See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/308411458

The Relationship between War Trauma, PTSD, Depression, and Anxiety among
Palestinian Children in the Gaza Strip

Article · August 2016

DOI: 10.4172/1791-809X.1000100501

CITATIONS READS

39 1,653

3 authors, including:

Abdel Aziz Panos Vostanis

York University University of Leicester
201 PUBLICATIONS 4,058 CITATIONS 371 PUBLICATIONS 11,642 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Abdel Aziz on 22 September 2016.

The user has requested enhancement of the downloaded file.

 Research

iMedPub Journals Health Science Journal 2016

http://www.imedpub.com/ Vol.10 No.5:1
ISSN 1791-809X
DOI: 10.4172/1791-809X.1000100501

The Relationship between War Trauma, PTSD, Depression, and Anxiety among
Palestinian Children in the Gaza Strip
Abdelaziz M Thabet1*, Sanaa S Thabet1 and Panos Vostanis2
1Child and Family Training and Counseling Center, Gaza, Palestine
2University of Leicester, Greenwood Institute of Child Health, Palestine
*Correspondence: Abdelaziz M. Thabet, Child and Family Training and Counseling Center, Gaza, Palestine. E-mail: [email protected]
Received: 17.06.2016; Accepted: 12.07.2016; Published: 22.07.2016

Introduction
Abstract Gaza’s population is considered a young as almost half the
population of the Gaza Strip is under the age of 15. This is
Aims: The aim of the study was to examine the likely to increase in the near future, because of the annual rate
relationship between war trauma, PTSD, depression, and of population growth (6%). Children living in the Gaza Strip
anxiety among Palestinian children in the Gaza Strip. have been exposed to and are suffering from a range of
trauma and abuse. This puts them at high risk for the
Method: A sample consisted of 251 children aged 6-16 development of mental health problems while they are still
were selected from 3 summer camps in the Gaza Strip.
young and the continuation of such problems into adulthood,
Children were interviewed using the following scales:
which affects the next generation of parents. Eighty percent of
sociodemographic scale, Gaza Traumatic Events Checklist,
the population in Gaza falls below the poverty line of US$2 per
Impact of Events Scale, Children Revised Manifest Anxiety
Scale, and Children Depression Inventory.
day (up from 30 percent in 2000) and the unemployment level
stands at approximately 50 percent. In addition, people in
Results: The results showed that the most common Gaza have been subject to military occupation, causing
traumatic events due to war on 2009 reported by children significant psychological trauma, particularly for children [1].
were hearing shelling of the area by artillery, hearing the From a health point of view, the impact of violence in
sonic sounds of jetfighters, watching mutilated bodies on general may be seen within a traumatization framework, i.e.
TV, and hearing shootings and bombardment. Mean that the different types of violence, including political violence,
Impact of Events Scale was 18.37, intrusion subscale mean
induce physical and/or mental harm to (i.e. traumatize)
was 8.98, avoidance subscale mean was 9.49, 148
individuals, groups or populations. A separation of physical
children were in the clinical range for post-traumatic
and mental traumatization is difficult, since physical
stress disorder symptoms (59%). Study showed that
21.9% of children had anxiety and 50.6% had depression.
traumatization can hardly occur without being accompanied
Total traumatic events were significantly correlated PTSD, by mental traumatization [2]. The violence and cruelty of
avoidance, arousal symptoms, anxiety, and depression. conflict are associated with a range of psychological and
behavioural problems, including depression and anxiety,
Clinical implications: The findings showed that political suicidal behaviour, alcohol abuse and post-traumatic stress
violence due to war trauma is related to the development disorder. Furthermore, psychological trauma may become
of PTSD and depression in Palestinian children in Gaza evident in disturbed and antisocial behaviour, such as family
Strip. conflict and aggression towards others. This situation is often
exacerbated by the availability of weapons and by people
Different levels of programs and interventions had to be becoming inured to violence after long exposure to conflict.
described; such interventions under extremely adverse The impact of conflicts on mental health is, however,
circumstances can be put in place after children’s basic extremely complex and unpredictable. It is influenced by a
needs have been met. This is because existing emergency host of factors such as the nature of the conflict, the kind of
aid agencies have already responded to the local trauma and distress experienced, the cultural context, and the
infrastructure in specialized and culturally appropriate resources that individuals and communities bring to bear on
ways and so can serve as a channel for the provision of their situation [3]. In a study of Silove et al., [4] war-affected
additional services. 107 subjects of Tamils living in Australia. Tamils exposed to
torture returned statistically higher PTSD scores than other
Keywords: Anxiety; Depression; Gaza strip; PTSD; Trauma war trauma survivors after controlling for overall levels of
trauma exposure. The torture factor identified by the PCA was
found to be the main predictor of PTSD in a multiple
regression analysis. In similar study of Eisenman et al., [5]
aimed to determine rates of exposure to political violence

