Publications

S. Qouta, PhD; J. Odeh, MD

Abstract: Violence permeates all parts of the West Bank and Gaza Strip. Since the onset of the Al-Aqsa Intifada on the September, 28, 2000, through October 31, 2003, more than 51,000 Palestinians have been injured and 2700 have been killed. Palestinian children suffer from various physical aliments due to their disadvantaged situation, including 10% who suffer from moderate to severe malnutrition. The children also suffer from significant mental health disorders, including 33% with acute levels of posttraumatic stress disorder, 49% with moderate levels and 15.6% low levels. In “hot” areas, 55% of the children have acute levels of posttraumatic stress disorder, 35% moderate levels, and 9% low levels.
Key words: children, Palestinians, posttraumatic stress disorder, war

POLITICAL violence permeates all parts of the West Bank and Gaza Strip. It affects virtually all Palestinians young and old in various community settings including households, schools, and institutions. The present article summarizes studies documenting the impact of the Israeli-Palestinian conflict on the health of Palestinian children. In addition, this article will summarize one original study that investigates further the impact of the war on the mental health of Palestinian children.

Children living in conditions of political violence andwar have been described as “growing up too soon,”“losing their childhood,”and taking political responsibilities before achieving ample maturation (Boothby et al., 1992). This development leads to negative psychological consequences (Garbarino et al., 1991). Mental health professionals show increasing concern about developmental risks for children who fall victims to political violence and war. Family and parent-child attachment are considered important in providing a protective shield for children’s psychological wellbeing in dangerous conditions (Garbarino et al., 1991; Freud & Burlingham, 1943).

Palestinian families in the Gaza Strip are large, and members show strong affiliation to their families. “El Hamula” (the extended family) continues to play an important protective role in modern life too. Traditionally, children submit to the authority of their parents, and older members of the family enjoy special respect. However, the Intifada has created a situation that has apparently shaken traditional parent-child relations and the family hierarchy. First, the increased influence of political parties has decreased the social role of the extended family. Second, children and youths have played a very active role in the national struggle. They were and continue to be an essential element in the initiation, planning, and organization of demonstrations against and confrontations with Israeli soldiers (Kuttab, 1998).

Palestinians have expressed serious concern about the future consequences of these shattered parental bonds. Anecdotally, some believe that children who throw stones (“children of the stones”)and fight against the occupation army also challenge their parents’ authority. Parents face difficulties in protecting their children from sights of destruction, violence, and abuse. Many Palestinian children have taken an active part in their national struggle. Even if they were not actively fighting on the streets, as so many are, they still could not help but experience the national struggle on an emotional level.

THE IMPACT OF THE WAR ON THE HEALTH OF PALESTINIAN CHILDREN

Physical health

Since the onset of the Al-Aqsa Intifada on September 28, 2000 through March 31, 2004, more than 51,228 Palestinians have been injured and 2762 have been killed. Many of thosewere children under the age of 18 years, among whom 14,179 were injured and 701 were killed. Approximately 12% of the injured children are suffering from a permanent disability. Most of the victims’ injuries were in the upper part of their bodies, including their heads and eyes. Adolescents, aged 12–18 years, represent the majority of the affected young victimized population.

Palestinian children suffer from various physical aliments owing to their disadvantaged situation. The preliminary findings of a nutritional assessment for a stratified random sample of 1000 Palestinian households in the West Bank and the Gaza Strip showed high levels of anemia and malnutrition (as defined by the World Health Organization) in children (Palestinian Central Bureau of Statistics with Birzeit University and UNICEF, 2002; Child Nutrition in Exceptional Circumstances, 2002). This cross-sectional survey was completed during the period of March–June 2002 and focused on the nutritional status of children living in the West Bank and Gaza Strip. The ages of the children included in this study ranged from 6 to 59 months. Three indicators were used to assess nutritional status: hemoglobin level, stunting and wasting. The survey found that 37.9% of children were anemic (33.5% in the West Bank and 38.7% in the Gaza Strip). Around 2.5% of children suffered from acute malnutrition (2.9% in theWest Bank and 2.0% in the Gaza Strip) and 9.0% from chronic malnutrition (8.0% in the West Bank and 10.5% in the Gaza Strip). Rates of anaemia and malnutrition had all increased from the levels found in a previous survey carried out in 2000.

The explanations for these increases in cases of malnutrition and anemia are multifactorial. Child health and nutrition experts stated that these results reflected the critically disadvantaged situation in the Gaza Strip as well as the serious, deteriorating situation in the West Bank. In general, the results reflect a status of chaos and crisis, exacerbated by a breakdown in the functioning of the Palestinian National Authority.

Possibly the most tragic example of the impact of this political chaos on the health of the Palestinian population is the outcomes of pregnant mothers at checkpoints (which often take hours and/or days to pass through): 39 deliveries; 22 deaths of pregnant mothers; and 27 deaths of newborn babies.

