European Journal of Psychotraumatology

ISSN: 2000-8198 (Print) 2000-8066 (Online) Journal homepage: https://www.tandfonline.com/loi/zept20

UCLA PTSD reaction index for DSM-5 (PTSD-RI-5): a psychometric study of adolescents sampled from communities in eleven countries

Ana Doric, Dejan Stevanovic, Dusko Stupar, Panos Vostanis, Olayinka Atilola, Paulo Moreira, Katarina Dodig-Curkovic, Tomislav Franic, Vrljicak Davidovic, Mohamad Avicenna, Multazam Noor, Laura Nussbaum, Abdelaziz Thabet, Dino Ubalde, Petar Petrov, Azra Deljkovic, Monteiro Luis Antonio, Adriana Ribas, Joana Oliveira & Rajna Knez

To cite this article: Ana Doric, Dejan Stevanovic, Dusko Stupar, Panos Vostanis, Olayinka Atilola, Paulo Moreira, Katarina Dodig-Curkovic, Tomislav Franic, Vrljicak Davidovic, Mohamad Avicenna, Multazam Noor, Laura Nussbaum, Abdelaziz Thabet, Dino Ubalde, Petar Petrov, Azra Deljkovic, Monteiro Luis Antonio, Adriana Ribas, Joana Oliveira & Rajna Knez (2019) UCLA PTSD reaction index for DSM-5 (PTSD-RI-5): a psychometric study of adolescents sampled from communities in eleven countries, European Journal of Psychotraumatology, 10:1, 1605282, DOI: 10.1080/20008198.2019.1605282 To link to this article: https://doi.org/10.1080/20008198.2019.1605282

© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

Published online: 07 May 2019.

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CLINICAL RESEARCH ARTICLE UCLA PTSD reaction index for DSM-5 (PTSD-RI-5): a psychometric study of adolescents sampled from communities in eleven countries

Ana Doric a, Dejan Stevanovic b, Dusko Stuparb, Panos Vostanisc, Olayinka Atilola d, Paulo Moreira e, Katarina Dodig-Curkovicf, Tomislav Franic g, Vrljicak Davidovic h, Mohamad Avicennai, Multazam Noor j, Laura Nussbaum k, Abdelaziz Thabet l, Dino Ubaldem, Petar Petrovn, Azra Deljkovico, Monteiro Luis Antoniop, Adriana Ribasq, Joana Oliveira r and Rajna Knez s,t,u aDepartment of (Center for ), Faculty of Humanities and Social Sciences, University of Rijeka, Rijeka, Croatia; bChild Psychiatry, Clinic for Neurology and Psychiatry for Children and Youth, Belgrade, Serbia; cSchool of Psychology, Leicester University, Leicester, UK; dDepartment of Behavioural Medicine, Lagos State University College of Medicine Ikeja, Lagos, Nigeria; eCIPD, Porto Lusíada University, Porto, Portugal; fMedical Faculty Osijek, Faculty for Dental Medicine and Health, University Health Center Osijek, Osijek, Croatia; gChild and Adolescent Psychiatry, School of Medicine, University of Split, Split, Croatia; hDepartment of Psychiatry, Clinical Hospital Centre Split, Split, Croatia; iFaculty of Psychology, State Islamic University Syarif Hidayatullah, Jakarta, Indonesia; jPsychiatry department, Dr Soeharto Heerdjan Mental Hospital Jakarta, Jakarta, Indonesia; kDepartment of Child and Adolescent Psychiatry, University of Medicine and Pharmacy “Victor Babes”, Timisoara, Romania; lSchool of Public Health, Al Quds University, Gaza Branch, Palestine; mDepartment of Psychology, St. Dominic College of Asia, City of Bacoor, Philippines; nDepartment of Child and Adolescent Psychiatry, University Hospital St. Marina, Varna, Bulgaria; oMental Health Center, Pljevlja, Montenegro; pUniversidade Estacio de Sá in Rio de Janeiro, Rio de Janeiro, Brazil; qFederal University of Rio de Janeiro, Rio de Janeiro, Brazil; rCIPD, Lusíada University, Porto, Portugal; sDepartment of Women´s and Children´s health, Skaraborgs Hospital, Skövde, Sweden; tDepartment of Psychiatry and Psychological Medicine, Medical School, University of Rijeka, Rijeka, Croatia; uUniversity of Gothenburg, Sahlgrenska Academy, Institute of Neuroscience and Physiology, Göteborg, Sweden

ABSTRACT ARTICLE HISTORY Background: Children and adolescents are often exposed to traumatic events, which may Received 3 February 2019 lead to the development of posttraumatic disorder (PTSD). It is therefore important for Revised 22 March 2019 clinicians to screen for potential symptoms that can be signs of PTSD onset. PTSD in youth is Accepted 28 March 2019 a worldwide problem, thus congruent screening tools in various languages are needed. KEYWORDS Objective: The aim of this study was to test the general psychometric properties of the Instrument; post-traumatic Traumatic Stress Disorder Reaction Index for children and adolescents (UCLA PTSD) Reaction stress disorder; DSM-5; Index for DSM-5 (PTSD-RI-5) in adolescents, a self-report instrument intended to screen for cross-cultural validation; trauma exposure and assess PTSD symptoms. measurement invariance Method: Data was collected from 4201 adolescents in communities within eleven countries worldwide (i.e. Brazil, Bulgaria, Croatia, Indonesia, Montenegro, Nigeria, Palestine-Gaza, PALABRAS CLAVE Philippines, Portugal, Romania, and Serbia). Internal consistency, discriminant validity, and instrumento; Trastorno de a confirmatory factor analysis of a four-factor model representing the main DSM-5 symp- estrés postraumático; DSM- 5; validación intercultural; toms of the PTSD-RI-5 were evaluated. invariancia de medida Results: The PTSD-RI-5 total score for the entire sample shows very good reliability (α = .92) as well as across all countries included (α ranged from .90 to .94). The correlations between 关键词 anxiety/depressive symptoms and the PTSD-RI-5 scores were below .70 indicating on good 测量工具; 创伤后应激障 discriminant validity. The four-factor structure of the scale was confirmed for the total 碍; DSM-5; 跨文化验证; 测 sample and data from six countries. The standardized regression weights for all items varied 量不变性 markedly across the countries. The lack of a common acceptable model across all countries HIGHLIGHTS prevented us from direct testing of cross-cultural measurement invariance. • Conclusions: The four-factor structure of the PTSD-RI-5 likely represents the core PTSD The cross-cultural aspects of the DSM-5 PTSD reaction symptoms as proposed by the DSM-5 criteria, but there could be items interpreted in index for youth (PTSD-RI-5) a conceptually different manner by adolescents from different cultural/regional back- across multiple, worldwide grounds and future cross-cultural evaluations need to consider this finding. countries were addressed. • The four-factor structure of the scale that follows the Índice de Reacción TEPT de la UCLA para el DSM-5 (PTSD-RI-5): Un DSM-5 criteria for PTSD was Estudio Psicométrico de muestras de Adolescentes de Comunidades en confirmed. Once Países • Not all PTSD symptoms as measured by the instrument Antecedentes: Los niños y adolescentes a menudo están expuestos a eventos traumáticos, are relevant to adolescents que pueden llevar al desarrollo de un trastorno de estrés postraumático (TEPT). Por lo tanto, across different societies. es importante que los médicos examinen los posibles síntomas que pueden ser signos del inicio de un TEPT. Este trastorno en jóvenes es un problema global, por lo que se necesitan herramientas de detección congruentes en varios idiomas. Objetivo: El objetivo de este estudio fue probar en adolescentes las propiedades psicométricas generales del Índice de Reacción TEPT de la UCLA para el DSM-5 (PTSD-RI-5), que es un instrumento de auto-reporte destinado a evaluar la exposición al trauma y evaluar los síntomas de PTSD.

CONTACT Dejan Stevanovic [email protected] Clinic for Neurology and Psychiatry for Children and Youth, Dr Subotica 6a, 11000 Belgrade, Serbia © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 2 A. DORIC ET AL.

Método: Los datos se recopilaron de 4201 adolescentes en comunidades dentro de once países alrededor del mundo (es decir, Brasil, Bulgaria, Croacia, Indonesia, Montenegro, Nigeria, Palestina-Gaza, Filipinas, Portugal, Rumania y Serbia). Se evaluó la consistencia interna, la validez discriminante y un análisis factorial confirmatorio de un modelo de cuatro factores que representa los principales síntomas del DSM-5 del PTSD-RI-5 Resultados: La puntuación total de PTSD-RI-5 para toda la muestra reveló una muy buena confiabilidad (α = .92), así como en todos los países incluidos (α varió de .90 a .94). Las correlaciones entre los síntomas de ansiedad/depresión y las puntuaciones del PTSD-RI-5 fueron inferiores a .70, lo que indica una buena validez discriminante. La estructura de cuatro factores de la escala se confirmó para la muestra total y los datos de seis países. Las ponderaciones de regresión estandarizada variaron notablemente para todos los ítems en todos los países. La falta de un modelo aceptable común en todos los países nos impidió realizar pruebas directas de invariancia de medición intercultural. Conclusiones: La estructura de cuatro factores del PTSD-RI-5 probablemente representa los síntomas centrales del TEPT según lo propuesto por los criterios del DSM-5, pero podría haber elementos interpretados de manera conceptualmente diferente por adolescentes con diferentes orígenes culturales/regionales, y futuras evaluaciones interculturales deben con- siderar este hallazgo.

UCLA DSM-5PTSD 反应指数（PTSD-RI-5）：对来自11个国家的社区青少 年样本进行心理测量研究背景 背景：儿童和青少年经常接触创伤事件，这可能导致创伤后应激障碍（PTSD）。因此， 临床医生必须筛查PTSD发病迹象的潜在症状。青年PTSD是一个世界性问题，因此一致使 用的筛查工具需要有不同语言版本。目的：本研究的目的是在青少年样本中测试UCLA DSM-5 PTSD 反应指数（PTSD-RI-5）的一般心理测量学特性，PTSD-RI-5是用于筛查创伤暴 露和评估PTSD症状的自我报告工具。 方法：收集来自全球11个国家（即巴西，保加利亚，克罗地亚，印度尼西亚，黑山，尼 日利亚，巴勒斯坦 - 加沙，菲律宾，葡萄牙，罗马尼亚和塞尔维亚）4201名社区青少年的 数据。评估了PTSD-RI-5的内部一致性和区分效度，并进行验证性因子分析考察代表主要 症状的四因子模型。 结果：整个样本中（α= .92）和各个国家中（α范围从.90到.94），PTSD-RI-5总分显示出非 常好的内部一致性。焦虑/抑郁症状与PTSD-RI-5评分之间的相关性低于.70，表明良好的判 别效度。对来自六个国家的子样本和整体样本中，都验证了四因子结构。所有题目的标 准化回归权重在各国之间存在显著差异。所有国家缺乏共同的可接受模型使我们无法直 接考察跨文化的测量不变性。 结论：PTSD-RI-5的四因素结构可能代表DSM-5提出的PTSD核心症状，但由于来自不同文 化/地区背景的青少年可能对有些题目有不同的理解，还需要以后的跨文化研究来验证这 个发现。

1. Introduction be higher (Gunaratnam & Alisic, 2017). In such cases, studies show that up to 87% of female and 78% of male Exposure to adverse events appears to be common in Danish adolescents (Elklit, 2002), 78% of Malaysian stu- children and adolescents (Gunaratnam & Alisic, 2017; dents (Ghazali, Elklit, Balang, Sultan, & Kana, 2014), 86% Kolaitis, 2017). Exposure to potentially traumatic events of Greenland students (Karsberg, Lasgaard, & Elklit, (PTEs; i.e., exposure to actual or threatened death, serious 2012) and 95% of Kenyan students (Karsberg & Elklit, injury, or sexual violence; American Psychiatric 2012) experienced at least one adverse childhood event. Association, 2013) is present worldwide among youth Adolescents are very vulnerable to the exposure of (Gunaratnam & Alisic, 2017;Kolaitis,2017;Takada adverse childhood events (Karsberg & Elklit, 2012). et al., 2018). For example, studies conducted in Europe Impairments in emotion processing, cognitive function- show that 15% of Dutch primary school-aged children ing, and academic achievements (Hart & Rubia, 2012), as (Alisic et al., 2008), 56% of Swiss adolescents (Landolt, well as different internalizing and externalizing psycho- Schnyder, Maier, Schoenbucher, & Mohler-Kuo, 2013), pathologies (Dvir, Ford, Hill, & Frazier, 2014; Teicher & and up to 79% of Icelandic adolescents (Bödvarsdóttir & Samson, 2016) with different underlying neurobiological Elklit, 2007), reported exposure to at least one traumatic changes in brain structure and function (Teicher & event. In the USA, Copeland, Keeler, Angold, and Samson, 2016) were found among adolescents exposed Costello (2007) reported that more than two thirds of to trauma. Exposure to PTEs, combined with different American children and adolescents had been exposed to temperamental, environmental, genetic and physiologi- oneormorePTEs.McLaughlinetal.(2013)found cal factors (American Psychiatric Association, 2013), a similar prevalence, where many adolescents included couldleadtothedevelopmentofposttraumaticstress in that study (62%) had been confronted with more than disorder (PTSD; Cohen & Scheeringa, 2009;McLaughlin one PTE. When a broader range of stressful events is et al., 2013: Van Ameringen, Mancini, Patterson, & included, such as parental divorce and bullying, the num- Boyle, 2008). A meta-analysis of data from 3563 youth bers of youth exposed to adverse childhood events tend to EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 3 exposed to traumatic events showed a 16% prevalence of In 2013, the PTSD diagnostic criteria were revised in PTSD (Alisic et al., 2014). Another study showed that the DSM Fifth Edition (DSM-5; American Psychiatric almost 25% of youth develop PTSD following exposure Association, 2013). These changes included an addition to interpersonal traumatic events and 10% following of three symptoms (i.e., negative expectations of oneself/ exposure to non-interpersonal traumatic events world/others, distorted blame, and recklessness), (Kolaitis, 2017). Besides classical PTSD symptoms, a revision of existing symptoms, and a four-cluster rather namely intrusion avoidance, negative alterations in cog- than three-cluster structure (American Psychiatric nitions and mood, and arousal and reactivity (American Association, 2013). The PTSD-RI was revised accord- Psychiatric Association, 2013), adolescent PTSD could ingly into the PTSD-RI-5 (Pynoos & Steinberg, 2015). have some specificities compared to adult PTSD (e.g., The instrument now includes past exposure to Gerson & Rappaport, 2013; Herringa, 2017). At first a traumatic event (criterion A) and related symptoms place, symptoms expression could vary substantially, for each of the four clusters: intrusion (cluster B), avoid- for example avoidant symptoms may be associated with ance (cluster C), negative alterations in cognitions and restricted exploratory behavior, reduced participation in mood (cluster D), and arousal and reactivity (cluster E; new activities or reluctance to pursue opportunities in American Psychiatric Association, 2013;Pynoos& adolescents (American Psychiatric Association, 2013). Steinberg, 2015;Steinbergetal.,2013). Although studies Recently, it has been found that symptoms related to in different cultures have addressed sound psychometric intrusion, avoidance, negative affect, anhedonia, externa- properties of the PTSD-RI in youth for the DSM-IV lizing behavior, anxious, and dysphoric arousal best (Charak et al., 2014;Korb,2013;Steinbergetal.,2004, depict PTSD in adolescents (Cao, Wang, Cao, Zhang, 2013), two recent studies tested the psychometric proper- &Elhai,2017). In addition, there is heightened stress ties of the PTSD-RI-5 self-report (Kaplow et al., in press; sensitivity of developing neural systems in adolescents, as Takada et al., 2018). The first study reports on its sound well as delayed expression of the full effects of trauma internal consistency, criterion-referenced validity, and exposure compared to adults (Herringa, 2017). Some diagnostic accuracy in two independent samples of com- structural and functional brain abnormalities were also munity and treatment-seeking youth (Kaplow et al., in found, like reduced ventro-medial prefrontal cortex press). Sound reliability and validity of the instrument volume and impaired recruitment of lateral prefrontal was also showed in multi-site Japanese youth, namely cortex, but not reduced hippocampal volume, and hyper- child guidance centers, a psychiatric hospital, prefectures activity of the amygdala and insula as in adult PTSD in a tsunami devastated area and a general population (Herringa, 2017). In this regard, screening for exposure sample (Takada et al., 2018). to PTEs and PTSD symptoms in adolescents is important Considering culture-related diagnostic issues for making the diagnosis timely and initiating treatment (American Psychiatric Association, 2013), the use of (Hawkins & Radcliffe, 2006; Kassam-Adams & Winston, measures for youth psychopathology, including PTSD, 2004). across different regions/counties is still a challenge and The UCLA Post-Traumatic Stress Disorder reaction more psychometric studies are needed (Stevanovic et al., index for children and adolescents (PTSD-RI), devel- 2017a). The prevalence rates and characteristics of youth oped according to the Diagnostic and Statistical Manual psychopathology differ substantially across cultures and of Mental Disorders (DSM) 4th Edition, has been one of ethnic groups (e.g., Achenbach, Rescorla, & Ivanova, the most accepted and used tool for PTSD screening in 2012; Canino & Alegria, 2008). Besides being may be youth in clinical practice, as well as research, and it has genuine, such differences may be explained by biased been used in various countries worldwide (e.g., estimations because of the assessment method of Hawkins & Radcliffe, 2006;Korb,2013; Ohan, Myers, a given theoretical construct, that might not have the & Collett, 2002; Steinberg, Brymer, Decker, & Pynoos, same structure for different cultures, and therefore lack 2004; Steinberg et al., 2013; Thabet & Vostanis, 1999). measurement invariance (Borsboom, 2006; Dimitrov, This instrument has been widely used for clinical eva- 2010). This has also been reported for PTSD (Armour, luation, trauma research, and treatment outcome eva- 2015;Charaketal.,2014). In order to guarantee that luation, and therefore translated and validated across a scale will operate equivalently across groups and that sex, age groups and cultures (e.g., Koplewicz et al., 2002; as such is suitable for cross-cultural comparisons of psy- Korb, 2013; Pynoos et al., 1993; Steinberg et al., 2004, chopathology prevalence, a theoretical construct of 2013). Translations and psychometric evaluations of the a scale developed in one language should be replicated tools are well reported (Korb, 2013; Lack, Sullivan, & across different language/cultural groups (Byrne & Knight, 2008; Steinberg et al., 2004, 2013;Thabetetal., Watkins, 2003). Regarding the PTSD-RI-5, its proposed 2013). Overall, validation studies of the PTSD-RI structure needs to be invariant across different cultural showed appropriate internal consistency reliability contexts. In addition to the whole structure, cross- (Goenjian et al., 1995;Steinbergetal.,2004, 2013). culturally invariant items should be found when tested 4 A. DORIC ET AL. simultaneously across these groups (Borsboom, 2006; Table 1. Characteristics of the sample. Byrne & Watkins, 2003; Dimitrov, 2010; Gregorich, Country N participants N males/N females M age (SD) 2006; Milfont & Fisher, 2010). Thus, the aim of our Brazil 289 123/166 13.13 (1.24) Bulgaria 263 120/143 14.88 (1.41) study was to test the psychometric properties of the Croatia 549 165/384 16.45 (1.01) PTSD-RI-5 self-report among adolescents sampled Indonesia 453 173/280 15.35 (1.33) Montenegro 330 140/190 15.67 (1.51) from communities across eleven cross-culturally different Nigeria 367 159/208 14.57 (1.42) countries. Palestine-Gaza 319 163/156 14.98 (2.01) Philippines 286 158/128 16.53 (.68) Portugal 628 303/325 15.67 (1.85) Romania 329 163/166 15.28 (1.47) Serbia 388 156/232 15.57 (1.51) 2. Method 2.1. Participants and procedures 2.2. Instruments

Data for the present study was collected in accor- 2.2.1. PTSD-RI-5 dance to a project organized by the International The PTSD-RI-5 (Pynoos & Steinberg, 2015) is a self- Child Mental Health-Study Group (ICMH-SG) report instrument to screen for trauma exposure and aiming to research mental health among children PTSD symptoms assessment in school-aged youth. and adolescents living in low- and middle-income The instrument consists of a comprehensive trauma countries (LMIC – Atilola, Balhara, Stevanovic, history section, with provision to specify details Avicenna, & Kandemir, 2013). We obtained data regarding each type of trauma endorsed. For each from school-attending adolescents from at least one traumatic event, respondents report whether they communityinelevencountriesavailabletothe were a victim, witness, or learned/heard about the authors, namely Brazil, Bulgaria, Croatia, trauma. The next section is related to posttraumatic Indonesia, Montenegro, Nigeria, Palestine-Gaza, stress symptoms consisting of 27 items aiming to Philippines, Portugal, Romania, and Serbia. assess the nature of PTSD symptoms, as well as four Participants represented a sample of convenience additional items constructed to assess the Dissociative from rural and urban communities across these Subtype of PTSD. Young participants rated the fre- countries. Local project assistants with the authors quency of experienced symptoms over the past in each country collected the data. Ethical approval month (ranging from 0 – none of the time; to 4 – and informed consent from parents were obtained most of the time). When answering questions, the forallparticipants.Thesamerecruitmentproce- youth should think about the traumatic event that is dure was followed. First, it was sought permission most bothersome to him or her currently. Scores from local authorities and/or appropriate ethical range from 0 to 80. Items assessing main PTSD committees in each region to include adolescents symptoms are classified into four subscales based on in this study. Two to five high schools within DSM criteria (American Psychiatric Association, communities in each country were randomly 2013); five questions for Criterion B measuring intru- selected depending on the number of pupils and sion, two questions for Criterion C measuring avoid- the vicinity or availability to the project assistant. ance, seven questions for Criterion D measuring School and/or project assistants negative alterations in cognitions and mood, and six informed the adolescents and their teachers of the questions for Criterion E measuring alterations in research procedure. Only those who agreed to par- arousal and reactivity (Pynoos & Steinberg, 2015), ticipate and returned the written consent were with four additional items combined into two main included. The adolescents completed instruments specifiers for the Dissociative Subtype of PTSD. For at school to prevent a low response rate. We pro- the purpose of the study, the PTSD-RI-5 was trans- vided adolescents with sealable envelopes in which lated into ten languages (i.e., Arabic, Bulgarian, completed instruments were returned to project Bahasa Indonesian, Croatian, Montenegrin, assistants, in order to assure anonymity. Portuguese for Portugal, Portuguese for Brazil, Overall, the sample consisted of 4201 adolescents Romanian, Serbian, and Yoruba languages for (Nmale = 1823; Nfemale = 2378) aged from 12 to Nigeria). After obtaining the permission from the 18 years (Mage = 15.38; SD = 1.68; Table 1). The developers, the PTSD-RI-5 was translated and cultu- amount of missing data for items varied between 1.1 rally adapted using the same approach of two forward and 2.5% across the countries. The missing items translations, a single form development, a single were replaced by series means for confirmatory factor back-translation, and pre-testing. Firstly, all items analysis only. were translated from English into country native lan- EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 5 guages. After the first translation, independent trans- factor structure (e.g., Steinberg et al., 2004, 2013;Takada lators recoded the items back into the original et al., 2018), we explored the original structure of four English language. All discrepancies were then correlated factors, representing the main four DSM-5 searched for and questions were altered accordingly. criteria for establishing the diagnosis, by a confirmatory Finally, cognitive debriefing in a group of with up to factor analysis (CFA). The dissociation items were not ten adolescents was held in each country as a form of included in the CFA since they represent the extensions pre-testing. During the cognitive debriefing, each of the main criteria for a more specific diagnosis, namely adolescent firstly completed the PTSD-RI-5. PTSD with dissociative symptoms, thus could affect the Afterwards, each was asked to explain how he/she general underlying factor structure of the four categories. understood the meaning of every item and how an A satisfactory degree of data fit requires the comparative answer was created. Open discussion followed every fit index (CFI) and the Tucker–Lewis index (TLI) to be item/term/concept which appeared to be ambiguous, close to .95, and the model should be rejected when these confusing, unclear or problematic for responding indices are < .90 (Brown, 2006). The next fit index was anyhow. Following the cognitive debriefing and inte- root-mean-squared error of approximation (RMSEA), gration of reports from all sites, all items were con- where values ≤ .06 indicate excellent fit, and a value of sidered comprehensive, precise and relevant; and no ≥ .08 indicates inadequate fit (Browne & Cudeck, 1993; item was added, replaced or omitted in the transla- Kline, 2011). We tested the factor structure of the model tions. Thus, during this process of translation and for the entire sample and for the countries separately. It cultural adaptation, conceptually equivalent language was intended to implement multi-group CFA in order to versions to the original English PTSD-RI-5 were assess cross-country measurement invariance (i.e., developed. In a Japanese study, the PTSD-RI-5 total dimensional, configural, metric and scalar invariance) scale displayed satisfactory internal consistency relia- for the original model. If the original model were not bility (α = 0.85) and sound convergent validity, while represented by the data for each country (i.e., dimen- its four-factor structure of the PTSD-RI-5 was sup- sional invariance), other aspects of measurement invar- ported through confirmatory factor analysis (Takada iance would not be considered. In addition, standardized et al., 2018), which is in line with the findings of factor weights (λ) were analyzed in order to evaluate how a recent study (Kaplow et al., in press). allitemsbehavesinrelationtotheproposedfactors across countries. Besides being statistically significant 2.2.2. Revised child anxiety and scale (p < .05), λ should not be < .50 since this could indicate (RCADS) on possible problems with the local model fit (Joseph, The RCADS is a 47-item scale for anxiety and depres- Black, Babin, & Anderson, 2010). Finally, to determine sive symptoms in youth (Chorpita, Moffitt, & Gray, whether the proposed PTSD subscalesassessseparate 2005; Chorpita, Yim, Moffitt, Umemoto, & Francis, concepts from commonly present anxiety and depressive 2000). The six subscales correspond to separation symptoms in youth, correlations between the two anxiety, social , generalized anxiety, panic, RCADS scores and the PTSD-RI-5 were computed obsessive–compulsive, and major depressive disor- using Pearson’s correlation coefficient. The correlation ders. The respondent indicates on a 4-point scale coefficient should not exceed .70 in order to claim dis- how often each symptom is present, ranging from criminant validity (Ravens-Sieberer, 2006). Analyses ‘never’ (0 points) to ‘always’ (3 points). The RCADS wereperformedusingSPSS22andSPSSAmos21. has sound psychometric characteristics demonstrated in numerous international studied (Piqueras, 3. Results Martín-Vivar, Sandin, San Luis, & Pineda, 2017). In this study, the RCADS Anxiety (sum of five anxiety Table 2 shows the means, standard deviations, skew- subscales) and the RCADS Depression score were ness, and inter-item correlation for each item with used. Cronbach’s alpha of both measures was 0.93 the total score. The smallest and the largest items’ and 0.88, respectively. For details on the RCADS as estimates were both present in the D subscale. Each used in this project see Stevanovic et al. (2017b). of the items showed moderate to strong correlations with the total score (r ranging from .47 to .76). Item 2.3. Statistical analysis characteristics and correlations with PTSD-RI-5 total scores for each country are available on request. Internal consistency reliability was evaluated using Internal consistency reliability analyses for the Cronbach’s α coefficient, for the total, B, D, and PTSD-RI-5 total and subscales for the overall sample E subscales. Spearman–Brown coefficient was used for and individual countries are displayed in Table 3.The the C and Dissociation subscale, since they contain only PTSD-RI-5 total score had Cronbach’s α coefficient of two items. Internal consistency reliability was considered .92 for the overall sample, while α ranged from .90 to .94 appropriate if the coefficients were ≥ .70. In order to across the included countries. Subscales B and D had α provide comparable results to prior studies of PTSD’s of .83, whereas the E subscale of .71 for the overall 6 A. DORIC ET AL.