© Copyright iMedPub | This article is available from: www.hsj.gr/archive

1
 Health Science Journal 2016
ISSN 1791-809X Vol.10 No.5:1

among Latino 638 adult primary care patients who have for depression and 18% for PTSD, despite the differences in
immigrated to the United States its impact on mental health. years since trauma occurred. Similarly, Khamis [11] in study
The study showed that 54% of participants reported political aimed to assess the occurrence of post-traumatic stress
violence experiences in their home countries, including 8% disorder (PTSD) and psychiatric disorders (i.e., anxiety and
who reported torture. Of those exposed to political violence, depression) in Palestinian adolescents following intifada-
36% had symptoms of depression and 18% had symptoms of related injuries found that 137 adolescents (76.5%) in the
PTSD vs 20% and 8%, respectively, among those not exposed sample met full criteria for PTSD diagnosis after they had been
to political violence. Rosner et al., [6] in study of samples in injured by live ammunition. About 41 (29.9%) of the cases had
Sarajevo, Bosnia-Herzegovina, three years after the end of the a delayed onset; that is, the onset of symptoms occurred more
war. A total of 311 people surviving the siege of Sarajevo were than 6 months after the trauma. In regard to depression and
assessed. The study groups consisted of a randomly selected anxiety, significant differences were found between PTSD and
residents sample (n=98), a group of individuals in psychological non- PTSD adolescents on the depression scale and anxiety
treatment (n=114), and a group in medical treatment (n=99). scale. Adolescents who exhibited PTSD symptoms were more
Each individual survived an average of 24 traumatic events. likely to report higher levels of depression and anxiety.
According to the Diagnostic and Statistical Manual of Mental
Also, Thabet et al. [12] in study of 200 families from North
Disorders, 4th ed. criteria, 18.6% of individuals in the residents
Gaza and East Gaza showed that 70.1% of children were likely
sample, 32.7% of those in medical treatment, and 38.6% of
to present with PTSD, 33.9% were rated as having anxiety
those in psychological treatment developed PTSD. In the study
symptoms of likely clinical significance, and 42.7% were rated
of Qouta et al., [7] the prevalence and determinants of PTSD
as having significant mental health morbidity by their parents.
were assessed among 121 Palestinian children (6-16 years;
Fasfous et al. [13] in study aimed to evaluate the symptoms of
45% girls and 55% boys) living in the area of bombardment.
PTSD among Palestinian school children in two different areas
The results showed that 54% of the children suffered from
of Hebron. A total of 381 schoolchildren from different parts of
severe, 33.5% from moderate and 11% from mild and doubtful
Hebron participated in the study. Results indicate that 77.4%
levels of PTSD. Girls were more vulnerable; 58% of them
of the children living in Hebron show symptoms of moderate-
suffered from severe PTSD, and none scored on the mild or
to-severe PTSD, and 20.5% of them meet the DSM-IV
doubtful levels of PTSD.
diagnostic criteria for chronic PTSD. Similarly, Thabet et al.,
The study of Giacaman et al. [8] aimed to investigate the [14] in study of 386 Palestinian children and adolescents from
influence of exposure to humiliation in war-like conditions on Gaza Strip showed that, 12.4% of the children and adolescents
health status in 10th and 11th grade students living in the reported post-traumatic stress disorder. Also, Thabet and
Ramallah District, West Bank, Occupied Palestinian Territory. Thabet [15] in study of 502 randomly selected children from
There was a significant association between a high number of 16 districts of the Gaza Strip showed that 35.9% of children
subjective health complaints and demographic variables, reported PTSD and 30.9% of children had anxiety disorder. The
particularly for females compared with males, and refugee aim of this study was to examine the relationship between war
camp dwellers compared with village dwellers. In addition, trauma, PTSD, depression, and anxiety among Palestinian
exposure to humiliation was significantly associated with an children in the Gaza Strip.
increased number of subjective health complaints. Students
experiencing three forms of humiliation were found to be 2.5
times more likely to report a high number of subjective health
Method
complaints compared with those who had never been exposed
to humiliation (52% vs 21%), while those experiencing four Participants
forms of humiliation were three times more likely to report a The sample consisted of children (ages 6 to 16) with similar
high number of subjective health complaints (62% vs 21%). In socioeconomic characteristics in the Gaza Strip who had been
the study of Elbedour et al, [9] to evaluate and describe the enrolled in three summer camps in Gaza Strip. The sample
psychological effects of exposure of war-like circumstances on consisted of 251 children, 129 were boys (51.4%) and 122
this population. Participants for this study were 229 were girls (48.6%). Children ranged in age from 6-16 years with
Palestinian adolescents living in the Gaza Strip who were a mean age of 11.19 years (SD=2.71).
administered measures of post-traumatic stress disorder
(PTSD), depression, anxiety, and coping. Of the 229
participants, 68.9% were classified as having developed PTSD, Measures
40.0% reported moderate or severe levels of depression, The data was collected from children by using the following
94.9% were classified as having severe anxiety levels, and questionnaires:
69.9% demonstrated undesirable coping responses. Similarly
in study of Alexander [10] which described symptoms of Sociodemographic characteristic questionnaire
anxiety, depression and PTSD among Bosnian (n=17) and
Colombian (n=17) torture survivors served by the Florida This questionnaire includes sex, age, place of residence,
Center for Survivors of Torture. Findings show that 100% of parental information, and family income.
Bosnians are symptomatic for depression and over half
possess symptoms of PTSD compared to 35% of Colombians

