat and danger. Accordingly, their role in defending trauma victims from post-traumatic symptoms was examined. The sample considered of 128 Palestinian male political ex- prisoners who had reported various degrees of torture and ill-treatment. The first aim was to analyze the dimensionality and distribution of different defense mechanisms. The second was to examine which defenses would moderate the association between the reported torture and ill-treatment and the post-traumatic symptoms (PTSD). Third, the direct association between reported torture and ill- treatment and defenses and between the defenses and symptoms were explored. Defense mechanisms were assessed by a 40-item version of the Defense Style Questionnaire (DSQ), and Post-traumatic symptoms by the Harvard Trauma Questionnaire (HTQ), and experiences of torture and ill- treatment by a sale developed for that purpose. The results show, first, that men used predominantly mature defenses such as anticipation, sublimation, suppression, and rationalization, but also relatively frequently somatization and dissociation, which are characteristic responses among trauma victims. Second, the principal component analysis revealed four defense dimensions, differentiated by the level of maturity and the approach to reality: the mature reality-distorting consciousness-limiting, the immature reality-escaping, and the immature reality-distorting defense. Third, against our hypothesis, the moderating analyses indicated that the reported torture and ill-treatment were relatively more associated with vigilance, avoidance, and intrusion symptoms if men used consciousness-limiting defenses. Yet as expected, the mature reality-based defenses did not show a protective effect. Furthermore, a high level of reported torture and ill-treatment was associated with a low level of the mature reality- based defenses but not with a high level of immature defenses. Last, similarly to earlier studies, the immature reality-distorting and immature reality-escaping defenses associated directly with high, and mature reality-based defenses with low, levels of PTS-symptoms. “Resiliency Factors Predicting Psychological Adjustment after Political Violence among Palestinian Children"

Samir Qouta, Raija-Leena Punamaki, and Eyad El-Sarraj; International Journal of Behavioral Development, 2001, 25 (3), 256- 267.

The effects of cognitive capacity, perceived parenting, traumatic events and activity, which were first mentioned in the midst of the political violence of the Intifada in 1993, were examined on post-traumatic stress disorder (PTSD), emotional disorders, school performance, and neuroticism three years later in more peaceful conditions among 86 Palestinian children of 14.04 ± .79 years of age. The results showed, first, that PTSD was high among the children who had been exposed to a high level of traumatic events and had responded passively (not actively) to Intifada violence. Discrepant perceived parenting was also decisive for adjustment: children who perceived their mothers as highly loving and caring but their fathers as not so showed a high level of PTSD. High intellectual but low creative performance was also characteristic of the children suffering from emotional disorders. Second, the hypothesis that cognitive capacity and activity serve a resilience function if children feel loved and non- rejected at home was confirmed. Third, neuroticism decreased significantly over the three years, especially among the children who had been exposed to a high number of traumatic events.

“Mental flexibility as resiliency factor among children exposed to political violence”

Samir Qouta, Eyad El Sarraj and Raija-Leena Punamaki International Journal of Psychology, 2001, 36 (1), 1-7.

The research focused on mental flexibility versus rigidity in explaining psychological adjustment in the violent conditions of Intifada, and in more peaceful times 3 years later, among 86 Palestinian children. A picture test based on Brunswik (1949) was applied to measure flexible-rigid cognitive style, and neuroticism, self-esteem, emotional disorders, and PTSD were used as outcome variables. Results revealed a moderating role of mental flexibility by showing that children were protected from negative long-term consequences of traumatic events if their perception indicated mental flexibility. However, in the midst of violence mental flexibility was not associated with good psychological adjustment. Mental flexibility was, in turn, determined by environmental and cognitive factors. The more intelligent and less exposed to traumatic events children were, the higher mental flexibility they showed. “Health of Children in War Zones: Gaza Child Health Survey”

Thomas Miller, Assisted by Mustafa El-Masri and Samir Qouta, 2000

The Gaza Child Health Survey (GCHS) was conducted as a school-based, randomized, point prevalence survey of Palestinian children aged 6 and up. The main aim of the survey was to determine the prevalence rates of emotional and behavioral health and physical health of 669 children and their families living in Gaza Strip. Also, an attempt was made to understand the relationship between environment factors (e.g. trauma exposure, maternal depression etc.) and mental and physical health outcomes. The main emotional and behavioral outcomes assessed included: attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), emotional disorder (ED) and posttraumatic stress disorder (PTSD).