Table 2. PTSD-RI-5 item characteristics and correlations with Table 4. Confirmatory factor analysis model fit indexes. PTSD-RI-5 total scores. Country χ2 df χ2/df TLI CFI RMSEA Item M SD Skewness r Brazil 796.14 164 4.85 .72 .75 .12 B1 .84 1.23 1.01 .71* Bulgaria 424.3 164 2.59 .84 .86 .08 B2 .97 1.25 .83 .68* Croatia 662.66 164 4.04 .89 .90 .07 B3 .87 1.22 .10 .66* Indonesia 391.58 164 2.39 .90 .92 .06 B4 1.22 1.01 1.54 .72* Montenegro 524.84 164 3.20 .85 .87 .08 B5 1.03 1.29 .32 .69* Nigeria 330.24 164 2.01 .90 .92 .05 C1 1.16 1.33 .47 .65* Palestine 354.16 164 2.16 .89 .90 .06 C2 1.02 1.37 .44 .60* Philippines 2220.93 164 13.54 .41 .49 .21 D1 .68 1.06 1.57 .59* Portugal 570.83 164 3.48 .92 .93 .06 D2 1.73 1.20 1.14 .71* Romania 505.35 164 3.08 .82 .85 .08 D3 1.50 1.20 1.27 .66* Serbia 511.58 164 3.12 .89 .91 .07 D4 1.56 1.18 1.07 .76* Comparative fit index (CFI); the Tucker–Lewis index (TLI); root-mean- D5 .68 1.15 1.36 .55* squared error of approximation (RMSEA). D6 .95 1.25 .80 .64* D7 .85 1.23 .98 .63* E1 .97 1.16 .92 .53* E2 .79 1.17 1.31 .59* C subscale was .60 for the total sample and ranged from E3 1.19 1.23 1.01 .47* .38 to .69 across the countries, while it was .76 for the E4 1.07 1.25 .83 .61* E5 1.08 1.16 .92 .57* dissociation subscale and ranged from .61 to .85 across E6 .83 1.17 1.31 .60* the countries. Dis1 .82 1.18 1.32 .59* Dis2 .92 1.21 1.18 .64* The four-factor structure of the PTSD-RI-5 on the Diss – Dissociation item; r – average inter-item correlation for an item overall sample was confirmed. The data showed an ade- χ2 with the total score; * p < .01 quate model fit ( (164) = 2090.90, p < .01, χ2/df = 12.75, RMSEA = .05, CFI = .94, TLI = .93). The model does not show adequate data fit for the data from Brazil, Bulgaria, Table 3. Internal consistency reliability of the PTSD-RI-5 scores across countries. Montenegro, Philippines and Romania (Table 4). Country Total B C D E Diss Therefore, due to a lack of a common acceptable model Brazil .91 .82 .43 .81 .67 .62 across all eleven countries, it was not possible to perform Bulgaria .91 .84 .52 .77 .74 .76 multi-group CFA and test all types of measurement Croatia .94 .83 .69 .85 .76 .85 Indonesia .90 .77 .63 .80 .67 .61 invariance. Montenegro .93 .85 .67 .82 .72 .82 The standardized regression weights for all items Nigeria .91 .76 .38 .79 .67 .63 in each country are given in Table 5. Across the Palestine-Gaza .90 .79 .64 .76 .65 .63 Philippines .90 .78 .55 .82 .57 .77 countries, the standardized regression weights were Portugal .94 .88 .62 .85 .75 .78 statistically significant (p < .01), except for item E3 Romania .90 .79 .51 .78 .66 .68 Serbia .93 .87 .69 .82 .80 .68 (‘on the lookout for danger or things that I am afraid Diss – Dissociation. of’; λ = .04, p = .48) in the Philippines. Eight items (B2-5, C1, D2-4) had λ > .50 across all included sample. Across the countries included, for the countries, while 12 items had λ < .50 across one or B subscale α ranged from .76 to .88, for the D subscale more countries. α ranged from .76 to .85, and for the E subscale α ranged Finally, the RCADS scores and the PTSD-RI-5 from .57 to .80. Spearman–Brown coefficient for the scores correlated below .70 for the whole sample,

Table 5. Standardized regression weights for PTSD-RI-5 items for the overall sample and across eleven countries. Item Overall sample Brazil Bulgaria Croatia Indonesia Montenegro Nigeria Palestine Philippines Portugal Romania Serbia B1 .71 .64 .77 .71 .69 .75 .61 .71 .43 .77 .71 .72 B2 .68 .67 .69 .69 .68 .72 .61 .59 .67 .75 .59 .74 B3 .66 .62 .70 .70 .56 .66 .55 .50 .68 .77 .50 .75 B4 .74 .81 .70 .71 .68 .77 .63 .70 .88 .78 .68 .81 B5 .70 .66 .70 .73 .56 .70 .59 .73 .55 .77 .74 .75 C1 .69 .54 .62 .74 .56 .80 .50 .70 .68 .61 .76 .74 C2 .62 .50 .56 .69 .60 .61 .46 .67 .54 .73 .45 .70 D1 .57 .56 .51 .59 .58 .59 .54 .48 .32 .55 .51 .47 D2 .71 .71 .63 .74 .69 .70 .67 .65 .79 .70 .64 .70 D3 .63 .75 .61 .61 .62 .53 .67 .51 .62 .71 .65 .66 D4 .76 .84 .70 .78 .72 .75 .71 .65 .61 .79 .60 .74 D5 .53 .36 .39 .60 .46 .44 .35 .51 .42 .59 .56 .52 D6 .62 .52 .56 .66 .51 .73 .53 .52 .53 .74 .47 .69 D7 .61 .51 .53 .68 .57 .63 .45 .57 .86 .57 .55 .62 E1 .51 .46 .60 .54 .35 .46 .44 .48 .27 .55 .45 .63 E2 .59 .47 .61 .62 .53 .60 .58 .33 .68 .59 .52 .65 E3 .42 .58 .48 .50 .50 .44 .44 .50 .04* .45 .34 .54 E4 .58 .56 .60 .59 .58 .61 .56 .55 .20 .68 .43 .68 E5 .55 .41 .53 .60 .44 .53 .45 .54 .74 .58 .60 .64 E6 .59 .57 .59 .65 .55 .60 .45 .47 .67 .60 .63 .70 * p > .05; All other standardized regression weights were statistically significant. EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 7

Table 6. Correlation coefficients among RCADS scores and countries. Irrespective of the adequacy of data fit, the PTSD-RI-5 scores. not all items within the model had satisfactory asso- PTSD-RI-5 subscale RCADS Anxiety score RCADS Depression score ciation with the proposed subscales (Joseph et al., B .54 (.23–.65) .45 (.16–.63) C .44 (.16–.52) .36 (.11–.42) 2010). Eight items had standardized regression D .59 (.25–.69) .58 (.22–.73) weights of > .50 across all countries; the B (four out E .57 (.48–.67) .56 (.40–.69) of five items; B2-5) and D subscale (three out of Diss .48 (.20–.59) .48 (.27–65) seven; D2-4) and item C1. The other items had low Diss – Dissociation; Whole sample correlation and range of the correla- tions across countries. values of standardized regression weights, of which eight had lower values across two or more countries and across all countries, except for the correlation compared to the others. Particularly problematic between RCADS Depression score and D subscale could be the left four D items (i.e., D1, D5-7) and for Portugal (.73; Table 6). three items in the E subscale (i.e., E1, E3, and E5). In addition, it was observed that the standardized regression weights for all PTSD-RI-5 items varied 4. Discussion across all countries. For example, item B4 (‘When The results of the inter-item and item-scale analyses something reminds me of what happened I get very demonstrated sound associations in-between and upset, afraid, or sad’) had values ranging from .63 in within the proposed subscales and the total score Nigeria to .81 in Brazil. Taken all findings together, for all items in the PTSD-RI-5, which may indicate although the four-factor structure of PTSD could be that all items the likely matching the proposed under- unique, not all items are common to оr equally rele- lying construct of PTSD. However, further analysis vant to all adolescents worldwide, nor interpreted in demonstrated sound internal consistency reliability a conceptually similar manner, which could be an only for the total score, B and D subscale. The indicator of cultural/society effects on the PTSD mea- E and dissociation subscale had low internal consis- surement. It appears that the least sensitive to these tency reliability in six out of 11 countries, while the effects, with the most satisfactory level of cross- internal consistency reliability of the C subscale was cultural undimensionality, could be items measuring low across all countries. Aside that the C and disso- symptoms of intrusions, while the most sensitive ciation subscale are created of only two items, insuf- could be items measuring alterations in arousal and ficient internal consistency reliability indicates that reactivity. Thus, the study confirmed only the config- the co-variances between the items are not similar, ural invariance of the PTSD-RI-5, which seems to be ideally identical, and these subscales may not be uni- an insufficient form of invariance for appropriate dimensional and homogenous in measuring proposed cross-cultural comparisons with the whole instru- symptoms of avoidance, alterations in arousal and ment (Gregorich, 2006). Compared to the others, reactivity, and dissociation symptoms. This is con- the poorest model fit, with the lowest regression trary to the findings of a Japanese study of the instru- weights, was evident for the Philippines’ sample, ment that showed internal consistency reliability of which could be largely due to very low item-total .77 and .85 for the two subscales, respectively, and > score relationships for B1, B5, D1, E1, E3, and E4 .70 for the other two and the total of the instrument found. This finding could indicate that these items (Takada et al., 2018). Possible explanations for our are highly sensitivity to and would be more affected result could be that there might be cultural factors by different group experiences, understandings, com- affecting the homogeneity, not all items are equally munication and behaviors in response to traumatic relevant in these cultures/populations, or not all items events in the Pilipino adolescents compared to others. contribute a similar amount of information for Thus, it warrants further investigation and possibly a proposed underlying construct for the C, E and reconsideration of how the PTSD-RI-5 is formulated dissociation subscale, which all was not necessary in this country considering that some recent findings reflected through the items in the B and D subscale. with adults, although reporting some specificities, The results of the next analyses showed that the largely agree with the DSM-5 PTSD symptomatology original factor structure of the instrument was con- (e.g., Mordeno, Carpio, Nalipay, & Saavedra, 2017; firmed for the overall sample indicating that the main Mordeno, Go, & Yangson-Serondo, 2017). four DSM-5 criteria for PTSD are unique to youth These above results for the factor structure open worldwide. However, some inconsistencies were a long debate over the last two decades about the observed within the measurement model across the latent structure of PTSD (see for details Liu et al., included countries. The original four-factor model 2014). Specifically, some studies on earlier versions of had inadequate fit degree for data from Brazil, the instrument questioned the dimensionality of Bulgaria, Montenegro, Philippines and Romania and DSM criteria and their applicability across various the current structure was common only for six nations (Charak et al., 2014; Liu et al., 2014). It is 8 A. DORIC ET AL. mostly agreed upon that the four-factor models can varied markedly from very weak to moderate/ provide a good representation of PTSD latent struc- strong across the participating countries, which ture (Elhai & Palmieri, 2011; Gootzeit & Markon, may indicate that the association between the mea- 2011; Yufik & Simms, 2010). However, it remains suring constructs is culturally dependent, too. On unclear which structure is more suitable. The four the other hand, a Japanese study demonstrated structure models include the four-factor numbing convergent validity only for the B and C subscales model (King, Leskin, King, & Weathers, 1998), the (Takada et al., 2018). four-factor dysphoria model (Simms, Watson, & There are many potential sources of differences Doebbeling, 2002), and the DSM-5 conceptualization across cultures when one congruent quantitative scale of symptoms which is closer to the four-factor numb- is used among children and adolescents (Stevanovic ing model. Studies in general support the DSM-5 et al., 2017b). Given so, some conceptual and metho- model. For example, Biehn et al. (2013) compared dological constraints need to be noted when interpret- the DSM-5 model and the DSM-5 dysphoria model ing the findings of this study. First, there may still be in a sample of trauma-exposed undergraduates and significant differences in evaluating, reporting, mani- found support for the DSM-5 model. Elhai et al. festing and/or expressing psychological symptoms (2012) tested four alternative models: the DSM-5 among cultures (Achenbach et al., 2012; Charak et al., model, alternative four-factor and five-factor models, 2014; Goodman et al., 2012; Heiervang, Goodman, & and the DSM-IV model. They reported that the Goodman, 2008; Lambert, Essau, Schmitt, & Samms- DSM-5 model fit the data adequately. Vaughan, 2007). Conflicting findings have been Armour, Műllerová, and Elhai (2016) conducted reported regarding ethnic differences PTSD (Pole, a systematic review of studies assessing the PTSD Best, Metzler, & Marmar, 2005; Roberts, Gilman, symptoms latent structure. They showed that the Breslau, Breslau, & Koenen, 2011;Ruchkinetal., four-structure model proposed by DSM-5 (in an 2005). For example, studies with Asian samples indicate overall of 14 different samples) showed adequate fit the collectivistic and fatalistic nature of expressing to data. However, when compared to alternative symptoms after a traumatic experience (Charak et al., models, only three studies showed optimal data fit 2014) as well as a predominance of somatic symptoms (21%). In all studies, there were 18 different PTSD (Terheggen, Stroebe, & Kleber, 2001). Such behavior models assessed via CFA, ranging from one to seven could alter the latent structure of PTSD. Second, it is factors. In another study, they proposed an alterna- possible that some items are more sensitive to one tive seven-factor hybrid model (Armour et al., 2015). culture and less to another. Moreover, they could easily Liu et al. (2014) showed that a six-factor model best be confounded by the culture-specific attributes related described PTSD symptoms in a Chinese population. to the construct. Considering the latter, some items In summary, studies on the latent structure of DSM-5 might not represent specific psychopathology as PTSD symptoms are limited, and even though the intended, but rather the general propensity to current four structure model is mostly confirmed, a psychopathology, or some items could be of less mixed findings still arise (Yufik & Simms, 2010). important when comparing cultural specifics and refer- The CFA results in our study suggest that the pro- ence norms (Heine, Lehman, Peng, & Greenholtz, posed DSM-5 model might not be culturally universal 2002). Therefore, inherent economic, social, and cul- and suitable in different countries. Therefore, it is tural factors could attribute to cultural differences important to highlight the remaining unclear concep- (Camras & Fatani, 2006; Hackett & Hackett, 1999; tualization of the PTSD clusters, which could also Lehman, Chiu, & Schaller, 2004; Mabe & Josephson, affect the psychometric properties of the PTSD-RI-5 2004; Nikapota & Rutter, 2008). In addition, in instrument. Further research should shed light on the a specific culture, some items might be more sensitive conceptualization and theoretical organization of the to factors such as age and gender than others (Charak PTSD criteria and their cross-cultural validity (Liu et al., 2014). For example, countries with traditional and et al., 2014). non-traditional gender roles could show different pat- The final analysis showed that the correlations terns of PTSD in males and females, implying an influ- among the RCADS and the PTSD-RI-5 scores were ence of culturally sanctioned gender roles on PTSD lower than expected indicating that the proposed symptoms (Charak et al., 2014; Norris, Perilla, Ibañez, PTSD subscales including dissociation symptoms &Murphy,2001). Differences in the manifestation of likely assess separate concepts from common anxi- symptoms and cultural construct interpretation could ety and depressive symptoms in youth, which pro- thus lead to differences in the factor structure of PTSD- vides preliminary evidence for discriminant RI-5 (Charak et al., 2014). validity. The only problematic correlation was Regarding the methodology of our study, it should between the RCADS Depression and D subscale be noted that only adolescents who agreed to participate scores for Portugal (r = .73). However, the strength were included and that the response rates varied sub- of the association between the two instruments stantially between countries. For this reason, there were EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 9 less than 330 participants for five countries for which the whole instrument cannot be used for within- CFA results did not replicate the original factor struc- country evaluations especially for those in which the ture of the instrument. In addition, we could not obtain structure was confirmed (i.e., Croatia, Indonesia, enough data for different sub-cultural and sub-racial Nigeria, Palestine-Gaza, Portugal, and Serbia). Given groups. Reasons for not participating remain unex- our study, it is important to address possible revisions plored. Furthermore, even though schools in the to the PTSD-RI-5, which could primarily be based on regions were randomly selected, participants were creating items that are more culturally independent, sampled from regions of convenience, which could for them to be easily implemented in multicultural limit the generalizability of the findings to adolescents contexts. This could be achieved by providing experts from other regions in each country. Next, the data were with research attempting to contrast weaker items based solely on self-reports, which could have affected found in the present study with open-ended questions the findings (Charak et al., 2014), since the authenticity or, preferably, interviews to validate the meaning, of youth self-report depends on many factors, i.e. understanding and rating of those items across differ- achild’s developmental level and factors about the ent cultures. In this regard, more psychometric studies event itself (Hawkins & Radcliffe, 2006). Multimethod are needed to test different aspects of reliability and approaches, including corroborative parent and teacher validity, as well as diagnostic accuracy in reports, (Hawkins & Radcliffe, 2006; Jensen et al., 1999), a multicultural context, but also cognitive interviewing were not obtained in this study. In addition, we studies to explore cultural sensitivity, relevance and included data from all adolescents who completed the appropriateness of PTSD items (Willis & Miller, instrument irrespective of trauma/adverse childhood 2011). Attempts to revise the measurement model event exposure, and the analyses of only these adoles- should be based on a more precise sampling method; cents may have yielded different results. Of relevance include parent, teacher and self-reports; and at risk could be youth experiencing complex trauma symp- and clinical samples. Given so, establishing the cross- toms, which may not be fully reflected through a self- cultural validity of the PTSD-RI-5 will improve the report. Related to this, since we have not tested how accuracy of childhood PTSD prevalence, and will facil- dissociative symptoms contribute to the overall model itate both the recognition and evaluation of interven- represented by four main DSM categories, it would be tion, as is the case for all other youth psychopathology relevant to see how these specifiers contribute to a more (Stevanovic et al., 2017a). specific diagnosis, namely PTSD with dissociative symptoms. Finally, no behavioral observations or clin- Acknowledgments ical indices were used to confirm this self-report mea- sure (Purgato & Barbui, 2012). We would like to thank to two unknown reviewers and the Summarizing, our study showed good internal con- Editor who assessed our article and gave fruitful comments. sistency reliability of the PTSD-RI-5 in all eleven coun- tries included in the study and for PTSD symptoms Disclosure statement related to B and D DSM-5 criteria. E criteria and specifiers for PTSD with dissociative symptoms had No potential conflict of interest was reported by the low internal consistency reliability in some countries, authors. while C criteria across all. However, evidence for dis- criminant validity was found for all PTSD criteria Funding against anxiety and depressive symptoms. The four- factor structure of the PTSD-RI-5 likely represents the This study was not funded. core PTSD symptoms in adolescents worldwide as proposed by the DSM-5 criteria. However, the PTSD- Data availability statement RI-5 items are likely interpreted in a conceptually dif- The data that support the findings of this study are avail- ferent manner by adolescents from different cultural/ able on request from the corresponding author [DS]. regional backgrounds. Thus, besides reflecting the uniqueness of the current DSM-5 model, the findings imply that the PTSD-RI-5 self-report might not allow ORCID direct cross-cultural/region comparisons and every Ana Doric http://orcid.org/0000-0001-6681-3942 single cross-cultural comparison should explore the Dejan Stevanovic http://orcid.org/0000-0001-8236-5246 structure of the instrument first and consider the Olayinka Atilola http://orcid.org/0000-0001-9835-6432 items for cultural/reginal relevance in the comparison. Paulo Moreira http://orcid.org/0000-0002-5454-7971 If further replicated, this finding has implications for Tomislav Franic http://orcid.org/0000-0002-5240-7166 Vrljicak Davidovic http://orcid.org/0000-0002-3547- epidemiological and clinical research, as well as for the 9408 conceptualization of PTSD. The inappropriateness to Multazam Noor http://orcid.org/0000-0002-0330-1664 conduct cross-country comparison does not imply that Laura Nussbaum http://orcid.org/0000-0003-0422-918X 10 A. DORIC ET AL.

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iMedPub Journals Health Science Journal 2019 www.imedpub.com Vol.13 No.1:621 ISSN 1791-809X

DOI: 10.21767/1791-809X.1000621 The Relationship between War Trauma, PTSD, Anxiety and Depression among Adolescents in the Gaza Strip Hana'Ahmed Qeshta1, Ahmed M AL_Hawajri2 and Abdelaziz M Thabet3*

1MCMH-Ministry of Education, Palestine 2Director of Counseling Unit, Ministry of Education, Palestine 3Department of Child and Adolescent Psychiatry, School of Public Health, Al Quds University, Gaza, Palestine *Corresponding author: Abdelaziz M Thabet, Department of Child and Adolescent Psychiatry, School of Public Health, Al Quds University, Gaza, Palestine, Tel: 0599604400, 2834292; E-mail: [email protected] Received date: 01 August 2018; Accepted date: 04 February 2019; Published date: 11 February 2019 Copyright: © 2019 Qeshta H, et al. This is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. Citation: Qeshta H, Hawajri AMA, Thabet AM (2019) The Relationship between War Trauma, PTSD, Anxiety and Depression among Adolescents in the Gaza Strip. Health Sci J Vol.13.No.1:621. total PTSD, re-experiencing, avoidance and arousal. There was statistical correlation between anxiety and Abstract depression, anxiety and PTSD and there was statistical significant correlation between PTSD and depression. Aim: The study aimed to investigate the relationship between war trauma and PTSD (Post-Traumatic Stress Keywords: Adolescents; Anxiety; Depression; Gaza Strip; Disorder), anxiety and depression problems among PTSD; Trauma secondary school students in Gaza Strip.

Method: The study sample consisted of 408 randomly selected secondary school students (204 boys and 204 Introduction girls). Adolescents were interviewed using socio- The extended effects of wars and conflicts depend on a demographic questionnaire, Gaza Traumatic Events Checklist, Birleson Self-Rating Depression Scale, and complex interaction of different factors that include Revised Children's Manifest Anxiety Scale. demographic considerations and the specific nature of the individual’s war and traumatic experiences [1]. However, Results: The results showed that the most common research on war conflicts and other survivors of traumatic reported traumatic experiences by adolescents were experiences found that more time spent in potential danger watching mutilated bodies in TV (93.1%), hearing shelling can lead to increased levels of trauma and subsequently of the area by artillery (92.4%), hearing the loud voice of affecting their mental health [2-4]. The Palestinians generally drones (90.4%), forced to leave you home with family and Gazans' people specially experienced a new wide range of members due to shelling (67.6%), and Inhalation of bad war trauma that affected everything in their life which smells due to bombardment (67.6%). Mean traumatic reflected negatively on their mental health. During the war events were 10. many of the Gazans' people lost their families, children and many close relatives in addition to some families completely There were statistically significant differences toward lost. Furthermore, they lost their work, possessions, cultural boys. Our results showed that 25.5% showed partial PTSD continuity and places they love which considered one of the and 16.4% of children showed full criteria of PTSD. PTSD most significant factors in mental health instability [5-7]. was more in children with family monthly income less than 1700 NIS. Using cut-off point of the scale, 92 of The DSM-IV-TR (Diagnostic and Statistical Manual of Mental children reported anxiety (22.2%). There were statistically Disorders-Fourth Edition (Text Revision)) has made some significantly differences in anxiety in favour of girls. modifications, which have attempted to compensate for the Anxiety was more in children from poor families (monthly difference in symptom presentation in children and income less than 1700 NIS). Using cut-off point of the adolescents. These current criteria focus on re-experiencing, scale, 139 of children reported depression (34.1%). avoidance and hyperarousal; however even these broad Depression was more in children from poor families categories of criteria may manifest themselves differently in (monthly income less than 1700 NIS). children which then may lead to failure to fully capture PTSD symptoms displayed in a younger population [8]. The results showed that there was significant correlation between total traumatic events reported by children and While, Khamis in study of Palestinian children found that 34.1% of the children diagnosed as Post-Traumatic Stress

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Disorder (PTSD) [9]. Moreover, Elbedour et al. [10] in study of PTSD symptoms was 18.37, intrusion mean was 8.98, Palestinian children found that 68.9% were reported as PTSD avoidance symptoms subscale mean was 9.49. Almost sixty cases. Furthermore, Thabet et al. [5] in study of Palestinian percent of children had posttraumatic stress disorder children and families, showed that children experienced a symptoms, 21.9% of children had anxiety and 50.6% had mean number of 8 traumatic events, 138 children out of 197 depression. Numbers of traumatic events was associated with (70.1%) were likely to present with PTSD, 33.9% were rated as PTSD, avoidance, arousal symptoms, anxiety, and depression. having anxiety symptoms of likely clinical significance, 42.7% Silwala et al. [17] in a study assessed the prevalence of Post- were rated as having significant mental health morbidity by Traumatic Stress Symptoms (PTSS) and depressive symptoms their parents. Scrimin et al. [11] in study of 58 school-age and explored potential risk factors among adolescents exposed children three years after the terrorist attack in Beslan, Russia in 2015 to two major earthquakes in Nepal. They were 893 in 2004. The analysis of the UCLA PTSD Index data revealed students aged 11–17 in school grades 7–10. They lived in two that overall, 17 (29.3%) children met criteria for PTSD three districts affected by the earthquakes: Sindhupalchok and years after the terrorist attack. Of these, 15 had been directly Kathmandu. The prevalence of PTSS in the Sindhupalchok and exposed to the attack (50% of directly exposed group) and only Kathmandu districts were 39.5% and 10.7% and depression 2 had been indirectly exposed to the attack (7% of indirectly symptoms were 40.4% and 23.2% respectively. exposed group) and no significant differences were found in More recently, Thabet et al. [7] in study of 61 children from relation to gender. Gender differences in rates of exposure and 2 community centers in one refugee camp in the Gaza Strip. trauma-related symptom profiles have been investigated. This study showed that children commonly reported traumatic Women are more frequently exposed to childhood sexual events such as watching pictures of killed and wounded people abuse, domestic violence and sexual assault, whereas men are on TV (90.7%), hearing the shootings and bombardment due more likely to have experienced natural disasters, motor to fighting in the streets (85.2%), and Hearing arrest or vehicle accidents, and other accidents [12]. Women often kidnapping of someone or a friend (77.8%). For PTSD, 29.6% of exhibit higher rates of PTSD and some other trauma-related children were considered as PTSD, 24.1% of children reported symptoms, such as internalizing disorders (i.e., anxiety and and 22.2% of children reported depression. depression) and somatic complaints than men who experience The results showed that there was significant association more externalizing disorders (i.e., conduct and substance use) between total traumatic events reported by children and PTSD [12,13]. Thus, women may be more vulnerable to developing, and total anxiety. In addition, total anxiety was associated with or more willing to report experiencing, some adverse trauma- total PTSD. related symptoms than men. Moreover, Thabet et al. [13] in study sample consisted of 358 adolescents aged 15 to 18 years The last war on Gaza Strip was in August 2014, it was old age. The study showed that, the mean traumatic events considered the most destructive one in comparison with two reported by adolescents was 13.34. The results showed the previous wars, which lasted for 51 day. This war caused killing mean total anxiety was 41.18, obsessive compulsive subscale 2,145 Palestinians, 578 of them were children and was 8.90, generalized anxiety subscale was 4.46, social phobia adolescents, about 11,000 others had been wounded, more was 6.99, separation anxiety was 6.16, physical injury fears than 500,000 Palestinians internally displaced at the height of were 5.48 and panic/ was 5.4. The results showed the hostilities, over 100,000 still displaced, and approximately that girls had more anxiety problems than boys including all 18,000 housing units destroyed or severely damaged (OCHA, anxiety subscales. Regard PTSD, the study showed that 34.31% 2014) https://www.ochaopt.org/reports/ situation-reports. reported symptoms meeting criteria for partial PTSD, while The study objectives were 1) To identify the levels of war 29.8% reported symptoms meeting criteria for full PTSD trauma related to secondary school students in Gaza Strip 2) according to DSM-IV-TR. The results showed that girls reported To find prevalence of depression, PTSD, and anxiety among more PTSD than boys. Similarly, study of children after war on secondary school students in Gaza Strip 3) To examine the 2014 on Gaza indicated that approximately 30 percent of the relationship between war trauma, PTSD, depression and Palestinian children who were exposed to higher levels of war anxiety among secondary school students in Gaza Strip. traumas have developed PTSD with excess risk for co- morbidity with other disorders such as emotional symptoms and neuroticism [14]. Lee et al. [15] in study of the prevalence Method and associated factors of Post-Traumatic Stress Disorder (PTSD) symptoms among a sample of 57 students (29 boys and Participants 28 girls) who survived the Sewol ferry disaster 20 months after that disaster. The results showed that 26.3% of participants A simple random sample of 408 secondary school students were classified in the clinical group by the Child Report of Post from governmental schools was taken using the proportional traumatic Symptoms score, PTSD symptoms were positively ratio between the gender and governorates. Out of 408 correlated with the number of exposed traumatic events. students, 204 (or 50%) are female and 204 (or 50%) are male. Moreover, Thabet et al. [16] in study 251 children from 3 135 students (33.1%) aged 16 years old, 138 students (33.8%) summer camps aged 6-16. The study showed that children aged 17 years old and 135 students (33.1%) were at 18 years commonly reported traumatic events such as hearing shelling old. of the area by artillery, hearing the sonic sounds of jetfighters and seeing images of dead and injured people on TV. Mean 2 This article is available from: www.hsj.gr Health Science Journal 2019 ISSN 1791-809X Vol.13 No.1:621

The researcher expected that the study will take 10 months Revised Children’s Manifest Anxiety Scale (RCMAS): RCMAS starting from October 1st 2014 till August 1st 2015. is designed to measure symptoms of generalized anxiety in children and youths. The 37 scale items are answered “Yes” or Instruments “No”. Nine items comprise a Lie scale, thus symptom severity scores range from 0-28. The clinical cut-off score has been set The researcher will develop the study instruments according to 18 [20]. Reliability by Cronbach’s alpha has been found to be to literature review and will benefit from other ready tools. high (0.85) [21]. A high correlation (r=0.85) has been found between RCMAS and other instruments measuring trait Socio-demographic questionnaire anxiety [22]. The Arabic version of RCMAS has been applied in several research projects conducted in Arabic Palestinian Socio-demographic Questionnaire consisted of variable that population [5,23]. The reliability of our Arabic version of the contained in the study that include age, sex, place of depression scale in this study was α=0.86; split half =0.80. residence, number of sibling, family income and other variables that may affect the psychological conditions of the children. Study Procedure Gaza Traumatic Events checklist (51 days war): This scale An ethical approval was approved for from School of Public contains 28 item, that checked by ''yes'' or ''no'' and which Health at Al-Quds University and Ethical Helsinki Committee. measures the traumatic events that children experience during Another letter obtained from the Ministry of Education was wars and it helps identify the types of traumatic events that granted. Furthermore, A consent form was taken from the encounter the Palestinian children in Gaza strip. The scoring of respondents (students) after clarifying the aim of the study the scale ranged between 0 for those who choose ''No'' and 28 and its objectives and grantee that they protected from any for those who choose ''Yes''. In this study, the Cronbach’s harm resulting from their agree or disagree for participation. Alpha was 0.81 [14]. Also, the researcher grantee that the collected information will be used for scientific research only and will be kept for this PTSD Scale for DSM-IV (Arabic version): The items of the A purpose. Data collection was conducted by 5 professionals PTSD scale indices are keyed to DSM-IV criteria and can with previous experience in data collection. A list of involved provide preliminary PTSD diagnostic information. Self-reports schools were randomly selected and were given to field for children and adolescents exist, as well as a parent report of workers in each area with age, sex, and place of residence of PTSD symptoms [5]. The adolescent Version (for adolescent the students. In the selected schools, a random three classes aged 13 years and older) contains a total of 22 questions, have were chosen and from the registration book of each class, also been administered in school classroom settings. A 5-point randomly selected names of students were selected. Likert scale from 0 (none of the time) to 4 (most all the time) is used to rate PTSD symptoms. Only 17 items were included in At the end 408 students from total of 420 study population the total score because two items were not DSM-IV criteria responded to the interview. They were 204 girls and 204 boys. and three items were repeated symptoms. Although there is The students were completed the questionnaires after giving limited information about the specific cut-off score for a them through instructions by data collectors in the specified particular trauma type or population, a cut-off score of 38 has schools. Each student completed the questionnaire in 30 been proposed in the literature Steinberg. In this study, the minutes. We collect the data from governmental schools Cronbach’s Alpha was 0.83. during March 2015. Depression Self-Rating Scale for Children–DSRS: The DSRS- C is simple to use. It is brief and only takes a child a few Statistical Analysis minutes to complete. Children with poor reading skills or short-term auditory memory difficulties may require help in All analyses were carried out using Statistical Package for understanding the longer items, but the scoring patterns of the Social Sciences SPSS ver. 23 for data entry and analysis. younger children have been found to be very similar to those Frequencies and percentages of trauma, PTSD, anxiety and of their elder peers [18,19]. Explain that there is no right or depression items were calculated. Independent t-test was wrong answer and that the important thing is to say how they conducted to find differences between two groups. Pearson’s have really felt. They were asked to choose whether the correlation coefficient tested the association between trauma, statement applied to them "most of the time", "sometimes" or PTSD, anxiety and depression. Linear regression investigated "never". Item responses are simply scored in the direction of the association between independent (traumatic events) and disturbance, i.e. depressive items score 2, "sometimes" items PTSD as dependent variable was conducted to find the score 1, and non-depressive items score 0. For items 1, 2, 4, 7, predictor factors of psychopathology in children. A p-value ≤ 8, 9, 11, 12, 13 and 16 'mostly' scores 0, 'sometimes' scores 1 0.05 was considered statistically significant. and 'never' scores 2. For items 3, 5, 6, 10, 14, 15, 17 and 18 'mostly' scores 2, 'sometimes' scores 1 and 'never scores 0. The item scores are summed to give the total score. In this study, the Cronbach’s Alpha was 0.83 [19].