2 This article is available from: www.hsj.gr/archive

 Health Science Journal 2016
ISSN 1791-809X Vol.10 No.5:1

Gaza traumatic events checklist (Thabet et al., Study procedure

[16]) We selected the sample from summer camps organized by
This checklist consists of 31 items covering different types of three non-governmental organizations working with children.
traumatic events that a child may have been exposed to in the Camps were located in Gaza City, Middle area, and Rafah area
particular circumstances of the regional conflict and Israeli south of Gaza Strip. We held a meeting with supervisors of the
violence in the last 6 months. This checklist covers three summer camps to explain the aims of the study. A cover letter
domains of trauma. The first domain covers witnessing acts of was sent to each parent to obtain written permission from
violence such as the killing of relatives, home demolition, them to interview their children in the study and for
bombardment, and injury of others. The second domain covers permission to participate in the study. Sociodemographic
hearing experiences such as hearing of the killing or injury of information for the study population was collected from
friends or relatives. The third domain covers personal parents. In cooperation with the camp supervisors a total
traumatic events such being shot, injured, or beaten. This number of 251 children (97%) complete the scales and the 9
checklist can be completed by children aged 6-16 (‘yes’ or children did not complete the questionnaires. The data was
‘no’). In this study the 31-item trauma scale, Cronbachs’s alpha collected by 6 social workers and psychologists who were
was 0.90. trained for 4 hours prior to interviewing children inside the
summer camps. Children were given the self-report
instruments to complete, interviewers gathered children into
The children’s revised impact of events scale groups of 10 children they read the questions a loud to the
(CRIES-8) children, Children were informed by data collectors that there
This scale measures symptoms of post-traumatic stress was no right or wrong answers and that they were free to
disorder (PTSD). This includes all 8 items of the original Impact withdraw from the study at any time. Children were also
of Events Scale [17]. Individual items were rated according to informed that if they had questions when completing the
the frequency of their occurrence during the past week scales, they could raise their hands and ask any questions. The
(none=0, rarely=1, sometimes=3, a lot=5) and in relation to a study was approved by Local ethical committee (Helsinki
specific traumatic event written at the top of the scale. In this Research Committee) as part of Ministry of Health in Gaza
study the revised IES was translated from English to Arabic and Strip. The data was collected during summer 2011.
back translated. A cut-off score of 17 and above has been
found to indicate the likelihood of PTSD Yule, 1991). A total Statistical Analysis
score was provided, as well as subscale scores for intrusion,
arousal and avoidance PTSD symptoms. In this study the 8- All analyses were carried out using Statistical Package for
item Impact of Events Scale, Cronbachs’s alpha was 0.73. the Social Sciences SPSS ver. 20 for data entry and analysis.