The GCHS was one of the three health surveys conducted by Health Reach (now the War and Health Programme), McMaster University in the Former Yugoslavia, Sir Lanka and Gaza. The survey design stage of the Gaza survey began in 1994 and data collection occurred between January to May of 1996.

The GCHS was conducted by an international team of researchers in psychiatry, pediatric, family medicine, psychology, anthropology, and statistics. A two-stage sampling method was used where stage one involved randomly selecting school from a list of all the public, private and UNRWA schools in Gaza. Stage two involved randomly selecting students from each school. Interviews of main care givers and youth were conducted at home; teacher interviews and physical health assessments were conducted in the schools. “An Epidemiological Study in the Prevalence of Stress Related Psychiatric Disorders among Palestinians in the Gaza Strip"

Samir Qouta, Eyad El-Sarraj, and Mustafa El-Masri. 1998

The goal of this study was to provide an overall profile of mental health in the Gaza Strip, through three specific objectives: to assess the extent and nature of exposure to trauma among Gazans, to identify the psychological consequences of trauma and the prevalence of stress-related psychiatric disorders, and to identify different risk factors associated with psychiatric disorders. Post Traumatic Stress Disorder was the most common diagnosis, occurring in 14.7% of refugees and 11.7% of citizens. 36.6% reported at least one type of maltreatment during their childhood, most commonly verbal abuse by parents and elder family members; 42.2% had witnessed the death of a family member, while 35.1% had witnessed violent clashes with the Israeli army. “House Demolition and Mental Health: Victims and Witnesses”

Samir Qouta, Raija-Leena Punamaki, and Eyad El-Sarraj; Journal of Social Distress and the Homeless, 1997, 6 (3), 203-211.

The research examines the immediate effects of losing one's home and witnessing the demolition of others' houses on the mental health of Palestinian adults and children. The loss group consisted of 47 adults whose homes were demolished, the witness group of 24 adults who witnessed the house demolition, and the control group of 33 adults. The groups were compared for their anxiety, depression and paranoiac symptoms. In addition, 38 children in the loss group, 36 children in the witness group and 50 children in the control group were compared for their psychological symptoms. The results showed that adults who were exposed to house demolition showed a higher level of anxiety, depression and paranoiac symptoms than the witness and control groups. The children in the loss group showed a higher level of psychological symptoms than the children in the witness and control groups. The witness group differed from the control group in having more depression among women and more psychological symptoms among children. Women suffered more from anxiety, depression and paranoiac symptoms than men in the loss and witness groups but not in the control group. “Relationships between Traumatic Events, Children's Gender, and Political Activity, and Perceptions of Parenting Styles"

Raija-Leena Punamaki, Samir Qouta, and Eyad El-Sarraj; International Journal of Behavioral Development, 1997, 27 (1), 91-109.

The associations between traumatic events, children's gender and political activity, and parenting styles were examined among 108 Palestinians of 11-12 years of age. The results showed that the more the children were exposed to traumatic events, the more they perceived both their parents as strictly disciplining, rejecting, and hostile, and their mothers as more negatively evaluating. The boys perceived both their parents as treating them more negatively than the girls did. Affectionate parenting, such as intimacy and love, for its part, was not associated with traumatic events, and did not vary according to the child's gender or political activity. The gender of the child affected the association between traumatic events, political activity, and perceived parenting. Traumatic events increased perceived parental rejection and hostility only among the boys, and perceived strict disciplining only among the girls. Although politically active children perceived both of their parents as more negative in general, in the families exposed to a high level of traumatic events passive boys perceived their fathers as more rejecting and hostile than active boys did. It is suggested that mothers and fathers rear girls restrictively and with greater attention, and boys with rejection, when the family faces traumatic events. In exposed families, fathers also tend to discourage boys' political passivity and apparently encourage activity. “Models of Traumatic Experiences and Children's Psychological Adjustment: The Roles of Perceived Parenting and the Children's Own Resources and Activity"

Raija-Leena Punamaki, Samir Qouta and Eyad El-Sarraj; Child Development, Vol. 64, (4), 718-728, 1997.

The relations between traumatic events, perceived parenting styles, children's resources, political activity and psychological adjustment were examined among 108 Palestinian boys and girls of 11 to 12 years of age. The results showed that exposure to traumatic events increased psychological adjustment problems, both directly and via two mediating paths. First, the more traumatic events children had experienced, the more negatively they perceived their parenting; and the poorer they perceived parenting, the more they suffered from high neuroticism and low self-esteem. Second, the more traumatic events children had experienced, the more political activity they showed; the more active they were, the more they suffered from psychological adjustment problems.