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Results 1701-2400 NIS, 15.7% had a monthly income 2401-4000 NIS, 9.3% had monthly income more than 4001 NIS. Regard fathers education, 4.8% fathers were uneducated, 22.2% had Socio demographic characteristics of the preparatory school education, 34.4% had elementary children and adolescents education, 29.8% had secondary education, 7.7% had university degree and 1.0% held a post graduate degree. The sample consisted of 204 boys (50%) and 204 girls (50%). Regard fathers job, 32.4% of fathers were unemployed, 14% According to the selection criteria, the age range was 16-18 were simple workers, 6.1% were skilled workers, 27.7% were years, with a mean age of 17 years (SD=0.81). Regard place of civil employee and working, 12% were civil employee not at residence, 70 of adolescents were from north Gaza (17.2%), work and getting salary and 7.8% were merchants. For 135 live in Gaza area (33.1%), 61 live in Middle area (15%), 94 mothers education, 4.8% of mothers were uneducated, 22.2% live in Khan Younis (23%), and 48 live in Rafah area (11.8%). had preparatory education, 34.4% had elementary education, Regard place of residence, 68.9% live in family own house, 29.8% had secondary education, 7.7% had university degree, 4.9% live in rented houses, 1.7% live in camps, and 24.5% live 1% held a post graduate degree. Regard mothers job, 88.5% of house with extended family. Regard siblings, families were of mothers were housewives, 1.2% were simple workers, 1% large size, as 21.1% of the participating families had 4 or less were civil employee and working and 7.1% were civil employee siblings, 48.8% had 5-7 siblings, and 30.1% had 8 or more not at work and getting salary (Table 1). siblings. Regard family monthly income, 58.8% of the families had a monthly income under 1700 NIS, 16.2%% between

Table 1 Socio-demographic information of the children (N=408).

Variable No %

Gender

Male 204 50

Female 204 50

Place of residence

North Gaza 70 17.2

Gaza 135 33.1

Middle area 61 15

Khan Younis 94 23

Rafah area 48 11.8

Type of residence

Own 281 68.9

Rented 20 4.9

Camp 7 1.7

With family 100 24.5

No of siblings

Four and less 86 21.1

Five to seven siblings 199 48.8

Eight and more siblings 123 30.1

Family monthly income

Less than 1700 NIS 240 58.8

1701-2400 NIS 66 16.2

2401-4000 NIS 64 15.7

More than 4000 NIS 38 9.3

Paternal Job

4 This article is available from: www.hsj.gr Health Science Journal 2019 ISSN 1791-809X Vol.13 No.1:621

Unemployed 132 32.4

Simple worker 57 14

Skilled worker 25 6.1

Civil employee and working 113 27.7

Civil employee not at work 49 12

Merchant 32 7.8

Maternal job

House wife 361 88.5

Simple worker 5 1.2

Civil employee and working 4 1

Civil employee not at work 29 7.1

Type and severity of traumatic events smells due to bombardment (67.6%). While, the least common traumatic experiences were: Witnessing arrest of a close The most common traumatic experiences reported by relative by the army (10.8%), witnessing arrest of a friend and children were: watching mutilated bodies in TV (93.1%), physical injury due to bombardment of your home (10.3). The hearing shelling of the area by artillery (92.4%), hearing the study showed that Palestinian children in the Gaza Strip had loud voice of drones (90.4%), forced to leave you home with experienced from 0-28 traumatic events with mean of 10 family members due to shelling (67.6%) and Inhalation of bad traumatic events (SD=4.79) (Table 2).

Table 2 Types of traumatic events due to 51 days’ war on Gaza in children (N=408).

Yes No

Traumatic events No. % No. %

Hearing shelling of the area by artillery 394 96.6 14 3.4

Watching mutilated bodies in TV 385 94.4 23 5.6

Hearing the loud voice of Drones 380 93.1 28 6.9

Hearing killing of a friend 322 78.9 86 21.1

Inhalation of bad smells due to bombardment 285 69.9 123 30.1

Witnessing demolition of big buildings 238 58.3 170 41.7

Forced to leave you home with family members due to shelling 238 58.3 170 41.7

Witnessing firing by tanks and heavy artillery at neighbours’ homes 235 57.6 173 42.4

Threaten by telephone to leave the home for bombardment of home 217 53.2 191 46.8

Receiving pamphlets from Airplane to leave your home at the border and to move to the city centres 173 42.4 235 57.6

Hearing killing of a close relative 154 37.7 254 62.3

Deprivation from water or electricity during detention at home 138 33.8 270 66.2

Witnessing assassination of people by rockets 113 27.8 294 72.2

Threaten by shooting 107 26.2 301 73.8

Witnessing shooting of a friend 106 26 302 74

Destroying of your personal belongings during incursion 76 18.6 332 81.4

Witnessing shooting of a close relative 75 18.4 333 81.6

Witnessing killing of a friend 69 16.9 339 83.1

Witnessing firing by tanks and heavy artillery at own home 64 15.7 344 84.3

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Witnessing killing of a close relative 55 13.5 353 86.5

Threatened with death by being used as human shield by the army to move from one home to home 50 12.3 358 87.7

Witnessing arrest of a friend 39 9.6 369 90.4

Threaten of killing of your closed relative in front of you 39 9.6 369 90.4

Shot by bullets, rocket, or bombs 36 8.8 372 91.2

Personal threat if killing by the army 34 8.3 374 91.7

Witnessing arrest of a close relative by the army 30 7.4 378 92.6

Physical injury due to bombardment of your home 29 7.1 379 92.9

Being arrested during the land incursion 29 7.1 379 92.9

Differences in traumatic events according to event, including images, thoughts, or (49%), acting socio-demographic variables or feeling as if the traumatic event were recurring (44.8%), intense psychological distress at exposure to internal or In order to find differences in traumatic events according to external cues that symbolize or resemble an aspect of the socio-demographic variables such as sex, age, place of traumatic event (34.8%) (Table 3). residence, education, family monthly income a t-independent test was conducted. T-independent test was done in which Means and standard deviations of PTSD mean of trauma was independent variable and sex of children was dependent variable. The results showed that the mean The results showed mean total scores of PTSD was 25.92 traumatic event in boys were 10.91 (SD=4.51) and 9.24 for girls (SD=11.83), mean re-experiencing symptoms was 9.63 (SD=4.06). There were statistically significant differences (SD=4.69) mean avoidance was 8.39 (SD=4.89) and mean toward boys (t=3.9, p=0.001). There were no statistically arousal was 7.90 (SD=4.69) (Table 4). significantly differences in traumatic events and age of adolescents.

PTSD symptoms The most common post traumatic reactions in adolescents were: recurrent and intrusive distressing recollections of the

Table 3 Post-traumatic distress symptoms in children (N=408).

Never/ Scale items Rarely Sometimes Much/ often

Recurrent and intrusive distressing recollections of the event, including images, thoughts, or 19.9 31.1 49 1 perceptions.

2 Recurrent distressing dreams of the event 51.9 27.9 20.1

3 Acting or feeling as if the traumatic event were recurring 28.9 26.2 44.8

Intense psychological distress at exposure to internal or external cues that symbolize or resemble 40 25.2 34.8 4 an aspect of the traumatic event

Physiological reactivity on exposure to internal or external cues that symbolize or resemble an 61.3 14.2 24.6 5 aspect of the traumatic event

6 Efforts to avoid thoughts, feelings, or conversations associated with the trauma 40.7 26.7 32.6

7 Efforts to avoid activities, places, or people that arouse recollections of the trauma 52.2 19.9 27.9

8 Inability to recall an important aspect of the trauma 64.2 18.6 17.1

9 Markedly diminished interest or participation in significant activities 63.2 19.4 17.4

10 Feeling of detachment or estrangement from others 74.1 13 13

11 Restricted range of affect (e.g., unable to have loving feelings) 81.7 9.1 9.3

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Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a 64.7 14.7 20.6 12 normal life span)

13 Difficulty falling or staying asleep 60.8 17.9 21.3

14 Irritability or outbursts of anger 56.6 21.8 21.5

15 Difficulty in concentration 49.8 24 26.2

16 Hyper vigilance (On edge been easily distracted or had to stay) 45.1 22.1 32.9

17 Exaggerated startle response 51 20.1 28.9

Table 4 Means and Standard deviations of PTSD.

Mean Std. Deviation

Total PTSD 25.92 11.83

Re-experiencing 9.63 4.69

Avoidance 8.39 4.89

Arousal 7.9 4.69

Prevalence of PTSD results showed that there were no significant differences in total means of PTSD age of children, place of residence. According to DSM-IV diagnosis method of PTSD of summing However, Post-hoc analysis using Tukey’s statistical test of (one re-experiencing, 3 avoidance and 2 arousal symptoms). showed that PTSD was more in children with family income The results showed that 129 of children (31.6%) showed no less than 1700 NIS. PTSD, 108 of children (26.5%) showed at least one criteria of PTSD (B or C or D), 104 showed partial PTSD (25.5%) and 67 of Anxiety symptoms children showed full criteria of PTSD (16.4%). The study showed that the most common anxiety symptoms Differences between different socio-demographic variables reported by adolescents were: I get nervous when things do such as sex, family monthly income and PTSD: t independent not go the right way for me (82.1%), I worry about what is test was performed to find sex differences in PTSD and sub going to happen (64.5%), It is hard to keep my mind on my scales. The results showed that there were no statistically school work (46.6%), I worry about what other people think significant differences in total PTSD scores (Mean=26.98 girls about me (46.8%) and I wiggle in my seat a lot (45.6%). Using vs. 24.87 for boys) (t=1.8, p=0.07) and also no significant for cut-off point of the scale, 92 of children reported anxiety avoidance, and arousal subscales, but the girls reported more (22.2%) (Table 5). re-experiencing symptoms than boys (t=5.16, p=0.001). The

Table 5 Anxiety symptoms in children (N=408).

Yes No

No. % No. %

1 I have trouble making up my mind 122 28.5 286 66.8

2 I get nervous when things do not go the right way for me 335 82.1 73 17.9

3 Others seem to do things easier than I can 179 43.9 229 56.1

4 Often I have trouble getting my breath 161 39.5 247 60.5

5 I worry a lot of the time 176 43.1 232 56.9

6 I am afraid of a lot of things 152 37.3 256 62.7

7 I get mad easily 178 43.6 230 56.4

8 I worry about what my parents will say to me 189 46.3 219 53.7

9 I feel that others do not like the way I do things 122 29.9 286 70.1

10 It is hard to get to sleep at night 122 29.9 286 70.1

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11 It is hard to keep my mind on my school work 190 46.6 218 53.4

12 I feel alone even when there are people with me 101 24.8 307 75.2

13 Often I feel sick in my stomach 102 25 306 75

14 My feelings get hurt easily 171 41.9 237 58.1

15 My hands feel sweaty 124 30.4 284 69.6

16 I am tired a lot 121 29.7 287 70.3

17 I worry about what is going to happen 263 64.5 145 35.5

18 Other children are happier than I 140 34.3 268 65.7

19 I have bad dreams 123 30.1 285 69.9

20 My feelings get hurt easily when I am fussed at 203 49.8 205 50.2

21 I feel someone will tell me I do things the wrong way 184 45.1 224 54.9

22 I wake up scared some of the time 128 31.4 280 68.6

23 I worry when I go to bed at night 98 24 310 76

24 I worry about what other people think about me 191 46.8 217 53.2

25 I wiggle in my seat a lot 186 45.6 222 54.4

26 I am nervous 140 34.3 268 65.7

27 A lot of people are against me 133 32.6 275 67.4

28 I often worry about something bad happening to me 269 65.9 139 34.1

Differences between different socio-demographic variables total means of anxiety (F=3.935, p=0.009) according to family such as sex, family monthly income and anxiety: There were income in favor of those who have less than 1700 NIS. statistically significantly differences in anxiety according to sex of adolescents in favour of girls (X2=1.71, df=2, p=0.005). There Depression symptoms were no significant differences between the total means of anxiety (F=0.01, p=0.98) according to age of adolescents. The study showed that the most common depression symptoms reported by adolescents were: I like talking with No significant differences between the total means of my family (68.4%), I can stick up for myself (63%), and I feel so anxiety (F=1.32, p=0.26) according to number of siblings. There sad I can hardly stand it (54.9%). Using cut-off point of the were no significant differences between the total means of scale, 139 of children reported depression (34.1%) (Table 6). anxiety and place of residence (F=1.304, p=0.268). The results showed that there were significant differences between the

Table 6 Depression symptoms in children (N=408).

Depression items Always Sometime No

I look forward to things as much as I used to 35.8 52.9 11.3

I sleep very well 40.9 45.1 14

I feel like crying 31.1 46.6 22.3

I like to go out to play 27.5 35.8 36.8

I feel like running away 40.4 33.6 26

I get tummy aches 13.2 45.8 40.9

I have lots of energy 9.3 31.4 59.3

I enjoy my food 40.2 51.7 8.1

I can stick up for myself 63 31.4 5.6

I think life isn't worth living 27.7 42.2 30.1

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I am good at the things I do 42.6 51 6.4

I enjoy the things I do as much as I used to 29.9 52.5 17.6

I like talking with my family 68.4 23.3 8.3

I have bad dreams 50.7 40 9.3

I feel very lonely 52.7 33.6 13.7

I am easily cheered up 42.4 43.4 14.2

I feel so sad I can hardly stand it 54.9 35.3 9.8

I feel very bored 23.5 53.9 22.5

Differences between different socio-demographic variables were negative correlation between depression and family such as sex, family monthly income and depression: t income” toward families with family income less than 1700NIS. independent test was performed to find sex differences in We can find that most of population their family monthly Depression. The results showed that there were statistically income less than 1700 NIS significant differences in total Depression scores toward boys Relationship between total trauma and PTSD, anxiety and (mean=14.07 boys vs. 15.16 for girls) (t=2.32, p=0.02). There depression in adolescents: Pearson correlation test was done were no significant differences between the total means of to find the association between total trauma and PTSD, anxiety depression and number of siblings. and depression in adolescents. The results showed that there The results showed that there were significant differences was significant correlation between total traumatic events between the total means of depression (F=5.91, p=0.001) reported by children and total PTSD (r=0.26, p=0.001), re- according to family income in favor of those who have less experiencing (r=0.22, p=0.001), avoidance (r=0.26, p=0.001), than 1700 NIS. and arousal (r=0.18, p=0.01). There was statistical correlation between anxiety and depression (r=0.60, p=0.001), anxiety Post-hoc analysis according to Tukey’s statistical test was and PTSD (r=0.61, p=0.001) and there was statistical significant done and indicated; the total means of depression according correlation between PTSD and depression (r=0.47, p=0.001) to family income “Less than 1700 NIS, 1700-2400 NIS, (Table 7). 2410-4000 NIS, 4001 and more” as shown in the Table 7, there

Table 7 Pearson correlation test between total trauma and PTSD, anxiety and depression in adolescents.

1 2 3 4 5 6

Trauma 1

Depression 0.09 1

Anxiety 0.09* 0.60** 1

PTSD 0.26** 0.47** 0.61** 1

Re-experiences 0.20** 0.28** 0.37** 0.72** 1

Avoidance 0.22** 0.26** 0.30** 0.69** 0.38** 1

Hyperarousal 0.14** 0.45** 0.58** 0.75** 0.46** 0.43**

*Statistical correlation between anxiety and depression **Statistical correlation between anxiety and PTSD

Prediction of PTSD by traumatic events someone or a friend (β=0.11, p=0.01), hearing killing of a friend (β=0.14, p=0.01), threaten by telephone to leave the In order to test the predictive value of specific traumatic home for bombardment of home (β=0.12, p=0.01), forced to events on PTSD symptoms, total PTSD was entered as the leave you home with family members due to shelling (β=0.14, dependent variable in logistic regressions, with 28 types of p=0.01), deprivation from water or electricity during detention traumatic events as the covariates. The events that were at home(β=0.12, p=0.01), hearing the loud voice of Drones significantly associated with PTSD were: receiving pamphlets (β=0.11, p=0.01) (R2=0.12, F=9.3, p=0.001) (Table 8). In order from Airplane to leave your home at the border and to move to test the predictive value of specific traumatic events on to the city centers (β=0.12, p=0.01), witnessing arrest of

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PTSD symptoms, total PTSD was entered as the dependent variable in logistic regressions, with 28 types of traumatic

Table 8 Regression analysis of PTSD and traumatic events.

Unstandardized Standardized t 95.0% Confidence Interval for B Coefficients Coefficients Sig. Lower Upper B Std. Error Beta Bound Bound

Constant 13.21 2.52 5.25 0.001 8.26 18.16

Receiving pamphlets from Airplane to leave your home at the border and to move to the city centres 2.83 1.17 0.12 2.42 0.02 0.53 5.13

Hearing killing of a friend 3.18 1.41 0.11 2.25 0.02 0.4 5.95

Threaten by telephone to leave the home for bombardment of home 3.33 1.15 0.14 2.89 0.001 1.06 5.6

Forced to leave you home with family members due to shelling 2.81 1.17 0.12 2.4 0.02 0.51 5.1

Deprivation from water or electricity during detention at home 3.03 1.22 0.12 2.49 0.01 0.63 5.42

Hearing the loud voice of Drones 4.94 2.22 0.11 2.23 0.03 0.58 9.29

Discussion Boys statistically significantly reported severe traumatic events than girls. The researchers hypothesized that for long- The most common traumatic experiences reported by term exposure of wars and conflicts in the area that children were: watching mutilated bodies in TV (93.1%), contributed for different levels of trauma among children. The hearing shelling of the area by artillery (92.4%), hearing the results showed than mean traumatic event in boys were 10.91 loud voice of drones (90.4%), forced to leave you home with (SD=4.51) and 9.24 for girls (SD=4.06), there were statistically family members due to shelling (67.6%) and Inhalation of bad significant differences toward boys. The researcher attributed smells due to bombardment (67.6%). While, the least common that for mobility of male children and their connection to traumatic experiences were: witnessing arrest of a close fathers more than the female children did. The male children relative by the army (10.8%), witnessing arrest of a friend and move freely and go here and there, but female children physical injury due to bombardment of your home (10.3). The connected to their mothers and stay at home. The results were researcher proposed that for continuous exposure for direct consistent with the study of Thabet et al. [5] that showed that effects of war, since the Palestinian people have been suffering boys reported more exposure to severe traumatic events than for long time of wars 2008/2009; 2012; and the last one was girls did. Moreover, the authors reported that Palestinian on 2014. So the population generally and young children children in the Gaza Strip had experienced from 3-17 traumatic specially have a compound effects of these wars and suffer events with mean of 7.5 traumatic events. from different types of war trauma that affect their Moreover, our study showed that prevalence of PTSD was psychological condition. 16.4%. Moreover, Dawas et al. [25] in study a sample consisted The results of current study consistent with the results of of 400 secondary school students. The results showed that Thabet et al. [13], they showed that the most common 10.5% had full criteria of PTSD. Our prevalence rate of PTSD traumatic experiences reported by children were; 1) Hearing was lower than the rate found in study aimed to find the loud noises of drones; 2) Hearing shelling of the nearby area prevalence rate of PTSD, anxiety and depression among by artillery.; 3) Hearing the sonic sounds of fighter jets; 4) orphaned children in Gaza Strip, which showed that 34.6% Watching mutilated bodies on television. However, the results showed severe PTSD [26]. Our results were consistent with of the current study consistent with the results of Al-Arjani et Thabet et al. [7] study a sample consisted of 449 children al. [24] that found 92.8% of martyrs' children witnessing selected randomly from the entire Gaza Strip, which showed photos of martyrs' and injured in TV, 71.6% witnessing raids that 12.4% of children had reported full criteria of post- attack of houses and streets by missiles and 66.8% exposure to traumatic stress disorder. The current study showed that there long hours wait on checkpoints. And consistent with the study were significant differences in total PSTD and subscales results of Thabet et al. [5] which showed that both children according to family monthly income. Total PTSD was more in and parents reported a high number of experienced traumatic families with monthly income less than 1700 NIS. The events. Both war trauma and parents' emotional responses researcher proposed that the families with high income were significantly associated with children's PTSD and anxiety satisfied positively with different types of traumatic events, symptoms. because they were able to secure the basic life needs during

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the war, but the families with low income have intensified significant anxiety and depressive symptoms were 20.5% and problems in addition to traumatic problems. The current study 22.3% respectively. Girls reported significantly more consistent with the results of Thabet et al. [26] that found depressive symptoms than boys. More recently, Thabet et al. children coming from families with incomes of less than $ 300/ [26] in study aimed to find the prevalence rate of PTSD, anxiety month, living in a city, whose parents had less than elementary and depression among orphaned children in Gaza Strip. The education were found to suffer more frequently from PTSD. study sample consisted of 81 orphaned children from Al-Amal Institute for Orphans. The study showed that 67.9% of children In this study, using cut-off point of the scale, 22.2% of reported depression. Depression was more in children from children reported anxiety. Our rate of anxiety was less than north Gaza had more depression than those coming from the found in study of Thabet et al. [5] of 197 children aged 9-18 other four areas of the Gaza Strip. Orchard et al. [29] in study years, 33.9% were rated as having anxiety symptoms of likely of adolescents (N=100, aged 12-17 years), referred for clinical significance. Similarly, Ingridsdatter et al. [27] in study depression to a routine public healthcare child and adolescent of a sample of 139 Palestinian adolescents 12 to 17 years old, mental health service, in the south of England. Forty-two of an estimated 33 out of 139 adolescents (23.74%) scored above the 100 young people met criteria for a depressive disorder as the cutoff (>18) on RCMAS and were categorized as likely cases the primary diagnosis on the KSADS. Thirty-seven met criteria of clinical anxiety. Moreover, our results rate of anxiety was for MDD, three met criteria for MDD with , and two less that found in children exposed to trauma due to war in participants met criteria for schizoaffective depressive disorder Gaza Strip in which 30.9% of children were found to suffer [30-33]. from anxiety disorders [13]. Similar in study aimed to find the prevalence rate of PTSD, Conclusion anxiety and depression among orphaned children in Gaza Strip, showed that 30.9% of children rated as anxiety cases The finding of the current study suggest a collective [26]. The study results showed that there were statistically assessment for war related trauma and follow up of the significantly differences in anxiety and family monthly income mental health problems among different age groups to test toward families with monthly income less than 1700 NIS. The the connection between war trauma and other variables. War researcher hypothesized that socio-demographic variable related traumas have dramatic effects upon the school age usually plays a role in psychological factors which reflected on children and so wide spread as to assume far-reaching the families and their children psychological condition. The low consequences for the community and society as a whole. income families suffering in achieving the basic needs and However, it is imperative that government, institutions and requirements and this expose them to stress, fear, anxiety and organizations dealing with trauma recognize that in spite of other psychological problems in addition to the traumatic very pressing material needs, structured research and data are events that generated by wars and conflicts in the area. Where essentially lacking elements in the pursuit of long term Thabet et al. [13] found that anxiety was more frequently solutions. found in children living in camps than in a city or in a village, among children coming from families with monthly incomes of It is vital to develop a deeper understanding of the less than $ 300/month and among children whose parents did repercussions of such overwhelming trauma. Considering the not have an education. consequences of war traumatic events on the psychological well-being of the school age children is the vital part in Using cut-off point of the scale, 139 of children reported recognizing the war effects. Upon the finding of the study, it is depression (34.1%). Low mood and depression often emerge essential to develop a recognized program for monitoring and during adolescence, nearly 6% of adolescents meet criteria for evaluation of the children psychological conditions on a a depressive disorder at any given time, with the cumulative periodical basis. This program should be followed by trained frequency of depression rising to as high as 20% by the end of psychiatrists and psychologists to define the consequences of adolescence. The results of the study consistent with the study war–related traumas and measuring the mental health of Thabet et al. [28] in study a sample included 374 children problems among the children groups. The connection between aged 6 to 17 years, The results showed that 237 of children war trauma and mental health problems call alerts for deep had no anxiety or depression (63.5%), 95 children had either investigation and follow up on a standard basis. depression or anxiety (25.5%) and 41 children had comorbidity of depression and anxiety (11%). No gender differences in depression scores, and no statistical association between total Clinical Implications trauma and depression scores. However, total depression This study showed that there is need for providing psycho- scores were positively predicted by being forced to leave home education and trauma-focused therapy, including cognitive under threat of war and being threatened with shooting, while behavioral techniques for secondary school students by the physical injury due to bombardment of their home negatively school counselor. Provide psychosocial support for school age predicted depression. Moreover, Ingridsdatter et al. [27] in students since they're in real need for such services that study of a sample of 139 Palestinian adolescents 12 to 17 years mediate the trauma effects including psycho-education and old, showed that 52.21% scored above the recommended trauma-focused therapy, including cognitive behavioral clinical cut-off of 15 in depression scale. Thabet [26] in study of techniques, establish educational programs including 449 Palestinian children of 7 to 18 years, the rates of instructions on how the community participates in helping, © Copyright iMedPub 11 Health Science Journal 2019 ISSN 1791-809X Vol.13 No.1:621

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© Copyright iMedPub 13 The Arab Journal of Psychiatry (2019) Vol. 30 No.1 Page (8 – 17) (doi-10.12816/0052931)

The Relationship between Mental Health of Palestinian Mothers Due to Siege and Child Attachment

Abdelaziz Mousa Thabet اﻟﻌﻼﻗﺔ ﻣﺎ ﺑﯿﻦ اﻟﻀﻐﻮط اﻟﻨﻔﺴﯿﺔ اﻟﻨﺎﺗﺠﺔ ﻋﻦ اﻟﺤﺼﺎر واﻟﺼﺤﺔ اﻟﻨﻔﺴﯿﺔ ﻟﻸﻣﮭﺎت اﻟﻔﻠﺴﻄﯿﻨﯿﯿﺎت و اﻟﺮﺑﺎط ﻣﻊ أطﻔﺎﻟﮭﻦ ﻋﺒﺪ اﻟﻌﺰﯾﺰ ﻣﻮﺳﻰ ﺛﺎﺑﺖ

Abstract

im: The current study investigated the relationship between mothers’ stressors due to siege, their mental health and A the attachment styles of their children. Methods: Participants were recruited from a list of previously studied Palestinian families in the Gaza Strip, which was part of a three-stage prospective study of 184 households. N=140 mothers were recruited to the study. Ages ranged from 18 to 64 years with a mean age of 41.53 years. Participants completed self- report questionnaires, which included a sociodemographic scale, the Gaza Siege Checklist, the Hopkins Symptoms Checklist (HSCL-25), and the Parent/Child Reunion Inventory (P/CRI). Data were collected from October to November 2008. Results: Mothers reported from 2-20 stressors due to siege (M=10.83, SD=4.07). Those with monthly income of less than $350 US reported experiencing more stressors than mothers whose families had a monthly income of $351 US or more. Results identified 16.8% of mothers met the criteria for psychiatric conditions; 19.0% reported anxiety and 15.2% reported depression. Mothers living in cities reported fewer mental health problems compared with those living in villages and camps. Further, insecure attachment of children was positively associated with total stressors and mothers’ anxiety, and depression. Conclusion: Maternal depression and anxiety was associated with insecure attachment styles in children. Maternal depression and anxiety were also associated with experiences of siege stressors and an insecure attachment style in children. The study highlights potential targets for future intervention.