Regarding the two subscales, Cronbach’s alpha for the Frequencies and percentages of trauma, PTSD, anxiety, and
avoidance items was 0.57; for the intrusion items, Cronbach’s depression items were calculated. Independent t test was
alpha was 0.69. conduced to find differences between two groups. Pearson’s
correlation coefficient tested the association between trauma,
PTSD, anxiety, and depression. Linear regression investigated
The revised children’s manifest anxiety scale the association between independent (traumatic events) and
(RCMAS) [18] PTSD, anxiety, and depression as dependent variable was
This is a standardized 37-item self-report questionnaire for conducted to find the predictor factors of psychopathology in
children aged 6-19. It measures the presence or absence of children.
anxiety-related symptoms (‘yes’/‘no’ answers) in 28 anxiety
items and 9 lie items. A cut-off total score of 19 has been Results
found to predict the presence of anxiety disorder [19]. In this
study the total anxiety scale reliability, Cronbach’s alpha was Sociodemographic characteristics of the
0.82.
sample
Child depression inventory (CDI) The sample consisted of 251 children, 129 were boys
(51.4%) and 122 were girls (48.6%). Children ranged in age
The CDI is a standardised self-report questionnaire of
from 6-16 years with a mean age of 11.19 (SD=2.71). Young
depressive symptomatology [20]. This has been developed for
children (ages 6 to 12) represented 68.5% of the sample with
children and young people aged 6-17. The CDI includes 27
31.5% of the sample being adolescents (ages 13 to 16).
items, each scored on a 0-2 scale (from ‘not a problem’ to
According to place of residence, 61.8% of children live in cities,
‘severe’) for the previous two weeks. The total score ranges
24.7% live in camps, and 13.5% live in villages. According to
between 0-54, and a score of 19 and higher has been found to
family monthly income, 53.4% of the families’ monthly income
indicate the likelihood of a depressive disorder. The CDI has
is less than $300, 27.1% ranged from $301-500, 10.4% of
been adapted for use with Arab children [21]. In this study the
27-items depression inventory, Cronbach’s alpha was 0.65

© Copyright iMedPub 3
 Health Science Journal 2016
ISSN 1791-809X Vol.10 No.5:1

families’ income ranged from $501-750, and only 9.2% had More than 8 children 58 23.1
income more than $751 monthly income (Table 1).
Monthly income in US dollar

Table 1 Sociodemographic characteristics of the study Less than $300 134 53.4
population (N=251).
$301-500 68 27.1

N % $501-750 26 10.4

Sex More than $751 23 9.2

Male 129 51.4

Female 122 48.6

Types of traumatic events due to war
Mean=11.19 Palestinian children reported a variety of traumatic events
Age (SD=2.76) as a result of the repeated incursions in the area. The most
Young children (6-11 years) 172 68.5
common traumatic events reported by children were: hearing
shelling of the area by artillery (85.4%), hearing the sonic
Older children (12-16 years) 79 31.5 sounds of jetfighters (81.5%), watching mutilated bodies on TV
No. of siblings (78.2%), and hearing shootings and bombardment (76.7%)
(Table 2).
Less than 4 57 22.7

5-7 children 136 54.2

Table 2 Types of traumatic events.

