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“Prevalence of PTSD among Palestinian children in
Gaza Strip” Samir Qouta, PhD - Eyad El Sarraj, MD Gaza Community Mental Health Programme |
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Abstract This research study aimed
to get acquainted with the prevalence of PTSD, and other psychological suffering
among Palestinian children living under severe conditions during the last two
and half years of the Al-Aqsa
Intifada. The sample consists of 944 children whom age ranged between 10-19
years. The group excluded those with previous mental health problems. In this
research, trauma scale, PTSD scale, the Child Posttraumatic Stress Index, the
Children’s PTSD-symptoms, The CPTS-RI and open questions had been used
as tools. The results indicated that 32.7% of the children started to develop
acute PTSD symptoms that need psychological intervention, while 49.2% of them
suffered from moderate level of PTSD symptoms. Also the results showed that
the most prevalent types of trauma exposure for children are for those who
had witnessed funerals (94.6%), witnessed shooting (83.2%), saw injured or
dead who were not relatives (66.9%), and saw family members injured or killed
(61.6%). Key words: PTSD In September, 2000, a new
Palestinian uprising began against the now 36-year old Israeli military
occupation. The immediate cause was the visit of then Israeli Knesset Member
Ariel Sharon accompanied by over 1000 fully armed Israeli riot police to what
Jews call the Temple Mount and Muslims, the Noble Sanctuary (“El-Haram
A-Sharif”) on which sits Al-Aqsa Mosque. Palestinians’ protest of the
violation of their holy place resulted in Israeli police shooting several
unarmed protesters. This event provided the immediate spark for Palestinian
protests throughout the West Bank and Gaza Strip, as well as the name for an
uprising that continues at this writing, “The Al-Aqsa Intifada.” The more
distant cause for this second and more violent Intifada was the evident
failure of the Oslo peace process. Instead of a lasting peace between
Israelis and Palestinians, Oslo agreement has followed by a 50% increase in
Israeli settlement building and land confiscation (KUKA), a decrease in
Palestinian freedom of movement and lack of civil liberties (KUKA), and
economic de-development including high unemployment. As the “Al–Aqsa
Intifada” continues into its fourth year, the Israeli army frequently shells
and destroys the Palestinian homes. Since October 2000 until 31 of January
2004, 3062 homes have been completely and partially demolished and 2524 homes
need to be repair in Gaza Strip (UNRWA, 2004). The army uses a variety of
methods to destroy homes, including tank shells, bulldozing, helicopter
gunship, and fighter aircraft. As homes have been bombarded and made
uninhabitable, many Palestinian families have found themselves living in
tents. When families
witness the destruction of their own homes by enemy soldiers, the
psychological effects can be serious. Loss of home can be a traumatic
experience for not only material loss but for psychological meaning. The home
means a shelter and heart of family life. It contains memories of joy and
pain as well as attachment to the families’ objects. Home is associated with
feelings of security and consolation. As in all modern wars,
the victims of the latest Middle Eastern war are mainly civilians. We have an
accumulated knowledge about the children’s responses to air raids,
bombardment, shelling, loss of family members and being target and witnessing
killing and destruction. It involves research on acute responses during the
II World war (Brander, 1941; Dunsdon, 1941; Freud & Burlingham, 1943),
mental health Middle Eastern children during military attacks (Bryce &
Walker,1986; Baker, 1990; Macksoud & Aber, 1996; Milgram & Milgram,
1976; Ziv & Israeli, 1973; Saigh, 1991), as well as military violence and
persecution in Africa (Dawes, 1992; Cliff, 1993) and Europe (Smith, Perrin,
Yule, & Rabe-Hasketh, 2001). Children’s responses to danger and
life-threat include anxiety, somatization and withdrawal symptoms, and
especially younger children may regress into the earlier stages of
development (Yule, 2002). While almost all children respond with excessive
fear, sleeping difficulties and clinging to parents in acute trauma, only a
smaller minority develop posttraumatic disorders. A substantial amount of
research is available on the severity of PTSD symptoms and predictive factors among Middle Eastern
children, especially of Kuwaiti children during the nine-months of Iraqi occupation (Hadi, & Llabre,
1998; Llabre & Hadi, 1994; Macksoud & Aber, 1996; Nader, & Pynoos,
1993; Pynoos, 1994; Nader & Fairbanks, 1984) and Israeli children during the Iraqi
scud missile bombardment (Klingman, 1992; Lavee & Ben-David, 1993; Laor,
Wolmer, & Cohen, 2001; Laor, Wolmer, Mayers, Gershon, Weitzman, &
Cohen, 1997; Weisenberg, Schwarzwald, Waysman, Solomon,
& Klingman, 1993; Rahav & Ronen, 1994; Rosenthanl & Levy-Shiff,
1993). The percentages of PTSD diagnosis vary from 22% among Israeli
(Laor et al., 1997, 27% among Lebanese (Saigh, 1991) 41% among Palestinian
children from Gaza exposed to shelling, (Thabet & Vostanis, 1999) 48%
among Cambodian refugee children (Kinzie, Sack, Angell, Manson, & Rath,
1996; Sack, Clarke, & Seeley, 1995), 52% among children from
Bosnia-Hercegovina (Smith, Perrin, Yule, Hacam, & Stuvland, 2002), and 78-88%
among Iraqi children exposed to bombardment (Dyregrov, Gjestad, &
Raundalen, 1993). Longitudinal studies on the PTSD are rare, and they reveal