Mental health

The psychological sequelae of political violence on children are severe and very traumatizing. While many of the injured children have acquired a permanent physical disability, many more have developed psychological impairments. For example, around 50% of injured children have developed posttraumatic stress disorder diagnosis. Even among mainstream Palestinian school-age children, around 34% have developed posttraumatic stress disorder (Khamis, 2000).

In a recent study on 1000 school-age Palestinian children, 54.7% (547) reported experiencing at least 1 high-magnitude traumatic event in their lifetime (Khamis, 2000a). Political traumas inflicted by the Israeli army were the most commonly experienced events (270 children, 27%). Among these 270 children, 23% (125) were injured, 18% (96) had a family member killed, 8% (45) had been imprisoned and beaten up, and 0.7% (4) had their houses demolished. Of the 547 children who had been exposed to traumatic events, 63% (341) were diagnosed as having full posttraumatic stress disorder symptomatology according to diagnostic criteria, which is 34% of the entire sample.

Research also indicates that the prevalence of attention deficit hyperactivity disorder among school-age children has risen to about 14% during the Al-Aqsa Intifada. The prevalence ratio varied across the 3 attention deficit hyperactivity disorder subtypes: 3.5% for the combined type, 7.6% for the inattentive type, and 2.8% for the hyperactiveimpulsive type (Khamis, 2002b).

One of the authors (Quota) undertook a survey in 2003 of 944 children (aged 10–19), randomly selected from all parts of the Gaza Strip (mean age 15.1 years), made up of a similar proportion of boys (49.7%) and girls (50.3%). Refugee children represented 76.8% of the sample and the rest were either citizens or residents of the Gaza Strip.

The measures utilized were as follows:

  1. Trauma questionnaire scale: This was developed for this study by the Gaza Community Mental Health Programme. It consists of 12 traumatic events frequently experienced by Palestinian children during the Al-Aqsa Intifada (Table 1). Seven events refer to direct exposure to the traumatic events (eg, tear gas, shooting, or deprivation of medical help), while 5 events refer to witnessing military violence (eg, witnessing killing and/or injuring).
  2. PTSD Scale (Posttraumatic Stress Disorder Scale) (DSM-IV criteria; American Psychiatric Association, 1994); For the purposes of this study, PTSD is used to refer to chronic and not acute PTSD since the events described by the youths were associated with lifetime trauma exposures. The scale was based on the article on clinician-administered PTSD published in the Journal of Traumatic Stress (Blake et al., 1995).
  3. The Child Posttraumatic Stress Reaction Index (CPTS-RI): This follows DSM-IV criteria, developed by Nader, and is used to measure PTSD in youths aged 12 and more (Nader et al., 1993). Children’s PTSD symptoms were assessed by the Child Posttraumatic Stress Disorder Reaction Index (CPTS-RI) (Pynoos, 1987). This 20-symptom scale is used to assess the degree of a child’s reactions to a selected traumatic event, and covers the intrusive re-experiencing of the event, avoiding related memories, numbing feelings and increased hyperarousal. The older children (13–16) reported themselves, and the interviewer estimated together with younger children the occurrence of the symptoms on a 5-point scale: none of the time (0), little of the time (1), some of the time (2), much of the time (3), and most of the time (4).The maximum sum score is 80 and minimum 12, and in our sample the range was 11 to 68. Averaged sum variables were constructed for intrusive (9 items), avoidance (7 items), and hyperarousal (4 items) symptoms. The CPTS-RI has been found to be reliable and valid in predicting trauma impacts among Arab children in Palestine (Punam¨aki et al., 2001; Qouta et al., 2001) and Kuwait (Hadi & Llabre, 1998).
  4. Open questions. We presented a picture of “Fatima,” a 15-year-old sitting by herself and looking out into empty space. We asked children to imagine what kinds of problems Fatima might be thinking of and how they, the children, could help solve them. In an effort to avoid suggestibility, the researcher provided the children with no additional information regarding “Fatima.” This research, summarized in Table 2, showed the results of psychological suffering among Palestinian children living under severe conditions during the last 21/2 years of the Al-Aqsa Intifada in conflict-ridden and public space areas of the Gaza Strip.
Table 1. Trauma questionnaire scale* Yes No
Item No.

The following are a number of questions related to difficult events that you were exposed to. It has nothing to do with a disorder or a normal event

1. Was your house exposed shelling?
2. Were you exposed to inhaling tear gas?
3. Were you exposed to burns?
4. Were you shot by live ammunitions?
5. Were you exposed to shooting by rubber bullets?
6. Were you shot in the head to the degree that you lost conscious?
7. Were you derived of medical care when you needed it?