Trauma No %

Hearing shelling of the area by artillery 210 85.4

Hearing the sonic sounds of the jetfighters 203 81.5

Watching mutilated bodies on TV 194 78.2

Hearing the shootings and bombardment 191 76.7

Witnessing the signs of shelling on the ground 170 68.5

Witnessing assassination of people by rockets 153 62.4

Witnessing arrest or kidnapping of someone or a friend 142 57

Hearing killing of a close relative 141 56.4

Hearing killing of a friend 121 48.4

Deprivation from water or electricity during detention at home during incursion 106 42.7

Beating and humiliation by the army 97 39.4

Witnessing firing by tanks and heavy artillery at neighbors homes 94 37.9

Being detained at home during incursions 91 36.8

Witnessing of a friend home demolition 90 36.3

Threaten by telephone call from Israelis security force to evacuate their home before bombardment 86 34.8

Witnessing arrest of someone or a friend 84 34

Threaten by shooting 83 34.3

Witnessing shooting of a close relative 82 32.9

Destroying of your personal belongings during incursion 82 33.2

Witnessing of own home demolition 81 32.8

Witnessing firing by tanks and heavy artillery at own home 80 32.7

Witnessing shooting of a friend 79 32.1

Deprivation from going to toilet and leave the room at home where you was detained during incursion 79 32.1

4 This article is available from: www.hsj.gr/archive

 Health Science Journal 2016
ISSN 1791-809X Vol.10 No.5:1

Witnessing killing of a friend 76 30.6

Being exposed to shooting during the last shooting and confrontations 76 30.8

Witnessing killing of a close relative 75 30.4

Threatened to death by being used as human shield to arrest your neighbors by the army 73 29.6

Being shot by bullets, or rocket parts, or bombs 69 27.9

Threaten of family member of being killed 69 27.8

Physical injury due to bombardment of your home 65 26.3

Threaten of being killed 64 25.8

Mean and standard deviations of traumatic CDI of 19 and above for depression, 127 children (50.6%) were
depressed. In order to find the differences in depression and
events sex, an independent t test was performed. The results showed
The number of traumatic events ranged from no traumatic that there was no statistically significant differences between
event to 31 traumatic events with a mean of 13.17 events boys and girls in depression (t=0.93, p=ns). There were no age
(SD=7.50). Males (M=14.51, SD=7.80) reported significantly differences in reported depression (Table 3).
more exposure to trauma than females (M=11.75, SD=6.93), t
(249)=4.52, p>0.003. There was no mean difference in Table 3 Means and standard deviations of PTSD, depression,
reported exposure to traumatic events between young and anxiety.
children (M=12.93, SD=7.78) and older children (M=13.68,
SD=6.90), t (249)=3.96, p>0.05. Mean SD

PTSD 18.37 8.67

Prevalence of post-traumatic stress disorder Avoidance 9.49 4.88

Children’s post-traumatic stress disorder scores ranged Intrusion 8.92 5.36

between 0 and 36. IES-8 items mean was 18.37 (SD=8.67).
Intrusion subscale mean was 8.98 (SD=5.36), avoidance Anxiety 13.9 5.97

subscale mean was 9.49 (SD=4.88). In order to estimate the Depression 18.38 6.48
prevalence of PTSD, the sum of the 8 items of IES was recoded
in to PTSD/No PTSD with a cut off point of 17 and above as
PTSD. The results showed that 148 children were in the cut-off Relationships between trauma, PTSD, anxiety,
range indicating a likely diagnosis of post-traumatic stress and depression
disorder (59%).
In order to find the relationships between the dependent
In order to find the differences in PTSD and sex, an and independent variables, Pearson correlation coefficient test
independent t test was performed. The results showed that was done. Total traumatic events were significantly correlated
there was no statistically significant differences between boys to total PTSD total scores (r=0.33, p=0.01), avoidance (r=0.26,
and girls in PTSD (t =0.33, p=ns). There were no age differences p=0.01), arousal (r=32, p=0.01) anxiety (r=0.36, p=0.01), and
in reported PTSD. depression (r=0.36, p=0.01) (Table 4).