Key word: Attachment, Gaza Strip, Anxiety, Depression, Siege, Stressors, Mothers

Declaration of interest: None

Introduction participants from five areas of the Gaza Strip, the most common stressful situations due to siege were: feelings of Since the Israeli Government enacted the full Gaza living in a big prison, being unable to complete blockade in 2007, which has restricted the free movement construction and repair work in their house due to shortage of goods and people in and out of the Gaza Strip almost of cement and building materials, a sharp increase in completely, the population there has suffered ever- prices in the last few years. Participants commonly increasing infringements of their economic and social reported traumatic events, such as hearing artillery rights. The access-restricted area (the so-called “buffer shelling in the area, hearing the sonic sounds of jetfighters, zone” or no man’s land) was imposed by Israel within hearing loud drones, and witnessing mutilated bodies on Gaza territory and covered 35% of key agricultural land; television. Men and boys experienced more severe it highlights how fundamentally the right to movement is traumatic events than women and girls. People living in ignored with 113,000 people unable to access their farms.1 cities reported more traumatic events than those living in Siege on the Gaza Strip since 2007 has been a unique villages or camps. As a reaction to stress and trauma, situation and there have been very few studies on the Palestinians participants reported anxiety symptoms such impact of siege in the area. as nervousness or shakiness inside, feeling tense or keyed up; while depressive symptoms were expressed as feeling A study of N=386 Palestinian adults in the Gaza Strip showed that people commonly reported the following sad and physically weak. However, feelings of siege stressors: prices were sharply increased (97.67%), worthlessness and thoughts of ending life were rarely they feel they are in a big prison (92.23%), they cannot expressed.3 find things they need in the market (91.70%), they quit making daily purchases for basic needs (88.30%), and Bowlby's attachment theory is an essential reference for social visits were less frequent than before (85.23%).2 In understanding relational aspects, which can impact mental another study involving 502 randomly selected dysfunction. The attachment system is theorized as a set

8 The Relationship between Siege Stressors, the Mental Health of Palestinian Mothers and Child Attachment

of instinctive affective, behavioral, cognitive, and The aim of the current study was to investigate the motivational mechanisms designed to encourage infants relationship between mothers’ stressors due to siege, their to seek proximity to protective caregivers during times of mental health and their children’s attachment styles. stress. By viewing caregivers as attachment figures to turn to in times of emotional stress or uncertainty, infants can Methodology feel comfortable exploring the world around them, Participants knowing that their caregivers are available if needed.4,5 6,7 The current study recruited N=140 mothers with at least Attachment in children is defined as a long-lasting one child aged between 6 to 18 years. Mothers’ ages emotional bond formed between a child and his/her ranged from 26 to 65 years with a mean age of 41.61 caregiver. When children feel secure in their relationships (SD=8.79) years. with attachment figures, they perceive them as consistently available, sensitive and responsive to their Instruments needs. Children form insecure relationships with attachment figures that show deficiencies in sensitivity Data were collected from mother/child pairs by using the and responsiveness. Accordingly, by preschool age, the following questionnaires: child with secure attachment shows relaxed and enjoyable Demographic questionnaire interactions with the parent, and uses the caregiver as a secure base from which to explore the environment. In Demographic information about the participants was comparison with secure children, children with avoidant obtained using a form developed by the authors. The attachment tend to show greater affective neutrality and questionnaire included gender, age, citizenship, education physical avoidance. Children with ambivalent attachment level, place of residence, and number of children in the show exaggerated emotional expression and immature or family. angry behavior toward the parent. These children are 2,3 known to show resistance, conflict or excessive Gaza Siege Checklist – mothers’ form dependence on the caregiver. Children with disorganized The checklist consisted of 21 items covering a wide range attachment show contradictory or incoherent behavior in of daily life situations affected by the Gaza Siege, proximity to the caregiver, such as simultaneous or including family, health, education, social life, and successive approach and avoidance, disordered, economic issues. The first checklist was developed after incomplete, or undirected sequencing of movements, and conducting a focus group for 20 professionals working in confusion or apprehension. They seem unable to use their different sectors of health, education, social services, and caregivers as a secure base for exploration and havens of economic sectors. In the current study, the split half 8 safety. Moreover, certain attachment patterns are reliability of the scale was (r=.76). particularly relevant to mental health; namely, the four attachment styles (secure, dismissing, preoccupied, and Hopkins Symptoms Checklist (HSCL-25) 14 fearful), which can measure attachment dimensionally in terms of anxiety (the fear of being abandoned or rejected Hopkins Symptoms Checklist measures the presence and in close relationships) and avoidance (the preference for degree of symptoms of anxiety and depression during the emotional distance).9 A growing body of research links past seven days. Each item was scored on a scale from 0 attachment insecurity to the whole spectrum of mental (not at all) to 3 (extremely). Examples of items are health problems in both children and adults.10 Another ‘Nervousness or shakiness inside’ and ‘Feeling hopeless study showed that maternal depression and anxiety have about the future.’ The checklist comprises total anxiety been linked to insecure parent-child attachment and depression scales, an overall problem scale, as well as relationships.11 Another reported that fearful attachment is clinical cut-offs (set at 1.75). The Arabic translated more often found in people diagnosed with depressive version has proved reliable and valid in a multicultural 15 disorders, while the depression related to bipolar or context. The internal consistency of the scale was is often associated with those calculated using Cronbach’s alpha (α=.92). who experience a more dismissive attachment style.12 Parent/Child Reunion Inventory 16 LeCompte et al.,13 examined the psychological, social and cultural risk factors for child insecure attachment in a The Parent/Child Reunion Inventory (P/CRI)16 relies on sample of N=33 South Asian immigrant families the child’s internal working model of his/her attachment experiencing high migration stress in Montreal, Canada. relationship. It is based on direct observations of Results suggested that child attachment security scores childhood reunions and it provides parents with were associated with maternal depression, although hypothetical everyday separation situations. Parents are statistically marginal, suggesting that high maternal asked to select behaviors that are shown by their child at depression is related to low child attachment security.

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reunion times. To assist with this, parents are asked to Statistical Analysis remember the last separation they had from their child lasting one hour or more. Parents rate each behavior as Data entry and analysis were carried out using the ‘usually’ (2), ‘occasionally’ (1) or ‘never’ (0). The P/CRI Statistical Package for Social Science version 20 (SPSS allows for the calculation of total secure and insecure Inc. Chicago Ill, US). Frequency and percentages were scores. Six items measure secure attachment (range 0-12), used to express quantitative data of types of stressful and 14 items measure insecure attachment (range 0-28). situations, mother’s mental health disorder, attachment The P/CRI is tentatively split into five insecure factors: and resilience. For continuous variables, means and insecure–avoidant-distancing (items 7, 8), insecure– standard deviations were reported. For differences avoidant (items 9, 10, 11, 12), insecure-anxious (items 13, between means of two groups independent t tests were 16), insecure–controlling (items 14, 15), and insecure- used. ANOVA tests were used for measuring differences unspecified (items 17, 18, 19, 20). This scale was between more than two groups of continuous variables, translated from English by Dr Thabet and was back such as place of residence and stress, mother’s mental translated by a professional with a diploma in Translation health and child attachment style. Spearman’s correlation There were no major changes identified in the coefficient was used to test the association between translations.17 The Cronbach’s alpha for the secure and number of stressors, mother's mental health and child insecure subscales were α=0.65 and α=0.77, respectively. attachment style. Multivariate regression analysis was conducted in which each stressor was entered as the independent variable and the psychological symptoms of mothers (HSCL) entered as the dependent variable. Procedure

Eight mental health professionals (four social workers, four psychologists) received four hours of training during Results which the aims of the current study were reviewed. All had previous experience in data collection. Participants Sociodemographic characteristic were recruited from list of previously studied Palestinian families in the Gaza Strip, which was part of a three-stage A total of N=140 mothers responded. Their ages ranged prospective study of 184 households. One hundred and from 26 to 65 years with mean age of 41.61 y (SD=8.79). forty mothers were contacted. A letter outlining the study According to place of residence, 26.1% were from North aims was given to each and written consent to participate Gaza, 37.5% from Gaza, 14.7% from the middle region of was obtained. Sociodemographic information for the Gaza, 3.8% were from Khan Younis and 17.9% were from study population was collected from mothers at home. Rafah (south of Gaza). According to type of residence, Each interview took 30 minutes to complete. Data 43.5% lived in cities, 12.5% lived in villages, and 44% collection was done between September and November lived in camps. In terms of number of children, 13.6% of 2008. families had less than 4 children, 61.4% had 5-7 children, and 25% had 8 and more siblings. As for family monthly income, 60.9% earned less than $350 US per month, 30.4% earned $351-700 US, and 8.7% earned more than $701 US.

Table 1. Sociodemographic characteristic of the study sample (N=140)

N % Address North Gaza 37 26.4 Gaza 53 37.9 Middle area 21 15.0 Khan Younis 6 4.3 Rafah area 23 16.4 Place of residence City 58 41.4 Village 16 11.4

10 The Relationship between Siege Stressors, the Mental Health of Palestinian Mothers and Child Attachment

Camp 66 47.1 Number of children Less than 4 14 10.0 5-7 children 90 64.3 8 and above 36 25.7 Monthly family income Less than $350 US 84 60.0 $351-700 US 42 30.0 More than $701 US 14 10.0 Husbands’ education Uneducated 7 5.0 Secondary school and less 89 63.6 University and above 44 31.4 Husbands’ employment status Unemployed 70 50.0 Skilled worker 13 9.3 Employee 47 33.6 Others 10 7.1 Mothers’ education Uneducated 4 2.9 Secondary school and less 131 93.6 University and above 5 3.6 Mothers' employment status Housewives 133 95.0 Employee 7 5.0

Frequency of stressors related to the siege of Gaza in (87.8%), I was not able to get specific medicine for me or mothers for one of the family members due to shortage of fuel and absence of transportation (75.7%). Mothers reported from Results showed that the most common stressors arising 3-18 stressors relating to the siege with mean of 10.16 from the siege of Gaza as rated by mothers were: prices (SD=3.76). have increased sharply (89.3%), I feel I am in a big prison

Table 2. Frequency of items of siege of Gaza (N = 140)

Items N= % No. % Prices are sharply increased 125 89.3 15 10.7 I feel I am in a big prison 122 87.8 17 12.2 I was not able to get specific medicine for me or for one of the family 106 75.7 34 24.3 members due to shortage of fuel and absence of transportation I stopped sending my children to school due to shortage of money and I let 103 73.6 37 26.4 them do other jobs Social visits are less than before due to shortage of fuel and absence of 93 66.9 46 33.1 transportation I was not able to get specific medicine for me or for one of my family 92 65.7 48 34.3 members due to shortage of physicians and nurses Ability to send children to school due to shortage of money 85 60.7 55 39.3

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Social visits are less than before due to shortage of money due to 84 60.0 56 40.0 unemployment I was not able to get specific medicine for me or for one of my family 82 58.6 58 41.4 members due to shortage of medicine and equipment Losing the job due to shortage of cement, and basic construction materials 80 57.1 60 42.2 I started borrowing from banks and people to keep my family demands 80 57.1 60 42.9 I cannot find things I need in the market 78 55.7 62 44.3 I went to Zakat organizations and other organizations to get food 71 50.7 69 49.3 I sold some of my furniture and wife’s gold 64 45.7 76 54.3 I thought of immigration 60 42.9 80 57.1 I postponed the marriage ceremony of my sons due to shortage of furniture 60 42.9 80 57.1 and building materials I cannot finish some construction and repair work in my house due to 60 42.9 80 57.1 shortage of cement and building materials I need to travel outside the Gaza Strip and cannot 40 28.6 100 71.4 I started doing the papers for immigration 25 17.9 115 82.1

Siege stressors in mothers and sociodemographic Mean and standard deviation of mental health using variables HSCL

A one-way ANOVA test was used to find differences in The results showed the mean HSCL was 1.15 (SD=0.56), total siege stressors and other sociodemographic mean anxiety subscale score was 1.17 (SD=.64), and mean variables, such as number of children, monthly family depression subscale score was 1.14 (SD=0.57). Taking in income, education, place of residence. Post Hoc test using consideration the cutoff point of <1.76 of HSCL, 16.8% Tukey showed that mothers with low family income (less of mothers were rated as having psychiatric conditions, than $250 US) (F(2/137)=9.6, p=0.001), not educated 19.0% reported experiencing anxiety and 15.2% reported (F(5/134)=6.7, p=0.001), and mothers living in North symptoms related to depression. Gaza (F(4/135)=7.94, p=0.001) had reported more stressors.

Table 3. Mean and standard deviation of mental health using HSCL

Mean SD Mean HSCL 1.15 .56 HSCL - Anxiety subscale 1.17 .64 HSCL - Depression subscale 1.14 .57

Differences between mental health problems rated by of less than $350 US reported more mental health HSCL and other socioeconomic variables (place of problems than the other two groups. This group were more residence, number of siblings, and family monthly affected by siege that the other groups (F (1/137)=4.5, income) p=0.01).

In order to find the differences between the places of residence, number of siblings, monthly income and mental health, a one-way ANOVA test was performed. Post hoc Parent/Child Reunion (attachment style of children) Tukey test showed that mothers living in cities reported The current study showed that mean secure attachment fewer mental health problems compared with those who was 8.67 (SD=2.40) and mean insecure attachment was lived in villages and camps (F (2/137)=15.2, p=0.001). 14.16 (SD=5.10). Results also showed that mothers with a monthly income

12 The Relationship between Siege Stressors, the Mental Health of Palestinian Mothers and Child Attachment

Table 4. Means and Standard deviations of attachment

Attachment Mean SD Secure attachment 8.67 2.40 Insecure attachment 14.16 5.10

Differences between attachment and other The relationships between stressors arising from siege socioeconomic variables (place of residence, number of and mental health of mothers and child attachment siblings, and family monthly income) styles

A one-way ANOVA test was performed. Post hoc Tukey In order to find the relationship between stressors due to test showed that children living in families with monthly the siege of Gaza and the mental health of mothers as incomes of less than $350 US demonstrated more insecure relates to parent/child reunion, the Pearson correlation attachment than the other two groups (F (2/137)=3.15, coefficient test was conducted. Results indicated that the p=0.04). total stressors were positively associated with maternal mental health (r (140)=0.27, p<0.001), anxiety (r (140)=0.25, p<0.001), depression (r (140)=0.26, p<0.001) and insecure attachment of children.

Table 5. Relationships between stressors related to siege as experienced by mothers and attachment of children

Siege Mean Anxiety Depression Secure HSCL attachment Maternal experience of siege stressors Mean HSCL .27** Anxiety subscale .25** .92** Depression subscale .26** .95** .74** Secure attachment-child -.14- -.13- -.10- -.14- Insecure attachment-child .34** .22* .16 .24** .02

Prediction of child insecurity and maternal stressors due independent variables. Total secure attachment: I sold to the siege of Gaza some of my furniture and my gold. (β= 0.32, t (135), p<0.001). I need to travel outside the Gaza Strip and Using a multivariate regression model, insecure cannot (β= 0.18, t (135), p<0.01), and negatively predicted attachment scores were entered as dependent variables by I thought of immigration (β=-0.17, t (135) p<0.02), and each siege-related stressor reported by mothers as R2=.23, F (1/135)=12.20, p=0.001.

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Table 6. Multivariate regression model predicting child insecure attachment style and maternal stressors arising from the Gaza siege

Unstandardized Standardized t p 95.0% Confidence Coefficients Coefficients Interval for B B Std. Beta Lower Upper Error Bound Bound (Constant) 12.42 0.63 19.86 0 11.19 13.66 I sold some of my 3.3 0.79 0.32 4.2 0 1.75 4.86 furniture and my gold I need to travel outside 3.19 0.88 0.28 3.62 0 1.45 4.94 the Gaza Strip and cannot I thought of immigration -1.79 0.79 -0.17 -2.28 0.02 -3.35 -0.24

Prediction of child secure attachment style and maternal an independent variable, secure attachment was stressors due to the siege of Gaza negatively predicted by stressor: I went to Zakat organizations and other organizations to get the food (β=- In a multivariate regression model, secure attachment 0.28, t(135), p<0.001b, R2=.0.06, F(1/135)=9.20, scores were entered as dependent variables and each p=0.001 stressor of siege experienced by mothers was entered as

Table 7. Multivariate regression model predicting child secure attachment style and maternal stressors due to siege of Gaza

Unstandardized Standardized t P 95.0% Confidence Secure attachment Coefficients Coefficients Interval for B B Std. Beta Lower Upper Error Bound Bound

(Constant) 9.3 0.28 33.1 8.75 9.86

I went to Zakat organizations -1.22 0.4 -0.25 -3.05 0.001 -2.01 -0.43 and other organizations to get food

Discussion conditions were identified for 16.8% of mothers, 19.0% reported anxiety and 15.2% reported symptoms related to The current study investigated the impact of siege depression. Mothers living in cities reported fewer mental stressors on the mental health of Palestinian mothers and health problems compared with those who lived in attachment style of their children. Results showed that the villages and camps. Results also found that mothers with most commonly reported stressors relating to the siege of a monthly income of less than $350 US reported more Gaza as experienced by mothers were: prices have mental health problems than the other two groups. It increased sharply (89.3%); I feel I am in a big prison appears that this group were more affected by siege than (87.8%); I was not able to get specific medicine for me or the other groups. Similarly, in a study of university for one of the family members due to shortage of fuel and students in the Gaza Strip, Juma and Thabet18 found that absence of transportation (75.7%). The mean stressors the most commonly reported stressors arising from siege arising from an experience of the siege of Gaza was 10.16. were the sharp increase in prices due to border closures Higher levels of stress were reported by mothers who had (92%) and an adverse impact on their ability to study due low monthly family income (less than $250 US), were to Gaza’s electricity being cut off and also gas shortages educated, and lived in the North of Gaza. The current (83.5%). Within the student population studied, the mean study found the mean subscale scores for anxiety and number of stressors reported by men was 12.38 and 10.33 depression were 1.17 and 1.14, respectively. Psychiatric

14 The Relationship between Siege Stressors, the Mental Health of Palestinian Mothers and Child Attachment

for women. For symptoms related to depression, 9.5% of were consistent with those of Campbell et al.24 who found men and 12% women reported severe symptom levels; that mothers who experienced intermittent or chronic 10.3% men reported experiencing anxiety compared to symptoms of depression and who evidenced less 13.8% of women. There was a positive correlation sensitivity to their children’s needs had offspring at between total stress due to siege and symptoms associated greater risk of experiencing insecure attachment. with depression and anxiety among students. Moreover, a Therefore, while children of depressed mothers are more study of N=502 Palestinian families in the Gaza Strip vulnerable to attachment insecurity, not all will be found the most common stressful situations arising from adversely affected or respond in a similar manner. the siege were: feelings of living in a big prison, being Similarly, in a longitudinal study of postnatal depression unable to finish some construction and repair work in their and maternal attachment in middle-class mothers (N=111) homes due to shortages of cement and building materials, and their infants, chronic maternal depression was prices increased sharply in the last few years.3 Further, significantly associated with less secure attachment 12 there was a positive relationship between stressors due to months after birth.25 the siege and closure and psychological symptoms. By way of further comparison, studies on mental health A similar finding was identified in a population-based following earthquakes in Lushang and Wenchang, China study in the Netherlands of N=606 infant-mother dyads. found prevalence rates for anxiety and depression Results showed that infant attachment moderated the remained high nearly five years later. 19 The current study effect of parent stress on child emotional and behavioral found that mental health problems among mothers was problems. Parent stress was related to more aggression lower than a study on 114 refugee women-at-risk who had and attention problem behaviors in insecurely attached been resettled to Australia, as well as factors contributing children, but not in securely attached children. Moreover, to symptoms of trauma, anxiety, depression, and higher levels of stress in parents was associated with more somatization.20 The level of psychiatric symptomatology withdrawal problem behaviors in insecurely attached is compared to reference groups of women from Sudan children. This was particularly the case for insecure 26 and Burma. Participants’ psychiatric distress met levels resistant and disorganized children. The current study symptomatic for traumatization (41%), PTSD (20%), showed that children living in families with a monthly anxiety (29%), and depression (41%). Forty two percent income of less than $350 US appeared to have less secure also reported high levels (≥1.75) of somatization. Results attachments compared with the other two groups. were not consistent with the secondary analysis on The importance of economic stability as a mediating baseline data from N=288 HIV-positive women, enrolled factor for the development of secure attachments was also in a parenting intervention in Uganda. Total JHCL-25 supported in Fraley et al.27 Their longitudinal research of mean score was 1.9, mean depression score was 2.0, and mother-child dyads examined attachment from one month 21 mean anxiety score was 1.8. In the Middle East, Karam post-natal until the children reached 18 years of age. et al., assessed a nationally representative sample of the Conducted at the National Institute of Child Health and Lebanese population (N=2857 adults). Human Development on the Study of Early Child Care Respondents were interviewed using the fully structured and Youth Development, the study concluded that secure World Health Organization (WHO) Composite children were more likely than insecure children to have International Diagnostic Interview 3.0. Lifetime had more supportive parenting over time, to have come prevalence of any Diagnostic and Statistical Manual of from families characterized by stability (e.g., low levels of Mental Disorders, Fourth Edition (DSM-IV) disorder was parental depression, fathers living in the household), and 25.8%. Anxiety (16.7%) and mood (12.6%) were more to have had higher-quality friendships in adolescence. A common than impulse control (4.4%) and substance study conducted in the Gaza Strip with N=392 parents (2.2%) disorders.22 (n=380 mothers; n=12 fathers) of preschoolers indicated that 86% of preschoolers were securely attached and 9.7% The study showed that mean secure attachment was 8.67 were insecurely attached to their mothers. Further, the and mean insecure attachment was 14.16. Such findings insecure attachment with mothers was among children were inconsistent with previous research using the same with low monthly income. 17 Consistent with the current scale in a sample of N=13 mothers previously admitted to findings, Lecompte et al.,28 found that maternal depressive psychiatric hospital. In the study, the mean secure symptoms were related to lower child attachment security attachment score was 11.33 and mean insecure attachment scores. Lower support from friends was related to greater score was 5.00.23 Results suggested that total stressors child ambivalent attachment behaviors. A higher sense of experienced by mothers during the siege of Gaza were belonging to the country of origin was related to greater positively associated with their experience of mental child disorganized attachment behaviors. These findings health, anxiety, and depression and linked also to having suggest that migration stresses, which include maternal insecurely attached children. The current study results depression, lack of social support and the sense of

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belonging, are associated with child attachment, and these 8. Ainsworth MDS. Attachments beyond infancy. variables should be considered in the design of American . 1989;44:709-716. appropriate interventions. 9. Bartholomew K, Horowitz LM. Attachment styles among young adults. A test of a four-category model. J. Pers. Soc. Psychol. 1991;61:226-240. 10. Ein-Dor T, Doron G, Simpson JA, Rholes WS. Limitations Psychopathology and attachment. Attachment Theory and Close Relationships. Guilford, New York. 2015; The present study has some limitations that are important 346-373. to consider when interpreting the results: (1) the data were 11. Santona A, Tagini A, Sarracino D, de Carli P, Pace C derived from children/adolescents (and mothers) as part of S, Parolin L, Terrone G. Maternal depression and a cohort who were studied when Gaza was experiencing attachment: The evaluation of mother-child traumatic stressors related to siege and war; and, (2) the interactions during feeding practice. Frontiers in Psychology, 2015; 6: 1- study sample may not be representative of the whole 10.doi:10.3389/fpsyg.2015.01235 Palestinian population suffering from other types of war 12. Mikulincer M, Shaver PR. The attachment behavioral trauma and stress. system in adulthood: Activation, psychodynamics, and interpersonal processes. In: Zanna M, editor. Advances in experimental social psychology. Vol. 35. Academic Press; New York. 2003;53-152.doi: Conclusion 10.1016/S0065-2601(03)01002- 13. Lecompte V, Miconib D, Rousseaua C. Challenges The current study is the first to explore the impact of siege related to migration and child attachment. A pilot stressors on the mental health of Palestinian mothers and study with South Asian immigrant mother-child dyads the attachment style of their children. Data showed that Attachment & Human Development. 2018;20(2):208- maternal depression and anxiety is associated with 222. insecure attachment children. Maternal depression and 14. Derogatis LR, Lipman RS, Rickels K, Uhlenhuth E H, anxiety were associated with the siege-related stressors Covi L. The Hopkins Symptom Checklist: a self- they experienced and how securely their children were report symptom inventory. Behavioral Science attached to them. Findings highlight potential targets of Checklist HSCL. 1974;19:1-15. intervention, including identifying and treating mothers 15. Afana AH, Dalgard OS, Bjertness E, Grunfeld B. The ability of general parishioners to detect mental affected by stress and trauma in the Gaza Strip and disorder among primary care patients in stressful supporting the development of secure mother-infant environment: Gaza Strip. J Pub Health Med. attachment relationships, particularly in populations at 2002;24(4):326-331. high risk of stress and trauma exposure. 16. Marcus RF. Concordance between parent inventory and directly observed measures of attachment. Early Child Development and Care, 1997;135:109-117. 17. Abu Shawesh E, Abu Hein, Thabet AA. The Relation References between Parenting Styles and Attachment among 1. http://www.pchrgaza.org/files/weapon/english/2009/r Preschool Children in the Gaza Strip. Glob J Intellect eport17. Dev Disabil. 2017;3(3):555-612. 2. Thabet AA, Abu Tawahina A, El Sarraj E, Vostanis P. 18. Juma A, Thabet AA. Relationship between stressors Siege and Quality of Life of Palestnians in the Gaza due to siege of Gaza Strip on anxiety, depression and Strip. Arabpsynet, 2008;20:157-164. coping strategies among university students. Arab J 3. Thabet AA, Thabet S. Stress Trauma, Psychological Psychiatr. 2015;25:39-48. (doi: 10.12816/0010504). Problems, Quality of Life, and Resilience of 19. Xie Z, Xu J, Wu Z. Mental health problems among Palestinian Families in the Gaza Strip. J Clin survivors in hard-hit areas of the 5.12 Wenchuan and Psychiatr. 2015;1(2):1-10. 4.20 Lushan earthquakes J Ment Health. 4. Bowlby J. Attachment and Loss, Vol. 1: Attachment. 2017;26(1):43-49. Pp. 146. Basic Books; New York: 1969.1982. 20. Schweitzer RD, Vromans L, Brough M, AsicKobe M, 5. Bowlby J. Attachment and Loss. Vol. 2: Separation: Correa-Velez I, Murray K, Lenette C. Recently anxiety and anger. New York, NY: Basic Books. resettled refugee women-at-risk in Australia evidence 1973. high levels of psychiatric symptoms trauma and post- 6. Bowlby J. Attachment and Loss: Vol. 3: Loss sadness migration factors predict outcomes. BMC Medicine. and depression. Pp.38. Basic Books; New York: 1980. 2018;16:149-162. 7. Bowlby J. Caring for children: some influences on its 21. Seffrena V, Familiarb I, Murrayc S, Augustinaviciusc development. In Parenthood, ed. R. S. Cohen, S. H. J, Boivinb M, Nakasujjad N, Opokae R, Bassc J. Weissman, and B. J. Cohler, New York: The Guilford Association between coping strategies, social support, Press. 1982. and depression and anxiety symptoms among rural

16 The Relationship between Siege Stressors, the Mental Health of Palestinian Mothers and Child Attachment

Ugandan women living with HIV/AIDS. AIDS Care. depression on infant attachment. J Child Psychol 2018;30(7):888-895. Psychiatr. 2006;47(7):660-669. 22. Karam EG, Mneimneh ZN, Dimassi H, Fayyad JA, 26. Tharner A, Luijk MPCM, van IJzendoorn MH, Karam AN, et al. Lifetime prevalence of mental Bakermans-Kranenburg MJ, Jaddoe VDV, Hofman A, disorders in Lebanon: First onset, treatment, and Verhulst FC, Tiemeier H. Infant Attachment, exposure to war. PLoS Med. 2008;5(4):e61. doi:10. Parenting Stress, and Child Emotional and Behavioral 1371/journal.pmed.0050061 Problems at Age 3 Years. J Parent Sci Pract. 23. Judi Cunningham J, Harris G, Vostanis P, Oyebode F, 2012;12:261-281, DOI: Blissett J. Children of mothers with mental illness: 10.1080/15295192.2012.709150 attachment, emotional and behavioural problems. 27. Fraley RC, Roisman GI, Booth-LaForce C, Owen MT, Early Child Development and Care. 2004;174(7- Holland AS. Interpersonal and genetic origins of adult 8):639-650. attachment styles: a longitudinal study from infancy to 24. Campbell SB, Brownell CA, Hungerford A, Spieker early adulthood. J. Personal Soc Psychol. SI, Mohan R, Blessing JS. The course of maternal 2013;104:817-838. depression and maternal sensitivity as predictors of 28. Lecompte V, Miconib D, Cécile Rousseaua C. attachment security at 36 months. Developmental Challenges related to migration and child attachment: Psychopathology. 2004;16:231-252. A pilot study with South Asian immigrant mother- 25. McMahon CA, Barnett B, Nicholas M, Kowalenko child dyads. Attach Human Devel. 2018;20(2):208- NM, Christopher C, Tennant CC. Maternal attachment 222. state of mind moderates the impact of postnatal

ﻤﻠاﻟ ﺺﺨ

اﻟﮭﺪف ﻣﻦ اﻟﺪراﺳﺔ ھﻮ اﻟﺒﺤﺚ ﻓﻲ اﻟﻌﻼﻗﺔ ﺑﯿﻦ اﻟﻀﻐﻮط اﻟﻨﺎﺟﻤﺔ ﻋﻦ اﻟﺤﺼﺎر ﻋﻠﻰ ﻏﺰة واﻟﻤﺸﺎﻛﻞ اﻟﻨﻔﺴﯿﺔ ﻋﻨﺪ اﻷﻣﮭﺎت وﺑﯿﻦ اﻟﺮﺑﺎط ﻣﻊ اﻷطﻔﺎل داﺧﻞ اﻟﻌﺎﺋﻼت اﻟﻔﻠﺴﻄﯿﻨﯿﺔ . .