The perception of good parenting protected children's psychological adjustment by making them less vulnerable in two ways. First, traumatic events decreased their intellectual, creative, and cognitive resources, while in a model excluding perceived parenting a lack of resources caused many psychological adjustment problems; second, political activity increased psychological adjustment problems in the same model, but not in the model including perceived parenting. “Prison Experiences and Coping Styles among Palestinian Men,"

Samir Qouta, Raija-Leena Punamaki, and Eyad El-Sarraj; Peace and Conflict: Journal of Peace Psychology, 3 (1), 19-36, 1997.

Our aim was to describe different types of prison experience and to analyze their relations with background and psychological variables. Seventy-nine male Palestinian ex-prisoners were interviewed about their prison experiences, ways of coping, personality, and psychological well-being. The results of qualitative analysis revealed seven different types of prison experience. Only one of these reflected exclusively negative feelings, characterized by suffering and disillusionment. The other included relatively rewarding perceptions characterized as a struggle between strength and weakness, heroic fulfillment, developmental tasks, a normative stage in a man's life, growth in personal insight, and a return to religion. Results showed that older men, town residents, and those exposed to a high level of torture perceived the imprisonment more as suffering and disillusionment than other men. Ex-prisoners who perceived their experience as suffering and disillusionment typically coped by using wishful thinking, avoidance, escape, and distraction. Torture and ill-treatment increased wishful thinking and self-controlling as coping styles. “The Relations between Traumatic Experiences, Activity, and Cognitive and Emotional Responses among Palestinian Children”

Samir Qouta, Raija-Leena Punamaki, and Eyad El Sarraj. International Journal of Psychology, 1995, 30 (3), 289-304

The relations between the level of traumatic experiences, degree of active participation in the Intifada, and cognitive and emotional responses were studied among 108 Palestinian children of 11-12 years of age in the Gaza Strip. The results showed that the more traumatic experiences the children had and the more they participated in the Intifada, the more concentration, attention and memory problems they had. Traumatic experiences also increased neuroticism and risk-taking, and Intifada participation decreased self-esteem. Children's active participation in the Intifada could not protect children from developing emotional problems, as was originally assumed. The highest level of neuroticism was found among active boys who were exposed to many traumatic experiences. “The Impact of the Peace Treaty on Psychological Well-Being: A Follow-up Study of Palestinian Children"

Samir Qouta, Raija-Leena Punamaki, and Eyad El-Sarraj; Child Abuse & Neglect, 1995, 19 (10), 1197-1208.

This research examined the impact of the Israeli-Palestinian peace treaty and Palestinian children's perception of it on their self-esteem and neuroticism. We also studied the relative importance of earlier exposure to traumatic experiences and psychological resources indicated by children's creativity, intelligence and political activity in influencing their psychological well-being after the peace treaty. The sample used was a follow-up group of 64 Palestinian children, 11-12 years of age, living in the Gaza Strip. The results showed that the level of neuroticism was significantly lower after the peace treaty than before. The children's earlier exposure to traumatic experiences was still significantly related to a high neuroticism and low self-esteem after the peace treaty. Acceptance of the treaty and participating in the subsequent festivities mitigated the negative impact of the traumatic experiences on their well-being. Increased neuroticism and low self-esteem were found only among children who refused to accept the peace treaty and did not participate in the festivities. Creativity and Intifada activity promoted their post-peace treaty well-being, in terms of psychological resources. The more creative the children were, the more their neurotic symptoms decreased because of the treaty and the higher self-esteem they had after it. The more active the children were during the Intifada, the more their self- esteem increased because of the treaty. "Palestinian Children under Curfew"

Samir Qouta and Eyad El-Sarraj. Journal of Psychological studies vol. (4), 1-12, 1994.

This study is based on field research work. The purpose of the study was to estimate the effect of the curfew on children. 547 mothers were asked to record the behavioral changes of their children during curfew by using the Rutter scale. Results showed that 66.1% of children began to fight each other and that 54% were afraid of new things. Significant differences were observed in behavioral and neurotic symptoms between camp children, resettled children, and town children. “Level of Anxiety in Gaza before and after the Intifada”

Samir Qouta and Eyad El-Sarraj. Journal of Psychological studies vol. (1), 1-11, 1993.

This study is based on field research work to estimate the level of anxiety among the Palestinian people in Gaza Strip, as a measure of the effect of stress. In comparison with a similar study which was conduced in 1984, significant differences were observed in the level of anxiety, psychosomatic symptoms and rigidity and significant rise of anxiety among the citizens of Gaza in comparison with the camp refugee following the Intifada.