Anxiety symptoms Table 4 Pearson correlation values of trauma exposure-PTSD

symptoms, anxiety, and depression.
The minimum symptoms were 0 and maximum were 28
with mean anxiety 13.90 (SD=5.97). Considering cutoff points 1 2 3 4 5
of 19 and above as anxiety, 55 children (21.9%) had anxiety. In
Total trauma 1
order to find the differences in anxiety and sex, an
independent t test was performed. The results showed that Total PTSD 0.33** 1
there was no statistically significant differences between boys Avoidance
and girls in total anxiety scores (t=-0.08, p=ns). There were no Symptoms 0.26 ** 0.84** 1
age differences in reported anxiety.
Arousal
symptoms 0.32** 0.86** 0.46** 1
Depression Anxiety 0.36 ** 0.26** 0.21** 0.24** 1
Palestinian children reported symptoms of depression. The
minimum symptoms were 0 and maximum were 36 with mean
depression 18.38 (SD=6.48). Considering the cutoff point of

© Copyright iMedPub 5
 Health Science Journal 2016
ISSN 1791-809X Vol.10 No.5:1

Depression 0.36 ** 0.37** 0.27** 0.37** 0.78** multiple regression model, with total PTSD scores as the
dependent variable, two traumatic events were significantly
associated with PTSD: witnessing killing of a close relative
Prediction of PTSD by traumatic events due to (B=3.86, p=0.001), and witnessing of a friend home demolition
war lost the main source of income (B=2.69, p=0.01) (F=19.87,
p<0.001, R2=0.14) (Table 5).
In a univariate linear regression analysis, each traumatic
event of war was entered as an independent variable in a

Table 5 Linear regression analysis for predictor variables of trauma for the PTSD.

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

Witnessing killing of a
close relative -4.88 1.27 -0.27 -3.86 0.001 -7.38 -2.39

Witnessing of a friend
home demolition -3.21 1.19 -0.19 -2.69 0.01 -5.57 -0.86

Prediction of anxiety by traumatic events anxiety: witnessing of own home demolition (B=3.17,
p=0.001), threaten by telephoned to evacuate your home
In a univariate linear regression analysis, each traumatic before bombardment (B=3.22, p=0.001), and hearing the
event was entered as an independent variable in a multiple shootings and bombardment (B=2.20, p=0.03) (F=17.6
regression model, with total anxiety scores as the dependent p<0.001, R2=0.17) (Table 6).
variable, three events were significantly associated with

Table 6 Linear regression analysis for predictor variables of trauma for the anxiety.

Unstandardized Standardized 95.0% Confidence Interval

Coefficients Coefficients for B
t p
Lower Upper
Beta
B Std. Error Bound Bound

Witnessing of own home demolition -5.62 1.77 -0.22 -3.17 0.001 -9.11 -2.13

Threaten by telephoned to evacuate

your home before bombardment -5.61 1.74 -0.23 -3.22 0.001 -9.04 -2.17

Hearing the shootings and

bombardment 3.72 1.69 0.14 2.2 0.03 0.38 7.06

Prediction of depression by traumatic events dependent variable, three events were significantly associated
with depression: witnessing of own home demolition (B=4.08,
In a univariate linear regression analysis, each traumatic p=0.001), and threaten by threaten by shooting (B=2.83, p=0.
event was entered as an independent variable in a multiple 01 (F=21.19, p<0.001, R2=0.15) (Table 7).
regression model, with total depression scores as the

Table 7 Linear regression analysis for predictor variables of trauma for the depression.