that once the fighting and danger are over, the posttraumatic symptoms
decrease considerable (Laor et al., 2001; Punamäki, Qouta, & El Sarraj,
2001). Among Kuwaiti children, the share of severe level of PTSD was 4% after
one year of traumatic events, among Iraqi children and among Israeli children
0% after five years (Laor, et at. 2001). Dyregrow et al (2002) followed
shelled children at six months, one year and two years, and showed first
increase from 84% to 88%, and then decrease to 78% of PTSD. The physical and
emotional proximity, severity and nature of the traumatic event prescribe the
nature and severity of psychological problems (Macksoud & Aber, 1996;
Qouta, Punamäki, & El-Sarraj, 1996; Punamaki, 1998; Pynoos, 1987;
Klingman, 1992). For example, Bryce et al. (1989) found that especially
displacement from home increased depression among Lebanese children and women
during the 1982 Israeli invasion. Laor
et al., (1997; 2001) found among Israeli children that while posttraumatic
stress symptoms decreased generally after the Iraqi shelling, the symptoms
increased among displaced children. The present study
examines the levels of PTSD among Palestinian children during the current
Intifada. We further study how the nature of trauma (personal exposure to and
witnessing military violence) correlates with the children vision to their
future, and we guess that these
traumatic experiences will affect the way, in which the child see his
perspectives and solving problems. Method
-
The Sample The
sample consisted of 944 children ranging between 10-19 years, randomly
selected from all part of Gaza Strip with Arithmetic mean (15.1±1.5). 49.7%
of the sample were boys while 50.3% were girls. Refugee children represented
76.8% of the sample and the rest were citizen’s residents. Seven field
workers had participated in the field work, which done at schools, with
co-operation of the teacher and headmasters, -
Measurements 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” (Box 1). Seven events refer to direct exposure to the traumatic
events (e.g., tear gas, shooting, or deprivation of medical help), while five
events refer to witnessing military violence, (e.g. witnessing killing and
injuring). Reliability by Alpha Cronbach was .82
Box 1. Trauma questionnaire scale 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.
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.
Note: the trauma scale is answered by the child not
the mother 2. PTSD
Scale (Posttraumatic Stress Disorder Scale) (DSMIV, American Psychiatric
Association, 1994). For the purposes of this study, PTSD refers to chronic
and not acute PTSD since the events described by the youths were associated
with lifetime trauma exposures. The scale was based the Clinician
Administered PTSD published in the Journal of Traumatic Stress. The
Child Posttraumatic Stress Reaction Index (CPTS-RI): this
follows DSMIV
criteria, developed by Nader and used to measure PTSD in youths aged 12 and
over(1)
Children’s PTSD-symptoms were assed by the Child Posttraumatic Stress
Disorder Reaction Index (CPTS_RI).(2) The
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 and numbing feelings and increased
hyper-arousal. The older children (13-16) reported themselves and the
interviewer estimated together with younger children the occurrence of the
symptoms on a five-point scale: (0) none of the time, (1) little of the time,
(2) some of the time, (3) much of the time, and (4) most of the time. The maximum
sum score is 80 and minimum 12, and in our sample the range was 11-68. Averaged sum variables were
constructed for intrusive (9 items, a =.80), avoidance (7 items, a =.77) and
hyperarousal (4 items, a =.66) symptoms. The CPTS_RI has been fond reliable and valid in predicting
trauma impacts among Arab children in Palestine (Punamäki et al., 2001;
Qouta, et al., 2001) and Kuwait (Nader et. al., 1993; Nader, & Pynoos,
1993; Hadi, & Llabre, 1998).
3. 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.” rESULTS: Research on the "Prevalence of
PTSD among Palestinian Child during in Gaza Strip” showed the results of the
psychological suffering among Palestinian children living under severe
conditions during of Al-Aqsa
Intifada in hot and community areas of the Gaza Strip. The most prevalent
types of trauma exposure for children in the community areas is for those who
had witnessed funerals 94.6%, witnessed shooting 83.2%, witnessed shooting, 66.9
%; saw a friend or a neighbor being injured or killed 61.6% and were tear
gassed 36.1%. (see table 1). TABLE 1
Prevalence rate of the traumatic experiences among children in the community
areas
It was found
that 32.7% of the children in the community areas suffered from acute level
of PTSD while 49.2.1% children suffered from moderate level of PTSD at the
same time 15.6% children suffered low level of PTSD and we can say that 2.5%
children had no symptoms while in hot areas 54.6% of the children suffered
from acute level of PTSD (see table 2). While 34.5% children suffered from
moderate level of PTSD at the same time 9.2% children suffered low level of
PTSD and we can say that 1.7% children had no symptoms. TABLE 2 The
severity of PTSD according to the child’s gender PTSD score
The study found
significant differences between boys and girls. In the acute level of PTSD,
57.9% girls developed such symptoms while the percentage among the boys was
42.1% (see table 3). TABLE
3 The severity of
PTSD according to the child’s gender PTSD score
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