اﻟﻤﻨﮭﺠﯿﺔ: ﺗﻢ اﺧﺘﯿﺎر ﻋﯿﻨﺔ ﻣﻜﻮﻧﺔ ﻣﻦ 140 أم ﻣﻦ اﺻﻞ 184 أب و أم ﻣﻦ ﻗﺎﻋﺪة ﺑﯿﺎﻧﺎت اﻟﺪراﺳﺔ اﻟﺘﺘﺒﻌﯿﺔ ﻟﻠﻌﺎﺋﻼت اﻟﻔﻠﺴﻄﯿﻨﯿﺔ ﻓﻲ ﻗﻄﺎع ﻏﺰة - اﻟﻤﺮﺣﻠﺔ اﻟﺜﺎﻟﺜﺔ واﻟﺘﻲ ﺗﻢ اﺧﺘﯿﺎرھﺎ ﻣﻦ ﺟﻤﯿﻊ اﻟﻤﻨﺎطﻖ ﻓﻲ ﻏﺰة . وﺗﺮاوﺣﺖ اﻷﻋﻤﺎر ﻟﻼﻣﮭﺎت ﺑﯿﻦ 18 اﻟﻰ 64 ﺳﻨﺔ وﻛﻦ اﻟﻤﺘﻮﺳﻂ اﻟﺤﺴﺎﺑﻲ ﻟﻠﻌﻤﺮ =41.53 ﺳﻨﺔ، و اﻻطﻔﺎل ﻣﻦ -6 18 ﺳﻨﺔ، وﺗﻢ ﺟﻤﻊ اﻟﺒﯿﺎﻧﺎت ﺑﺈﺳﺘﺨﺪام ﻣﻘﯿﺎس اﻟﺨﺼﺎﺋﺺ اﻟﺪﯾﻤﻐﺮاﻓﯿﺔ واﻻﺟﺘﻤﺎﻋﯿﺔ ، واﺳﺘﺒﯿﺎن اﻟﻀﻐﻮط اﻟﻨﺎﺟﻤﺔ ﻋﻦ اﻟﺤﺼﺎر، واﺳﺘﺒﯿﺎن ﻗﺎﺋﻤﺔ ﺟﻮن ھﻮﺑﻜﻨﺰ، و ﻣﻘﯿﺎس اﻻﻧﻔﺼﺎل و اﻻﻟﺘﺼﺎق ﺑﺎﻷم (اﻟﺮﺑﺎط). وﺗﻤﺖ ﻋﻤﻠﯿﺔ ﺟﻤﻊ اﻟﺒﯿﺎﻧﺎت ﻓﻲ ﺷﮭﺮي أﻛﺘﻮﺑﺮ وﻧﻮﻓﻤﺒﺮ ﻣﻦ ﻋﺎم 2008 . .

اﻟﻨﺘﺎﺋﺞ: أظﮭﺮت اﻟﻨﺘﺎﺋﺞ أن أﻛﺜﺮ أﻧﻮاع اﻟﻀﻐﻮط اﻟﻨﻔﺴﯿﺔ اﻟﻨﺎﺗﺠﺔ ﻋﻦ اﻟﺤﺼﺎر ﻋﻠﻰ ﻗﻄﺎع ﻏﺰة ھﻲ :اﻻرﺗﻔﺎع اﻟﺤﺎد ﻟﻸﺳﻌﺎر(%90.8)، وأﺷﻌﺮ أﻧﻰ ﻓﻲ ﺳﺠﻦ ﻛﺒﯿﺮ(%88.5)، ﻻ أﺳﺘﻄﯿﻊ إﯾﺠﺎد ﻣﺎ أﺣﺘﺎﺟﮫ ﻣﻦ اﻟﺒﻘﺎﻟﺔ (%91.70) ، وﻻ أﺳﺘﻄﯿﻊ اﻟﺤﺼﻮل ﻋﻠﻰ اﻟﻌﻼج ﻟﻲ أو ﻷﺣﺪ ﻣﻦ أﻓﺮاد ﻋﺎﺋﻠﺘﻲ ﺑﺴﺒﺐ ﻧﻘﺺ ﻓﻲ اﻟﻮﻗﻮد أو ﻏﯿﺎب اﻟﻤﻮاﺻﻼت (%73.4) ، وﻻ أﺳﺘﻄﯿﻊ اﻟﺤﺼﻮل ﻋﻠﻰ اﻟﺪواء ﻟﻲ أو ﻷﺣﺪ أﻓﺮاد ﻋﺎﺋﻠﺘﻲ ﺑﺴﺒﺐ ﻧﻘﺺ اﻟﺮﻋﺎﯾﺔ اﻟﺼﺤﯿﺔ (%62.58). و ﻛﺎن ﻣﺘﻮﺳﻂ اﻟﻀﻐﻮط اﻟﻨﻔﺴﯿﺔ اﻟﻨﺎﺟﻤﺔ ﻋﻦ اﻟﺤﺼﺎر ھﻮ 10.83 وأظﮭﺮت اﻟﻨﺘﺎﺋﺞ أن اﻷﻣﮭﺎت اﻟﻠﻮاﺗﻲ ﯾﻌﺸﻦ ﻓﻲ أﺳﺮ دﺧﻠﮭﺎ اﻟﺸﮭﺮي أﻗﻞ350 دوﻻر ﻟﺪﯾﮭﺎ ﺿﻐﻮط ﻧﻔﺴﯿﺔ أﻋﻠﻰ ﻣﻦ اﻻﻣﮭﺎت اﻟﻠﻮاﺗﻲ ﯾﻌﺸﻦ ﻓﻲ أﺳﺮ دﺧﻠﮭﺎ اﻟﺸﮭﺮي 351 دوﻻر وأﻋﻠﻰ .

وﻣﻦ اﻻﻋﺮاض اﻟﻨﻔﺴﯿﺔ ﻟﻸﻣﮭﺎت: اﻟﺒﻜﺎء ﺳﺮﯾﻌﺎً (21.7 )% ، وﺻﻌﻮﺑﺔ ﻓﻲ اﻟﻨﻮم (%16.8)، واﻟﻘﻠﻖ اﻟﻤﺴﺘﻤﺮ %( 16.3)، واﻟﺼﺪاع (15.2 )% ، واﻟﺸﻌﻮر ﺑﺎﻟﺘﺸﻨﺞ واﻟﺘﻮﺗﺮ (15.2%). أظﮭﺮت اﻟﻨﺘﺎﺋﺞ أن 19%ﻣﻦ اﻻﻣﮭﺎت ﻟﺪﯾﮭﻦ ﻗﻠﻖ و15.2%ﻟﺪﯾﮭﻦ اﻛﺘﺌﺎب. وﺗﺒﯿﻦ أن اﻷﻣﮭﺎت اﻟﻠﻮاﺗﻲ ﯾﻌﺸﻦ ﻓﻲ اﻟﻤﺪﯾﻨﺔ ﻟﺪﯾﮭﻦ ﻣﺸﺎﻛﻞ ﻧﻔﺴﯿﺔ أﻗﻞ ﻣﻦ اﻟﻠﻮاﺗﻲ ﯾﻌﺸﻦ ﻓﻲ اﻟﻘﺮي واﻟﻤﺨﯿﻤﺎت. وأظﮭﺮت اﻟﻨﺘﺎﺋﺞ أﯾﻀﺎ أن اﻷﻣﮭﺎت اﻟﻠﻮاﺗﻲ ﯾﻘﻞ اﻟﺪﺧﻞ اﻟﺸﮭﺮي ﻟﺪﯾﮭﻦ ﻋﻦ 350دوﻻر ﺷﮭﺮﯾﺎً ﯾﻌﺎﻧﯿﻦ ﻣﻦ ﻣﺸﺎﻛﻞ ﻧﻔﺴﯿﺔ أﻛﺜﺮ ﻣﻦ اﻟﻠﻮاﺗﻲ ﻟﺪﯾﮭﻦ دﺧﻞ ﻣﺮﺗﻔﻊ . وﻗﺪ أﺷﺎرت اﻟﻨﺘﺎﺋﺞ أن اﻟﺮﺑﺎط ﻏﯿﺮ اﻵﻣﻦ ﻣﻊ اﻷطﻔﺎل أرﺗﺒﻂ ﻣﻊ زﯾﺎدة اﻟﻀﻐﻮط وﻗﻠﻖ واﻛﺘﺌﺎب اﻻﻣﮭﺎت .

اﻟﺨﻼﺻﺔ: ھﺬه اﻟﺪراﺳﺔ اﻻوﻟﻰ اﻟﺘﻲ ﺗﻜﺸﻒ أﻧﻮاع اﻟﻀﻐﻮط اﻟﻨﺎﺟﻤﺔ ﻋﻦ اﻟﺤﺼﺎر واﻟﻤﺸﺎﻛﻞ اﻟﻨﻔﺴﯿﺔ ﻟﺪي اﻷﻣﮭﺎت اﻟﻔﻠﺴﻄﯿﻨﯿﺎت وﻋﻼﻗﺔ ذﻟﻚ ﺑﺎﻟﺮﺑﺎط ﻣﻊ اﻷطﻔﺎل. وأظﮭﺮت اﻟﻨﺘﺎﺋﺞ ﺑﺄن اﻹﻛﺘﺌﺎب واﻟﻘﻠﻖ ﯾﺮﺗﺒﻄﺎن ﺑﺎﻟﺮﺑﺎط ﻏﯿﺮ اﻵﻣﻦ ﻣﻊ اﻷطﻔﺎل. وأﯾﻀﺎ ﻓﺈن اﻹﻛﺘﺌﺎب واﻟﻘﻠﻖ ﯾﺮﺗﺒﻄﺎن ﺑﺎﻟﻀﻐﻮط اﻟﻨﻔ ﯿﺴ ﺔ اﻟﻨﺎﺗﺠﺔ ﻋﻦ اﻟﺤﺼﺎر . وﻋﻠﯿﮫ ﻧﻨﺼﺢ ﺑﺘﺪﺧﻼت ﻧﻔﺴﯿﺔ إﺟﺘﻤﺎﻋﯿﺔ ﻟﻌﻼج اﻻﻣﮭﺎت اﻟﻤﺘﺄﺛﺮات ﺑﺎﻟﻀﻐﻮط واﻟﺼﺪﻣﺎت ﻓﻲ ﻗﻄﺎع ﻏﺰة ودﻋﻢ ﺗﻄﻮﯾﺮ ﻋﻼﻗﺔ اﻟﺮﺑﺎط ﺑﯿﻦ اﻻﻣﮭﺎت واﻟﺮﺿﻊ وﺧﺎﺻﺔ ﻋﻨﺪ اﻷﻣﮭﺎت اﻷﻛﺜﺮ ﻋﺮﺿﺔ ﻟﺨﻄﺮ اﻟﻀﻐﻮط اﻟﻨﻔﺴﯿﺔ واﻟﺼﺪﻣﺎت اﻟﻨﻔﺴﯿﺔ.

Author

Professor Abdelaziz M Thabet, Professor Emeritus of Psychiatry

School of Public Health, Al Quds University - Palestine State

Affiliated Scholar with Centre for Refugee Studies, York University - Canada

Chairman and Consultant at Child and Family Training and Counselling Centre, Gaza - Palestine

Email: [email protected]

17 Prevalence of Psychosomatic Symptoms among Traumatized Palestinian Adolescents in the Gaza Strip

Thabet Abdelaziz1*, N. Abu Sneada2, Dajani Khuloud Khayyat1 and Panos Vostanis3

DOI:

ABSTRACT

Aims: To estimate the prevalence of psychosomatic symptomsamong traumatized Palestinian adolescents in Gaza Strip. Methods: The study sample consisted of 380 adolescents randomly selected from secondary schools in Gaza Strip, of whom 171 were boys and 209 were girls between 15-18 years. Data was collected using a socio-demographic checklist, the Gaza Traumatic Events Checklist, and the Psychosomatic Symptoms Scale. For statistical analysis, questionnaire data was normally distributed, for this reason independent t-test was used to investigate differences between two groups. Associations between continuous variables were measured by the Pearson's correlation coefficient test. One-way ANOVA post hoc Tukey was used to investigate differences between more than two groups. Results: The most common reported traumatic events due to the war on Gaza were: Watching mutilated bodies and wounded people in TV (92.3%), and hearing shelling of the area by artillery (89.4%). The mean number of traumatic events experienced by Palestinian adolescents was 14. Boys reported significantly more traumatic events than girls. Adolescents from family with monthly income less than 150 US $ experienced more traumatic events than the other groups. Mean psychosomatic symptoms was 48.19, digestive system symptoms was 19.97, cardiovascular symptoms was 10.23, respiratory system symptoms was 3.82, urogenital system symptoms was 2.98, skeletal musculature symptoms was 5.29, and skin symptoms was 7.34. Boys scored more in total psychosomatic and skin symptoms. There was a significant relationship between traumatic experiences and psychosomatic symptoms. Conclusion: Palestinian adolescents experienced significant traumatic events due to the war on Gaza Strip which were significantly associated with developing psychosomatic symptoms. Such findings highlight the urgent need for establishing community mental health school based programs to help adolescents with such symptoms and increase awareness about their nature and management. Also there is need for conducting training courses for teachers and school counsellors to increase their knowledge about general mental health problems in schools and ways of dealing with such problems. Also, training courses for primary care and hospital physicians, who might attribute to physical causes, and liaison between physical and mental health services.

Keywords: Adolescents; Gaza; psychosomatic symptoms; trauma; war.

1. INTRODUCTION

Each year millions of children are exposed to variable types of extreme traumatic stressors. These include natural disasters (e.g., tornadoes, floods, and hurricanes), motor vehicle accidents, life- threatening illnesses and associated painful medical procedures (e.g., severe burns, cancer, and limb

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1School of Public Health, Community Mental Health Department and Child Institute, Al Quds University, Palestine. 2Department of Community Mental Health, Palestinian Ministry of Health, Palestine. 3School of Medicine, Leicester University, Greenwood Institute of Child Health, School of Psychology, Leicester, UK. *Corresponding author: E-mail: [email protected]; amputations), physical abuse, sexual assault, witnessing domestic or community violence, kidnapping, and sudden death of a parent [1].

Children of Gaza have been subject to a wide range of traumatic and violent events over the last few decades, which, when considered alongside other risk factors such as gender, socio-economic status and previous mental health history, these have led to significant psychosocial problems [2]. On Saturday 27th December 2008, there was a new political escalation and violence against the Palestinians in the Gaza Strip. Within the first 20 minutes the Israeli air force bombarded the security positions in the Gaza Strip, leaving hundreds of killed people and more than a thousand of injured. This war on Gaza continued for 23 days. The total toll of this war was 1,330 killed persons and 5,500 injured [3].

A number of studies showed the negative psychological consequences of traumatic experiences on child development and well-being. During the war in Bosnia-Hercegovina, a community sample of 2,976 children aged between 9 and 14 years was selected. Children reported a high prevalence of posttraumatic stress symptoms and grief reactions. Girls reported more distress than boys, but there were few meaningful age effects within the age band studied [4].

In a study in the Nangarhar province in Afghanistan, a sample of 1011 Afghani aged 15 years or older was selected. During the previous ten years, 43.7% of them had experienced between 8 and 10 traumatic events, and 14.1% had experienced 11 or more traumatic events. The study showed that 38.5% of participants reported symptoms that fulfilled clinical criteria for depression, 51.8% reported anxiety, and 20.4% reported posttraumatic stress disorder [5].

In a study of Palestinian adolescents exposed to both political and domestic violence, whereas there was no significant gender difference in the level of exposure to political violence, female adolescents exhibited higher levels of psychological symptoms compared to their male counterparts. Girls also reported higher levels of exposure to domestic violence and lower levels of family functioning than boys [6]. In another study of 358 Palestinian adolescents, the mean number of traumatic events reported by adolescents was 13.3. The most frequently reported traumatic experiences were watching mutilated bodies on TV (90.8%) and hearing shelling of the area by heavy artillery (88.5%). Almost one third of the young people (29.8%) reported symptoms meeting criteria for a full post traumatic stress disorder (PTSD) [7].

Overall, previous research has primarily focused on the impact of trauma on a range of emotional disorders. Surprisingly, there has been limited evidence on the prevalence of psychosomatic symptoms and disorders, or on their relationship with trauma exposure, despite the well documented link of such presentations with emotional psychopathology. Psychosomatic disorders are typically defined as those in which psychological factors are thought to contribute significantly to the development, exacerbation, or maintenance of the illness [8]. Psychosomatic symptoms and somatization are distinct from malingering in that the patient is truthfully reporting his or her bodily sensations and not consciously using these symptoms to manipulate or control others or the situation [9]. Recently, the definition of psychosomatic disorder has been changing according to the Diagnostic and Statistical Manual of Mental Disorders (DSM). The term psychosomatic disorder refers to physical symptomatology appeared to be caused, influenced or worsened by psychological factors rather than by an underlying physical illness [10].

Depending on the sample and measures, the prevalence rate of psychosomatic complaints in children and adolescents has been found to be between 10 and 25% [11,12].

Such symptoms were particularly high among Palestinian University students who had suffered sexual abuse, together with depressed mood, withdrawal, suicidal or self-injurious behaviors, illegal acts, running away, and [13].

Another study of 1,828 children aged 6 to 16 years, of whom 842 had been affected by a devastating earthquake in Wenchuan County in the Northwest Sichuan Province of China and 986 lived in a non- affected area, total psychosomatic symptoms were significantly higher among those exposed [14]. As

2 there has been limited knowledge on the presentation of psychosomatic symptoms following war conflict, this was the rationale of this study with traumatized Palestinian adolescents in the Gaza Strip.

2. METHODS

2.1 Participants and Procedure

The sample consisted of 380 adolescents. The age ranged from 15 to 18 years, with a mean of 16.6 years (SD=0.08). The sample was randomly selected from ten schools in the Gaza Strip (two schools from each of the five governorates of the Gaza Strip - one all-boys and one all-girls school). From each school, three classes were selected randomly (10th, 11th and 12th class), following which we selected randomly the sample from each class registration book. At the end of the selection process, the sample consisted of 171 boys (45%) and 209 girls (55%).

2.2 Research Procedure

We trained three mental health professionals (two male and one female) on data collection for three hours, during which the aim of the study was explained, the sampling, questionnaires and interview techniques. The study was approved by the Palestinian Ministry of Health Ethics Committee. Also, an official letter was obtained from the General Director of the Ministry of Education in order to conduct the study in governmental secondary schools and to facilitate the process of data collection. Each young person received an explanatory letter explaining the aim of the study and that the information gathered would be kept confidential for the purpose of the research only. A similar letter to the parents was send with the participants, and if agreed, they obtained a written permission for their adolescent’s participation. Data collection took place in the classroom during April 2010.

3. MEASURES

3.1 Socio-demographic Checklist

Information was collected from the adolescents on gender, age, place of residence, number of siblings, parents’ education and employment status, and family income.

3.1.1 War on Gaza traumatic events checklist [15]

This had been used in the same area [15] and during this period of conflict, It was modified to include 30 items covering different types of traumatic events that adolescents may have been exposed to in the particular circumstances of the 2008-2009 war on Gaza Strip. This checklist covers three domains of trauma. The first domain cover hearing experiences such as hearing to the killing or injury of friends or relatives (item number 1-5). The second domain describes witness acts of violence such as the killing of relatives, home demolition, bombardment, and injury of others (item number 6-17). The third domain covers personal experiences of traumatic events such as being shot or beaten (item number 18-30). The checklist can be completed by children aged 6-16 ('yes' or 'no'). In this study the reliability of the scale using Cronbach’s alpha was 0.92 and the split half was 0.86.

3.1.2 Psychosomatic symptoms scale [16]

The scale consists of 59 items that describe different types of psychosomatic symptoms. This scale covers six psychosomatic domains such as digestive system symptoms (23 items), cardiovascular symptoms (7 items), respiratory system (6 items), skin (12 items), urogenital system (5 items), and muscular-skeletal system symptoms (6 items). The items of the scale are rated on a 5-point scale: 1=not at all (0 point), 2= a little bit (1 point), 3= moderately (2 points), 4=quite a bit (3 points) and 5=extremely (4 points). This scale was validated in the Arabic culture (Egypt) [16]. The internal consistency of the Arabic version was satisfactory (Cronbach’s alpha = 0.98) and its split half was 0.98. This scale had been previously used in the Gaza Strip, with similar psychometric properties

3 Cronbach’s alpha = 0.98) and split half= 0.98 [17]. In this study, the reliability of the scale using Cronbach’s alpha was 0.97 and its split half was 0.84.

3.2 Statistical Analysis

Data was entered and analyzed using the Statistical Package for Social Sciences (SPSS) software version 18. The questionnaire data was normally distributed, for which reason an independent t-test was used to investigate between-group differences. Associations between continuous variables were measured by the Pearson's correlation coefficient test. One-way ANOVA post hoc Tukey was used to investigate differences between more than two groups.

4. RESULTS

4.1 Socio-demographic Characteristics (Table 1)

The sample consisted of 380 adolescents, 171 of whom were male (45%) and 209 were female (55%) between the ages of 15-18 years (mean=16.6, SD=0.08). Regarding the place of residence, 26.1% lived in North Gaza, 18.9% in Gaza city, 23.2% in the middle area, 14.2% in Khan Younis area, and 17.6% lived in the Rafah area (13.4%).

Table 1. Demographic characteristics of the study sample (N=380)

No % Sex Male 171 45 Female 209 55 Age in years, MEAN age was 16.64 years 15 y 30 7.9 16y 131 34.5 17y 165 43.4 18y 54 14.2 Place of residence North Gaza 99 26.1 Gaza 72 18.9 Middle area 88 23.2 Khan Younis 54 14.2 Rafah area 67 17.6 Family monthly income Less than 150 US $ 129 33.9 151- 300 US $ 86 22.6 301 – 650 US $ 102 26.8 More than 651 US $ 63 16.6

4.2 Frequency of Traumatic Events Due to War on Gaza

The most commonly reported traumatic events due to the war on Gaza were: 92.3% watched mutilated bodies and wounded people on TV, 89.2% heard shelling of the area by artillery, and 89.2% heard the sonic booms from jetfighters.(Table 2).

4.3 Traumatic Events and Socio-demographic Variables

Traumatic experiences were recoded into three categories (hearing: items 1-5; witnessing: items 5-16; and direct: items 17-30). The mean number of total traumatic experiences were 14.21, mean hearing experiences was 3.61, mean witnessing experiences 5.76, and mean direct experiences 4.84. Boys reported significantly more traumatic events than girls (t-test = 2.19, p <0.04); also, boys reported

4 more hearing traumatic experiences than girls (t-test = 2.81, p <0.01). However, there were no gender differences on reporting witnessing and personal experiences.

Adolescents with family monthly income less than 150 US$ had experienced more traumatic events than the other groups with higher family income (F=3.23, p=0.02).

4.4 Psychosomatic Symptoms

As shown in Table 3, the mean number of psychosomatic symptoms was 48.19 (SD= 27.94) with estimated weight 20.42% (mean/No of items 59*4(0-4 scale)*100), digestive system symptoms was 19.97 (SD= 11.85), cardiovascular symptoms was 10.23 (SD = 11.85), respiratory system symptoms was 3.82 (SD = 3.51), urogenital system symptoms was 2.98 (SD = 2.91), skeletal musculature symptoms was 5.29 (SD =3.76), and skin symptoms was 7.34 (SD = 6.7) (Table 4).

Table 2. Frequency of traumatic events due to war on Gaza

No Traumatic events Yes % 1 Watching mutilated bodies in TV 350 92.3 2 Hearing shelling of the area by artillery 339 89.4 3 Hearing the sonic sounds of the jetfighters 338 89.2 4 Witnessing the signs of shelling on the ground 336 88.7 5 Witnessing firing by tanks and heavy artillery at neighbors homes 265 69.9 6 Witnessing assassination of people by rockets 261 68.9 7 Hearing of arrest of someone or a friend 242 63.9 8 Forced to leave your home during the war 235 62 9 Hearing killing of a friend 235 62 10 Witnessing of a friend home demolition 235 62 11 Deprivation from water or electricity during detention at home 234 61.7 12 Hearing killing of a close relative 216 57 13 Threaten by shooting 198 52.5 14 Being detained at home during incursion 159 42 15 Witnessing killing of a friend 136 35.9 16 Witnessing firing by tanks and heavy artillery at own home 128 33.8 17 Witnessing of own home demolition 128 33.8 18 Destroying of your personal belongings during incursion 127 33.5 19 Threaten of family member of being killed 121 31.9 20 Witnessing shooting of a friend 120 31.7 21 Witnessing shooting of a close relative 115 30.3 22 Witnessing killing of a close relative 115 30.3 23 Deprivation from going to toilet and leave the room at home where 114 30.1 you was detained 24 Exposure to burn by bombs and phosphorous bombs 100 26.4 25 Beating and humiliation by the army 100 26.4 26 Threatened to death by being used as human shield to arrest your 97 25.6 neighbors by the army 27 Shooting by bullets, rocket, or bombs 89 23.5 28 Threaten of being killed 89 23.5 29 Being arrested during the last incursion 83 21.9 30 Physical injury due to bombardment of your home 83 21.9

4.5 Psychosomatic Symptoms and Socio-demographic Variables

There were significant gender differences in skin symptoms (boys > girls: 8.32 vs. 6.54; t = 2.64, p = 0.01). No statistically significant gender differences were detected in other psychosomatic symptoms.