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

Witnessing of own home

demolition -7.76 1.9 -0.28 -4.08 0.001 -11.51 -4.02

Threaten by shooting -5.37 1.89 -0.19 -2.83 0.01 -9.1 -1.64

6 This article is available from: www.hsj.gr/archive

 Health Science Journal 2016
ISSN 1791-809X Vol.10 No.5:1

Discussion of children and families. Different levels of programs and

interventions had to be described, such interventions under
Children living in regions of war and political conflict are extremely adverse circumstances can be put in place after
exposed to numerous types of potentially traumatic events children’s basic needs have been met. This is because existing
that have a significant impact on their psychological and emergency aid agencies have already responded to the local
physical wellbeing. The number of traumatic events that infrastructure in specialized and culturally appropriate ways
children in this study were exposed to ranged from 13.17. and so can serve as a channel for the provision of additional
While the most prevalent types of traumatic events involved services. There is already some research evidence on
hearing shellings, sonic sounds of the jetfighters, and strategies to prevent or minimize children’s response to
shootings and bombardment, a substantial number of children trauma through ongoing political conflict. Implementation of
(approximately 75%) reported watching mutilated bodies on aid efforts are more likely to be successful through agencies
TV resulting. Nearly half of the children had heard about operating in the area and in collaboration with schools, which
killings of close relatives or friends and approximately twenty- are the main source of stability and safety for the children.
five to thirty-four per cent had actually witnessed the killings International organizations such the United Nations (under
with deaths. An estimated 1 in 4 children reported that they or whose auspices, for example, all schools in the Gaza refugee
a family member had been threatened to be killed. The camps operate) and UNICEF have a major role to play in
reported level of war trauma exposure had a significant impact providing as much socioeconomic stability, education,
on children’s mental health with more than half of the children alternative coping strategies, and awareness of the impact of
reporting in the clinical range of posttraumatic stress reactions trauma, as is humanly possible in these sad and untoward
and depression and about a fifth of the children reporting circumstances.
clinical levels of anxiety. The findings of this study were
consistent with literature on the impact of political violence on Acknowledgment
children living in areas of war and conflict [7,9,12,14-16,22].
This study showed no differences in exposure to trauma We appreciate so much the help of the summer camps
posttraumatic stress, anxiety and depression according to supervisors in helping us in data collection and also to children
children gender or age. who participate in this study.
Our study results were consistent with other studies of
children in Gaza exposed to political violence [9] and were References
inconsistent with other studies with which shoed that girls had
more posttraumatic stress than boys [7]. Our results were 1. Palestinian Central Bureau of Statistics (2006). Demographic and
socioeconomic status of the palestinian people at the end of
consistent with reviewed studies by Tolin and Foa [23] which 2006.
suggested that for children exposed to combat, war and/or
terrorism there is no difference in PTSD between young girls 2. World Health Organization (2002) World report on violence and
health. World Health Organization Geneva.
and boys, but during adolescence, sex differences in PTSD
become more prevalent with girls reporting higher levels of 3. Summerfield D (1991) Guatemala: Health, human rights, and
posttraumatic stress. However, it may be that in times of landlessness. The Lancet 337: 1028-1029.
extreme widespread continuous violence and in a context of a 4. Silove D, Steel Z, McGorry P, Miles V, Drobny J (2002) The impact
worldview where there becomes a sense of collective trauma, of torture on post-traumatic stress symptoms in war-affected
these types of difference in distress based on tamil refugees and immigrants. Compr Psychiatry 43: 49-55.
sociodemographic characteristics such as sex or age are not 5. Eisenman D, Gelberg L, Liu H, Shapiro M (2003) Mental health
revealed until times of decreased violence or peace. Further and health-related quality of life among adult latino primary
research in the area of age and sex as vulnerabilities for care patients living in the United States with previous exposure
children exposed during and after war-like conditions is to political violence. JAMA 290: 627-634.
needed. Nevertheless, there is strong evidence of the 6. Rosner R, Powell S, Butollo W (2003) Posttraumatic stress
associations between children’s exposure to political violence disorder three years after the siege of sarajevo. J Clin Psychol 59:
and posttraumatic distress [7,14,15,22,24,25]. The unique 41-55.
situation in the Gaza Strip during the last years puts more 7. Qouta S, Punamaki RL, El Sarraj E (2003) Prevalence and
burden on Palestinian children to cope with different types of determinants of PTSD among Palestinian children exposed to
traumatic events and to continue normal life beside the siege military violence. Eur Child Adolesc Psychiatry 12: 265-272.
of Gaza in the last 10 years [26].
8. Giacaman R, Mataria A, Nguyen-Gillham V, Safieh AR, Stefanini A
et al. (2007) Quality of life in the Palestinian context: An inquiry
Conclusion and Implications in war-like conditions. Health Policy 81: 68-84.
9. Elbedour S, Onwuegbuzie AJ, Ghannam J, Whitcome JA, Hein FA
The study showed that children had mental health problems (2007) Post-traumatic stress disorder, depression, and anxiety
due to war. This need effort of increasing media and policy among Gaza strip adolescents in the wake of the second uprising
attention on children living in war zones provides a good (Intifada). Child Abuse Negl 31: 691-397.
opportunity to consider the implications of these research
findings for international initiatives to improve the well-being