Witnessing traumatic events: The following questions are related to events that you may have witnessed or heard about. Now I would like you to answer them

1. Witnessing shooting, fighting, or explosion
2. Witnessing strangers being injured or killed
3. Witnessing family members, neighbors, or relatives being injured or killed
4. Witnessing family members being injured or killed
5. Witnessing shelling and funerals

*The truma questionnaire scale is answered by the child not the mother.

Our study also found that 33% of the children were having acute levels of Posttraumatic stress disorder, 49% from moderate levels and 16% low levels. In “hot” (close to Israeli settlements) areas, 55% of the children suffered from acute levels of posttraumatic stress disorder, 35% from moderate levels, and 9% low levels. In this study, we also explored how children cope with their problems using the picture of “Fatima,” a 15-year-old student. We asked children how “Fatima” can solve their problems.We found that 66% of the children would like to concentrate their effort on school issues, 25% would like to be a martyr, 9% would like to encourage the peace process, 0.1% would like to become involved in the national struggle, and 0.5% would like to focus on religion.

Table 2. Prevalence rate of traumatic experiences among children in community areas

Direct personal experience Frequency %
Shelling of the home 179 19.0
Tear-gassed 341 36.1
Severe burns 89 9.4
Shot by live bullets 26 2.8
Shot by plastic bullets 31 3.3
Head injury, with loss 23 2.4
of consciousness

Deprivation of medical help

73 7.7
Witnessing traumatic events
Saw shooting, fighting, or explosion 785 83.2
Saw stranger being injured or killed 632 66.9
Saw friend or neighbor being injured or killed 584 61.6
Saw family member being injured 239 25.3
Saw funerals 893 94.6 893 94.6

CONCLUSIONS

With regard to the source of trauma for the Palestinian people, many research studies indicate that Palestinians hold Israeli authorities responsible for the majority of their direct exposure to trauma. In our view, this belief has face validity since tear gassing, home demolitions, and injuries due to bullet wounds have been widely reported by news agencies, Israeli and Palestinian human right organizations, and an UNRWA field investigator The research summarized in this article confirms that a safe home fulfils a basic need and makes it possible to establish secure and adaptive human relationships. Tragically, the protective shield that is essential for children’s mental health is dramatically destroyed when their families are faced with the shelling and demolition of their homes. Until the occupation of Palestinian lands is ended, there is a need for concerted action from the Palestinian National Authority, international agencies, and nongovernmental organizations, including practical programs, to help the children in greatest need, and further research documenting the impact of these interventions on the health and social well-being of these children.

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Blake, D. D.,Weather, F.W., Nagy, L. M., et al. (1995). The development of a clinician administered PTSD scale. Journal of Traumatic Stress, 8(1), 75–90.
Boothby, N., Upton, P., & Sultan, A. (1992). Children of Mozambique: The cost of survival [Special issue]. Washington, DC; U.S. Committee for Refugees.
Freud, A., & Burlingham, D. T. (1943). War and Children. New York: Medica War Books.
Garbarino, J., Kostelny, K., & Dubrow, N. (1991). No place to be a child: Growing up in a war zone. Lexington, MA: Lexington Books. Hadi, F. A., & Llabre, M. M. (1998). The Gulf crisis experience of Kuwaiti children: Psychological and cognitive factors. Journal of Traumatic Stress, 11, 45–56.
Khamis, V. (2000). Political violence and the Palestinian family: Implications for mental health and wellbeing. New York: Haworth Press.
Khamis, V. (2002a). Posttraumatic stress disorder among school age Palestinian children. Manuscript submitted for publication. Khamis, V. (2002b). Family environment and parenting as predictors of attention-deficit and hyperactivity among palestinian children. Manuscript submitted for publication.
Kuttab, D. (1998). A profile of the stonethrowers. Journal of Palestinian Studies, 17, 14–23.
Nader, K., Pynoos, R., Fairbanks, L., Al-Ajeel, M., & Al- Asfour, A. (1993). A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis. British Journal of Clinical Psychology, 32, 407–416.
Palestinian Central Bureau of Statistics. Child nutrition in enceptional circumstances. The case of Palestinian children aged 6–59 months in the Palestinian territory. (Policy Report, 2002). Retrieved from http:// www.pcbs.org/english/health/2002/policy.html
Palestinian Central Bureau of Statistics with Birzeit University and UNICEF. Nutritional Survey 2002. Ramallah, Palestine: Author. Punam¨aki, R. L., Qouta, S., & El Sarraj, E. (2001). Resiliency factors predicting psychological adjustment after political violence among Palestinian children. International Journal of Developmental Behaviour, 25, 256–267.
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Qouta, Q., Punam¨aki, R. L., & El-Sarraj, E. (2001). Mental flexibility as resiliency factor in traumatic stress. International Journal of Psychology, 36, 1–7.

J Ambulatory Care Manage
Vol. 28, No. 1, pp. 75–79
© 2005 Lippincott Williams & Wilkins, Inc.

Design: Shai Zauderer, Developed by Migo