5 4.6 Relationship between Trauma and Psychosomatic Symptoms

Table 5 shows that total psychosomatic symptoms was significantly correlated positively with total traumatic events (r = 0.17, p = 0.01), hearing trauma (r = 0.12, p = 0.01), witnessing trauma (r = 0.10, p = 0.01), and personal trauma (r = 0.18, p = 0.01).

Table 3. Independent t- test for mean traumatic experiences and sex of adolescents

Sex N Mean SD t p Total trauma Male 171 15.01 6.23 2.03 0.04 Female 209 13.56 7.40 Hearing trauma Male 171 3.60 1.11 -0.23 0.82 Female 209 3.62 1.08 Witnessing trauma Male 171 6.21 2.66 2.81 0.01 Female 209 5.40 2.92 Personal trauma Male 171 5.20 4.04 1.52 0.13 Female 209 4.54 4.32

Table 4. Means, standard deviations of psychosomatic symptoms (N=380)

Mean Std. deviation Total psychosomatic symptoms 48.19 27.94 Digestive system symptoms 19.97 11.85 Cardiovascular symptoms 10.23 6.37 Respiratory system symptoms 3.82 3.51 Urogenital system symptoms 2.98 2.91 Skeletal musculature symptoms 5.29 3.76 Skin symptoms 7.34 6.74

Table 5. Pearson correlation coefficient test between trauma and psychosomatic symptoms

Total trauma Hearing trauma Witnessing trauma Direct trauma Total psychosomatic r 0.17 0.12 0.10 0.18 symptoms P 0.01 0.05 0.10 0.00 No. 380 380 380 380 Digestive system r 0.15 0.10 0.12 0.15 symptoms P 0.01 0.07 0.04 0.01 No. 380 380 380 380 Cardiovascular r 0.19 0.15 0.08 0.19 symptoms P 0.00 0.00 0.13 0.00 No. 380 380 380 380 Respiratory system r 0.13 0.10 0.05 0.13 symptoms P 0.02 0.05 0.36 0.01 No. 380 380 380 380 Urogenital system r 0.16 0.13 0.05 0.16 symptoms P 0.00 0.01 0.30 0.00 No. 380 380 380 380 Skeletal musculature r 0.16 0.15 0.07 0.15 symptoms P 0.00 0.01 0.19 0.01 No. 380 380 380 380 Skin symptoms r 0.21 0.16 0.10 0.21 P 0.00 0.00 0.08 0.00 No. 380 380 380 380

6 4.7 Prediction of Psychosomatic Symptoms by Types of Traumatic Events

In a univariate linear regression analysis, each traumatic event was entered as an independent variable, with total psychosomatic symptoms and subscales scores as the dependent variable. Two traumatic events were significantly associated with total psychosomatic symptoms: being detained at home during incursion (B=0.16, p=0.01); and destroying of child personal belongings during incursion (B=0.14, p=0.03) (Table 6).

Table 6. Linear regression analysis of traumatic events and psychosomatic symptoms

Psychosomatic Traumatic events Unstandardized Standardizedt p coefficients coefficients B Std. Beta error Total Being detained at home 8.93 3.52 0.16 2.54 0.01 Psychosomatic during incursion symptoms Destroying of your personal 8.08 3.73 0.14 2.17 0.03 belongings during incursion Digestive system Being detained at home 3.91 1.39 0.16 2.82 0.01 symptoms during incursion Hearing killing of a friend 2.82 1.40 0.12 2.01 0.05 Shooting by bullets, rocket, or -6.10 1.90 0.22 3.21 0.001 bombs Threaten of family member of 4.94 1.76 0.19 2.80 0.01 being killed Cardiovascular Being detained at home 3.91 1.39 0.16 2.82 0.01 symptoms during incursion Hearing killing of a friend 2.82 1.40 0.12 2.01 0.05 Shooting by bullets, rocket, or -6.10 1.90 0.22 3.21 0.00 bombs Threaten of family member of 4.94 1.76 0.19 2.80 0.01 being killed Respiratory Threaten of being killed 1.36 0.37 0.19 3.71 0.00 system symptoms Urogenital system Deprivation from water or 0.98 0.34 0.16 2.92 0.00 symptoms electricity during detention at home Hearing killing of a friend 0.64 0.32 0.11 2.00 0.05 Skeletal Threaten of being killed 1.02 0.41 0.14 2.53 0.01 musculature Deprivation from water or 1.04 0.44 0.13 2.34 0.02 symptoms electricity during detention at home Skin symptoms Deprivation from water or 2.85 0.79 0.19 3.60 0.00 electricity during detention at home Witnessing firing by tanks and 2.01 0.74 0.15 2.73 0.01 heavy artillery at neighbors homes

5. DISCUSSION

The results of our study showed that Palestinian adolescents had experienced a variety of traumatic events as a result of the War on the Gaza Strip in 2008-2009, as on average they reported a mean 14

7 traumatic events. The most commonly reported traumatic events were watching mutilated bodies on TV (92.3%). These findings were consistent with research on previous conflicts in the are [7,15]. An earlier study of 600 adolescents aged 12-16 years from South Lebanon and the Gaza Strip found that 29.8% of adolescents had experienced at least one high-magnitude traumatic event in their lifetime due to war; 19.8% involved a family member being killed, 12.5% a family member being injured, and 13.6% had had their house demolished [18]. Our result showed that boys experienced more traumatic events than girls was also consistent with other research [7,15,19]. This may be explained by the socialization of girls in the contemporary Palestinian society. Girls remain at home under stricter surveillance and protection, whereas boys participate in activities and events outside their home, which make them more vulnerable to exposure to trauma. In particular, according to the Arabic culture, girls are expending their time at home helping their mothers in homework.

There were also significant differences in experiencing traumatic events according to monthly family income, which indicates that adolescents of lower socioeconomic status are more at risk of experiencing traumatic events. We postulate such findings to the increased level of poverty due to the siege, and to the repeated wars in the area for the last decade [20].

Adolescents mean score of psychosomatic symptoms was 48.19 of with estimated weight 20.42%. Similarly, in a study of adolescents living in a devastating area struck by earthquake in the Wenchuan County in the Northwest Sichuan Province of China compared to a similar number from non-affected area showed that the psychosomatic factor scores of the experimental group were significantly higher than those of the control group [14]. Other studies indicated that extreme natural disasters contributed to psychosomatic symptoms among children and adolescents [21].

According to the results of the first nationwide epidemiological survey of or psychosomatic disorders among Japanese children, 5.8% of all children who visited the outpatient pediatric clinics on a given day were considered to have psychosomatic disorders [22].

There were no significant gender differences in psychosomatic symptoms, except for skin symptoms which were reported more by boys. Most studies do not find any gender difference in the prevalence of specific somatization disorders before puberty; in contrast, adolescent girls tend to report more symptomatology than boys [23,24]. In a study of 2,558 school children and adolescents aged 8–16 showed that 37.6% reported at least one somatic symptom, headache being the most prevalent. In terms of age distribution, 26.8% of children and 52.1% of adolescents reported somatic symptoms. Girls reported more somatic symptoms than did boys [25]. Also in previous research, headache and stomach-ache were more frequently reportedby girls than by boys [26].

This study showed positive significant correlation between traumatic events, including witnessing, hearing, and personal experiences, and psychosomatic symptoms. Our findings were congruent with previous studies which showed that exposure to traumatic events was predicating a range of child and adolescent psychopathology [27,28].

6. STUDY LIMITATIONS

There were few limitation in this study in which the scale for psychosomatic was long one and adolescents took time to finish it. Also, another limitation was we did not study other mental health problems such as PTSD and anxiety.

7. FURTHER RESEARCHES

According to the results of this study further studies in the area are needed to narrow the knowledge gap including effect of trauma on mental health among families of traumatized adolescents, peritraumatic symptoms and acute traumatic stress among victims of last war in Gaza Strip on 2014, associations between trauma and psychosis: an exploration of cognitive and dissociative factors.

8 8. CLINICAL IMPLICATIONS

Our study showed that Palestinian adolescents experienced traumatic events due to war on Gaza Strip, which were associated with psychosomatic symptoms. There may be a risk of such trauma exposure in developing such mental health problems, although this could not be ascertained by the current cross-sectional research design. Nevertheless, such findings highlight the urgent need for establishing community mental health and school-based programs to help adolescents with such symptoms, initially by increasing awareness about their nature. Also, there is need for conducting training courses for teachers and school counsellors to increase their knowledge and recognition of mental health problems within schools, and ways of managing the simplest presentations, thus avoiding referral to sparse specialist services. Furthermore, more training courses to educate paediatricians and primary care physicians will also be important in recognising these symptoms and not necessarily dismissing or attributing to physical causes, i.e. they need to liaise with mental health services. Overall, intervening in communities and schools will enhance opportunities for adolescents, their families, friends, teachers and professionals to promote their resilience and well-being. Establishing educational programs such as in problem-solving skills will assist young people in confronting various traumatic events in the face of ongoing adversity.

9. CONCLUSION

The importance of our study was in findings the impact of trauma due to war on psychosomatic disorders and not only PTSD in adolescents. Such finding highlights the need for more research in the field of somatization in the adolescents and in application of new intervention programs which increase coping and resilience of Palestinian adolescents to overcome in the negative impact of trauma on adolescents. Also, the need for community sessions for children and adolescents to increase their awareness about psychosomatic and somatization disorders and ways of dealing with such problems.

COMPETING INTERESTS

Authors have declared that no competing interests exist.

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10 Biography of author(s)

Thabet Abdelaziz School of Public Health, Community Mental Health Department and Child Institute, Al Quds University, Palestine.

He is a adolescent Psychiatrist, was educated in Palestine, Austria, and United Kingdom in child psychiatry. His main interest was in dealing with Palestinian children affected by First Intifada which was erupted in 1987. He was running the clinical setting in Gaza city and was seeing adults and children victims of trauma and political violence. Cases were varied from depression, psychosomatic problems, anxiety, PTSD in adults. Children were referred due problems such as fears, anxiety, bed wetting, , PTSD, ADHD, and . In seeing such cases, he decided to study the impact of trauma on children in the Gaza Strip in 1993. On the last three decades professor Thabet had conducted very interesting research including the prevalence of mental health problems in Gaza and West Bank, coping strategies used by children and parents. He targeted different ages and preschool children were in the target group in which he carried out studies of the mental health of children in preschool age and their mothers. He also studied patients in different departments in the hospitals such as End Stage Renal Failure, Cancer patients both in children and adult departments. After a while he conducted evaluation of intervention studies including different intention programs such as writing therapy, school based intervention, psychoeducation, psychodrama. In the last years, he started to lock for risk and protective factors in children and adults victims of political violence, stress, and trauma. He had conducted studies to see the impact of trauma, stress on resilience and PTG of adolescents and adults. His research includes both qualitative and quantitative ways of data collection. Also, Prof Thabet had targeted marginalized population such as Labor, orphaned, children lost their fathers in war, children with special needs, children under dialysis. His main interest is the impact of stress and trauma on children and adults and the coping as medication factor and resilience as the outcome, gender based violence, women mental health. ______© Copyright 2019 The Author(s), Licensee Book Publisher International, This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

DISCLAIMER This chapter is an extended version of the article published by the same authors in the following journal with CC BY license. British Journal of Education, Society & Behavioural Science, 8(2): 94-103, 2015.

Reviewers’ Information (1) Ask Elklit, Danish National Center for Psychotraumatology, University of Southern Denmark, Odense, Denmark. (2) Matias Carvalho Aguiar Melo Universidade Federal do Ceará, Brazil. (3) Nobuyuki Kobayashi, Department of Psychosomatic Medicine, Takano Hospital, Kumamoto, Japan. (4) Vedat Sar, VKV American Hospital, Istanbul, Turkey. (5) Anonymous, Colombia.

11 Chapter 02 ISBN: 978-81-934224-2-7

Impact of Trauma on Palestinian Children PTSD, Anxiety, Depression and Coping Strategies

Abdel Aziz Mousa Thabet 1* , Panos Vostanis 2 and S. S. Thabet 3

DOI:10.9734/BPI/ctmmr/v1

ABSTRACT

Aim: The aim of the paper was to investigate the impact of trauma after one year of Gaza War on children PTSD, anxiety, depression, and coping strategies as mediator factors. Methods: The study sample consisted of 449 children from the children who were exposed to the Israeli war on the Gaza Strip, 51.9% of the them were boys and 48.1% were girls. Children completed measures of experience of traumatic events (Gaza Traumatic Events Checklist-20 items, War on Gaza), PTSD, Birleson Depression Scale, and Child Revised Manifest Anxiety Scale. The data was collected on March 2010 from the entire Gaza Strip. Results: After one year, still the Palestinian children reported many traumatic events, 90.4% of children reported watched mutilated bodies in TV, 44.6% exposed to deprivation from water, food, or electricity during the war, 33.5% left their homes with families and relatives, 29.8% witnessed firing by tanks and heavy artillery at neighbors’ homes, 4.1% threaten with being killed, 4.1% threatened with death by being used as human shield by the army to arrest their neighbor. Our results showed that each child experience 5.92. The study showed that 56.6% of children still reporting mild trauma (0-5 events), 32.9% reported moderate trauma (6-10), and 10.6% reported severe trauma level. There were no significant sex and age differences in exposure to trauma. Children with high traumatic experiences reported more self-criticism, also children with high exposure to trauma had less social support. For post traumatic stress reactions, 43.4% of children reported that when something reminds them of what happened during the war, they get very upset, afraid or sad. 31.5% afraid that the bad thing will happen again. 30.4% feel jumpy or startle easily, like when I hear a loud noise or when, 30% try to stay away from people, places, or things that make me remember what happened. Using DSM-TR criteria for PTSD, 24.9% of children had no symptoms, 30.2% had at least one cluster of symptoms (intrusion or avoidance or hyperarousal), 32.5% had partial PTSD (Two cluster of symptoms), and 12.4% had full criteria of PTSD. No significant sex differences in PTSD. Children living in families with monthly income less than $300 had more PTSD, intrusion, avoidance and hyperarousal than the other groups. The study showed that children live in cities showed more PTSD symptoms than those in villages and camps. There was significant correlation between total traumatic events and PTSD. For fear symptoms, commonly children: always my parents tell me to be careful of all people (72%), I become tired quickly when I run from the house (60.4%), scream when I see and hear the plane in the air (56.2%). The results showed that total fears symptoms were 9.27 (SD =5.13). For anxiety symptoms, the most common symptoms were: Feel worried when things do not go as they want (79.1%), being anxious to what is happening in the future (67%), they are always anxious for bad things can happen to them (64.4%), hurt easily their feelings when they are anxious (54.8%), while the less items was they always feel that they are am alone when they are with people (22.1%). Using cut-off point of RCMAS, 20.5% of children scored above cut-off point of anxiety. There were significant correlations between total anxiety and total traumatic events score. There were statistically significant differences in anxiety toward boys. Children with anxiety scored more in total coping strategies, more resignation, and social withdrawal as coping strategies than children without anxiety. ______1Emeritus Professor of Child and Adolescent Psychiatry-School of Public Health - Al Quds University- Jerusalem- Palestine state. Affiliated Scholar at Center for Refugee Studies at York University-Canada, President of 2Child and Family Training and Counseling Center –Gaza. 2Department of Neuroscience, Child Mental Health, Psychology and Behavior Centre for Medicine, United Kingdom. 3Child and Family Training and Counseling Center, Palestine. *Corresponding author: E-mail: [email protected];

Current Trends in Medicine and Medical Research Vol. 1 Impact of Trauma on Palestinian Children PTSD, Anxiety, Depression and Coping Strategies

The results showed that the most common depression symptoms were: 82.3% suffer from pain in the stomach, 77% said they never love talk with my family and with others 69.8% feel that life is not worth anything, 69.6% would like to run away, and 60.7% children scored above cut-off point of Birleson Depression scale. Depressed children had less social withdrawal and less social support than children without depression as coping strategies. The results indicated that coping strategies of children were: 72.6 % of the children try to feel better by spending time with others like family, grown-ups or friends, 65.7% try to sort out the problem, 63.3% try to sort out the problem by doing something or talking to someone about it. The results showed that the total coping mean was 10.32. While the highest coping subscales means used by children was social withdrawal (mean =2.88) followed by emotional regulations (mean =2.61), and distraction (2.53). The result showed that children with PTSD and without PTSD were not different is total coping strategies. However, however, children with PTSD were significantly used less social withdrawal, wishful thinking, and self criticism as coping strategies than children without PTSD Conclusion: This study showed that after one year of Gaza war still Palestinian children had the impact of traumatic experiences on their mental health. Children are suffering of depression, anxiety, PTSD, and fears. All those reactions were related to traumatic events. However, children are able to cope with such reactions by using different ways of coping, mainly try to feel better by spending time with others like family, grown-ups or friends, try to sort out the problem, and try to sort out the problem by doing something or talking to someone about it. Implications: These findings highlight the needs for more community-based interventions to improve children mental health. This could apply in schools and other community centers by trained psychologists and psychiatrists. Also parental training of early detection of children with mental health problems and dealing with such problems by behavior modification and more listening to their children. Also, programs of increasing children ability to cope with conflicts and gaining more health coping strategies could be useful.

Keywords: One year of Gaza War; children; PTSD; depression; anxiety; coping.

1. INTRODUCTION

A number of studies from war zones and different cultures have reported high rates of posttraumatic stress disorder (PTSD) among children exposed to trauma. For example, in a study of Palestinian children in the Gaza Strip, 41% reported moderate to severe posttraumatic stress (PTS) reactions [1]. Studies indicate that children can develop PTS after exposure to a range of traumatic stressors, including violent crime, sexual abuse, natural disasters, and war [2]. In addition to examining the prevalence of PTSD and other psychiatric disorders, subsequent research investigated risk factors, including the extent of exposure. In contrast to peacetime disasters, stressors during war are generally multiple, diverse, chronic, and recurrent such as the violent death of a parent, witnessing the killing of close family members, separation and displacement, terror attacks like bombardment and shelling [3,4]. There are few studies on the long-term effects of mass trauma on victimized communities [5]. In the aftermath of major natural disasters, acute stress reactions are expected, and overall resilience is the rule rather than the exception. Many studies have shown that 1–6 months post-trauma, PTSD is reduced by approximately 50%; nevertheless, there are doubts as to whether there is further reduction of PTSD after 6 months post-trauma [6]. In addition, Palestinian children continuously witness severe internal (familial and societal) and external violence (due to occupation). According to Thabet et al. [7], in study of 77 Palestinian children showed that the most common traumatic events for the children attending our clinic were witnessing acts of violence against relatives or non- relatives, beating to themselves, and being injured by shooting.

Children emotional responses have been found to increase in line with the levels of violence encountered [8,9]. Another study with 309 Palestinian preschoolers also found that direct and indirect exposure to war trauma increased the risk of ill mental health from a young age [10]. Traumatic events might come from natural disasters or human action, but the chronic traumatic events in Palestine have been transferred from generation to generation as a result of war, occupation and conflict since 1948. Although the Palestinian children are used to facing daily trauma, they are still exposed to sudden and unexpected events and continuous damage to their psychological stability and the social structures which support them [11]. Overall, the majority of studies conducted in the

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Current Trends in Medicine and Medical Research Vol. 1 Impact of Trauma on Palestinian Children PTSD, Anxiety, Depression and Coping Strategies

Occupied Palestinian Territories have emphasized the high rates of dysfunction and maladaptation in Palestinian children, and reported a high prevalence of common mental health problems and more severe disorders [3,7,8].

A review of studies on PTSD prevalence in youth exposed to a variety of traumas found a wide range of prevalence rates depending on the type of trauma exposure and measure used [9]. The highest rates of PTSD were found in studies of children and adolescents exposed to war or political violence and repression. For immigrants and refugees, it is also important to consider the added effects of immigration exit circumstances and their potential mental health consequences via the added stressors of lost social supports and status, acculturative stress, and displacement out of their homes [12]. In such a study in the Gaza Strip areas exposed to the war of 23 days, among 374 children aged 6-17 years, using self-report questionnaires, 29.9% suffered from moderate PTS reactions, and 61.5% from severe to very severe PTS reactions [11]. In a similar study with children six months after the Gaza war, 39.3% fulfilled partial and 9.8% full DSM-IV criteria for PTSD [12]. A study [13] found that, Palestinian children reported a range of traumatic experiences: 95% had heard sonic sounds of jetfighters, 92% had heard shelling by artillery, 92% had seen mutilated bodies on television, 80% had been deprived of water or electricity during the war and 51% had left their home for a safer place.

Coping is defined as "constantly changing cognitive and behavioural efforts to manage specific external or internal demands that are appraised as taxing or exceeding the resources to the person" [14]. There is no unifying theory regarding the underlying elements of child and adolescent coping, although three dimensions are most commonly used to categorize coping strategies: (a) problem- focused and emotion-focused coping, (b) primary and secondary control coping, and (c) engagement and disengagement coping (also referred to as approach versus avoidance coping) [15]. These conceptualizations do not address coping in the context of sudden, and often devastating, stressors such as a disaster or terrorist attack [16].

To date, much of the research with children and adolescents has been based on the framework by Folkman and Lazarus (albeit initially developed for adults), which emphasized the context in which the coping actions occur, the attempt rather than the outcome, and the fact that coping is a process that changes over time, as the person and the environment are continuously in a dynamic, mutually influential relationship [15,16, 17]. This is often referred to as the transactional model of coping. Depending on the type, severity, duration, and chronicity of trauma – in association with the child’s age, prior vulnerability, and the response of primary caregivers – child maltreatment and traumatic exposure may result in vastly different outcomes. These outcomes potentially affect every aspect of the child’s development and functioning, including brain development, neurochemical pathways, psychosocial adaptation, and preferential responses to subsequent stress and other life experiences [18].

Coping can affect children’s emotional well-being independently of their prior mental health status. It is equally likely that children experiencing poor mental health use different and fewer effective strategies than those with adaptive mental health. In a study with children of depressed parents, negative cognitions were associated with three types of coping, i.e. primary control, secondary control, and disengagement. Furthermore, coping style and negative cognitions made independent contributions to depressive symptoms [19,20]. Based on several studies, coping skills and self-efficacy are linked to reduction of anxiety symptoms [21]. Maric et al. [22] indicated that one of the strongest predictors of anxiety is the underestimation of the ability to cope.

Young people in the Gaza Strip commonly used coping strategies such as self-reliance and optimism; engaging in activities that were demanding of themselves and within their control such as getting their bodies in shape and getting better grades; and exploring ways to figure out how to deal with problems or tensions on their own. Avoidance behaviour by drinking alcohol, or using illicit drugs were the least used coping strategies [23]. Two studies have reported the positive correlation between exposure to traumatic events and the use of active cognitive coping in Palestinian [24] and Israeli [25] children. Maltreated male adolescents, also in the Gaza Strip, were found to rely on emotional and problem- solving coping strategies [25]. Similarly, in another study of 250 Palestinian children who had lost their fathers due to war conflict in the Gaza Strip, significant differences were found on mental

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disengagement, focus on and venting of emotion, use of instrumental social support, active coping, religious coping, restraint, and planning according to trauma levels all of which were mainly used by children exposed to severe traumatic events [26]. In Western societies, coping strategies are often connected to the individualistic approach, where the individuals can seek help through professional channels, such as counselling. In comparison, within the context of developing countries the coping approach is more collective. Individuals are part of the community and they resolve their problems and get their support within community networks, since professional assistance is rarely available [25].

In research with other ethnic groups such as African American high school students, coping styles range from “getting through,” which included both an acceptance of community conditions; “getting along,” which included self-defense techniques; “getting away,” which included avoidance coping strategies; and “getting back,” which consisted of confrontational coping strategies. Boys are more likely to report confrontational coping styles than girls, who instead utilize more avoidance approaches [27]. It is possible that what has previously been seen as greater perceived stress in individuals at risk for psychosis may actually indicate a decreased ability to activate or mobilize coping strategies [28]. Others found similar ways of coping with terrorism attacks. Moscardino et al. 2014, in study of 60 adolescents (aged 14–18 years) who survived the 2004 terrorist attack against a Russian school in Beslan, found that self-blame was related to increased risk of PTSD, which provided further evidence for the association between emotion-focused coping strategies and posttraumatic symptomatology [29]. Living in constant threat of attack and exposure to terrorism could challenge a sense of self- efficacy, and increase the fear of loss of loved ones or economic resources, it might, on the other hand, enhance one’s sense of self-efficacy or, at least, create a buffer to the stress consequences, or, perhaps, increase an inoculation effect or self-control [30].

Overall, coping strategies have been found to mediate and/or moderate the relationship between exposure to stressors and mental health in children and adolescent [31]. The aims of this study were to investigate: 1) the types and severity of traumatic events after 16 months of the war on Gaza on children; 2) the prevalence of PTSD, anxiety, and depressive symptoms; 3) the types of coping strategies used by children; and 4) the mechanisms between trauma, coping strategies and psychopathology. Coping with the fear of terrorism and dealing with terrorist attacks will be increasingly important in global human resource management. Proper psychological preparation, particularly coping skills of international assignees, will be necessary to ensure adjustment, performance, well-being, and assignment completion [30].

2. METHODS

2.1 Setting and Sample

The Gaza Strip is a narrow elongated piece of land, bordering the Mediterranean Sea between Israel and Egypt, which covers 360 km 2. It has high population density. About 17% of the population lives in the north of the Gaza Strip, 51% in the middle, and 32% in the south area. There are high unemployment, socioeconomic deprivation, family overcrowding, and short life expectancy. Nearly two-thirds of the population are refugees, with approximately 55% living in eight crowded refugee camps. The remainder live in villages and towns [32].

The target population consisted of 449 children of 7 to 18 years, who were exposed to the war on the Gaza Strip between December 2008 and January 2009, and who lived in five localities of the Gaza Strip (North, Gaza, Middle, Khan Younis, Rafah) . They were 233 boys (51.9%) and 216 girls (48.1%).

2.2 Measures

2.2.1 Gaza traumatic events checklist [9]

The checklist was developed to reflect the particular circumstances of the regional conflict, which cold not be captured by other war trauma measures, and has been reported previously [1,2]. This consists

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of 17 items covering three domains of events typical of the war on Gaza: (1) witnessing personally acts of violence (e.g., killing of relatives, home demolition, bombardment, or injuries); (2) experiencing loss or injury of family and other close persons; and (3) being personally the target of violence (e.g., being shot, injured, or beaten up by soldiers). The respondents rated whether they had been exposed to each of these events as (0) ‘no’ or (1) ‘yes’. A total score was estimated. The Cronbach alpha for the Gaza Trauma Events Scale was 0.80 and the split half was 0.75.

2.2.2 Revised children’s manifest anxiety scale (RCMAS) [33]

The RCMAS is a standardized 37-item self-report questionnaire for children of 6-19 years of age. It measures anxiety-related symptoms (‘yes/no’ answers) on 28 anxiety and 9 lie items. This instrument has been previously used by the authors in the Gaza Strip, including in a total population study, where 21.5% of children scored above the cut-off score for anxiety disorders [34].

In the current study, the internal consistency of the scale, calculated using the Cronbach’s alpha, was high ( α=0.86), as was its split half reliability (r=0.82).

2.2.3 Depression self-rating scale for children (DSRC) [35]

The Depression Self Rating Scale (DSRC) is an 18-item self-report questionnaire in which the child is asked to rate his/her own situation during the last week on a 3-point scale. Scores of 2, 1 or 0, respectively, in the direction of disturbance, refer to ‘most of the time’, ‘sometimes’ or ‘never’. The DRSC includes 18 items. The Cronbach’s alpha was α=0.63 and the split half reliability was r=0.61.

2.2.4 The University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index [36]

The items of the UCLA PTSD indices are keyed to DSM-IV criteria and can provide preliminary PTSD diagnostic information. Self-reports for children and adolescents exist, as well as parent reports. The adolescent Version for aged 13 years and above includes 22 questions. A 5-point Likert scale from 0 (none of the time) to 4 (most all the time) is used to rate PTSD symptoms. Only 17 items were included in the total score, because two items did not constitute DSM-IV criteria and three items were repeated symptoms were used [36]. The original English version of this scale was adapted to the Palestinian context (Cronbach α for Arabic Palestinian version was 0.89) [1, 37]. Reaction Index was highly satisfactory (Cronbach’s alpha = 0.90), with a split half of 0.86.