© Copyright iMedPub 7
 Health Science Journal 2016
ISSN 1791-809X Vol.10 No.5:1

10. Alexander A, Blake S, Bernstein MA (2007) A comparison of 19. Reynolds C, Richmond B (1997) What I think and feel: a revised
torture survivors from Bosnia and Colombia and their rates of measure of children’s manifest anxiety. J Abn Child Psychology
anxiety, depression and PTSD. Torture 17: 1-10. 25: 15-20.
11. Khamis V (2008) Post-traumatic stress and psychiatric disorders 20. Kovacs M (1985) The children’s depression inventory (CDI)
in Palestinian adolescents following intifada related injuries. Soc Psychopharmacology Bulletin 21: 995-998.
Sci Med 67: 1199-1207.
21. Gharib A (1985) Arabic version of CDI. Nahda E, Cairo EM, Haj-
12. Thabet AA, Tawahina AA, Eyad ES, Panos V (2008) Exposure to Yahia MM (2007) Challenges of studying the psychological
war trauma and PTSD among parents and children in the Gaza effects of Palestinian children’s exposure to political violence
strip. Eur Child Adolesc Psychiatry 17: 191-199. and their coping with this traumatic experience. Child Abuse
Negl 31: 691-697.
13. Fasfous AF, Peralta-Ramírez I, Pérez-García M (2013) Symptoms
of PTSD among children living in war zones in same cultural 22. Thabet AA, Thabet SS (2016) The relationship between trauma
context and different situations. J Muslim Ment Health 7: 47-61. due to winter storm alexa, PTSD, mental health of Palestinians in
the Gaza Strip. Res Health Sci 1: 11-21.
14. Thabet AA, Thabet S (2015) Trauma, PTSD, anxiety, and
resilience in Palestinian children in the Gaza strip. Brit J Educ Soc 23. Tolin DF, Foa EB (2006) Sex differences in trauma and
Behav Sci 11: 1-13. posttraumatic stress disorder: A quantitative review of 25 years
of research. Psychol Bull 132: 959-922.
15. Thabet AA, Tawahina AA, Punamäki RL, Vostanis P (2015a)
Trauma, PTSD, and traumatic grief among Palestinian children. 24. Thabet AA, Abed Y, Vostanis P (2004) Comorbidity of PTSD and
SM J Community Med 1: 1-11. depression among refugee children during war conflict? J Child
Psychol Psychiatry 45, 533-542.
16. Thabet AA, Abdulla T, El Helou M, Vostanis P (2006) Prevalence
of AHDH and PTSD among Palestinian children in the Gaza and 25. Vizek-Vidović V, Kuterovac-Jogodić G, Arambašić L (2000)
west bank. Arabpsynet E J 12: 57-64. Posttraumatic symtomatology in children exposed to war. Scand
J Psychol 41: 297-306.
17. Horowitz M, Wilner N, Alvapez W (1979) Impact of events scale:
a measure of subjective stress. Psychosom Med 41: 209-218. 26. World Health Organization (2006) WHO-Aims report on mental
health system in west bank and Gaza. A report of the
18. Reynolds C, Richmond B (1978) What I think and feel: A measure assessment of the mental health system in west bank and Gaza
of children’s manifest anxiety. J Abn Child Psychology 6:
using the World Health Organization - Assessment instrument
271-280.
for mental health systems (WHO-AIMS).

8 This article is available from: www.hsj.gr/archive

View publication stats