2.2.5 Kidcope-young children [38]

The Kidcope is a brief self-report measure of children’s and adolescent’s use of coping strategies [38]. The 15-item is designed for children between the ages of 7 and 18 years. The framework underpinning its development is based on the theory that coping is a process of changes in cognitive and behavioral strategies rather than a stable personality trait. The Kidcope allows children to identify the problem they consider the most stressful in their lives, and to assesses ten coping strategies (distraction, social withdrawal, cognitive restructuring, self-criticism, blaming others, problem solving, emotional regulation, wishful thinking, social support, and resignation) related to this specific problem.

The mean item scores for all eight scales are then summed. Relative scores, which are expressed as percentages, are calculated for each scale: mean item score for a particular scale/ summed mean item scores for all eight scales * 100.

The Kidcope was administered in relation to the traumatic events of the war on Gaza, and was scored for positive coping style (the sum of responses to the cognitive restructuring, problem solving, emotional regulation, and social support subscales) and negative coping style (the sum of responses to the distraction, withdrawal, criticizing self, blaming others, wishful thinking, and resignation subscales). Each item/coping strategy is scored as 0 (‘no’) or 1 (‘yes’). Earlier research established test–retest reliability coefficients for short intervals (3–7 days) ranging from 0.41 to 0.83 [38].

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2.3 Study Procedure

The data collection was carried out by eight trained psychologists and social workers, under the supervision of the first author. They were trained for six hours in data collection and interviewing techniques. The data was collected during 2010. Children completed self-administered questionnaires at home with assistance from the researchers. The completion of the self-administrative measures took at least one hour for each child. Sociodemographic information was collected from the parents, while measures for exposure to traumatic events, PTSD, depression, anxiety, and coping strategies were completed by the children. Ethical permission was granted from Local Institute Review Board in Gaza (IRB).

2.4 Statistical Analysis

The analysis was conducted on the SSPS for Windows (version 20). Questionnaire data was normally distributed, for this reason independent t-test was used to investigate differences between two groups. Associations between continuous variables were measured by the Pearson's correlation coefficient test. One-way ANOVA post hoc Tukey was used to investigate differences between more than two groups. To test the fourth aim, a multivariate regression analysis was conducted, in which trauma scores were entered as the independent variable, each psychopathology score (depression, anxiety, PTSD and coping strategies) entered as the dependent variable.

3. RESULTS

3.1 Sociodemographic Characteristics

As shown in table one, the target population consisted of 449 children of 7 to 18 years, who were exposed to the war on the Gaza Strip between December 2008 and January 2009, and who lived in five localities of the Gaza Strip (North, Gaza, Middle, Khan Younis, Rafah). They were 233 boys (51.9%) and 216 girls (48.1%). Regard to the area of residence, 34.3% of children lived in Gaza area, 19.2% in Khan Younis, 18.3% in the middle area, 16.3% in the northern Gaza Strip, and 12% in the Rafah area. Most of them lived in cities (64.2%), 25.5% in refugee camps and 10.3% in villages. According to family monthly income, 73.4% of families had less than $300, 22.6% had $301-625, and only 4% had a monthly income of more than $626-750. In regards to employment status, 46.5% of children’s fathers were unemployed, 8.1% Unemployed and received benefit, and 13.6% were government employees, 7.1% were simple workers, 6% were skilled workers, 13.6% were governmental employee 3.5% were United Nations Relief and Works Agency for Palestine Refugees (UNRWA) employee, 2.3% were given unemployment benefits, 3.2% were farmers, and 9.7% were working in other jobs (Table 1).

3.2 Exposure to Traumatic Events

As shown in table two, the most commonly reported traumatic events experienced by children during the last war were: watching mutilated bodies and injured Palestinians on television (90.4%); deprivation from water or electricity during detention at home (44.6%); and fforced to leave their home during the war (33.5%) (Table 2).

Overall, children reported a range of 0 to 15 traumatic events, with a mean number of 3.59 (SD=2.92). There were no significant differences between males and females in reporting traumatic events (t=-0.88, p=0.37). When children were grouped in the 7-11, 12-15 and 16-18 years age groups, there were no differences on reporting traumatic events (F=0.33, p<0.71). Furthermore, there were no differences in exposure to trauma according to place of residence or family monthly income.

3.2.1 Level of traumatic events

The total traumatic events were recoded in to mild trauma (0-5 events), moderate trauma (6-10 events) and severe trauma (11 and above events). The results showed that 80.6% of children reported mild trauma, 16% reported moderate level, and 3.3% reported severe level. (Table 3).

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Table 1. Sociodemographic characteristics (N = 449)

Items No. % Gender Boys 233 51.9 Girls 216 48.1 Area of residence North Gaza 73 16.3 Gaza 154 34.3 Middle area 82 18.3 Khan Younis 86 19.2 Rafah 54 12 Type of residence City 274 64.2 Village 44 10.3 Camp 109 25.5 Monthly family income Less than $300 292 73.4 $301-625 90 22.6 $626-750 16 4 Father job Unemployed 202 46.5 Unemployed and received benefit 35 8.1 Simple worker 31 7.1 Skilled worker 26 6 Governmental employee 59 13.6 United Nations Relief and Works Agency for Palestine Refugees 15 3.5 (UNRWA) employee Unemployment benefit 10 2.3 Farmer 14 3.2 Other 42 9.7 Mothers job Housewives 422 94.0 Simple worker 6 1.3 Governmental employee 10 2.2 Other 11 2.4

Table 2. Type of traumatic experiences

Traumatic events Yes No Watching mutilated bodies in TV 90.4 9.6 Deprivation from water or electricity during detention at home 44.6 55.4 Forced to leave your home during the war 33.5 66.5 Witnessing demolition of neighbours homes 29.8 70.2 Witnessing firing by tanks and heavy artillery at neighbours homes 26.6 73.4 Being detained at home during the war 25.3 74.7 Threaten by shooting 22.6 77.4 Witnessing shooting of a friend 14.3 85.7 Destroying of your personal belongings during incursion 13.7 86.3 Witnessing killing of a friend 13.6 86.4 Witnessing firing by tanks and heavy artillery at own home 10.1 89.9 Shooting by bullets, rocket, or bombs 8.3 91.7 Witnessing killing of a close relative 7.6 92.4 Beating and humiliation by the army 6.3 93.7 Exposure to burn by bombs and phosphorous bombs 5.4 94.6 Threaten by shooting 4.1 95.9 Being exposed to danger by used as human shield by the Israeli army 4.1 95.9

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Table 3. Level of trauma

Level of Trauma No. % Mild (0-5 events) 362 80.6 Moderate (6 -10 events) 72 16.0 Severe (11 and above events) 15 3.3 Total 449 100.0

3.2.2 Children’s post-traumatic stress reactions

The most common post traumatic reactions in children were: 43.4% reported that when something reminds them of what happened during the war, they get very upset, afraid or sad. 31.5% afraid that the bad thing will happen again. 30.4% feel jumpy or startle easily, like when I hear a loud noise or when, 30% try to stay away from people, places, or things that make me remember what happened.

Table 4. Post-traumatic stress symptoms for children and adolescents (N= 421)

Never/ sometimes Much/ Rarely often I watch out for danger or things that I am afraid of. 48.5 24.5 26.9 I have upsetting thoughts, pictures, or sounds of what happened 56.4 18.8 24.8 come into my mind when I do not want them to. I feel grouchy, angry or mad. 61.5 16.6 22 I have dreams about what happened or other bad dreams. 63.7 13.7 22.7 I feel like I am back at the time when the bad thing happened, 54.8 19.2 26 living through it again. I feel like staying by myself and not being with my friends. 85.2 8.1 6.7 I feel alone inside and not close to other people. 83.5 8.7 7.9 I try not to talk about, think about, or have feelings about what 70.4 12.8 16.8 happened. I have trouble feeling happiness or love. 68.1 14.8 17.1 I have trouble feeling sadness or anger. 71.7 13.2 15 I feel jumpy or startle easily, like when I hear a loud noise or 56.2 13.4 30.4 when I have trouble going to sleep or I wake up often during the night. 66.2 17.2 16.5 I think that some part of what happened is my fault. 83.7 8.1 8.2 I have trouble remembering important parts of what happened. 67.6 17.6 14.8 I have trouble concentrating or paying attention. 57.5 23 19.5 I try to stay away from people, places, or things that make me 47 23 30 remember what happened. When something reminds me of what happened, I have strong 57.2 17 25.8 feelings in my body, like my heart beats fast, my head aches, or my stomach aches. I think that I will not live a long life. 73.9 10 16.1 I have arguments or physical fights. 69.4 16.7 13.9 I feel pessimistic or negative about my future. 57.5 24.2 18.4 I am afraid that the bad thing will happen again. 42 26.6 31.5

3.3 Prevalence of PTSD according to UCLA PTSD

The results showed that 24.9% of children showed no any symptoms, 30.2% reported at least one criteria (B or C or D), 23.5% reported partial PTSD (B and C, C and D, or B and D), and 12.4% of children reported full criteria of PTSD.

3.3.1 Mean post traumatic stress reactions according to UCLA PTSD scale

The results showed mean PTSD was 20.36 (SD =12.4), mean intrusion was, mean avoidance was 6.54 (SD= 4.78), mean hyperarousal was 6.56 (SD = 4.45).

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Table 5. Prevalence of PTSD according to UCLA PTSD (N= 421)

PTSD No. % No symptoms 105 24.9 One criteria 127 30.2 Partial PTSD 137 32.5 Full criteria of PTSD 52 12.4

Prevalence of PTSD (N= 421) 32.5 30.2

24.9

12.4

No symptoms One criteria Partial PTSD Full criteria of PTSD

Fig 1. Prevalence of PTSD (N= 421)

3.3.2 Sex and age differences in PTSD

T independent test was performed to find sex differences in PTSD and subscales, the results showed no statistically significant difference between boys and girls in PTSD, intrusion, avoidance, and hyperarousal. Also, the results showed that no statistically significant age differences in reporting PTSD of children according to age groups of children.

Table 6. Differences in means of PTSD, intrusion symptoms, avoidance, and hyperarousal Sex differences in PTS reactions

PTSD Sex Mean SD t p Total PTSD Male 20.50 12.80 0.23 //0.81 Female 20.21 11.97 Intrusion Male 7.21 4.74 -0.35 //0.72 Female 7.37 4.54 Avoidance Male 6.53 4.90 -0.04 //0.96 Female 6.55 4.66 Hyperarousal Male 6.91 4.62 1.68 //0.93 Female 6.19 4.23 ** p<0.01; *p<0.05; // p>0.05

3.3.3 Differences between different sociodemographic variables such as family monthly income and PTSD reactions

In order to find the differences between different sociodemographic variables such as place of, family monthly income, place of residence and PTSD reactions, One way ANOVA was done in which PTSD, intrusion symptoms , avoidance, and hyperarousal were entered as dependent variables and sociodemographic variables as independent variables. Post hoc test using LSD, the results showed

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that there were significant differences in total PSTD toward children coming from families with family income less than 300$ (F = 6.01, p = .003). These differences were also applied to all subscales intrusion symptoms (F 4.57, p = .01), avoidance (F = 3.45, p = .03), and hyperarousal (F = 7.47, p = .001). Regard place of residence , t he results showed that there were significant differences in total PSTD toward children living in cites (F = 4.05, p = .01). These differences were also applied to all subscales intrusion symptoms (F 3.44, p = .03), avoidance (F = 3.1, p = .04), and hyperarousal (F = 3.02, p = .05).

3.4 Anxiety Disorder

3.4.1 Anxiety symptoms

The results indicate that more items answered by the children for this measure is the item I feel worried when things do not go as I want (79.1%), I'm anxious to what is happening in the future (67%), I'm always anxious for bad things can happen to me (64.4%), I hurt easily my feelings when I'm anxious (54.8%). Table 7. Percentage of anxiety symptoms

Anxiety symptoms Yes No I have trouble making up my mind 52.1 47.9 I get nervous when things do not go the right way for me 79.1 20.9 Others seem to do things easier than I can 54.1 45.9 Often I have trouble getting my breath 40.6 59.4 I worry a lot of the time 42.7 57.3 I am afraid of a lot of things 49.4 50.6 I get mad easily 47 53 I worry about what my parents will say to me 38.1 61.9 I feel that others do not like the way I do things 40.9 59.1 It is hard to get to sleep at night 29.8 70.2 It is hard to keep my mind on my school work 44.5 55.5 I feel alone even when there are people with me 22.1 77.9 Often I feel sick in my stomach 22.8 77.2 My feelings get hurt easily 44.5 55.5 My hands feel sweaty 41.5 58.5 I am tired a lot 36.5 63.5 I worry about what is going to happen 67 33 Other children are happier than I 53.5 46.5 I have bad dreams 46.8 53.2 My feelings get hurt easily when I am fussed at 54.8 45.2 I feel someone will tell me I do things the wrong way 43.2 56.8 I wake up scared some of the time 36.2 63.8 I worry when I go to bed at night 33.8 66.2 I worry about what other people think about me 48.6 51.4 I wiggle in my seat a lot 43.7 56.3 I am nervous 46.9 53.1 A lot of people are against me 32.5 67.5 I often worry about something bad happening to me 64.4 35.6

3.4.2 Prevalence of anxiety disorder

The results showed that 20.5% of children reported anxiety problems and 79.5% did not show any anxiety problems. Chi square test showed that 12.90% of boys reported anxiety disorder compared to 7.6% of girls. There were statistically significant differences in anxiety toward boys ( χ2 = 5.27, df = 1, p <0.01).

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3.5 Depressive disorder

3.5.1 Depressive Symptoms

The results indicated that the most common depression symptoms rated by the children were: 82.3% suffer from pain in the stomach, 77% said they never love talk with my family and with others 69.8% feel that life is not worth anything, 69.6% would like to run away, and 60.7% never do things well, and 63.2% never enjoy eating.

Table 8. Percentage of depression symptoms according to Birleson Depression Scale (N= 448)

Depression symptoms Always Sometimes Never I still see the things in my life as it used to 50.7 49.3 0 I sleep well. 0.2 34 65.8 I feel that I will cry. 45.6 33.6 20.8 I like to go out on the street to play. 0 26 74 I would like to run away. 69.6 17.2 13.2 I enjoy a great power. 10.7 27.9 61.4 I suffer from pain in the stomach 82.3 17.7 0 Enjoy eating. 0 36.8 63.2 I can do to serve myself. 62.7 28.6 8.7 I feel that life is not worth anything. 69.8 30.2 0 I do things well. 0 39.3 60.7 Enjoy as you do what's in the past. 48.5 51.5 0 I love to talk with my family and with others. 0 23 77 I dream of disturbing dreams. 40.8 37.7 21.4 I feel very lonely. 62.9 25.5 11.6 Is easy to rejoice 54.2 45.8 0 I feel so miserable unbearable 13.2 28.1 58.7 I am bored. 28.6 45.5 25.9

3.5.2 Prevalence of depression disorder according to Birleson depression scale

The results showed that 100 children which represented 22.3% reported depression (17 above cut-off point) and 349 of children which represented 77.7% did not show any depression. Chi square test showed that 7.82% of boys reported depression compared to 14.71% of girls. There were statistically significant differences in depression toward girls ( χ2 = 15.9, df = 1, p <0.001).

3.6 Coping Styles of Children to Overcoming the Daily Problems

The results showed that 72.6 % of the children try to feel better by spending time with others like family, grown-ups or friends, 65.7% try to sort out the problem, 63.3% try to sort out the problem by doing something or talking to someone about it.

3.6.1 Means and SD of Coping Styles of Children

Kidcope consisted of 15 items with 10 subscales. The results showed that the total coping mean was 16.78. While the highest coping subscales used by children was social withdrawal ( M=2.88) (17.19%) followed by emotional regulations (mean =2.61), and distraction (2.53).The least used coping strategies were resignation ( M=0.27) and self criticism ( M=0.70).

3.6.2 Differences in coping styles and sex of children

In order to find the differences in coping styles according to gender, independent t test. The results showed that there were significant differences according to sex of children, girls used more solving problems than boys (t(449)=-2.80, p = 0.01) and boys used cognitive reconstruction more than girls (t(449)=-2.80, r = 0.05).

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3.6.3 Differences in coping strategies and PTSD

In order to find differences between children with PTSD and coping strategies used by children, t independent test was performed in which coping strategies were entered as independent variable and PTSD as independent variable. The results showed that children with PTSD and without PTSD were not different are total coping strategies. However, children with PTSD were significantly used less social withdrawal (t=-3.64, p-value<0.001), wishful thinking (t=-2.33, p-value<0.02), and self criticism (t= -2.34, p<0.02) as coping strategies than children without PTSD.

Table 9. Coping styles of children to overcoming the daily problems

Never/rarely Sometimes Regularly 1. Try to forget it 16.8 37.6 45.7 2. Do something like watch TV or play a game to forget it 8 34.3 57.7 3. Stay on your own 31.1 37.6 31.3 4. Keep quiet about the problem 8.8 46.2 45 5. Try to see the good side of things 9.6 37 53.5 6. Blame yourself for causing the problem 24 39.2 36.8 7. Blame someone else for causing the problem 17.1 40 42.9 8. Try to sort out the problem 6.2 28.1 65.7 9. Try to sort out the problem by doing something or 7.6 29.1 63.3 talking to someone about it 10. Shout, scream or get angry 24.6 38.6 36.8 11. Try to calm yourself down 5.8 48.2 46 12. Wish the problem had never happened 9.6 28.4 61.9 13. Wish you could make things different 12.7 34.3 53 14. Try to feel better by spending time with others like 4.4 23 72.6 family, grown-ups or friends 15. Do nothing because the problem couldn't be solved 37.4 34.7 27.9

Table 10. Means and SD, percentage of coping styles of children

N Mean % Coping styles 449 16.78 1. Distraction 441 2.54 15.13 2. Social withdrawal 442 2.88 17.19 3. Problem Solving 439 2.34 13.93 4. Emotional regulation 442 2.61 15.56 5. Wishful thinking 439 2.40 14.28 6. Social support 447 0.90 5.37 7. Resignation 446 0.27 1.63 8. Cognitive reframing 445 0.73 4.37 9. Self criticism 445 0.51 3.01 10.Blaming others 444 0.70 4.17

3.6.4 Differences in coping strategies and anxiety

In order to find differences between children with anxiety disorders and coping strategies used by children, t independent test was performed in which coping strategies were entered as independent variable and anxiety as independent variable. The results showed that children with anxiety scored more in total coping strategies, had more resignation (t =2.26, p <0.05), and more social withdrawal (t= 2.16, p<0.05) than children without anxiety.

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Current Trends in Medicine and Medical Research Vol. 1 Impact of Trauma on Palestinian Children PTSD, Anxiety, Depression and Coping Strategies

Table 11. Differences in coping strategies and sex of children

Coping style s Sex Mean SD t p Total Coping styles Male 16.94 4.20 .85 .39 Female 16.62 3.70 Distraction Male 2.53 0.61 -.48 .63 Female 2.55 0.63 Social withdrawal Male 2.89 0.57 .31 .76 Female 2.88 0.60 Problem solving Male 2.27 0.51 -2.80 .01 Female 2.41 0.57 Emotional regulation Male 2.61 0.56 -.15 .88 Female 2.62 0.58 Wishful thinking Male 2.35 0.55 -1.91 .06 Female 2.45 0.57 Social support Male 0.91 0.29 .61 .54 Female 0.89 0.31 Resignation Male 0.28 0.45 .48 .63 Female 0.26 0.44 Cognitive restructuring Male 0.77 0.42 2.00 .05 Female 0.69 0.46 Self-criticism Male 0.52 0.50 .70 .48 Female 0.49 0.50 Blaming others Male 0.66 0.47 -1.83 .07 Female 0.74 0.44

3.6.5 Differences in coping strategies and depression

In order to find differences between children with depression disorders and coping strategies used by children, t independent test was performed in which coping strategies were entered as independent variable and depression as independent variable. The results showed that there were no significant differences in children with depression and total coping strategies. Also, depressed children had less social withdrawal (t= 2.12, p<0.03). Children with depression disorder had less social support than children without depression (t =4.2, p <0.001). But, no other differences in depression and other coping subscales.

3.7 Pearson Correlation Test between Trauma, PTSD, Depression, Anxiety, and Coping

Pearson correlation test was done to find the association between coping strategies and trauma, depression, anxiety, and coping. Pearson correlation test was done to find the association between trauma, PTSD, depression, anxiety, and coping. Pearson correlation test was done to find the association between PTSD and trauma. The results showed that there was significant correlation between total traumatic events reported by children and total PTSD (r = 0.39, p = 0.01), intrusion (r=0.43, p = 0.01), avoidance (r=0.26, p = 0.01), and hyperarousal (r=0.37, p = 0.01). The results showed that there was significant correlation between total traumatic events reported by children and total Depression (r = 0.32, p = 0.01), anxiety ( r=0.38, p<0.001) and coping strategies ( r= 0.17, p<0.01).

3.7.1 Prediction of children PTSD by traumatic events

In a multivariate regression model, PTSD scores was entered as dependent variables and each traumatic events as independent variables, Total secure attachment was predicted by following traumatic events: Deprivation from water or electricity during detention at home ( β= 0.39, t (405), p<0.001), Threaten by shooting ( β= 0.10, t (405), p<0.01), and Witnessing shooting of a friend ( β = 0.11, t (405) p<0.02), R 2 = .28, F (4/405) =48.11, p = 0.001.

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Table 12. Pearson correlation test between trauma, PTSD, depression, anxiety and coping

Traumatic Anxiety Depression PTSD Intrusion Avoidance Arousal events Total traumatic events Anxiety .38 ** Depression .32 ** .59 ** PTSD .39 ** .66 ** .56 ** Intrusion .43 ** .58 ** .50 ** .90 ** Avoidance .26 ** .58 ** .50 ** .88 ** .67 ** Arousal .37 ** .60 ** .47 ** .89 ** .73 ** .66 ** Coping .17 ** .32 ** .18 ** .31 ** .31 ** .25 ** .28 **

Table 13. Multivariate regression model of Prediction of children PTSD by traumatic events

Unstandardized Standardized t p 95.0% confidence coefficients coefficients interval for B B Std. Beta Lower Upper error bound bound (Constant) 14.15 .72 19.58 .001 12.73 15.57 Deprivation from 9.69 1.17 .39 8.28 .001 7.39 11.99 water or electricity during detention at home Threaten by 2.81 1.42 .10 1.98 .05 .02 5.60 shooting Witnessing shooting 4.03 1.56 .11 2.57 .01 .95 7.10 of a friend

3.7.2 Prediction of children depression by traumatic events

In a multivariate regression model, depression scores were entered as dependent variables and each traumatic event as independent variables. Total depression was predicted by following traumatic events: deprivation from water or electricity during detention at home ( β= 0.30, t (432), p<0.001), Being detained at home during the war ( β= 0.16, t (432), p<0.01), watching mutilated bodies in TV ( β= -0.14, t (432), p<0.001), and witnessing firing by tanks and heavy artillery at own home ( β = 0.11, t (432) p<0.02), R 2 = .19, F (4/432) =25.30, p = 0.001.

3.7.3 Prediction of children anxiety by traumatic events

In a multivariate regression model, anxiety scores were entered as dependent variables and each traumatic event as independent variables. Total anxiety was predicted by following traumatic events: deprivation from water or electricity during detention at home ( β= 0.34, t (417), p<0.001), being detained at home during the war ( β= 0.14, t (417), p<0.01), forced to leave your home during the war (β= 0.11, t (417), p<0.001), and witnessing shooting of a friend ( β = 0.10, t (417) p<0.02), R 2 = .25, F (4/417) =35.15, p = 0.001.

3.7.4 Prediction of Children Coping Strategies by Total Traumatic Events, PTSD, Depression, and Anxiety

In a multivariate regression model, Total coping strategies was were entered as an independent variable; PTSD, total anxiety and depression scores as the dependent variable. Coping strategies of children was predicted by total PTSD ( β= 0.19, t (417), p<0.001) and anxiety ( β= 0.18, t (417), p<0.001) R2 = .11, F (2/390) =25.68, p = 0.001.

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Table 14. Multivariate regression model of prediction of children depression by traumatic events

Unstandardized Standardized t p 95.0% confidence coefficients coefficients interval for B B Std. Beta Lower Upper error bound bound (Constant) 13.65 .68 19.99 0 12.31 14.99 Deprivation from 2.92 .46 .30 6.34 .001 2.02 3.83 water or electricity during detention at home Being detained at 1.77 .54 .16 3.31 .001 .72 2.82 home during the war Watching mutilated -2.21- .72 -.14 -3.07 .001 -3.62- -.80- bodies in TV Witnessing firing by 1.80 .73 .11 2.45 .001 .36 3.24 tanks and heavy artillery at own home

Table 15. Multivariate regression model of prediction of children d anxiety by traumatic events

Unstandardized Standardized t p 95.0% confidence coefficients coefficients interval for B B Std. Beta Lower Upper Error bound bound (Constant) 9.46 .38 24.78 .00 8.71 10.21 Deprivation from 4.36 .61 .34 7.13 .00 3.16 5.56 water or electricity during detention at home Being detained at 2.02 .69 .14 2.94 .00 .67 3.37 home during the war Forced to leave your 1.53 .62 .11 2.46 .01 .31 2.75 home during the war Witnessing shooting 1.73 .80 .10 2.15 .03 .14 3.31 of a friend

Table 16. Multivariate regression model of prediction of children coping strategies by total traumatic events, PTSD, depression, and anxiety

Unstandardized Standardized t p 95.0% confidence coefficients coefficients interval for B B Std. Beta Lower Upper error bound bound (Constant) 14.18 .42 34.08 5.39E-119 13.36 15.00 Total PTSD .06 .02 .19 2.96 .00 .02 .10 Total anxiety .11 .04 .18 2.85 .00 .03 .19

4. DISCUSSION

This study investigated the types and severity of traumatic events after 16 months of war on Gaza on children; the prevalence of PTSD, anxiety, and depressive symptoms; to types of coping strategies used by children; and the mediating effect of coping strategies between trauma and child psychopathology. The results showed that, even such a long period after the conflict, children continued to report many traumatic events. The explanation of the continuation of reporting of

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traumatic could be due to the on-going conflict, stressors and threats of a new war on Gaza. Severity of trauma exposure was significantly associated with scores total PTSD an all subscales scores. Our findings were consistent with those of the International Society for the Traumatic Stress Studies [39] i.e. that individuals who have already experienced trauma (survivors of war, immigrants, refugees, or those who have lived through periods of unemployment or discrimination) are more vulnerable to severe stress reactions following a traumatic event. These individuals may be at greater risk for mental-health problems, including depression, anxiety, and PTSD.

More specifically, 12.4% of children reported full criteria of PTSD, 20.5% suffered from anxiety problems and 22.3% from depression of sufficient severity to indicate the need for clinical assessment and possibly treatment. The PTSD rates were lowered in this study than those detected among adolescents injured during Al-Aqsa intifada and who sustained permanent disability [40]. They were more consistent with a previous study of children in the Gaza Strip, [41], although these rates subsequently increased when children exposed to continuous shelling (33.9%). Depression rates were high, although even higher prevalence was previously established during the conflict [42].

The most commonly used coping strategies were: wishful thinking problem solving, emotional regulation, and distraction. This finding was consistent with that of a multi-site study of 166 adolescents infected with HIV in three major US cities, which showed that passive emotional regulation (80%) was rated by youth as both the most frequently used and most helpful strategy. Blaming others was the least frequently used strategy and was perceived as among the least helpful [43]. In a study of African American high school students, collaborative religious coping protected against suicidal ideation, whereas self-directed coping (i.e. relying on oneself to manage a problem) acted as a risk factor [44].

Trauma exposure was negatively correlated with social support, wishful thinking; and was positively correlated with self-criticism. This could be explained by postulating that family and community support is disrupted because of the ongoing conflict. Children living in war zones witness a variety of traumatic events and share daily suffering with family members, which can lead to less wishful thinking and self-criticism. These mechanisms may underpin our findings. These are consistent with previous research, for example, Berman and colleagues, in a multiethnic youth sample, found that negative coping (e.g., criticizing, blaming others, wishful thinking) was related to PTSD symptoms [45]. They were also consistent with an earlier study in the Gaza Strip [42], which found that negative coping was significantly associated with PTSD, depression and anxiety; while positive coping was strategies were used by people with depression and anxiety, but not by those suffering from PTSD. Cognitive reframing, which is conceptually similar to avoidance of reminders of trauma and numbing feelings, may prospectively predict more PTSD symptoms because denying the severity of a problem and trying not to think about it may lead to more recurrent and intrusive recollections of the trauma. Living in areas with other stressors such as siege and threat of war are additional maintain factors of PTSD.

The relationship, however, may also be reciprocal, in that higher levels of coping can have the deleterious effect of increasing distress. Our findings were consistent with a transcultural study of adolescents from four countries, which found that both Palestinian and Colombian youth were noted to be more likely to seek to belong, focus on the positives, engage in social actions, problem-solving, and seek spiritual support, than were German and Australian adolescents. Australian adolescents predominantly used non-productive strategies such as tension reduction, self-blame, ignoring, keeping to self and, most noticeably, worrying and wishful thinking [46]. Adolescents who survived the school terrorist attack in Beslan, Russia and who reported PTSD symptoms were more likely to blame themselves, thus providing further evidence for the association between emotion-focused coping strategies and posttraumatic symptomatology following terrorism 41 .Similar patterns have been reported following road traffic accidents [47].

This study had certainly limitations. Children’s recollections over 16 months of war may have been affected by previous and emerging traumatic experiences and stressors. These reports were not corroborated with parents and teachers. Coping was assessed by a brief screening measure. As

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suggested by the scale’s authors [32], using a brief measure may limit our ability to fully understand the adaptive and/or maladaptive nature of coping strategies and how these are applied by children. The way in which social withdrawal (an avoidance strategy) is assessed by this measure may overlap with the assessment of post traumatic stress, which brings to question the nature of this relationship.

5. CONCLUSION

This study found that, 16 months after war exposure, children continued to experience substantial trauma, and to suffer from associated mental health problems such as depression, anxiety, and PTSD. Children tried to cope with such reactions by using different strategies, mainly trying to feel better by spending time with family, grown-ups or friends; trying to sort out daily problems; and sharing with others. These findings highlight the need for community-based interventions to improve children mental health. These could apply in schools and other community centers by psychologists and psychiatrists, or trained specialists. Parent training in early detection of child mental health problems and their management should be a key objective. In addition, community programmes should enhance children’s resilience by helping them build adaptive individual and social strategies.

CONSENT

All authors declare that written informed consent was obtained from the patient (or other approved parties) for publication of this report.

ETHICAL APPROVAL

All authors hereby declare that all the research proposal and scales had been examined and approved by the appropriate Palestinian ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.

ACKNOWLEDGEMENT

We are grateful to all the Palestinian families in the Gaza Strip for their involvement. Also, to the data collectors for their valuable input.

COMPETING INTERESTS

Authors have declared that no competing interests exist.

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Biography of author(s)

Professor Abdel Aziz Mousa Thabet Emeritus Professor of Child and Adolescent Psychiatry-School of Public Health - Al Quds University- Jerusalem- Palestine state. Affiliated Scholar at Center for Refugee Studies at York University-Canada, President of 2Child and Family Training and Counseling Center –Gaza.

He is a Palestinian child and adolescent Psychiatrist and was educated in Palestine, Austria, and United Kingdom in child psychiatry. He worked as Emeritus professor at Al Quds University. Now he is affiliated with Center for Refugee Studies at York University. He is running the clinical setting in Gaza city and seeing adults and children victims of trauma and political violence. For the last three decades he had conducted research including the prevalence of mental health problems and evaluation of intervention methods in dealing with children in Gaza and West Bank. ______© Copyright 2019 The Author(s), Licensee Book Publisher International, This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

DISCLAIMER This chapter is an extended version of the article published by the same authors in the following journal with CC BY license. British Journal of Medicine & Medical Research, 5(3):330-340, 2015.

Reviewers’ Information (1) Anonymous, University of the Witwatersrand, Johannesburg, South Africa. (2) Anonymous, Advanced Pain Centers S.C., USA. (3) Olalekan Ogunsakin, Tulane University, New Orleans, USA. (4) Michelle A. Bosco, James A. Haley Veterans Affairs Hospital, University of South Florida, USA. (5) Anonymous, Stockholm University, Stockholm, Sweden.

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Cronicon OPEN ACCESS EC PSYCHOLOGY AND PSYCHIATRY Review Article

Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper

Abdel Aziz Mousa Thabet* Emeritus Professor of Psychiatry, Al Quds University, Gaza, Palestine

*Corresponding Author: Abdel Aziz Mousa Thabet, Emeritus Professor of Psychiatry, Al Quds University, Gaza, Palestine.

Received: November 10, 2018; Published: February 28, 2019

Abstract Background: On September 2000, the Al Aqsa Intifada erupted. Children and families have been exposed to a variety of traumatic events, ranging from hearing of killing, to bombardment by helicopters at the entire Gaza strip.

Aim: Aim of this review was to investigate the Palestinians psychological well-being indicators Strip, causes of mental illness, avail- able services for primary, secondary, and territory intervention, and recommendation for future research and intervention in the West Bank and Gaza Strip. Method: Gaza Strip and West Bank was done using Autobiographies/biographies of the author and other co-authors in the area, web based A combination of re-analysis of secondary data of previous work in the field of psychosocial well-being of Palestinians in the research including the Medline. Results: From the reviewed studies ,Psycho Info, and Scholar Portal that severity of violence in changing from time to time and types of traumatic experiences are similar including the watching mutilated bodies on the TV, hearing and seeing the shelling, exposure to sonic bombs, and witnessing home bombardment and demolition. These traumatic experiences and violence affect the Palestinians well-being and increase rate of psychological problems in the targeted group. One of the mental health problems was post-traumatic stress reactions which was ranged in children from 10% to 71% while the rate of PTSD in West Bank ranged from 35% to 36%. Rate of anxiety was ranged from 28.5% to 33.9%, and depression ranged from 40% in children of Gaza and West Bank to 50.6%, general mental health of children rated by parents and teachers were 20.9% and 31.8% and up to 49.6% rated by parents. For adults, studies showed that PTSD ranged from 34% in university students to 65% among adults exposed to shelling. Study showed this paragraph about adults to be removed that there were risk factors which interfere with well-being such as being a boy, living in big families, low socioeconomic status of the family, exposure to domestic and political violence, being orphaned child, working children, children with physical problems, and living near the border areas. Conclusion and Recommendations: The report showed that there are needs for new studies dealing with other risk and protective factors which can give very clear mental health indicators must be carried out. Also, to conduct new control trail studies to evalu- ate the effectiveness of new protocols for psychosocial intervention such as cognitive behaviour therapy, group intervention with bereaved people, expressive writings therapy, and other new techniques used in western societies after adaptation to local culture.

Keywords: Palestinian; Political and Community Violence; Trauma; Wellbeing; PTSD; Anxiety; Depression; Gaza Strip; West Bank

Introduction In the following paper, we will highlight the historical and political context of Palestinian children and families living in the Palestin- ian

Occupied Territories. During the last three decades many historical and political events had occurred. From the first Intifada to Oslo agreement to Al Aqsa Intifada to factional fighting, and lastly the 2014 war on Gaza.

Citation: Abdel Aziz Mousa Thabet. “Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper”. EC Psychology and Psychiatry 8.3 (2019): 197-205. Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper

198 Sociodemographic characteristics Gaza Strip is a narrow piece of land lying on the coast of the Mediterranean Sea. Its position on the crossroads from Africa to Asia made it a target for occupiers and conquerors over the centuries. The last of these was Israel who occupied the Gaza strip from Egyptians in 1967. Gaza Strip is very crowded place with area 365 sq. Km and constitute 6.1% of total area of Palestinian territory land. In mid-year of 2017 the population number is 1,881,135 mainly concentrated in the cities, small village, and eight refugee camps that contain two thirds of the population of Gaza Strip. In Gaza Strip, the population density is 5324 inhabitants/km2 governorates: North of Gaza, Gaza City, Mid-Zone, Khan-Younis, and Rafah (PCBS, 2017). Thirty nine percent of the population in Gaza falls that comprises the following main five below the poverty line and the unemployment level stands at approximately 34.4%. The West Bank is an area of land between Israel and Jordan, totalling 5860 square kilometres. With a population of 3,008,770, and nearly 42.2% of the population under the age of 14, growth rates are high. The West Bank and Gaza together constitute Palestine, which is administered by the Palestinian Authority (PA). Most of the population is Muslim, and common Palestinian values include rootedness to the land, strong family bonds, social identity from family and community, and a holistic outlook on life. Refugees account for 73.1% of Gaza Strip and 30.2% of West Bank populations [1].

Review design The research design is exploratory type which explores and investigates the Palestinians psychological well-being in the Palestinian Territories.

Main Aim The aim of this paper is to investigate the Palestinians psychological well-being indicators, causes of mental illness, available services for - tion for future research and intervention in the West Bank and Gaza Strip. primary, secondary, and territory intervention, university and other institution training in the field of mental health, and recommenda General Objectives To attain the aim of the study we had put the following objectives: 1. To explore the common adversities and causes of mental health problems in the Palestinian society such as the political, com- munity, domestic, and personal violence in the society and coping strategies and resilience in countering the negative effect of such adversities. 2. To investigate the effect of such adversities on psychological wellbeing of the Palestinian children, parents, and at risk groups. 3. To evaluate type and availability of intervention programs concerning helping of Palestinians to cope with such adversities. 4. To assess the education system concerning the mental health issues included different programs in the universities, institutions, and other non-governmental organizations.

Tools of review being of Palestinians in the Gaza Strip and West Bank. The research paper is based on the combining and re-analysis of secondary data of previous work in the field of psychosocial well- The following tools were used in gathering the data 1. Autobiographies/biographies of the author and other co-authors in the area. 2. Web based research including the Medline, Psycho info, OVID, Oxford University Press, and other data bases available such as UN organizations data bases. This was done by using the following key words “Psychosocial well-being of Palestinians”, “Inter- ventions used in psychosocial problems in Gaza Strip and West Bank”, “Mental health services in the Palestinians Territories”, “Sociodemographic characteristics of Palestinians”, “Effect of war on Palestinians”. The data was taken from articles published in the last 10 years (2007 - 2017). 3. Previous reports of different CBOs and ministries dealing with psychological wellbeing were reviewed.

Citation: Abdel Aziz Mousa Thabet. “Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper”. EC Psychology and Psychiatry 8.3 (2019): 197-205. Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper

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Analysis of psychological wellbeing was drawn considering the negative and positive results. Also the researcher point of view of such work was The data taken from previous work was criticised during all the stage of the research and conclusion of the previous work in the field included with comprehensive discussion.

Results et al. [2] in study of 229 Palestinian adolescents livi Many studies were carried out after infliction of siege on Gaza on 2007. Elbedour., ng in refugee camps of Rafah and Khan-Younis in the southern region of the Gaza Strip, 68.9% of the sample was classified as having severe anxiety levels. Al-Krenawi., et al. [3] in study of Palestinian adolescents in the West Bank. A random sample of 1775 participants developed PTSD, 40.0% of the participants reported moderate or severe levels of depression, 94.9% of the sample was classified as having (54.1% males, 45.9% females) between the ages of 12 - 18 in the West Bank. Findings revealed that although domestic violence (particu- larly violence between parents and children and between siblings) was found to contribute the most to psychological symptomatology, the exposure to political violence events also contributed to heightened psychiatric symptomatology. The results indicate that 21.3% of the variance of psychological symptomatology can be explained by the domestic violence, exposure to political violence events, and the family socio-economic status.

Restriction of movement and sonic booms formed the core collective punishment of Gaza population, causing severe stress during the Al Aqsa Intifada. The Gaza Strip was cut in three zones, and checkpoints between them were arbitrarily opened and closed. The everyday stress was substantial, for instance medical personnel could not reach their patients and parents were unable to return home from work. Preventing mourners from saying goodbye to dying relatives evoked strong feelings of guilt and helplessness. Sonic booms are a new kind of harassment that is caused by Israeli jets intentionally breaking the sound barrier to create supersonic booms over Gaza. They produce an enormously high and strong sound many times during each night, on arbitrarily chosen nights of the week. They severely deteriorate children’s sleep and cause uncontrollable fears among babies and children, causing anxiety, panic attacks, poor concentration In more detail, military trauma in middle childhood and stressful life-events in early adolescence formed a risk for PTSD and depressive symptoms and decreased satisfaction with the quality of life in adolescence [4].

Not only the effect of violence on children was studied, but also a group child which consider them children at risk such as those children who lost their parents due to sudden death, children living in orphans, labour children, and children with physical disabilities. Thabet Lamia., et al. [5] in a study aimed was to establish the level of emotional problems among 115 orphan children aged 9 - 16 years (average 13.4), who were living in two orphanages in the Gaza Strip. The results showed that children demonstrated high rates of anxiety, depressive, and post-traumatic stress reactions. Of the 112 children who completed the questionnaires, 55 (49.0%) reported CDI (depres- sion) scores above the clinical cut-off, 32 (28.5%) above the RCMAS (anxiety) cut-off, and 44 children (39.3%) scored within the severe spectrum of the CPTSD-RI (post-traumatic stress) range.

Moreover, Al Erjani and Thabet [6] in a study aimed to examine the effect of traumatic events that experienced by children lost their fat - sisted of 250 children from the martyr’s families in Gaza strip governorates by representative sample of 112 males and 138 females aged her in the current conflict and the coping strategies that adopted in front of stressful situations and father loss crisis. The sample con and injured in TV by 92.8%. The most used coping strategy was religious coping (86.4%), but the lowest coping strategy was substance 10 - 16 years old. The most common traumatic event for children lost their father in the current conflict was witnessing photos of martyrs use (30.3%).

During the Al Aqsa Intifada from 2000, many adolescents exposed to direct shooting and severe injury which left children and ado- lescents with permanent disability. Khamis [7] in study of 179 adolescent boys who were previously injured during Al-Aqsa intifada and as a result sustained a permanent disability. The results indicated that PTSD was not related to adolescents’ age, and geographic location i.e. West Bank, Gaza Strip. Adolescents from the Gaza Strip reported higher levels of depression and anxiety in comparison to adolescents from the West Bank.

Citation: Abdel Aziz Mousa Thabet. “Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper”. EC Psychology and Psychiatry 8.3 (2019): 197-205. Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper

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Home demolition during repeated incursions of the Gaza Strip was one of the aggression measures used against the Palestinians as collective punishment of the families. Thabet., et al. [8] in study of 45 boys living in border areas of the Gaza Strip (Rafah and Beit Lahia) to evaluate the effect of traumatic events and especially losing their home due to home demolition by the Israelis. Each child exposed to 9.4 traumatic events. The result showed that 20% of children had severe post traumatic stress reactions, 62.2% had moderate, and only 15.6% had mild reactions. Mean resilience in children was 99.5, commitment mean was 37.4, control mean was 28.4, and challenge mean was 33.7. The study showed that increasing resilience in children is correlated negatively with post traumatic stress reactions (i.e. increas- ing resilience is the outcome of low post traumatic stress reactions).

Child labour is another problem in countries with high unemployment rates which may press the children and families to push the children outside the school classes to earn money for support of the children and their families.

Abdeen., et al. [9] in a study of Palestinian students (n = 2100) from grades 9 - 11 were screened from both the West Bank (n = 1235) and Gaza (n = 724) and responded to self-report questionnaires Nearly all (99%) of participants reported some type of direct exposure to violence. Boys reported higher exposure than girls (67% vs. 33%), analyses showed that 36% of WB and 35% of GS participants reported symptoms meeting criteria for full PTSD according to DSM-IV-TR, and 12% of WB and 11% of GS reported symptoms meeting criteria for partial PTSD. Thabet., et al. [10] in study of 200 families from North Gaza and East Gaza who had exposed to continuous shelling in 2006, the sample includes 197 children and 200 parents. The results showed that children experienced a mean number of 8 traumatic events, 138 children out of 197 (70.1%) were likely to present with PTSD, 33.9% were rated as having anxiety symptoms of likely clinical sig- - nificance, 42.7% were rated as having significant mental health morbidity by their parents. Parents reported a mean number of 8.5 trau matic events, 60% of parents had symptoms of potential clinical significance. Of PTSD, and 26.0% reported severe to very severe anxiety symptoms. The rates of PTSD and anxiety symptoms among parents and children were of sufficient severity to require assessment and as for anxiety symptoms. Thabet., et al. [10] in study of a random sample of 412 children aged 12 - 16 years from the Gaza Strip and were intervention. Parents’ and children’s scores were significantly correlated for PTSD intrusion and arousal (but not for avoidance), as well assessed in Gaza Traumatic Events Checklist Clinical Administered PTSD scale for children Parenting Support Scale The mean number of traumatic events of war any particular child experienced was 8.2, The total prevalence of PTSD was 30.8%.

Thabet., et al. [11] in a study aimed to establish the association between labour-related variables and mental health problems among 780 children in labour (aged 9 - 18 years, mean 15.8) in the Gaza Strip. Measures included a demographic checklist, the Strengths and from large families (73.2% had eight or more siblings), mainly worked to increase family income, worked an average 6.8 h per day (range Difficulties Questionnaire, the Spence Children’s Anxiety Scale and the Depression Self-rating Scale for Children. Results Children came by poor friendship relationships and lack of health insurance; anxiety scores by selling in the streets, working to help family, low family 1 - 16), and only 37.1% had regular rest. Ratings of mental health problems were predicted by different factors, i.e. total difficulties scores income and lack of health insurance; and depression scores by parents’ dissatisfaction with the job and longer working hours.

In study of risk and protective factors of PTSD, Ingridsdatter., et al. [12] in a sample of 139 adolescents 12 to 17 years in the Gaza Strip. Results showed that adolescents reported elevated levels of intrusion, avoidance, and depression compared to levels in communities not affected by war in the recent past. The proportion scoring within the clinical range of post-traumatic stress disorder (PTSD) was 56.8%. -

Significant risk factors for PTSD were exposure, female gender, older age, and an unemployed father. Risk factors for anxiety were expo sure,Six female months gender, after theand end older of age,the Warwhereas on Gaza female that gender lasted wasfor 23 the days only in significant 2009, Thabet., risk factor et al. [13]for depression. in a study was conducted in the entire Gaza Strip. The study sample included 410 children aged 6 to 17 years. Using Diagnostic Manual of Mental Disorders-IV (DSM-IV) criteria for post-traumatic stress disorder, 39.3% of children reported partial post-traumatic stress disorder and 9.8% of children reported full

Citation: Abdel Aziz Mousa Thabet. “Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper”. EC Psychology and Psychiatry 8.3 (2019): 197-205. Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper

201 criteria for post-traumatic stress disorder. According to parent’s report, the results showed 31.3% of children met the criteria for inat- tentive type 36.3% of children was impulsive, and 29% met criteria for combined type. According to children report, the results showed 28.8% of children met the criteria for inattentive type 37.3% of children was impulsive, and 28.3% met criteria for combined type. Using -

DSM-IV diagnostic criteria of and oppositional defiant disorder, the study showed that 38.1% of parents reported con duct disorder in their children and 46.3% reported oppositional defiant disorder. While 39.3% of children themselves reported conduct disorder and 44% of them reported oppositional defiant disorder. comorbidity of post-traumatic stress disorder and impulsivity-hyperactivity disorder, and 4.4% had comorbidity of post-traumatic stress The study showed that 5.1% of children had comorbidity of post-traumatic stress disorder and attention deficit disorder, 4.4% had disorder and attention deficit with hyperactivity combined type. Also, 4.6% of children had comorbidity of conduct and post-traumatic stressThabet., disorder et al. and [14] 6.1% in a had study comorbidity sample consisted of oppositional of 380 adolescents defiant disorder randomly and post-traumatic selected from secondarystress disorder. schools in Gaza Strip, of whom 171 were boys and 209 were girls between 15 - 18 years. The most common reported traumatic events due to the war on Gaza were: watching mutilated bodies and wounded people in TV (92.3%), and hearing shelling of the area by artillery (89.4%). The mean number - lescents from family with monthly income less than 150 US $ experienced more traumatic events than the other groups. Mean psychoso- of traumatic events experienced by Palestinian adolescents was 14. Boys reported significantly more traumatic events than girls. Ado matic symptoms was 48.19, digestive system symptoms was 19.97, cardiovascular symptoms was 10.23, respiratory system symptoms was 3.82, urogenital system symptoms was 2.98, skeletal musculature symptoms was 5.29, and skin symptoms was 7.34. Boys scored moreKhamis in total V psychosomatic[15] in study investigated and skin symptoms. the long-term There effectswas a significant of the 2012 relationship war on children’s between psychological traumatic experiences distress in and Gaza psychosomatic. Strip. It was hypothesized that a) greater levels of exposure to war trauma would be associated with greater behavioral and emotional disorders, neuroticism, and PTSD symptoms; b) children who rely more on problem-focused coping will manifest less behavioral and emotional disorders, neuroticism, and PTSD symptoms whereas children who rely more on emotion-focused coping will manifest higher levels of be- havioral and emotional disorders, neuroticism, and PTSD symptoms; and c) certain children’s characteristics (i.e. age, gender, and family income) would be predictive of children’s behavioral and emotional disorders, neuroticism, and PTSD. Participants were 205 males and females aged 9 to 16 years. Questionnaires were administered in an interview format with participants at schools. Results indicated that approximately 30 percent of the Palestinian children who were exposed to higher levels of war traumas have developed PTSD with excess family income reported higher levels of emotion and behavioral disorders and neuroticism. While emotion-focused coping was positively risk for co-morbidity with other disorders such as emotional symptoms and neuroticism. The findings revealed that children with lower associated with emotional and behavioral problems, neuroticism, and PTSD, problem-focused coping was negatively associated with neu- roticism and PTSD. The clinical implications of these conclusions were discussed to formulate cognitive-behavioral coping interventions that can lead to positive outcomes in the post-trauma environment.

Moreover, Thabet., et al. [16] in a study of 251 children from 3 summer camps in Gaza. This study showed that children commonly rep dead and injured people on TV. Mean PTSD symptoms was 18.37, intrusion mean was 8.98, avoidance symptoms subscale mean was 9.49. orted traumatic events such as hearing shelling of the area by artillery, hearing the sonic sounds of jetfighters, and seeing images of Almost sixty percent of children had posttraumatic stress disorder symptoms, 21.9% of children had anxiety and 50.6% had depression. Numbers of traumatic events was associated with PTSD, avoidance, arousal symptoms, anxiety, and depression.

Furthermore, Thabet., et al. [17] in study of the prevalence of PTSD, depression, and anxiety among orphaned children in the Gaza Strip. The study sample consisted of 81 orphaned children from Al-Amal Institute for Orphans The minimum age was 9 years and the max- imum age was 18 years, Mean = 13.34 years. The mean post-traumatic stress disorder was 35.79, intrusion symptoms was 19.77, avoid- ance symptoms was 14.30 and mean arousal symptoms was 13.65, 55.6% of orphaned children showed moderate and 34.6% showed

Citation: Abdel Aziz Mousa Thabet. “Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper”. EC Psychology and Psychiatry 8.3 (2019): 197-205. Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper

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than those children live in a camp or a village. The study showed that 67.9% showed depression. Depression was more in children from severe PTSD. Girls reported significantly more PTSD, avoidance, and arousal symptoms than boys. A child living in a city had more PTSD north Gaza had more depression than those coming from the other four areas of the Gaza Strip. The results showed that 30.9% of children rated as anxiety cases. Children 13 - 15 years old had more anxiety than those younger and older age than them and children coming from north Gaza had more anxiety than those coming from the other four areas of the Gaza Strip. The result showed that there was positive correlated with arousal symptoms of PTSD. Anxiety was negatively correlated with PTSD and avoidance symptoms of PTSD. correlation with statistical significance between depression and anxiety, intrusion, and avoidance. While total depression was negatively Recently, Thabet and El Rabbaiy [18] in a study of the sample consisted of all children attending the orphanage institute (El-Amal Institute) in Gaza city (N = 83). The results showed that orphaned children reported from 3-28 traumatic events, mean traumatic events was 11.19, children in the age 12 - 14 years reported more traumatic events than the younger and older groups. Regard PTSD, the study showed that 49.4% reported no PTSD, 32.5% reported partial PTSD, and 18.1% reported full criteria of PTSD. Children in the middle age group (12 - 14 years) reported more PTSD than younger and older groups. Children living in the middle area reported PTSD than those live in the other four areas of the Gaza Strip. Regard posttraumatic growth, 78.31% said that they have a stronger religious faith, 70.7% said they learned a great deal about how wonderful people are. Total posttraumatic growth among orphan children mean was 25.27. The symptoms, and arousal symptoms. While, there were no correlation with posttraumatic growth. Also, no correlation between posttrau- study showed that there was statistically significant positive relationship between total traumatic events due to war and PTSD, numbness matic disorder and posttraumatic growth.

Efficacy of therapeutic measures to improve the mental health wellbeing of Palestinian children a number of studies have described or evaluated different models of interventions for mental health problems among children who had There has been limited research on the effectiveness of specific psychological interventions for children living in war zones. However, suffered abuse, experienced natural disasters, political, or exposed to community violence.

Thabet and Vostanis [19] in a study aimed to evaluate the short-term impact of a group crisis intervention for children aged 9 - 15 yea posttraumatic stress reactions and were allocated to group intervention (N = 47) encouraging expression of experiences and emotions rs from five refugee camps in the Gaza Strip during ongoing war conflict. Children were selected if they reported moderate to severe through story telling, drawing, free play and role-play; education about symptoms (N = 22); or no intervention (N = 42). Children com- pleted the CPTSD-RI the CDI pre- and post-intervention. No significant impact of the group intervention was established on children’s and the non-active nature of the intervention. posttraumatic or depressive symptoms. Possible explanations of the findings are discussed, including the continuing exposure to trauma Thabet., et al. - - [20] in a study aimed to evaluate the school-based debriefing sessions for children living in a zone of ongoing war con viewed about their war experiences and reactions to the violence before and after participating in the 2-week intervention in schools for flict. A randomly selected sample of 240 children aged 10 - 16 years who were affected by the current conflict in the Gaza Strip were inter 8 session. The sessions aimed at facilitating communication, discussion of fears, myths and beliefs, discharge of feelings, and empower- ment in building their future. Drawing, story-telling, and role-play were used. Children themselves reported decrease in all mental health problems after the intervention. However parents disagreed with their children and reported no change in behavioural and emotional problems of their children after the intervention.

Thabet., et al. [21] in a study 304 schoolchildren aged 6 - 16 (Mean age = 10.62 years).

Citation: Abdel Aziz Mousa Thabet. “Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper”. EC Psychology and Psychiatry 8.3 (2019): 197-205. Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper

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Sociodemographic scale and Gaza Child Mental Health Scale) September 2007 by 8 scholastic year on May 2008. According to children rep -

ort, the results showed that there was statistically significant decrease in total scores of child mental health and hyperactivity symp obsessive and overanxious symptoms after student mediation program. toms after student school mediation program. According to parents, the results showed that there was statistically significant decrease in Thabet., et al. [22] in study of the effectiveness of student mediation program in improving mental health status of Palestinian children in t - he Gaza Strip. An 84 school adolescents aged 12 - 17 to find the efficacy of psychodrama sessions on children victims of trauma and war in the Gaza Strip found that there was statistically significant decrease in total scores of child mental health problems and hyperac in obsessive and overanxious symptoms after student the intervention program. However, teachers did not report improvement in most tivity symptoms after psychodrama program. According to parents, the results showed that there was statistically significant decrease of adolescent’s mental health problems. However, there were discrepancies between the adolescents, parents, and teachers reports of improvement in mental health problems. Parents and adolescents agreed that the program improved the adolescent’s mental health. However, teachers said no effect. This highlighted the need for increasing the number of psychodrama sessions and time between each session. Also, other factors could be studied instead of only studying the mental health such as resilience and social skills [23,24].

Conclusion It was obvious from the reviewed studies that severity of violence in changing from time to time and types of traumatic experiences are similar including the watching mutilated bodies in the TV, hearing and seeing the shelling, exposure to sonic bombs, and witnessing home bombardment and demolition. These traumatic experiences and violence affect the Palestinians well-being and increase rate of psychological problems in the targeted group. For primary intervention most of the organizations working in West Bank and Gaza Strip are delivering such services through public meetings, workshops, home visits, group intervention in the community and schools. This included UNRWA, Ministry of Education, counselling centers and early childhood centers. Studies of impact of different types of preven- tion are increasing in the last few years with different protocols of intervention including group crisis intervention, psychodrama, school mediation, non-curriculum activities in schools and summer camps, and expressive writing therapy with promising results of decreasing anxiety, general mental health problems in children and women victims of violence and abuse.

Recommendations From previous review we can recommend the following:

Research

1. New studies dealing with other risk and protective factors which can give very clear mental health indicators must be carried out. 2. To target with new research people with special needs and margined populations such as older age and very young children. 3. Study aimed to investigate other biological and organic factors as risk factors for mental health problems in the area. 4.

5. ToMore conduct qualitative new control and applied trail studiesresearch to in evaluate the field the of effectivenessmental health of of new adults protocols and children. for psychosocial intervention such as cogni- tive behaviour therapy, group intervention with bereaved people, expressive writings therapy, and other new techniques used in western societies after adaptation to local culture.

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Citation: Abdel Aziz Mousa Thabet. “Psychological Well-Being of Palestinian Children and Adolescents in Gaza Strip and West Bank: Review Paper”. EC Psychology and Psychiatry 8.3 (2019): 197-205.